Healthcare professionals such as speech and language therapists are expected to change their practice throughout their career. However, from a practice perspective, there is a lack of knowledge around what practice change is, what it really takes, and why there are different trajectories. Consequently, therapists, managers and commissioners lack empirical evidence on which to base decisions about enabling practice change. In addition, intervention researchers lack basic sociological research around implementation that could inform their research designs, reporting and impact. This case-based sociological inquiry, underpinned by critical realist assumptions, was designed to address this knowledge gap. It includes a two-stage qualitative synthesis of 53 (then 16) studies where speech and language therapists explained the work of their practice in depth, and a primary qualitative study focused on one professional jurisdiction, children with speech sound difficulties (SSD). Forty two speech and language therapists from three NHS areas and independent practice in Scotland participated in individual interviews or self-organised pairs or focus groups to discuss in depth how and why they had changed their practice with these children. A variety of comparative methods were used to detail, understand and explain this particular aspect of the social world. The resulting theory of SSD practice change comprises six configured cases of practice change (Transforming; Redistributing; Venturing; Personalising; Delegating; Refining) emerging from an evolving and modifiable practice context. The work that had happened across four key aspects of this context (Intervention; Candidacy; Caseload; Service) explained what made each case possible, and how practice had come to be one way rather than another. Among its practical applications, the theory could help services plan more realistic practice change. In addition, the inductively developed layered model of SSD intervention change has the potential to contribute to speech and language therapy education as well as methodological discussions around complex interventions.

Les personnes atteintes de troubles concomitants (TC) de santé mentale et d’usage de substances présentent des besoins biopsychosociaux particuliers et complexes, qui peuvent rendre leurs prises en charge plus ardue pour les professionnels de la santé. Au Canada comme dans d’autres pays, les infirmières et les infirmiers sont fréquemment appelés à intervenir auprès de personnes atteintes de TC par le biais d’une approche intégrée des soins centrés sur leurs besoins particuliers. Toutefois, les études soulignent des difficultés et barrières inhérentes à la complexité de cette prise en charge par les infirmières, comme le sentiment de fardeau ou d’échec professionnel, les attitudes défavorables ou l’inconfort à l’égard de ces personnes et le manque de connaissances ou d’habiletés quant à certaines approches psychothérapeutiques essentielles. Qui plus est, rares sont les occasions de formation continue portant spécifiquement sur les TC pour soutenir et mieux outiller les infirmières dans le développement de leurs compétences. Cette thèse par articles présente les résultats d’une étude visant à comprendre dans quelle mesure et de quelles manières un programme de formation continue virtuel portant sur les TC a contribué au développement des compétences des infirmières. Le programme de formation continue virtuel sur les TC développé et mis en place en 2018 au Centre hospitalier de l’Université de Montréal (CHUM) en s’appuyant sur le modèle Extension for Community Healthcare Outcomes (©ECHO), s’adresse à l’ensemble des professionnels de la santé et des services sociaux du Québec. Celui-ci constitue un modèle de formation continue visant à soutenir le développement des compétences de ces professionnels dans la prise en charge de conditions de santé chroniques et complexes. Le modèle ECHO repose sur trois théories sociales de l’apprentissage, incluant la Théorie sociale cognitive, la Théorie des communautés de pratique et la Théorie de l’apprentissage situé. Le programme ECHO sur les TC comprend des séances éducatives virtuelles offertes en continu, d’une durée de 90 minutes à chaque deux semaines, guidées par une équipe interprofessionnelle d’experts dans le domaine des TC. La participation au programme s’effectue par l’entremise de visioconférences simultanées, au cours desquelles les professionnels inscrits au programme sont invités à présenter une situation clinique vécue, laquelle faisant ensuite l’objet d’une riche discussion entre pairs et d’une rétroaction personnalisée par l’équipe d’experts. Des capsules didactiques portant sur les pratiques exemplaires dans le domaine des TC sont également présentées aux participants, en fonction de leurs besoins d’apprentissage. Un devis mixte convergent a été utiliser pour collecter et analyser les données QUANtitatives et QUALitatives issues d’une population potentielle de 65 infirmières ayant participé au programme de formation ECHO sur les TC pour les vagues de formation 2018-2019 et 2019-2020. Dans le volet QUAN, une étude de cohorte prospective observationnelle a été mené pour mesurer l’évolution des infirmières à six mois (T1) et 12 mois (T2) suivant leur entrée au programme (T0) quant à leur: 1) sentiment d’auto-efficacité; 2) participation; 3) satisfaction et acceptabilité; 4) connaissances; 5) attitude; et 6) perception de la performance clinique. Dans le volet QUAL, une étude descriptive interprétative a été réalisée auprès de 10 infirmières ayant participé au programme ECHO, afin d’explorer leur expérience et perceptions à l’égard du développement et de la mise en pratique de leurs compétences, ainsi que des facteurs ayant influencé ce processus. Enfin, l’emploi d’une stratégie de comparaison des résultats QUAN et QUAL a facilité leur intégration, permettant ainsi de mettre en évidence leurs similitudes, différences ou éléments de complémentarité. Les analyses de variance effectuées dans le volet QUAN de l’étude ont indiqué une amélioration significative quant au niveau de connaissances sur les TC (pT1–T0 = 0,0045; pT2–T0 = 0,0014) et au score d’attitude à l’égard des TC (pT1–T0 = 0,0472 ; pT2–T0 = 0,0139) des infirmières (n = 28) à T1 et T2. En contrepartie, seules les infirmières (n = 16/28) ayant participé à au moins 25 % des 20 séances virtuelles offertes au cours d’un curriculum de formation ont montré une augmentation significative de leur sentiment d’auto-efficacité à T2 (pT2–T0 = 0,0213). En complémentarité, l’analyse thématique réalisée dans le volet QUAL de l’étude a mis en lumière qu’au cours de leur participation, les infirmières ont davantage développé huit éléments de compétences propres à la pratique auprès de personnes atteintes de TC, et que plusieurs facteurs d’ordre personnel, interpersonnel, contextuel et organisationnel avaient facilité ou contraint ce processus. Enfin, les constats mixtes de l’étude, illustrés par six thèmes, font état de six conditions clés pour favoriser le développement des compétences et leur mise en œuvre dans la pratique: 1) des expériences de mise en pratique et de validation; 2) des relations de réciprocité et de confiance en contexte de formation interprofessionnelle; 3) un partage d’expériences similaires entre pairs et des activités de mentorat; 4) une collaboration avec des experts; 5) une attitude positive solidifiée à l’égard de l’exercice de son rôle professionnel en situation de complexité et d’adversité; et 6) des expériences d’apprentissage d’équipe, adaptées aux particularités des milieux et en partenariat avec les organisations. Cette étude a permis de mieux comprendre comment un programme de formation continue virtuel sur les TC reposant sur le modèle ECHO a contribué au développement des compétences des infirmières. Les résultats suggèrent que dans certaines conditions, le programme de formation ECHO sur les TC peut favorablement contribuer au développement des compétences des infirmières et au renouvellement de leur pratique. Des recommandations sont formulées à l’effet d’orienter la recherche vers l’évaluation des effets du modèle ECHO sur le changement des pratiques et la santé des personnes atteintes; et d’explorer des avenues de recherche visant la conjugaison de stratégies auprès des professionnels et sur le plan de l’intervention, du contexte et des organisations, pour favoriser la mise en œuvre effective des pratiques exemplaires. / People with concurrent disorders (CD) in mental health and substance use have specific and complex biopsychosocial needs, which can make their care more challenging for healthcare professionals. In Canada, as in other countries, nurses are frequently called upon to intervene with people with CD through an integrated approach to care that focuses on their specific needs. However, studies point to difficulties and barriers for nurses caused by the complexity of this care. These include feelings of being burdened or of professional failure, judgmental attitudes about or discomfort with these individuals, and lack of knowledge or skills in certain essential psychotherapeutic approaches. Moreover, there are few continuing education opportunities specifically focused on CD to support nurses and give them the tools they need to develop their skills. This article-based thesis presents the results of a study carried out to understand how, and to what extent, a virtual continuing education program on CD contributed to nurses’ competency development. The virtual continuing education program for CD was developed and implemented in 2018 at the Centre hospitalier de l’Université de Montréal (CHUM), based on the Extension for Community Healthcare Outcomes (©ECHO) model. It is intended for all health and social services professionals in Quebec. ECHO is a model of continuing education designed to support the competency development of these professionals in the management of chronic and complex health conditions. The ECHO model is based on three social theories of learning, including the Social Cognitive Theory, the Communities of Practice Theory, and the Situated Learning Theory. The ECHO program for CD consists of 90 minute virtual educational sessions, offered bi-weekly on an ongoing basis. The sessions are guided by an interprofessional team of experts in the field of CD. Participation in the program takes place through videoconferences, during which professionals enrolled in the program are invited to present a real-life clinical situation, which is then the subject of a rich peer discussion and personalized feedback from the team of experts. Short didactic presentations on best practices in the field of CD are also presented to participants, based on their learning needs. A convergent mixed-methods design was used to collect and analyze QUANtitative and QUALitative data from a potential population of 65 nurses who participated in the ECHO CD program during its first two cycle (2018–2019 and 2019–2020). In the QUAN component, a prospective observational cohort study was conducted to measure nurses’ evolution at six months (T1) and 12 months (T2) following their entry into the program (T0) with respect to their: 1) self-efficacy; 2) participation; 3) satisfaction and acceptability; 4) knowledge; 5) attitude; and 6) perceived clinical performance. In the QUAL component, an interpretive descriptive study was conducted with 10 nurses who had participated in the ECHO program. The study explored their experiences and perceptions regarding the development of their competency and their clinical practice, as well as factors that influenced this process. Finally, a strategy of comparing QUAN and QUAL results facilitated their integration and thus highlighted their similarities, differences, or complementary elements. Longitudinal analyses of variance performed in the QUAN component of the study indicated a significant increase in the level of knowledge about CD (pT1–T0 = 0.0045; pT2–T0 = 0.0014) and in the attitude score toward CD (pT1–T0 = 0.0472; pT2–T0 = 0.139) of nurses (n= 28) at T1 and T2. In contrast, only nurses (n = 16/28) who participated in at least 25% of the 20 virtual sessions offered during a program cycle showed a significant increase in their self-efficacy score at T2 (pT2–T0 = 0.0213). In addition, the thematic analysis conducted in the QUAL component of the study revealed that, during their period of participation, nurses further developed eight competency elements specific to practice with people with CD, and that several personal, interpersonal, contextual, and organizational factors either facilitated or constrained this process. Finally, the study’s mixed-methods findings, illustrated by six themes, point to six key conditions that foster the development of nurses’ competencies and their implementation in clinical practice: 1) Opportunities for practice and validation; 2) Reciprocal and trusting relationships in an interprofessional learning environment; 3) Peer-to-peer sharing of similar experiences and mentoring activities; 4) Collaboration with experts; 5) Reinforcement of positive attitudes about performing professional role in complex and adverse situations; and 6) Learning experiences that are team-based, tailored to the setting specifics and receive organizational support. This study provides a better understanding of how a virtual continuing education program for CD, based on the ECHO model, contributed to nurses’ competency development. The results suggest that under certain conditions, the ECHO program for CD can contribute positively to the development of nurses’ competencies and the renewal of their clinical practice. Recommendations are made in two areas: first, to direct research toward evaluating the impact of the ECHO model on practice change and health outcomes; and, second, to explore research avenues for combining strategies among professionals and with regard to intervention, context and organizations, to support effective implementation of best practices.

Due to physical, cognitive and emotional impairments, many individuals are unemployed or under-employed following a traumatic brain injury. The research evidence links the rigour of a vocational evaluation to future employment outcomes. Despite this link, no specific guidelines exist for vocational evaluations. Using the research evidence and a diverse panel of clinical and academic experts, the primary objective of this doctoral research was to develop an inter-professional clinical practice guideline for vocational evaluation following traumatic brain injury. The objective of the guideline is to make explicit the processes and factors relevant to vocational evaluation, to assist evaluators (i.e. clients, health and vocational professionals, and employers) in collaboratively determining clients’ work abilities and developing recommendations for work entry, re-entry or vocational planning. The steps outlined in the Canadian Medical Association's Handbook on Clinical Practice Guidelines were utilized to develop the guideline and include the following: 1) identifying the guideline’s objective/questions; 2) performing a systematic literature review; 3) gathering a panel; 4) developing recommendations; 4) guideline writing; 5) pilot testing. The resulting guideline includes 17 key recommendations within the following seven domains: 1) evaluation purpose and rationale; 2) initial intake process; 3) assessment of the personal domain; 4) assessment of the environment; 5) assessment of occupational/job requirements; 6) analysis and synthesis of assessment results; and 7) development of evaluation recommendations. Results from an exploratory study of the guideline’s implementation by occupational therapists in their daily practices revealed that clinicians used the guideline to identify practice gaps, systematize their evaluation processes, enhance inter-professional and inter-stakeholder communication, and re-conceptualize their vocational evaluations across disability groups. Statistically significant improvements were also noted in clients’ participation scores on the Mayo-Portland Adaptability Inventory–4 following guideline use. This guideline may be applicable to individuals with TBI, clinicians, health and vocational professionals, employers, professional organizations, administrators, policy makers and insurers.

Due to physical, cognitive and emotional impairments, many individuals are unemployed or under-employed following a traumatic brain injury. The research evidence links the rigour of a vocational evaluation to future employment outcomes. Despite this link, no specific guidelines exist for vocational evaluations. Using the research evidence and a diverse panel of clinical and academic experts, the primary objective of this doctoral research was to develop an inter-professional clinical practice guideline for vocational evaluation following traumatic brain injury. The objective of the guideline is to make explicit the processes and factors relevant to vocational evaluation, to assist evaluators (i.e. clients, health and vocational professionals, and employers) in collaboratively determining clients’ work abilities and developing recommendations for work entry, re-entry or vocational planning. The steps outlined in the Canadian Medical Association's Handbook on Clinical Practice Guidelines were utilized to develop the guideline and include the following: 1) identifying the guideline’s objective/questions; 2) performing a systematic literature review; 3) gathering a panel; 4) developing recommendations; 4) guideline writing; 5) pilot testing. The resulting guideline includes 17 key recommendations within the following seven domains: 1) evaluation purpose and rationale; 2) initial intake process; 3) assessment of the personal domain; 4) assessment of the environment; 5) assessment of occupational/job requirements; 6) analysis and synthesis of assessment results; and 7) development of evaluation recommendations. Results from an exploratory study of the guideline’s implementation by occupational therapists in their daily practices revealed that clinicians used the guideline to identify practice gaps, systematize their evaluation processes, enhance inter-professional and inter-stakeholder communication, and re-conceptualize their vocational evaluations across disability groups. Statistically significant improvements were also noted in clients’ participation scores on the Mayo-Portland Adaptability Inventory–4 following guideline use. This guideline may be applicable to individuals with TBI, clinicians, health and vocational professionals, employers, professional organizations, administrators, policy makers and insurers.