Scandinavian Journal of Occupational Therapy. 2007; 14: 54 62
ORIGINAL ARTICLE
Challenges in implementation of research methodology in communitybased occupational therapy: The Housing Enabler Example
¨ NGE1, RALF RISSER1,3 & SUSANNE IWARSSON1 AGNETA FA Scand J Occup Ther Downloaded from informahealthcare.com by Lunds Universitet on 10/30/12 For personal use only.
1
Department of Health Sciences, Lund University, Lund, Sweden, 2Department of Technology and Society, Lund Institute of Technology, Sweden, and 3Factum OHG, Vienna, Austria
Abstract This paper focuses on challenges in implementation of research in community-based occupational therapy practice. Based on a two-year project in a south Swedish municipality aiming at studying implementation of structured assessment procedures in the housing adaptation process, the first purpose is to provide a detailed project description, and the second is to report on first results identifying challenges in implementation of research in practice. The project was managed following a non-profit marketing model involving activities based on user needs, e.g. assessment training, support visits, and seminars with the users, i.e. occupational therapists. In order to collect data on implementation challenges, a multidimensional approach was utilized. Involving all occupational therapists in the municipality under study, 422 housing adaptation cases were assessed by means of the Housing Enabler. Good inter-rater reliability was demonstrated (/k¯0:62); but large differences between districts in the municipality were seen. Qualitative analyses of diaries, e-mail correspondence and minutes from workshops and seminars elucidated three categories reflecting research implementation challenges: Utilizing research in practice is not straightforward ; Utilizing information technology is demanding ; and Establishing cooperation and communication is challenging . The results can be utilized for planning of research implementation projects in practice not used to scientific work.
Key words: Demonstration project, information technology, housing adaptation, non-profit marketing
Introduction Occupational therapists (OTs) are facing increasing demands to demonstrate that their interventions are efficient and effective, including demands to use research-based methodology (1 3). That is, even if practitioners are not directly involved in and do not generate original research, there are increasing requirements on them to implement research findings and to demonstrate their application in practice (2,4). In spite of this, many OT interventions are still being implemented without the use of structured, research-based methodology (5,6). This indicates that there are barriers to research implementation in practice (7), and that there is a need to study challenges in implementation processes. In particular, there is a lack of studies investigating research implementation processes in community-based OT practice.
Successful research implementation requires an active, multidimensional approach, combining different strategies (811). From a more general point of view, research implementation processes can be understood and explained by different theories. Communication theories (12,13), in particular non-profit marketing theories (14), provide frameworks for identifying user needs and the driving forces behind change, taking motivation as well as barriers and incentives to change into consideration. Moreover, adult learning theories (15,16) focus on motivation issues and issues of behaviour changes as well. Given the character of the project, applying a non-profit marketing approach was considered most useful (9,14). Accordingly, in the current study Kotler’s marketing model (14) was adopted as the theoretical framework. When it comes to strategies for enhancing research implementation, among the most effective are identification and reduction of
Correspondence: Agneta Fa¨nge, Division of Occupational Therapy and Gerontology, Lund University, Box 157, SE-221 00 Lund, Sweden. Tel: /46 46 222 19 72. Fax: /46 46 222 19 59. E-mail:
[email protected]
(Received 25 May 2006; accepted 30 November 2006) ISSN 1103-8128 print/ISSN 1651-2014 online # 2007 Taylor & Francis DOI: 10.1080/11038120601148520
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Implementation of research methodology in community-based OT barriers to implementation, provision of incentives, and ongoing support visits, as well as information and practical training (9,17,18). Most importantly, demonstrating the application of the research in the intended practice context under continuous support and coaching (18), i.e. setting up a demonstration project, seems to be a useful approach to enhance implementation. The current study is an example of such a demonstration project, representing an approach not often seen in OT research. When referring to non-profit marketing an idea has to be ‘‘sold’’. Based on thorough analysis of user needs, marketing activities involve communication measures, that is, arguments and practical implementation examples relevant from the users’ point of view should be developed, discussed and demonstrated. Moreover, non-profit marketing involves incentives, that is, opportunities for the users to try out tools and methods, aiming at demonstrating their efficiency. Additionally, marketing activities involves product-related activities, such as a userfriendly adaptation of technology, and development of understandable user instructions. Most important, all activities should be based on thorough analyses of user needs, as well as barriers and incentives to implementation (14). In the current study, the users at target were OTs in communitybased practice. The intervention targeted for this demonstration project is housing adaptation (HA). It is a common, individually tailored intervention in OT practice, defined as ‘‘the alteration of permanent physical features in the home and the immediate outdoor environment’’ (19), aiming at increasing accessibility and usability in the home in order to enhance daily activities and promote independent living. According to current Swedish legislation (20), the full costs for HA can be granted based on needs assessment and certification, often made by an OT on home visits. HA grants are applied for and decided upon at municipality level, with the client as the formal applicant and receiver of the grant. Both client needs and types of interventions undertaken are very diverse (5,21,22). In 2005, the total number of HAs in Sweden was 64 700, at the total cost of SKr 857 million (22). A number of evaluations of the results have been undertaken on an individual basis (5,21,23,24), while few *if any*attempts have been made to overview HA on the municipality level. Over several years a methodology for housing accessibility assessments based on the Enabler concept (25), i.e. the Housing Enabler (HE) instrument (26) has been developed and optimized. In the current demonstration project, the HE was the research methodology (‘‘product’’ in Kotler’s terminology) used to study an implementation process.
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The Enabler concept (25) is based on the notion of person environment (P E) fit as described in the Ecological Theory of Ageing (27), and renders it possible to quantify accessibility problems as an aspect of PE fit. Moreover, the methodology allows for aggregation of information from individual cases into comprehensive databases (28). Inter-rater reliability (29,30), as well as content and construct validity (31) of the HE have been developed (demo version available at http//:www.enabler.nu). The HE instrument is complex, and requires both specific training and continuous practice for reliable and valid assessments. Over the years the research team behind this study has run courses targeting OTs and other professionals in European countries, and the methodology has been used successfully in different research projects (5,30,32). Based on experiences and results from these studies we concluded that a municipalitylevel database comprising HE assessments accomplished for individual HA cases would have the potential to support housing provision and societal planning at municipality level. Subsequently, a twoyear project with the overall goal of developing systematic strategies for HE data collection, aggregation, and analyses in relation to HA cases, and to demonstrate their practical application on the municipality level, was designed and accomplished. Scientific reports describing implementation projects involving community-based OT practice are lacking. However, such reports would contribute to the methodological literature and serve as a basis for other researchers aiming at implementing research in practice. Given its specific focus on identifying challenges in implementation processes in community-based OT practice, the first purpose of this paper is to provide a detailed description of the demonstration project, while the second is to report on first results identifying challenges in implementation of research in practice. That is, since demonstration projects in OT practice have seldom been described, in this paper the project management organization is outlined, followed by description of the project preparation, pilot study, and data-collection phases. Thereafter, first results identifying challenges in the implementation process are accounted for. Further results will be presented in forthcoming publications.
Material and methods Project municipality The project was accomplished during 2004 and 2005 in a south Swedish municipality, more
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specifically the municipality that had been involved in a previous research project targeting HA cases (5). On 1 January 2004, the municipality had 75 000 inhabitants living in urban as well as rural areas. Healthcare and disability services were organized into three geographical areas, in this paper labelled district 1, district 2, and district 3, each of them headed by a local team manager. The number of inhabitants was about the same in the three districts. In a parallel organization serving the whole municipality, HA grant applications were administered and approved by two officials. Over the years, seasonal variations in numbers of applications have been found. That is, the number of HA applications is almost always lower during the summer months as well as in December and January, compared with the spring and autumn. At the time of the project there were 18 OT positions in the municipality, while due to continuous staff changes 25 OTs in total were involved during the study period. Assessment training course In order to conduct valid and reliable HE assessments, each rater requires specific training. The Housing Enabler assessment course is a four-day course comprising theory related to HA and P E fit and current housing provision policy, as well as teaching and practical training in HE administration. Moreover, theoretical and practical introduction to the HE software, as well as introduction to database construction and management, is included. Within a former research project (5), eight of the OTs employed in the municipality at project start had already been trained in and conducted numerous HE assessments, but for the current project the rest of the OTs participated in an HE training course. In addition, during the study period, additional courses were arranged to train newly employed staff. Methodology for identification of challenges in the implementation process In order to capture different aspects of an implementation process a multidimensional approach is required (811). That is, it is necessary to capture quality aspects of the methodology itself, in this case the HE, as well as different aspects of the implementation process as such. Accordingly, applying both quantitative and qualitative methodology the implementation process was monitored in three different ways: 1. In order to follow the OTs’ adherence to data-collection requirements the number of completed HE assessments each month was
calculated, and compared with the total number of HA in each of the three districts and in the total municipality. 2. In order to evaluate the reliability of the HE assessments, during project months 13 17 an inter-rater reliability study was conducted. Based on written and verbal information, organized in pairs of raters all OTs were instructed to conduct HE assessments in four ongoing HA cases each. The assessments were accomplished independently by each OT, with the other colleague in the pair of raters accomplishing her assessment with the same client during the following day. Twelve OTs accomplished this assessment task, and in all the interrater reliability study comprised 18 pair-wise HE assessments. Three of the OTs worked in district 1, three in district 2 and the remaining six OTs worked in district 3. Each OT conducted one to four HE assessments. The data were analysed by means of kappa statistics and percentage agreements (33), using the SAS system, version 8.2 (34). The kappa statistics results were interpreted following Altman’s guidelines (33). 3. In order to explore barriers and incentives to implementation processes, during project months 415 diaries were kept by the OTs, the two project leaders and the two research engineers. They were instructed to register for example cases where they found it useful/not useful to conduct an HE assessment, experiences of difficulties during the assessment, data-registration and data-entry procedures, technical difficulties, and other experiences and reflections they wanted to communicate. Furthermore, e-mail correspondence between the OTs, the project leaders, and the research engineers during the whole project period, and minutes from project steering group workshops and meetings (see below for description of the persons involved in the project), as well as from OT seminars, constituted an additional data source. In an iterative process, the first and third authors independently analysed all data sources by means of qualitative categorization of contents (35). In order to validate the findings and to increase trustworthiness (36), prior to the final categorization the second author and the rest of the steering group were asked to read and comment on the categories. Taking all comments into consideration, the first and third author in consensus finalized the qualitative analysis.
Implementation of research methodology in community-based OT May–December 2003
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Preparation phase Activities • Collaboration and cofinancing discussions • Project preparation advisory group meetings • Formal contract finalization • Seminars with municipality officials and staff representatives • Project leader appointment • Steering group establishment • HE assessment training course • Software optimization • Sampling discussions
January–March 2004 (project months 1–3)
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April 2004 – December 2005 (project months 4–24)
Pilot phase
D a ta c o l le c ti o n p ha s e
Activities • Project leader training (1–3) • HE assessment training course (2) • Project leader led seminars with raters (3) • Pilot HE assessments • Data entry and database management trials • Seminar with constructors, property owners, etc. (3) • Software optimization • Final sampling decisions (3)
Activities • HE assessment training courses and support (8, 10, 14, 21) • Project leader led seminars with raters (5,10, 18, 21) • Steering group meetings • Project management workshops (9, 21) • Support visits involving local project leader, raters, research team • Data entry and database management support • Software development and optimization • Palm computer introduction and training (11, 14, 16) • Project management meetings with municipality officials
Note. Figures within brackets denote the project month(s) when the activities were undertaken. No figures after the activity indicate that it was continous. HE = The Housing Enabler instrument (26) . Figure 1. Overview of the demonstration project phases and the activities accomplished in each phase.
Description of the demonstration project An overview of the activities accomplished during the different project phases is presented in Figure 1. A detailed description of the project management organization and activities, as well as the different phases, is given below. Project management The project was a joint venture between the municipality and Lund University. Accordingly, the project steering group comprised representatives from both parties. From the municipality the local project leader (an OT, at the same time one of the municipality officials in charge of HA grant administration) and the chief rehabilitation officer participated, while from the university the principal investigator (third author), the scientific project leader (first author), and two research engineers participated. An external consultant (second author) with specific competence in research implementation processes was affiliated, but not part of the project steering group. Six project steering group meetings were held during the project period (see Figure 1). Two of them were full-day workshops led by the consultant, and four of them were half-day meetings led by the scientific project leader. Based on non-profit marketing theory, during the two workshops specific attention was given to aspects of motivation in terms of barriers and incentives to project adherence among the OTs, and a set of support strategies directly targeting them was developed. For example, during the first workshop in project month 9, in order to
enhance the data-collection procedure and to consistently take motivational aspects into consideration, the steering group decided to intensify their support visits to the OTs, a list of incentives was developed, and practical HE implementation examples was developed and disseminated. During the second workshop (project month 21), the project process so far was evaluated and strategies for continuing use of the HE in the municipality were outlined and discussed. Four half-day seminars with all OTs, led by the two project leaders, were arranged in project months 5, 10, 18, and 21. Their purpose was to provide a meeting place for discussion about the project process in general, on specific issues related to instrument administration, as well as on practical implementation examples. From the pilot phase and throughout the entire project period, the research engineers and both project leaders were involved in HE instrument administration training and support of the OTs, individually and in groups. The research team also provided support to the local project leader, in particular when it came to data entry and database management, but also with regard to HE instrument administration issues. Project preparation Collaboration between Lund University and the project municipality’s Disability Care Department had been ongoing since 1998, actively involving the majority of the OTs involved in the current project. In this respect, preparations for the demonstration
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project reported in this paper were already initiated. Prior to project start there was a period of formal preparations and negotiations. In June 2003, a project preparation advisory group was established, engaging representatives from the OTs, the local team managers, municipality officials, and the research team. After four months of negotiations, project funding was applied for and subsequently granted. Prior to project start a formal, written agreement between the two parties and the private enterprise holding copyright of the HE software was signed.
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Pilot study and data collection phases During the pilot study each OT conducted several HE assessments and technical solutions for data entry and data base management were piloted. Due to changes in OT staff composition an additional HE training course was accomplished, and during this phase after several rounds of discussions the final sampling strategy was decided upon (see also Figure 1). During the data-collection phase (project months 424) all HA cases coming up in the municipality were to be assessed by the OTs, using the HE instrument. Each HE assessment was registered on site, and thereafter the data were manually entered into a database, with a separate one for each OT. The data were then sent electronically to the local project leader for inclusion in the municipality database. Initially, all data were registered using a paper protocol; however, this is an inefficient and time-consuming data-collection process. Subsequently, software for palm computer use was developed, aiming at reducing the time required for HE data entry. Palm computers (HP IPAQ 1930) were successively introduced, and during project months 1116 three short training courses were held. Instead of using the paper protocol, all OTs thereafter entered the data directly into a palm computer. Throughout the project, the palm computer software was regularly updated based on feedback from the OTs. During the data-collection phase, a strategy and time plan for approaching different actors within healthcare and social services, as well as the building and planning sectors, real estate companies, and user organizations, were set up. Challenges to implementation of research in practice Number of Housing Enabler assessments and inter-rater reliability During project months 424 approximately 750 HA grants were approved in the municipality, while the
Number of Housing Enabler assessments
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30 25 20 District 1 District 2 District 3
15 10 5 0
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Project month
Figure 2. Number of registered Housing Enabler assessments during the data collection phase (1 April 2004 31 December 2005), by district.
number of completed HE assessments was considerably lower (n /422; 56%). The number of HA grants approved did not differ between the three districts; however, differences in the number of accomplished HE assessments were found (n / 107, 173, and 142, respectively). During the first year of the project, the number of HE assessments was much lower than expected when compared with the total number of HA grants, and particularly so in district 1. Over time the number of assessments increased in all districts but, as illustrated in Figure 2, the differences between districts remained throughout the data-collection phase. In district 1 one OT did not conduct any assessments until the very end of the project. Mean kappa for the environmental component was k¯0:62 and the percentage agreement was 91. For the personal component the corresponding figures were k¯0:62 and 94%. That is, good interrater reliability was demonstrated. Subjective experiences of the implementation process Three main themes elucidating different aspects of the implementation process emerged from the data: Utilizing research in practice is not straightforward, Utilizing information technology is demanding , and Establishing cooperation and communication is challenging.
Utilizing research in practice is not straightforward. As reflected in their diaries, some OTs did not see any link between HE assessment results and their everyday practice, while such links were identified by both project leaders and the research engineers. The majority of the OTs did not use the HE assessment as a basis for HA decisions, and they considered the instrument too detailed and time consuming. Moreover, the decision to assess all houses coming up for HA was questioned; some OTs would have preferred to make those decisions themselves based on the
Implementation of research methodology in community-based OT complexity of each case. However, as exemplified by the quotation below, some OTs perceived that systematic assessment enhanced communication with HA grant receivers and professionals, and increased the quality of the HA case management process:
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It [the HE assessment] is helpful in repeated HA cases, [I] can visualize what the home looks like, I’m able to make a repeated HA process more efficient. An aspect put forward by the two project leaders was the fact that the project, by the use of scientific methodology, triggered quality issues in OT practice in general and not only related to HA case management. As one of the project leaders expressed it: I think this project is good for OT in many different ways, not only with respect to the project objectives. One has to reflect upon one’s practice, the basis for decisions, and how one uses time. It was also obvious from minutes and diaries that some OTs did not consider generating data useful for housing provision and societal planning at municipality level to be their professional responsibility. In this respect, they questioned the overall project objectives, i.e. using HE data to support housing provision and societal planning at municipality level. Such responsibilities were, however, actively voiced by the majority of the OTs as well as by both project leaders and the project steering group as a whole.
Utilizing information technology is demanding. Throughout the whole project, the need for technical support to the OTs was substantial, and the major problems documented in the OT diaries as well as in communication between the research engineers concerned information technology (IT) use, in particular with regard to the palm computers. Before the introduction of palm computers, many OTs expressed their expectations that the device would reduce the time required for each assessment, while later on they expressed dissatisfaction in this respect. As elucidated by the quotation below, the data entry process was considered complicated, and the OTs feared losing data when transferring data from the palm computers to their PCs. I feel that I should try using the palm computer more, but it is still difficult to trust it and myself. I’m afraid that everything can disappear and that I will do something wrong.
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I do want to learn (to use) the palm computer, but it’s going to take time. Lack of time, and stress. Furthermore, as reflected in the e-mail correspondence between the research engineers, technical problems related to local network management as well as specific requirements for the HE software installation and use came up, requiring time and effort to solve. Throughout the project, the research engineers were also very concerned about identifying the barriers to technology use and developing user-friendly solutions to technical problems, and to some extent they succeeded. In total, the technical problems obviously added to the workload of all involved. Even so, and even if the training process was strenuous, some OTs found it rewarding: I’m proud of myself that I have managed as far as this.
Establishing cooperation and communication is challenging. Different aspects of cooperation and communication challenges among project actors were revealed. The majority of them caused considerable friction and created challenges to constructive project management towards overall project objectives. More specifically, in their diaries a few OTs expressed their explicit resistance to cooperation in the project, since they felt they had not been part of the decision process. According to the project leaders, such questions were raised far too late in the process. Refusals to cooperate constituted a considerable threat to overall project goal attainment and had to be taken into consideration in all management activities. However, in their diaries both project leaders expressed their concern that some OTs did not make any HE assessments claiming that the instrument was too complicated, while offers to arrange additional support seminars were not often responded to. Moreover, the two research engineers highlighted a different kind of communication challenge, namely the communication between them and the local IT staff in the municipality. For example, a number of technical problems occurred in relation to how the database was built up and managed by the OTs, thus directly affecting the OTs’ working conditions. According to the research engineers, the technical problems encountered to a large extent were based on lack of mutual understanding of each other’s working conditions and professional obligations, and could have been avoided if face-to-face discussions had taken place early on in the project. As one research engineer expressed it:
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The first day of installations was unfortunately characterized by a number of problems related to the software update. It is my opinion that these problems to a large extent could have been avoided if we have had a more direct and continuous communication, including personal meetings in an early project phase.
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In this context, in her diary the local project leader expressed her concerns about being the link between the research engineers and the municipality technical staff, often having to negotiate between the two parties without having any technical knowledge. Discussion The focus of this paper was to identify challenges in research implementation processes, in particular in relation to community-based OT practice. The project description (first purpose) comprised the project management organization, and the different activities conducted during the project. The challenges identified (second purpose) reveal that implementation projects involving a whole municipality, in this case all OTs and all HA cases, offers considerable challenges for all involved. Some of the challenges were directly related to the use of a specific methodology, i.e. the HE instrument in OT practice, and to the knowledge, experiences, and use of IT among the practitioners involved. Other challenges were related to aspects of communication and cooperation between different actors and, thus, more general in character. This paper might be untraditional and unconventional but we argue that the kind of results presented are valuable and serve to increase our understanding of how implementation of research methodology and results in practice contexts can be facilitated. To begin with, one challenge faced in this project was related to the difficulties in utilizing data collected by means of systematic, research-based methodology in practice. Obviously, some OTs did not consider the HE instrument feasible for HA planning, claiming that the instrument is too extensive and complicated at least when it comes to minor HA cases. This was in fact one reason for the somewhat low adherence to the project. On the other hand, as also seen from our results, some OTs considered the HE assessment useful for HA decisions, and as a communication tool in relation to clients, relatives, and authorities. In this respect, it is worth noting the fact that the HE instrument is one of the few valid and reliable instruments at hand for assessment of one of the main targets for HA (19), i.e. accessibility. In spite of the pressure on all OTs to base their interventions on valid and reliable
methods (13), our results clearly indicate that there are considerable challenges when it comes to practice implementation. In this respect, it is also worth reflecting on the fact that the main motive for project resistance among a few OTs was that they did not consider a contribution to the housing provision and societal planning processes in the municipality to be their professional responsibility. That is, they questioned the overall goals of the demonstration project underlying this study. With regard to national professional guidelines (37) and current professional debate [see e.g. 1,2], this is a very challenging opinion. When it comes to the project leaders, such responsibilities were actively voiced throughout the project, thus illustrating the differences in professional perspectives between different actors in the project. On the one hand, the daily working situation in practice requires rapid decisions and interventions based on client needs, with little time for systematization and reflection, while on the other hand requirement for evidence-based practice is well known among practitioners (13). Such gaps between professional requirements and everyday practice contexts lead to conflicting interests and perspectives (12), as reflected also by the communication and cooperation challenges identified in this project. As already considered, a considerable challenge faced in this project was related to cooperation and communication between actors. To some extent these challenges reflect the motivation among the OTs towards the overall goals of the demonstration project underlying this study. Previous studies have shown that implementation projects require extensive preparation among all involved before project start (18), and that they require motivation as well as extensive communication and cooperation among actors. In the current project, the low motivation and high resistance among some of the OTs turned out to be a considerable threat to project accomplishment. This was, for example, illustrated by the low rate of accomplished HE assessment early in the project, in particular in district 1, where the OTs most resistant to the project worked. In hindsight, even if nearly half of the OTs involved had been engaged in a previous research project using the HE (5), it seems as if insufficient time was allocated to project preparation and discussions. During our project, technical problems were the most common reason for the frustration expressed by the OTs, and these kinds of problems also required most time to solve. As regards the utilization of IT there are many barriers to face, such as fear of the unknown and of not being in control; both aspects were frequently mentioned by the OTs involved in this project. Moreover, successful
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Implementation of research methodology in community-based OT implementation of IT is based on utilizing technology that is easy to use and complete from the beginning (38). In our study, however, the palm computer software was developed successively based on feedback from the OTs and, thus, the users faced a considerable number of technical problems along the way. As expressed, this contributed to their frustration, as well as to the total workload among the OTs and the research engineers. On the other hand, being able to learn how to use the palm computer provided positive feedback on professional competence among some of the users. Given the fact that a substantial number of the OTs prior to project start were unfamiliar with computer use in professional practice, and thus were facing new problems in every assessment situation, it is obvious that this was a challenge to all involved. When it comes to overall project management, we explicitly decided to use a non-profit marketing model (14) as our frame of reference. The major rationale for this is the well-known fact that multiple strategies are required for effective research implementation with marketing activities being one of the most efficient (8). Marketing models are not commonly in use in the healthcare sector, and they might seem out of scope for OT practitioners, for example. However, Kotler’s model (16) guided us in identifying barriers and incentives towards project accomplishment, and to developing enhancement strategies with user needs in focus. With regard to the results, to some extent our strategies were successful, for example illustrated by the increasing number of HE assessments accomplished in all three districts over time. However, the resistance among a small number of OTs even at the very end of the project may, together with the technical problems faced, illustrate that our arguments and support measures were not successfully tailored to user needs. Closely related to issues of communication and cooperation is the fact that the project steering group did not comprise any representatives among the practising OTs. They never responded to an initial invitation to elect representatives, while great benefits would have been gained by having practising OTs as active members of the project steering group. As seen from our results, implementation of research in practice is a dynamic and complex process of learning and adjustments, requiring considerable time and effort (17). At project start we concluded that frequent support visits and on-site coaching (17,18) were crucial. Throughout the project, the research team, as well as the local project leader, was easily available for support visits, and efforts were made to establish mentorship groups comprising both experienced and inexperienced OTs. Only in district 2 were such mentorship groups
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actually working, while in the other districts they did not seem useful. Moreover, during the project period the support visits to the OTs increased considerably in both number and length, aiming at enhancing data collection and database administration. However, in spite of the fact that those support visits were explicitly based on user needs (9,14,17) it seems as if they were not helpful to the extent anticipated. In conclusion, this paper elucidates different challenges in collaboration between researchers and OTs working in a Swedish municipality. In particular, challenges related to utilization of research-based methodology in practice were highlighted, together with challenges related to both communication and cooperation, as well to utilization of IT. In spite of the fact that our project was related to HA cases, our results and experiences are general in character, thus having implications for different kinds of research projects. Accordingly, our project design and project management organization, as well as our experiences and implementation results, can be utilized for planning of any related project aiming at implementation of research in practice contexts. Acknowledgements The authors are grateful to municipality officials and politicians, as well as the occupational therapists in Kristianstad municipality, who made great efforts within this project. Special thanks are offered to BSc B. Slaug for help with data computations and to reg. OTs M. Davidsson and G. Giljara˚s-Ma˚nsson, and to Lic Med Sc A. Johannisson. Financially, the project was supported by the Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning (FORMAS; main funding body), the Disability Care Department in Kristianstad municipality, and the Swedish Research Council. Hewlett-Packard Inc. provided the project with palm computers at a discount price.
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