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Development of a behaviour change intervention to increase upper limb exercise in stroke rehabilitation Connell, Louise A; McMahon, Naoimh E; Redfern, Judith; Watkins, Caroline L; Eng, Janice J Mar 12, 2015

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RESEARCH Open AccessDevelopment of a behaviour change interventionto increase upper limb exercise in strokeof PRACTISE is currently being explored in two other stroke rehabilitation units.ImplementationScienceConnell et al. Implementation Science  (2015) 10:34 DOI 10.1186/s13012-015-0223-3Lancashire, Preston PR1 2HE, EnglandFull list of author information is available at the end of the articleKeywords: Stroke, Upper limb, Behaviour change, Complex intervention, Development* Correspondence: laconnell@uclan.ac.uk1Clinical Practice Research Unit, School of Health, University of CentralLouise A Connell1*, Naoimh E McMahon1, Judith Redfern1, Caroline L Watkins1 and Janice J Eng2AbstractBackground: Two thirds of survivors will achieve independent ambulation after a stroke, but less than half willrecover upper limb function. There is strong evidence to support intensive repetitive task-oriented training forrecovery after stroke. The number of repetitions needed is suggested to be in the order of hundreds, but this is notcurrently being achieved in clinical practice. In an effort to bridge this evidence-practice gap, we have developed abehaviour change intervention that aims to increase provision of upper limb repetitive task-oriented training instroke rehabilitation. This paper aims to describe the systematic processes that took place in collaboratively developingthe behaviour change intervention.Methods: The methods used in this study were not defined a priori but were guided by the Behaviour Change Wheel.The process was collaborative and iterative with four stages of development emerging (i) establishing an interventiondevelopment group; (ii) structured discussions to understand the problem, prioritise target behaviours and analysetarget behaviours; (iii) collaborative design of theoretically underpinned intervention components and (iv) piloting andrefining of intervention components.Results: The intervention development group consisted of the research team and stroke therapy team at a local strokerehabilitation unit. The group prioritised four target behaviours at the therapist level: (i) identifying suitable patients forexercises, (ii) provision of exercises, (iii) communicating exercises to family/visitors and (iv) monitoring and reviewingexercises. It also provides a method for self-monitoring performance in order to measure fidelity. The developedintervention, PRACTISE (Promoting Recovery of the Arm: Clinical Tools for Intensive Stroke Exercise), consists ofteam meetings and the PRACTISE Toolkit (screening tool and upper limb exercise plan, PRACTISE exercise packand an audit tool).Conclusions: This paper provides an example of how the Behaviour Change Wheel may be applied in thecollaborative development of a behaviour change intervention for health professionals. The process involved wasresource-intensive, and the iterative process was difficult to capture. The use of a published behaviour changeframework and taxonomy will assist replication in future research and clinical use. The feasibility and acceptabilityrehabilitation© 2015 Connell et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly credited. The Creative Commons Public DomainDedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,unless otherwise stated.Connell et al. Implementation Science  (2015) 10:34 Page 2 of 9BackgroundThe evidence base for stroke rehabilitation has grownexponentially in recent years. There is now strong evi-dence supported by high-quality trials, and underpinnedby motor learning and neuroplasticity literature [1], tosupport intensive repetitive task-oriented training for re-covery after stroke [2]. After a stroke, two thirds of sur-vivors will achieve independent ambulation but less thanhalf will recover upper limb function at 6 months [3].Upper limb impairment after stroke has been shown tosignificantly influence quality of life [4] but remains acritical and neglected area of stroke rehabilitation [5]. Apositive relationship has been found between the timescheduled for therapy and recovery, suggesting that in-creased doses of therapy may lead to clinically meaning-ful improvements [6]. However, the optimal dose oftherapy in stroke rehabilitation is not yet known, withcurrent guidance recommending that stroke survivorshave as much opportunity as possible to repeatedly prac-tise upper limb tasks [7]. Neuroplasticity literature sug-gests that repetitions in the order of hundreds are likelyto be necessary [8] to maximise recovery after stroke.This contrasts starkly with clinical practice, where it hasbeen reported that the average amount of time spenttreating the upper limb in therapy sessions is between0.9 and 7.9 min [9] resulting in, on average, just 32 repe-titions per session [10].There exists a clear evidence-practice gap in strokerehabilitation with methods to increase the amount ofrepetitive task-oriented training for the upper limb ur-gently needed. GRASP (Graded Repetitive Arm Supple-mentary Program) is a self-directed arm and handexercise programme that was developed by researchersat the University of British Columbia. It is an evidence-based intervention that aims to address this gap andincrease the numbers of repetitions that stroke survivorscomplete during rehabilitation [11]. The stroke survivoris taught by a therapist how to complete a range ofupper limb exercises included in the GRASP manualand then completes the exercises outside of their therapytime, with the help of a family member or carer wherepossible. GRASP has experienced unusually rapid uptakeinto clinical practice. For example, despite only beingpublished in 2009, and not being explicitly recom-mended in the UK stroke guidelines, approximately 63%of UK therapists who responded to a survey were awareof GRASP by 2013, of whom 23% had used GRASP and11% were regular users [12]. In order to explore the rea-sons for this rapid uptake, a formative evaluation of theimplementation of GRASP in British Columbia, Canadawas carried out [13]. Therapists working in stroke re-habilitation reported that key factors in finding outabout the intervention were their own personal networkswith colleagues from academia and clinical practice, andthe free online availability of GRASP. A notable findingfrom this evaluation was that although the uptake ofGRASP was good, key components of the interventionwere modified when implemented by therapists in rou-tine clinical practice. For example, GRASP was pro-vided to non-stroke patients (e.g. spinal cord injury,brain injury patients); the exercises were often providedseparately as opposed to providing the full manual, andthe dose, when monitored, was less than the recom-mended amount.Low implementation fidelity has been reported in pre-vious trials in stroke rehabilitation, e.g. the training care-givers after stroke (TRACS) trial [14]. This was a clusterrandomised controlled trial (RCT) involving 36 strokeunits assigned to either an intervention to promotestroke carer training or usual care. The intervention wastargeted at routine multidisciplinary stroke staff and in-cluded multiple components: carer resources (trainingmanual and training record), taught sessions for staffand staff resources (slides and recorded staff trainingsessions). It was designed to be cascaded by trained staffto those not yet trained to incorporate the interventioninto usual care. However, a process evaluation pub-lished in this journal demonstrated poor implementa-tion, with no mechanisms existing for ensuring fidelityof the intervention in practice [15]. Results at 6 monthsdemonstrated no clinical or statistical differencesbetween groups on the primary outcomes of functionalindependence of patients or caregiver burden. The au-thors highlighted the need for the development of sys-tems to monitor intervention use within practice andfor researchers to consider implementation strategies apriori, ideally in partnership with the end users of theintervention.Rehabilitation interventions tend to be complex inter-ventions, i.e. interventions comprising several compo-nents acting either independently or interdependently[16]. Successful implementation of complex interven-tions, such as GRASP or TRACS, relies on changing thebehaviours of those responsible for their implementation[16]. However, consideration of behaviour change ofhealthcare professionals in the development and imple-mentation of complex interventions has traditionallybeen given cursory attention. Fewer still formally testthe feasibility of proposed interventions prior to evalu-ation [17]. Developing behaviour change interventions,which by definition are complex, is a growing field ofenquiry, but as of yet, there is no gold standard methodreported within the literature. Guidance, such as theMRC framework for the development and evaluation ofcomplex interventions [16], identifies the use of theoryas a fundamental component of intervention develop-ment, but how theories should be used to informmethods is less clear.development is novel as rehabilitation interventionshave traditionally been developed by academic re-search teams for the purposes of testing in efficacy tri-als with limited on-going practitioner input. However,as there is now a robust evidence base underpinningthe importance of intensity in stroke rehabilitation,the focus of research has shifted from efficacy studiesto translational research to implement this evidence inpractice. The rationale for the collaborative partner-ship was to maximise the “potential fit” of the devel-oped intervention, and intervention materials, withthe context in which the intervention would be imple-mented [21].Stage 2: Structured discussions to understand theproblem, prioritise target behaviours and analyse targetbehavioursIn stage two, the intervention development groupengaged in structured discussions to understand theFigure 1 Stages of development.Connell et al. Implementation Science  (2015) 10:34 Page 3 of 9One way to enhance the development of interven-tions targeting health professionals’ behaviour could bethrough applying the framework outlined in the Behav-iour Change Wheel (BCW) [18]. This was first detailedin a publication in 2011, with further information in abook which was published following the commence-ment of this project [19]. The BCW aims to provide asystematic process from behavioural analysis to inter-vention design. It was developed following a systematicreview and a synthesis of 19 existing frameworks ofbehaviour change. It has three layers; at its core, theCOM-B (capability, opportunity, motivation and be-haviour) model was surrounded by nine interventionfunctions and seven policy categories. The authorstested the reliability of the framework against twoexisting policies for tobacco and obesity management.However, the process of using the BCW to developnew interventions and the extent to which applyingthe BCW will lead to more successful interventionshas yet to be evaluated.Using the BCW as a guide, we have developed abehaviour change intervention that aims to increaseintensity of upper limb exercise in stroke rehabilita-tion. Many challenges exist both in devising the con-tent of behaviour change interventions and insystematically reporting interventions in a level ofdetail sufficient to allow replication in other studies orfor use in practice [20]. The aim of this paper is todescribe the processes that took place in developing abehaviour change intervention and to describe theresulting intervention. This will contribute to thegrowing evidence base on the development of complexinterventions and allow for improved interpretation offindings in future studies testing the effectiveness ofthe intervention.MethodsWe did not define the methods for developing the be-haviour change intervention a priori. It was an iterativeprocess that was guided, though not rigidly, by theBCW [18]. The stages of development that emergedduring the process are illustrated in Figure 1. As therewas no change in treatments provided to patients fromaccepted standards, ethical approval from the NationalResearch Ethics Service (NRES) was not required forthis phase of the study. Approval was obtained fromthe local Research and Development (R&D) office forthe site.Stage 1: Establish intervention development groupStage one entailed establishing an intervention devel-opment group that engaged key stakeholders and endusers of the intervention, as well as researchers. Thissustained collaborative approach to interventionproblem (i.e. how upper limb exercise could beincreased in the stroke rehabilitation unit) and identifyand to prompt discussion. Information from formativeunderpinned intervention componentsConnell et al. Implementation Science  (2015) 10:34 Page 4 of 9The methods in stage three were less aligned with theBehaviour Change Wheel. It entailed a collaborativedesign exercise to identify intervention components andwas informed by the Behaviour Change Technique Tax-onomy (v1) (BCTTv1) [23]. The aim of the BCTTv1 isto provide a reliable and systematic method of describ-ing and categorising behaviour change techniques(BCTs) used in interventions. Employing consistent ter-minology to describe these techniques allows developersto identify the active ingredients of interventions, testthese active ingredients and comprehensively describeinterventions to facilitate replication in future research[24]. During the design exercise, the BCTTv1 [23] wasused by the intervention development group to facilitatediscussion around potential behaviour change tech-niques, and delivery methods, to ensure all options wereconsidered. A description of what intervention compo-nents could look like was then drafted. The researchteam produced versions of the intervention componentswhich were presented back to the therapists foradditional feedback and refining.Stage 4: Piloting and refining of intervention componentsStage four represents the on-going reflexive cycle dur-research on current UK therapy practice for prescribingupper limb exercises [22], and how the GRASP hasbeen previously implemented [13], was used as a basisfor brainstorming possible target behaviours. A list ofall potential target behaviours was generated by thegroup, which the group then prioritised according tohow amenable to change they perceived them to beusing guidance from the BCW.Each target behaviour was analysed to determine howbest behaviour change could be achieved using theCOM-B model, the hub of the BCW [19]. COM-B is asimple model to understand behaviour based on cap-ability (psychological or physical ability to enact thebehaviour), opportunity (the physical and social envir-onment that enables the behaviour) and motivation(reflective and automatic mechanisms that activate orinhibit behaviour). A definition of the COM-B modeland previous examples were given to the group to fa-cilitate discussions to identify what needed to change inorder for therapists to be able to perform these targetbehaviours.Stage 3: Collaborative design of theoreticallybehaviours that could be amenable to change withinthe limits of the project using the BCW [18] as a guideing which the developed intervention components werepiloted and refined based on the experiences of the endusers. Between development meetings, the therapyteam had the opportunity to test each of the interven-tion components designed in the real-life clinical set-ting for a few weeks. At each development meeting,feedback was obtained and discussed, and the reflexivecycle repeated.ResultsStage 1: Establish intervention development groupThe intervention development group comprised a col-laborative partnership between two members of theresearch team (LC and NM) and a local therapy team(physiotherapists, occupational therapists, rehabilita-tion assistants) representative of the end users of theintervention. The site where intervention developmenttook place was originally identified through existingcontacts between LC and local therapists working instroke rehabilitation. The site was a stroke rehabilita-tion unit in a conurbation in the north west of England,located separately to the acute stroke unit. LC and NMlead the intervention development group meetings.Both are female chartered physiotherapists working fulltime in the field of stroke rehabilitation research andimplementation science. All members of the therapyteam were invited to attend meetings and attendanceranged from 4 to 8 staff members at each meeting. Asenior physiotherapist (NHS Band 6) with 4-year rota-tional experience of working in stroke rehabilitationtook the lead on keeping the rehabilitation team in-formed about the development process and progressand ensuring that the intervention documentation wasbeing completed. Meetings took place at the develop-ment site at times deemed suitable by the therapyteam. In total, eight meetings were held over a periodof 7 months.Stage 2: Structured discussions to understand theproblem, prioritise target behaviours and analyse targetbehavioursThe problem to be addressed was the intensity of upperlimb task-oriented training completed by stroke survi-vors in the stroke rehabilitation unit. Structured discus-sions during intervention development group meetingshighlighted a range of different interdependent behav-iours that need to be performed to bring about thisincreased intensity of exercise. These are illustrated inFigure 2.Based on the BCW method for prioritising targetbehaviours, it was decided by the intervention develop-ment group that therapist level behaviours would bethe focus of the intervention in this study for the fol-lowing reasons: (i) they were viewed as the first steps inthe causal chain and hence have spillover effect, (ii)they were considered by the group to be amenable toConnell et al. Implementation Science  (2015) 10:34 Page 5 of 9change and (iii) following piloting demonstrated strongpotential to positively increase upper limb exercise inthe stroke rehabilitation unit.The group prioritised four target behaviours at thetherapist level:1. Identifying suitable patients for exercises.2. Provision of exercises and equipment.3. Communicating exercises to family/visitors.4. Monitoring and reviewing exercises.Each target behaviour was analysed to determine whatneeded to change and how best behaviour change couldbe achieved using the COM-B model, the hub of theBCW. The views of the therapists discussed here werealso corroborated with formative research findings andother relevant literature. The results of the behaviouralanalysis for the target behaviours using the COM-Bmodel are shown in Figure 3.Capability All therapists had the physical capability to performthe four target behaviours. Therapists discussed thatFigure 2 The interdependent network of behaviours.from assessments, it was not always clear whoshould be prescribed upper limb exercises, inparticular who should be prescribed exercises to bepractised outside of therapy time. Therapists alsodiscussed that entry level therapists new to strokerehabilitation can often find it difficult to identifyexercises suitable to the stroke survivor’s level ofability. All therapists not only discussed theimportance of family and carer involvement inrehabilitation but also highlighted the challenge ofeffectively engaging families/visitors in therehabilitation process.Opportunity The most frequently discussed issue that needed tobe addressed in order for therapists to successfullyperform the four target behaviours was the limitedtime available to them in their working day.Therapists also discussed issues around socialopportunity such as the limited amount of emphasisplaced on addressing upper limb impairment ininpatient stroke rehabilitation settings compared tothat placed on recovery of the lower limb, transfersn esenConnell et al. Implementation Science  (2015) 10:34 Page 6 of 9COM-B modelIdentifying suitable patients for exercisesProvisioexercisequipmPhysical Capability Psychological Capability Physical Opportunity Social Opportunity Reflective Motivation Automatic Motivation and mobilising. In inpatient stroke rehabilitation,there is also limited physical opportunity fortherapists to monitor, review and progressprescribed exercises prior to discharge as a result ofcontinually reducing length of stay and earlydischarge of stroke survivors.Motivation Limited physical and social opportunity to performthe target behaviours was identified as having aneffect on therapist’s motivation. All therapistsdiscussed the importance of increasing intensity ofupper limb exercises in inpatient strokerehabilitation settings, and their desire to moreactively engage in this, but the lack of externaldrivers hampered this motivation. For example,currently, in the national stroke rehabilitationguidelines, there are targets for the time taken untilassessment and amount of therapy received but noquantifiable targets relevant to upper limbrehabilitation [7]. Does not need to chang Needs to change somewh Needs to change a lot tFigure 3 Behavioural analysis for the four target behaviours using thof  & tCommunicating exercises to family/ visitorsMonitoring and reviewing exercises      Stage 3: Collaborative design of theoreticallyunderpinned intervention componentsAs illustrated in the behavioural analysis (Figure 3),physical opportunity and social opportunity emerged asthe domains most in need of change to facilitate thera-pists in performing the target behaviours. To managethe scale, and the scope of the intervention, the inter-vention development group focused on developingintervention components, underpinned by behaviourchange techniques from the Behaviour Change Tech-nique Taxonomy (v1) that could address thesedomains.The developed intervention is PRACTISE (PromotingRecovery of the Arm: Clinical Tools for Intensive StrokeExercise). PRACTISE consists of team meetings and thePRACTISE Toolkit.1. Team meetings.Although the face-to-face meetings between the clin-ical team and research teams at this stage in the studywere initially required for the development process, theye to be able to perform target behaviourat to be able to perform target behaviouro be able to perform target behavioure COM-B modelwere ultimately identified as an important component ofthe intervention itself as they ensured commitment toimplementation and provided opportunity for self-monitoring of behaviour (i.e. measuring fidelity to thedeveloped intervention), problem solving and actionplanning.2. PRACTISE Toolkit.Stage 4: Piloting and refining of intervention componentsAs the intervention components were drafted, they werepilot tested by the therapy team. Pilot testing allowedthe group to establish whether or not the interventionimpacted on the prioritised behaviours in the desiredway and also to establish in what way, if any, the inter-vention components could be refined and improved. Fol-lowing piloting, all components stayed, but the formatchConnell et al. Implementation Science  (2015) 10:34 Page 7 of 9Please see Additional file 1: The PRACTISE Toolkitfor draft versions of each of the following components.The developed toolkit included:2a.A screening tool and upper limb exercise plan: toenable therapists to efficiently identify patients thatshould be receiving upper limb exercises anddocument prescribed upper limb exercises in themedical notes.2b.A PRACTISE exercise pack: to enable therapists toefficiently communicate (verbally and in writtenformat) the rationale for the exercise programme,the individual exercises (based on GRASP exercises,with written and pictorial instructions) to becompleted by the patient, and to enable thetherapist and the patient to monitor repetitions ofexercises using an exercise diary.2c.An audit tool: to enable therapists to self-monitorperformance around provision of upper limbexercises to suitable patients in the strokerehabilitation unit.Data from the screening tool and the upper limb ex-ercise plan were used as a source of information for theaudit tool to monitor the numbers of appropriate pa-tients in the unit for which the target behaviours werebeing performed (see Additional file 1: The PRACTISEToolkit). It should be noted that the components of thetoolkit are intended to have some flexibility in terms ofform (e.g. to fit with local systems/policies), but theintervention aim and BCTs are standardised. The inter-vention components, their underpinning behaviourchange techniques and what they aimed to change aresummarised in Table 1.Table 1 Intervention components, underpinning behaviourWhat needed to changePhysicalopportunityDue to time constraints, more efficient ways of performingthe target behaviours were neededSocialopportunityGetting upper limb rehabilitation higher up on the agendawas needed through managerial support and teamengagementwas often modified or refined. An example of this wasthe introduction of the “Front sheet” (see Additional file1: The PRACTISE Toolkit). Originally, the “ExercisePlan” was provided to patients as part of their PRAC-TISE Pack. However, feedback from therapists pilotingthe form suggested that it contained too much informa-tion and was too complicated for this purpose. The sim-pler “Front sheet” was developed to include the patient’sgoal, the exercises they had been prescribed, the namesof individuals willing to assist with the exercises and thedate for review.DiscussionThis paper describes our experience of developing acomplex behaviour change intervention that aims to in-crease upper limb repetitive task-oriented training instroke rehabilitation units. The developed interventionis PRACTISE. PRACTISE consists of team meetingsand the PRACTISE Toolkit (a screening tool and upperlimb exercise plan, PRACTISE exercise pack and anaudit tool).Developing and describing PRACTISE was resource-intensive. The efforts required for intervention develop-ment have been noted previously [14,25], yet securingfunding and publishing this type of work is still prob-lematic. In this study, we used the Behaviour ChangeWheel, although not rigidly, to guide the developmentprocess [19]. In trying to document the iterative processand maintain clarity, it is presented as more linear thanit actually was. Although the BCW did provide a frame-work, there are still many ways in which it could beapplied. In previous research studies applying the BCWto design an intervention, researchers have used inter-views and questionnaires with the target group to iden-tify factors that need to change in order for behaviour toange techniques and what they aimed to changeBehaviour change techniques Intervention components(see Additional file 1)4.1 Instruction on how to perform thebehaviour 3.2 Social support (practical)2a. Screening tool andexercise plan 2b. PRACTISEpack1.2 Problem solving 1.4 Action planning 1.9Commitment 2.3 Self-monitoring of1. Team meetings 2c. AudittoolbehaviourConnell et al. Implementation Science  (2015) 10:34 Page 8 of 9occur [26-28]. We built on formative research findings[13] and had structured discussions with the interven-tion development group. As the development processwas over several months, therapists were able to reflecton the discussions over time and consider the behav-ioural analysis during their clinical practice and couldstill input these into the development. This method hasthe limitations of being arguably less methodologicallyrobust (e.g. not transcribed/less reproducible) but meantthat it was insightful and comprehensive. The fact that itbuilt on formative research which involved therapistsboth in the UK and Canada provides some credence thatthe findings will be generalizable to other stroke re-habilitation units.The collaborative design of the intervention compo-nents (stage 3) was less aligned with the BehaviourChange Wheel. Based on the behavioural analysis, any ofthe BCW intervention functions could be selected andhence any of the policy categories. In addition, the policycategories are not well defined and, as the name sug-gests, aimed more at a policy level (e.g. legislation, fiscalmeasures). Our intervention would all fit under the cat-egory “service provision,” which incorporates a vast arrayof potential intervention components. It was thereforefelt the BCW was less directive and helpful at this stage.However, the Behaviour Change Technique Taxonomy(v1) was particularly useful during the intervention de-velopment process as it provided common terminologyto describe the purpose of the intervention components.This aligns with previous evidence suggesting that whendeveloping and testing complex interventions, there is aneed to be clear about the function of the interventioncomponents but to allow some flexibility with the formto allow adaptation at the local context [29]. Using spe-cified behaviour change techniques from a publishedtaxonomy, together with the embedded toolkit perform-ance measures, will provide components through whichfidelity to the intervention can be measured in futureresearch and clinical use. It is anticipated that this willassist with the difficult process of unpicking the activemechanisms within the intervention during an evalu-ation study, with the importance of undertaking thiscareful development work recognised [30].We also had the opportunity to test and refine devel-oped intervention components with the end users. Thisstage is not included in the BCW but emerged as key toour development process. Involving users has been dem-onstrated to be the best predictor for ensuring researchis translated into practice [31], and so, in this study, weendeavoured to maximise the acceptability of the inter-vention through collaborative working with users, i.e.stroke therapy teams. They reported that the developedtoolkit components were inexpensive, acceptable to thetherapy team and fitted well with current methods ofdocumentation, and were practical for therapists and pa-tients/families.Despite the fact that we did not define the develop-ment process in advance, numerous similarities can beseen between our methods and research in both theimplementation science literature and other areas suchas quality improvement, e.g. Plan-Do-Study Act (PDSA)cycles. It is often the same premise (i.e. understand, test,evaluate, refine), understood and explored using differ-ent theories or frameworks. Describing our developmentprocess should be of interest to others who are trying todevelop interventions to change behaviour of healthprofessionals.Future workFollowing the development and testing of PRACTISE,the intervention now needs to be tested in other strokerehabilitation units prior to a definitive effectivenesstrial, both in terms of change in health professional be-haviour and patient outcomes. A feasibility case study ofthe PRACTISE toolkit in two stroke rehabilitation unitsis currently on-going.ConclusionThis paper provides an example as to how the BehaviourChange Wheel may be applied in the collaborative de-velopment of a behaviour change intervention for healthprofessionals. The process involved was resource-intensive, and it was difficult to capture the iterativeprocess. The use of the Behaviour Change Wheel andbehaviour change techniques from a published tax-onomy provide an example of how these frameworksmay be applied and will assist replication in futureresearch and clinical use.Additional fileAdditional file 1: Practise Toolkit. Draft version of the PRACTISEToolkit.Competing interestsThe authors declare that they have no competing interest.Authors’ contributionsThe original idea for this research study was conceived by LC, supported byCW and JE. LC and NM led the intervention development process. Allauthors contributed to writing up the study findings and critically reviewedthe final version for publication. All authors read and approved the finalmanuscript.AcknowledgementsLouise Connell is funded by a National Institute for Health Research CareerDevelopment Fellowship. This article presents independent research fundedby the National Institute for Health Research (NIHR). The views expressed arethose of the authors and not necessarily those of the NHS, the NIHR or theDepartment of Health. We would like to acknowledge the contribution of alltherapists and stroke rehabilitation team members that participated in thedevelopment of PRACTISE.randomised controlled trial. Trials. 2014;15:38.26. Bonner C, Jansen J, McKinn S, Irwig L, Doust J, Glasziou P, et al. Generalpractitioners’ use of different cardiovascular risk assessment strategies: aqualitative study. Med J Aust. 2013;199:485–9.27. English M. Designing a theory-informed, contextually appropriate interventionstrategy to improve delivery of paediatric services in Kenyan hospitals.Implement Sci. 2013;8:39.28. Fuller C, Michie S, Savage J, McAteer J, Besser S, Charlett A, et al. TheFeedback Intervention Trial (FIT)—improving hand-hygiene compliance inUK healthcare workers: a stepped wedge cluster randomised controlled trial.PLoS One. 2012;7:e41617.29. Hawe P, Shiell A, Riley T. 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