RTSS Adoption Into Physiotherapists Documentation

Rehabilitation frameworks, such as the international classification of functioning, disability and health, 1 support the reasoning and identification of what should be targeted by clinicians to achieve desired patient outcomes. However, frameworks supporting the reasoning about how these targets should be treated are scarce. A promising candidate that provides this function is the rehabilitation treatment specification system (RTSS) 2. The RTSS encourages clinicians to hypothesise a claim (a treatment theory) about how they are going to treat an individual patient by identifying treatment components - the tripartite building block of a specified treatment composed of a singular (measurable) treatment target i.e., an aspect of function or disability that is to be changed directly by the ingredient(s), 1 or more (measurable) ingredients i.e., what the clinician does to modify the target, and the mechanism(s) of action (MoA) i.e., the causal chain through which the treatment is known or hypothesised to work (i.e. how the ingredients affect the target) 3. Proponents of the RTSS hypothesised that by facilitating clinicians to explicate their treatment theory, their treatment reasoning would develop 4. We explored this hypothesis in a first-phase pilot study which assessed whether a 6-week multi-modal RTSS teaching programme was feasible and had any effect on a small group of clinicians' clinical reasoning 5. We observed an improvement in self-reported measures of clinical reasoning despite the targeted behaviour (clinical uptake of the RTSS) remaining low. Critically, nested qualitative data revealed the difficulty clinicians experienced in transitioning to documenting the RTSS, citing the need for documenting training and more integrative electronic medical record (EMR) systems. Since the publication of this work, a quality improvement project within Guy's \& St Thomas' NHS foundation trust has seen the design and implementation of an RTSS EMR integration which physiotherapists have attempted to adopt.

Clinicians concur with the concept that documentation practices can enhance clinical reasoning and quality of care 6. They also report documenting as becoming increasingly burdensome, with a need to satisfy evolving legislative, funding and medico-legal purposes 7, 8 resulting in clinicians' time spent documenting becoming similar to time spent providing clinical care 9. As well as navigating the multitude of purposes, clinicians cite a number of personal and environmental factors that contribute to their documenting practices 10. If not considered, these can lead to non-adoption. For example one study concluded that a novel documenting practice for physiotherapists was infeasible due to time requirements, differing personal and interpersonal cultures, disagreements with the EMR structure, and a lack of organisational support and motivation 11. Thus, contextual exploration of the lived experience of physiotherapists attempting to adopt an RTSS EMR integration is imperative to better understand adoption behaviours and inform development of strategies that could enhance adoption.

This is a student project as part of a Masters in Clinical Research (MRes) course. Through critically exploring the experience of clinical physiotherapists attempting to adopt RTSS documentation practices through a framework analysis method, valuable insight will be provided on what and how determinants modulate RTSS documentation adoption, and inform implementation interventions that seek to utilise the RTSS in physiotherapy, and rehabilitation practice.

• The aim of this study is to explore attitudes and perceptions regarding the implementation of the RTSS into documentation practises of physiotherapists working in a hospital setting
• The primary objectives of this study are:
• To explore perceived facilitators to adoption of the RTSS into physiotherapists documentation practice
• To explore perceived barriers to adoption of the RTSS into physiotherapists documentation practices
• To understand how facilitators and barriers exert their influence on physiotherapists behaviours of adopting the RTSS into their documentation practices
• To identify implementation interventions that may support the behaviour of adopting the RTSS into documentation practices