4. Discussion
stroke, milder stroke
STROKE, LITTLE
Little evidence exists regarding what therapist attributes might impact fidelity and patient outcomes in complex rehabilitation interventions outside of the psychotherapy literature. This study found that only greater amounts of mentoring received per month during the stroke survivor case selected for fidelity assessment was associated with higher rates of fidelity to ESSVR delivery, and that more experience of stroke rehabilitation and higher fidelity rates were associated a greater likelihood of stroke survivor return-to-work at 12 months post-randomisation.Despite the importance of assessing fidelity in clinical trials, it is a construct often overlooked in occupational therapy interventions. The OTs in the present study were able to deliver ESSVR with 78.8% fidelity on average, which is relatively high compared with other studies with similar evaluations [Engagement with mentoring is predictive of fidelity in interventions delivered by OTs in other studies [Higher rates of fidelity have long been associated with more positive patient treatment outcomes [In our study, initial competence to deliver ESSVR was hypothesized to be a factor with the potential to influence fidelity outcomes because it has previously been demonstrated as a predictive factor of implementation fidelity in other studies [This study’s limitations should be seen in light of the exploratory nature of the study, coupled with the scarcity of other such occupational therapy and VR research attempting to explore the relationships between therapist attributes, fidelity, and treatment outcomes outside of psychotherapy. This is an important consideration because whilst psychotherapy is also a complex intervention, it is different from VR and is typically delivered by a non-occupational therapy workforce. Therefore, we cannot assume that the research findings from the field of psychotherapy necessarily translate/transfer to VR- and OT-delivered interventions.This study included large numbers of potential predictor variables and limited numbers of OTs and stroke survivors. Because of the small sample size, we were unable to explore in depth the interactions between the predictor variables themselves. The small sample of OTs in this study mostly included women (which is representative of the national picture of the profession, with 91% of OTs being women) [To assess fidelity in this study, OTs were asked for a specified stroke survivor’s intervention records to which a fidelity checklist [This study did not explore the impact of stroke survivor attributes on return-to-work outcome. There is a plethora of systematic reviews examining predictors of return-to-work after stroke which have identified attributes related to high likelihood of returning to work after a stroke, such as milder stroke severity [We suggest that providing support from expert mentors to OTs is a key implementation strategy for ensuring the faithful delivery of ESSVR and similar interventions. Future research should seek to further explore the mechanisms of action within mentoring to understand what underlying mechanisms of the mentoring might be facilitating delivery with fidelity (e.g., peer support, discussion of cases, etc.). Future studies should seek to include higher numbers of therapists and stroke survivors to achieve the statistical power needed to explore the relationships between attributes, fidelity, and patient outcomes more effectively [