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. 2025 Apr 9;25(1):515.
doi: 10.1186/s12913-025-12593-0.

Exploring factors influencing the consistent adoption of a post-stroke upper extremity outcome measure using Normalisation Process Theory

Silvana X Choo  1 , Joshua Yong  2 , Shaikh Abdullah Bin Mohamed Rafi  3 , Chen Ju Lo  4 , Jun Bin Tong  5 , Elaine Lum  6 , Julian Thumboo  7   8
Affiliations

Exploring factors influencing the consistent adoption of a post-stroke upper extremity outcome measure using Normalisation Process Theory

Silvana X Choo et al. BMC Health Serv Res. .

Abstract

Background: Stroke rehabilitation guidelines recommend using outcome measures like the Fugl-Meyer Assessment for Upper Extremity (FMA-UE) to assess post-stroke upper extremity function. However, integrating such outcome measures into routine clinical practice remains challenging, highlighting the need to understand factors affecting their implementation in evolving healthcare models.

Objective: Our study aimed to identify the barriers and facilitators to sustain the routine use of the FMA-UE among hospital-based occupational therapists (OTs) using a theory-driven approach.

Methods: Employing a mixed-method sequential exploratory study design rooted in Normalisation Process Theory (NPT), we gathered quantitative data through a validated survey followed by qualitative insights analysed with directed content analysis from focus group discussions involving occupational therapists from four hospitals.

Results: Survey findings (n = 34) revealed barriers primarily associated with NPT constructs of collective action and coherence. Facilitators were linked to the cognitive participation construct. Key barriers identified in focus groups included insufficient coaching, competing priorities, and perceived limited value of the FMA-UE. Facilitators included legitimation of therapists' role in outcome measurements and an open learning culture.

Conclusions: Through a theory-based approach, we identified barriers and facilitators to sustain the routine of the FMA-UE. Our findings offer insights for designing implementation strategies to embed the FMA-UE into routine practice, supporting its sustained use in stroke rehabilitation.

Keywords: Fugl-Meyer Assessment; Implementation science; Outcome measure; Rehabilitation; Stroke; Upper limb.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: Ethics approval was obtained from the SingHealth Centralised Institutional Review Board (CIRB Ref: 2021/2559). Prior to commencing the online survey, the webpage provided participants with brief study information and a statement detailing that the completion of the survey indicated their informed consent to participate in our study. Written informed consent was obtained for all focus group participants. This study was conducted in accordance with the principles of the Declaration of Helsinki. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Summary of responses of survey statements related to Coherence construct. For example, a response of “strongly agree” indicates that differentiation (seeing how the FMA-UE differs from usual ways of working) is perceived as highly important
Fig. 2
Fig. 2
Summary of responses of survey statements related to cognitive participation construct. For example, a response of “strongly agree” suggests that initiation (recognising key people who drive the use of the FMA-UE forward and get others involved) is seen as crucial
Fig. 3
Fig. 3
Summary of responses of survey statements related to collective action construct. For example, a response of “strongly agree” reflects that interactional workability (easily integrating the FMA-UE into existing work) is regarded as very significant
Fig. 4
Fig. 4
Summary of responses of survey statements related to reflexive monitoring construct. For example, a response of “strongly agree” signifies that systemisation (awareness of the reports about the adherence rate of the use of the FMA-UE) is considered very important
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