Evaluating an online stroke training programme for Saudi Arabian physiotherapists for improving their knowledge and confidence in long-term stroke care: a pilot mixed-methods study

Abstract

Background

Stroke is currently the second leading cause of death in Saudi Arabia (SA), with an annual incidence rate of 29 per 100,000 people. There is a huge demand for rehabilitation services for people who have had a stroke living in the community; however, the services in SA do not meet this need due to a lack of community rehabilitation services. Additionally, rehabilitation staff have reported a lack of knowledge and skills to deliver rehabilitation services for people post-stroke in the community. A first step towards developing these services is to train professionals working in this area to deliver community-based rehabilitation for patients with stroke. This is the first study to evaluate an online stroke training programme (STP) for physiotherapists in SA to enhance stroke care and enable them to deliver long-term care following the discharge of stroke patients.

Methods

A sequential mixed methods design was adopted with three measurements undertaken pre-training, post-training questionnaires and one-month follow-up interviews. Participants were eligible if they were physiotherapists of any gender who were currently providing therapy to stroke patients and working in SA. The STP consisted of four modules and was delivered via an online platform. Questionnaires developed for this study were key outcome measures used to measure the change in the participants’ knowledge, confidence and attitude. Chi-Square test and Wilcoxon test were used to compare pre- and post-training results.

Results

Twenty-six physiotherapists completed the STP. The results demonstrated a statistically significant increase (P < 0.05) in the participants’ knowledge and confidence in providing long-term care for patients with stroke. Additionally, the STP had a positive impact on the participants’ attitudes. Qualitative interviews post-training suggested that participants’ experiences of STP were positive. However, the training had limitations such as the lack of practical content and a short duration.

Conclusion

The STP was seen to be acceptable and found to improve participants’ knowledge and confidence in delivering long-term care for patients with stroke in this study. Future research should focus on evaluating impact of training in improvements in service delivery by physiotherapists.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-06837-0.

Introduction

Stroke is the second leading cause of death in Saudi Arabia (SA), with an annual incidence rate of 29 per 100,000 people. It is projected that the mortality rate from strokes in the region will nearly double by 2030 [1]. Strokes often lead to numerous physical, mental, social, and economic limitations for the patient following a stroke. These consequences significantly affect the ability of patients and caregivers to carry out daily activities and cope with ongoing care needs [2]. Physical rehabilitation effectively promotes recovery of function and mobility after stroke [3]. In the context of SA, rehabilitation of long-term conditions such as stroke have limited resources including limitations in the knowledge and skills of physiotherapists to deliver rehabilitation in the community.

Physiotherapists as key rehabilitation professionals must undergo proper training to acquire the information and skills necessary to effectively deliver interventions [4]. They are also required to regularly update their skills and knowledge to meet the demands of their profession and stay updated with changes in practice [5]. In SA, the undergraduate physiotherapy programme consists of four years of full-time studies, followed by one year of internship [6]. Despite the 5 years of training, evidence-based practice has not been extensively adopted by physiotherapists in SA [7]. This creates inconsistency in care delivered to patients with patients seldom receiving high-quality of care, depending on the therapist’s expertise and education.

Additionally, stroke incidence and prevalence are expected to rise significantly in the coming years, this has been identified as around 67% in 10 years in SA [8]. Previous research has identified that people with stroke in SA report high levels of unmet needs (informational, indicating burden on the patient, carer and the society [9–11]. This growing burden is further compounded by the increasing life expectancy in the country, which has led to an increase in the elderly population from approximately 1 million to nearly 2.5 million people in 2020 [12]. Thus, SA commission for health specialties called for increasing the number of stroke specialists to meet the projected demand for stroke care in SA including physiotherapists [13, 14]. They stated that currently, there are fewer than 60 stroke specialists in the country, whereas there is a need for at least 120 to 160 stroke specialists in the next 10 years [13]. Further, research has reported a considerable lack of physiotherapy programmes focused on stroke care in SA [15]. In addition to this, other research [16] has identified a lack of opportunities for continuing education in SA. This highlights the significant gap in training and professional development for physiotherapists in SA [16]. This is especially important because of the complexity of managing neurological patients and the advances in understanding how it is possible to meet the needs of the population [17].

In order to bridge the gap, continuing professional education could be a critical component of delivering high-quality services to patients with stroke and other conditions. There have been calls to establish post-professional programmes to provide patients with strokes with high-quality services [18]. The review indicated that rehabilitation professionals in SA including physical and occupational therapists often lack adequate training in stroke rehabilitation. Additionally, they recommended enhancing stroke rehabilitation education in the curricula for all healthcare professionals to cover stroke prevention, management, and rehabilitation [18]. However, the allocation of resources and funds for training is limited compared to other countries such as the UK [19]. This further limits the training and development of physiotherapists’ skills in delivering effective care to patients.

The lack of training provided to physiotherapists generally in SA has been highlighted in other studies. One study in SA investigated physiotherapists’ behaviour, attitudes, awareness, and knowledge of implementing evidence-based practice [20]. The study demonstrated insufficient implementation due to lack of training as most physiotherapists had poor basic knowledge of evidence-based practice with 89.9% unaware of its definition and 80.6% not understanding its aim. Additionally, 32.9% were unfamiliar with basic terms, and 70.2% had no formal training [20]. Another study found that the limited availability of educational workshops in SA may have contributed to the difficulty in understanding and using outcome measures [21]. Additionally, [22] indicated that limitation in education (45%) was the most significant barrier to implementing evidence-based practice in SA, while 42.7% identified insufficient resources and funding and 38.2% identified a lack of skills and research knowledge. A recent study indicated that 51% of physiotherapists lacked knowledge of the essential principles of evidence-based practice, 60.4% did not participate in any training sessions on research and 74.9% expressed a lack of confidence in their ability to analyse literature [23]. Studies on stroke care training for physiotherapists in SA are limited, yet available literature suggests that training should focus on the development of knowledge and skills for physiotherapists to ensure they meet the required standards and deliver high-quality care to patients [18]. Some studies in the Asian context have evaluated the training for physiotherapists to assess the improvement in their knowledge, skills, attitudes and behaviour towards evidence-based practice. Their results indicated a significant increase in the physiotherapist’s knowledge and skills pre- and post-training [24, 25].

A modern approach involves utilising the internet to deliver training, either entirely or partially, through training-specific websites or platforms [26]. E-learning is an easily expandable and accessible training method. Studies have indicated that digital training is equally or more effective compared to traditional methods, especially in knowledge and skills acquisition [27, 28]. Digitalisation is rapidly increasing in the healthcare system in SA [29]. Evidence from other countries supports the use of online platforms to deliver training for physiotherapists in task-specific training in physiotherapy after stroke [30], interpersonal psychotherapy [31], cognitive behaviour therapy [32], and self-management interventions [33].

Online training has been evaluated for its effectiveness in SA for delivering training for teachers [34] and dental practitioners [35]. The findings of both studies indicated an improvement in the participants’ skills and knowledge, leading to the conclusion that online training is effective. Further, one training programme provided comprehensive education to nurses in person about stroke care in SA [36] and found that the training was an effective way of learning for nurses. To the best of the author’s knowledge, no study has been conducted to date to evaluate an online training programme for physiotherapists to enhance stroke care in SA. Hence, this study aimed to address this gap by evaluating the effectiveness of such training.

Aim and objectives

This study aimed to evaluate an online training programme that was developed to build the knowledge and skills of physiotherapists to deliver long-term care following the discharge of stroke patients.

Objectives

1. To evaluate the effectiveness of the STP in improving physiotherapists’ knowledge, attitudes, and confidence.

2. To assess the perceptions of usefulness and acceptability of the STP.

3. To understand and relate reasons for improvement or lack of it in the knowledge, skills and confidence aspects using qualitative data through the opinions and perceptions of the physiotherapists.

Methodology

Design

This study was a pilot sequential explanatory mixed methods design with two phases. Phase one involved quantitative data from a before-and-after (pre-test and post-test) design, which is a widely used approach to assess online training programmes [37–39]. This phase aimed to measure the change in knowledge, confidence and attitudes between pre-training and post-training. The second phase comprised qualitative interviews, which aimed to gain a deeper understanding of physiotherapists’ perceptions and acceptability of the STP. The interviews were conducted one month after completion of the training. Ethical approval was sought from the Ministry of Health ethics committee, (Jazan Health Ethics Committee, Ref: 2416) on 31/01/2024 and the University of Birmingham on 29/02/2024 (Science, Technology, Engineering and Mathematics (STEM)) ethics committee, Ref: ERN_20-1836).

Participants

The participants recruited for this study were physiotherapists of any gender who were currently providing therapy to stroke patients and working in SA. Participants had to have access to the requisite online technology, such as Zoom or Teams, which enabled them to participate remotely. Participants were excluded if they were working outside the city for which ethical approval was sought.

The STP

A training programme called Stroke Training programme (STP) was developed based on the need for improved knowledge for physiotherapists on delivering education/information, discharge care and planning, improving intensity, continuity of care through long-term approaches such as self-management and telerehabilitation. The STP for physiotherapists consisted of four modules illustrated in detail in Table 1. The Template for Intervention Description and Replication (TIDieR) checklist can be found in supplementary file 1.

Table 1.

The STP modules

Themes covered in the STP	Topics included under each theme
Welcome	This section welcomed participants to the training and emphasised the importance of the training programme.
Module 1: Introduction to stroke care	This module provided an introduction to stroke pathology and stroke rehabilitation in hospitals and the community.
Module 2: Carer-education and care-transition	This module provided a demonstration of patient and carer education, discharge planning and home needs assessments.
Module 3: Outpatient care for patients with stroke	This module provided a demonstration of stroke assessment procedures, stroke outcome measures, and the process of goal setting in the community settings.
Module 4: Self-management and telerehabilitation	This module provided evidence-based practice regarding the provision of supported patient self-management approaches and the effective employment of telerehabilitation.

The outcome measure instrument

Researchers frequently adopt one of three primary methodologies when using a questionnaire-based approach: the utilisation of pre-existing questions, the modification and adaptation of existing questionnaires, or the development of a new questionnaire [40]. This study adopted the third approach, as to the best of the author’s knowledge, no available instrument currently covers all aspects of the STP. The instrument measured three main elements: knowledge, attitude, and confidence. The knowledge element in the questionnaire consisted of 15 multiple-choice items that reflected the content of the STP. The second element was attitude, which consisted of three multiple-choice questions and four items in the form of Likert-type scales designed to measure the change in physiotherapists’ attitudes. The final aspect was confidence, and consisted of five rating questions that covered the module aspects. Identical questions were repeated on both occasions (pre- and post-training). An additional section was added to the post-training questionnaire which assessed satisfaction. Fifteen items with Likert-type and open-ended response options were developed to assess the satisfaction and experience of an online programme. The questions in this section were adapted from a similar study [39]. The full copy of the questionnaires can be found in supplementary file 2.

The questions were translated into Arabic. The translated version was sent to a linguistic colleague for feedback on the Arabic version. The second version was sent to a physiotherapist (not eligible for the study, as he was not from the city for which we had ethical approval). Minor changes were made, including (1) adding diploma choice to the demographic section, (2) rephrasing one question in the satisfaction section, and (3) rephrasing two items in the knowledge section for clarity. The minor changes can be found in Supplementary file 3.

Procedure

The heads of the departments of the participating hospitals were informed of the study requirements by the principal investigator (PI). The PI then contacted them to obtain a list of physiotherapists, who were subsequently contacted and provided with an information sheet if they were interested and eligible. Potential participants had two days to consider participating, during which they had the opportunity to ask questions to the researcher. If they decided to participate, the PI obtained informed consent electronically. Consent forms were signed and sent by email or WhatsApp by participants themselves.

Data collection

The eligible therapists were contacted with the information on the procedure of the whole study. Firstly, participants were required to complete a pre-training questionnaire. The questionnaire was set up in Microsoft Forms and sent to the participants before the training. Quantitative data pre-training was collected from April 5 to June 12, 2024. Demographic information, including age, gender, education level, and years of clinical expertise, were collected. Once the pre-questionnaire had been completed, the link for the STP was sent. Participants were asked to inform the PI when they had completed the STP; otherwise, researchers checked if the training was completed. After training completion (within a week), participants received another questionnaire (post-training questionnaire). The post-training interview guide can be found in Supplementary file 4.

One month after the STP was completed, participants received an invitation via email to participate in a follow-up interview over the phone or on Zoom. The interview explored therapists’ experiences of the STP, what aspect of the learning sessions was considered the most valuable, and what modifications needed to be made to the STP. To facilitate the learning process, supplementary resources and additional materials were provided to the participants. These resources included tutorial access, guides, and links to online educational materials and videos. If participants did not complete the post-training questionnaire, their data were excluded from the study. Participants were given one month to complete the training.

Sample size

Quantitative phase: a convenience sample of 30 participants were used for this pilot study, which is supported by the recommendation of qualitative studies [41]. Thus, a sample size of 30 participants may provide valuable insights into the efficacy of the investigated intervention.

Qualitative phase: a convenience sampling was used to select participants for interviews from those who had completed the STP. In qualitative studies, no specific method is used in sample size calculation, so data saturation was used as a sample size guide [42]. However, it was argued that the concept of data saturation is not appropriate for use in reflexive thematic analysis [43]. Thus, the exact size was informed by information power [44]. Five key elements were identified to reach information power including study aim, sample specificity, use of established theory, quality of dialogue, and analysis strategy [44]. The aim of this study was clear and focused, targeting physiotherapists who attended the training and worked directly with stroke patients. The demographic characteristics and experiences of physiotherapy were considered similar, meaning with lower numbers of participants a common understanding of the experiences of training could be established. A well-structured interview guide facilitated detailed responses, using non-direct prompts such as tell me more and can you elaborate to gather rich data. Further, a previous study on physiotherapists training identified that 25 participants were required [45].

Data analysis

For phase one, frequency tables were used to summarise demographic variables. The Chi-Square test was used to compare categorical variables to determine whether there was a relationship between variables [46]. Wilcoxon’s test was used to compare data that were not distributed normally [47]. The significance level for all comparisons was set at p < 0.05. Additionally, to assess the change in the variables according to demographics, the Mann–Whitney test was used to assess the change against age and gender, while the Kruskal–Wallis test was used to measure the change according to participants’ education levels and their years of expertise in physiotherapy and stroke care. The analysis was limited to individuals who filled out both the pre-and post-training questionnaires.

For the data from the qualitative phase, reflexive thematic analysis was used [48]. The PI (BT) performed the coding and categorising of the data. Line-by-line coding was conducted to generate initial codes. The PI identified patterns and clustered similar codes together to generate themes [48]. The final step of the analysis was carried out to integrate the data from the two phases.

Quality of the study

Several measures were employed to enhance the quality of the questionnaire. Firstly, the validity of the questions was improved through assessments and reviews by senior researchers. Secondly, the accuracy of the translated version was enhanced by having a linguistic expert review the questions. The questions were piloted on one physiotherapist holding a master’s degree to identify and minimise any issues. Formatting bias was reduced by designing the questionnaires to follow the recommendations from previous studies [48]. Items were kept simple, short, and written in two languages to ensure clarity of the questions. The content was relevant to the STP, appropriate in length, and efforts were made to avoid leading questions. Additionally, selection and sampling bias were reduced by contacting every individual on the lists provided by the department heads at the two hospitals. Participants were blinded to the study’s aims to prevent response bias.

Findings

Detailed findings are presented in flow diagrams and tables in this section and only the significant findings have been presented in the narrative.

Participant flow

A total of 72 physiotherapists were contacted to participate in the study. Of them, 13 did not meet the inclusion criteria, 11 declined to participate, mainly because of time constraints, and 19 either did not reply or initially agreed to participate but subsequently failed to complete the pre-training questionnaire. Three participants completed the pre-training questionnaire but did not complete the training. A summary of the flow of participants in this study can be seen in Fig. 1, a total of 26 participants completed the programme and outcome measure assessment and 16 participants were interviewed one month post-training.

Fig. 1.

CONSORT flow diagram of participants in the study

Participant characteristics

Participants were most often female (17 female, 9 male) and the majority of participants (80.8%) were 30–39 years old, while the remaining 19.2% were 18–29 years old. In terms of participants’ education, 61.5% of the participants had bachelors’ degrees, 30.8% of the participants had masters’ degrees, and 7.7% were in their internship period. Most participants (61.5%) had 6 to 10 years’ experience as physiotherapists. The participants’ characteristics are presented in Table 2.

Table 2.

Summary of demographic characteristics

Variable	Characteristics	n (%)
Gender	Female	17 (65.4)
	Male	9 (34.6)
Age	18–29 Years	5 (19.2)
	30–39 Years	21 (80.8)
Education	Bachelor	16 (61.5)
	Internship	2 (7.7)
	Master	8 (30.8)
Total years of experience as a physiotherapist	Less than 1 Year	2 (7.7)
	1–5 Years	4 (15.4)
	6–10 Years	16 (61.5)
	11–20 Years	4 (15.4)
Total years of experience in stroke care	Less than 1 Year	5 (19.2)
	1–5 Years	6 (23.1)
	6–10 Years	14 (53.8)
	more than 10 Years	1 (3.8)

Quantitative results

Knowledge

Knowledge of education and planning

Education (Q1): Post-training, the improvement in knowledge in educating patients and carers was not statistically significant (p = 0.257). However, there was still an increase in correct responses to 23 (88.5%).

Planning (Q2-3): Post-training, while there was an improvement in knowledge on post discharge planning 10 (38.5%) to 15 (57.7%), this change was not statistically significant (p = 0.197). In contrast, a statistically significant improvement was identified in knowledge of the intensity of rehabilitation, with correct responses increased to 20 (76.9%) (p = 0.008).

Knowledge of stroke assessment

Stroke assessment (Q4-7): the results indicated significant improvements across all assessment items post-training. Stroke severity assessment knowledge increased significantly to 24 participants (92.3%) (p = 0.001). Further, there was a notable increase with the number of participants correctly identifying regular assessment intervals which increased to 15 (57.7%) (p = 0.001).

Following the training, knowledge of the Fugl-Meyer assessment scale significantly improved to 25 correct responses (96.2%) (p = 0.008), while recognition of the Barthel Index increased to 26 (100%) (p = 0.014).

Knowledge of goal-setting, self-management and telerehabilitation

Goal-setting (Q8-10): Knowledge of goal-setting and action-planning improved significantly post-training, with 25 (96.7%) participants showing correct knowledge (p = 0.001). Similarly, understanding of what constitutes a good action plan increased from 10 (38.5%) to 25 (96.2%) (p = 0.001). Additionally, familiarity with the Goal Attainment Scale (GAS) rose from 11 (42.3%) to 25 (96.2%) (p = 0.001).

Self-management (Q11-14): knowledge improved significantly in all self-management items.

Post-training, 23 participants (88.5%) demonstrated awareness of common self-management strategies (p = 0.021). Further, familiarity with Graded Repetitive Arm Supplementary Programme (GRASP) rose significantly from 8 participants (30.8%) to 20 participants (76.9%) (p = 0.001). Understanding of different GRASP versions also improved, increasing from 10 participants (38.5%) to 22 participants (84.6%) (p = 0.003). Post-training knowledge of Patient Activation Measure (PAM) reached 100%, with all 26 participants demonstrating awareness (p = 0.003).

Telerehabilitation (Q15): pre-training, most participants (21; 80.8%) understood safety measures during telerehabilitation. Post-training, comprehension of safety protocols significantly improved, with correct responses rising to 26 participants (100%) (p = 0.025). Table 3 demonstrates the findings of knowledge items in detail, and complete questionnaire item scores can be found in Table 5 in the Supplementary file 5.

Table 3.

Differences in items of knowledge between pre-and post-training

Category	Items	Pre (n/%)		Post (n/%)		Wilcoxon
		Correct	Incorrect	Correct	Incorrect	Test Value	P-value
Education	Q1	20 (76.9)	6 (23.1)	23 (88.5)	3 (11.5)	-1.13	0.257
Planning	Q2	10 (38.5)	16 (61.5)	15 (57.7)	11 (42.3)	-1.29	0.197
	Q3	10 (38.5)	16 (61.5)	20 (76.9)	6 (23.1)	-2.67	0.008**
Assessment	Q4	9 (34.6)	17 (65.4)	24 (92.3)	2 (7.7)	-3.87	0.001***
	Q5	1 (3.8)	25 (96.2)	15 (57.7)	11 (42.3)	-3.74	0.001***
	Q6	18 (69.2)	8 (30.8)	25 (96.2)	1 (3.8)	-2.65	0.008**
	Q7	20 (76.9)	6 (23.1)	26 (100)	0 (0)	-2.45	0.014*
Goal setting	Q8	11 (42.3)	15 (57.7)	25 (96.2)	1 (3.8)	-3.74	0.001***
	Q9	10 (38.5)	16 (61.5)	25 (96.2)	1 (3.8)	-3.87	0.001***
	Q10	11 (42.3)	15 (57.7)	25 (96.2)	1 (3.8)	-3.74	0.001***
Self-management and Telerehabilitation	Q11	15 (57.7)	11 (42.3)	23 (88.5)	3 (11.5)	-2.31	0.021*
	Q12	8 (30.8)	18 (69.2)	20 (76.9)	6 (23.1)	-3.21	0.001***
	Q13	10 (38.5)	16 (61.5)	22 (84.6)	4 (15.4)	-3.00	0.003**
	Q14	17 (65.4)	9 (34.6)	26 (100)	0 (0)	-3.00	0.003**
	Q15	21 (80.8)	5 (19.2)	26 (100)	0 (0)	-2.24	0.025*

^*p < 0.05

^**p < 0.01

^***p < 0.001

Knowledge and participant characteristics

The trends in knowledge gain levels in relation to participants’ characteristics were explored. Female participants’ knowledge gain level was significantly higher than that of male participants (p = 0.045). Participants who were in the younger age group demonstrated lower knowledge gain: the mean knowledge level of 30–39-year-olds was significantly higher than the mean for 18–29-year-olds (p = 0.028). Further, participants’ number of clinical years as a physiotherapist had an influence on the level of knowledge gain, with participants who had been practising for 6–10 years demonstrating a statistically significant knowledge gain than other groups (p = 0.008). Table 6 in Supplementary file 5 shows the change in knowledge gain levels according to demographic variables.

Attitude

Changes in attitudes about assessment, goal-setting, and goal achievement methods

Assessment methods prior to discharge: pre-training, 11 participants (42.3%) utilised the Include, Discuss, Educate, Assess, and Listen (IDEAL) discharge planning form to prepare patients for discharge. While 6 participants (23.1%) asked patients directly for goals, 4 participants (15.4%) developed their own assessment methods. Post-training, the percentage of participants using no particular method to assess patients’ the needs decreased from 5 (19.2%) to 1 (3.8%).

Goal-setting: Post-training, the number of participants with no specific goal-setting methods dropped to 2 (7.7%) from 10 (38.5%). In contrast, the use of the GAS increased slightly, with 11 participants (42.3%) indicated they utilised this scale. Additionally, 9 participants (34.6) adopted the G-AP approach.

Monitoring goal achievement: Post-training, the reliance on personal experience and clinical judgment decreased to 5 participants (19.2%). Furthermore, discussions regarding goals with the multidisciplinary team rose to 4 participants (15.4%). Table 4 illustrates the differences between pre-and post-training findings in assessment and goal-setting practice.

Table 4.

Differences between pre-and post-training in assessment, goal-setting and monitoring goals

Variable	Methods	Pre	Post
		n (%)	n (%)
Assessment methods of patients’ needs prior to discharge to community	No Particular Method	5 (19.2)	1 (3.8)
	Ask Patients	6 (23.1)	5 (19.2)
	IDEAL discharge planning form	11 (42.3)	10 (38.5)
	Team has developed its own method	4 (15.4)	6 (23.1)
	other	0 (0.0)	4 (15.4)
Goal setting	No Particular Method	10 (38.5)	2 (7.7)
	Goal attainment scale	10 (38.5)	11 (42.3)
	G-AP	0 (0.0)	9 (34.6)
	Team has developed its own methods	6 (23.1)	4 (15.4)
	Others	0 (0.0)	0 (0.0)
Monitoring of goals	Using outcome measures	11 (42.3)	12 (46.2)
	In discussion with the MDT	1 (3.8)	4 (15.4)
	I use my experience and clinical judgment (individually decided by staff)	11 (42.3)	5 (19.2)
	Decided by patient	3 (11.5)	5 (19.2)

Attitudes towards education, goal-setting, outcome measures and telerehabilitation

Following STP training participants showed improvement in attitudes, however, these changes in attitude scores for education, outcome measures, and goal-setting were not statistically significant. Nevertheless, a significant improvement was observed in attitudes toward telerehabilitation.

Pre-training, education for patients and carers was rated ‘extremely important’ by 20 participants (76.9%), increased to 23 (88.5%) post-training (p = 0.768). Similarly, the rating for using outcome measures as ‘extremely important’ rose from 16 participants (61.5%) to 21 (80.8%) after training (p = 0.599). Additionally, the importance of setting goals with patients increased from 14 participants (53.8%) pre-training to 22 (84.6%) post-training (p = 0.349).

In contrast, attitudes towards telerehabilitation showed a significant change, with those considering it ‘extremely important’ increasing from 15 participants (57.7%) pre-training to 18 (69.2%) post-training (p = 0.02). Table 5 presents the differences between pre-test and post-test attitude scores towards education, goal-setting, outcome measures and telerehabilitation.

Table 5.

Differences between pre-test and post-test in attitude towards education, goal-setting, outcome measures and telerehabilitation

Variable	Rating	Pre	Post	Chi-Square
		n (%)	n (%)	Test Value	P-value
Importance of patients’ and carers’ education	Moderate	1 (3.8)	0 (0.0)	0.53	0.768
	Very Important	5 (19.2)	3 (11.5)
	Extremely Important	20 (76.9)	23 (88.5)
Importance of using outcome measures in stroke care	Moderate	1 (3.8)	1 (3.8)	2.76	0.599
	Very Important	9 (34.6)	4 (15.4)
	Extremely Important	16 (61.5)	21 (80.8)
Importance of goal setting session with patients and family	Moderate	1 (3.8)	0 (0.0)	2.11	0.349
	Very Important	11 (42.3)	4 (15.4)
	Extremely Important	14 (53.8)	22 (84.6)
Importance of tele-rehabilitation for patients with stroke	Low	3 (11.5)	0 (0.0)	15.02	0.02*
	Moderate	5 (19.2)	3 (11.5)
	Very Important	3 (11.5)	5 (19.2)
	Extremely Important	15 (57.7)	18 (69.2)

^*p < 0.05

Further, considering demographics, the greatest attitude changes were seen in those who were in their internship period, younger participants (18–29 years), and those who had fewer than 5 years of experience. Table 4 in Supplementary file 5 shows the changes in attitude in relation to demographic variables.

Confidence

Pre-training, confidence in providing patients with the necessary support prior to discharge scored the highest, as the mean confidence score was 8.58 out of 10 (SD 1.68), and demonstrated the lowest change post-training, at 9.19 (p = 0.095). Confidence in providing carers with education and support during the rehabilitation process was the second highest item pre-training, with a mean score of 8.35 (SD 1.50), which rose post-training to 9.42 (SD 0.99) (p = 0.009).

The mean confidence in using outcome measures was moderate, at 7.15 (SD 2.68). This level increased post-training to 9.46 (SD 0.86) (p = 0.0001). While participants’ confidence in goal-setting was the lowest pre-training, goal-setting showed the greatest improvement post-training, rising from 6.73 (SD 2.24) to 9.46 (SD 0.95) (p = 0.0001). Further, the mean confidence level for providing effective telerehabilitation pre-training was 6.85 (SD 2.75). This level increased significantly to 8.69 (SD 2.02) (p = 0.0001). Table 6 shows the differences in items of confidence between the pre- and post-training.

Table 6.

Differences in items of confidence between the pre-test and post-test

Items	Pre	Post	Wilcoxon
	Mean (SD)	Mean (SD)	Test Value	P-value
Item 1: Carer education “I feel confident in providing carers the education and support they need to help in the rehabilitation process”	8.38 (1.50)	9.42 (0.99)	-2.611	0.009***
Item 2: Transition “I feel confident in providing patients with stroke the necessary support prior to discharge”	8.58 (1.68)	9.19 (1.27)	-1.669	0.095
Item 3: Outcome measures “I feel confident in using outcome measures related to stroke care”	7.15 (2.68)	9.46 (0.86)	-3.558	0.0001***
Item 4: Goal setting “I feel confident in using G-AP to set goals for patients with stroke”	6.73 (2.24)	9.46 (0.95)	-3.88	0.0001***
Item 5: Telerehabilitation “I feel confident in providing effective rehabilitation virtually”	6.85 (2.75)	8.69 (2.02)	-2.939	0.003**

^**p < 0.01

^***p < 0.001

Additionally, participants holding masters’ degrees showed higher confidence than other groups, with a mean of 83.44 (SD 32.95). Table 8 in Supplementary file 5 shows the change in confidence level based on the demographic variables.

Usage and satisfaction

The mean score for the appropriateness of the online format was 9.12 (SD 1.14), reflecting a high degree of appropriateness. The majority of participants (n = 17; 65.4%) completed the STP in one sitting, while 9 (34.6%) needed multiple sessions. Among those who did not complete the programme in one sitting, 4 (44.5%) returned three times, 3 (33.3%) returned four times, and the rest returned either twice or five times. Furthermore, 21 (80.8%) of participants believed that the duration of the online training programme was about right, with a small proportion finding it too short (n = 2; 7.7%). In terms of content quality, 24 (92.3%) of the participants found the training content to be informative and clear. Furthermore, 21 (80.8%) of respondents rated the content as adequate, 23 (88.5%) as appropriate, and 22 (84.6%) as both relevant and useful. The overall satisfaction with the training was very high for a majority of participants (n = 18; 69.2%). Additionally, 25 (96.2%) of the participants felt that the training covered everything they needed, with just 1 (3.8%) indicating that something was missing. Table 7 summarises the usage and satisfaction findings.

Table 7.

Satisfaction of the STP

Question	Category		n (%)
Complete the STP in ONE sitting	No		9 (34.6)
	Yes		17 (65.4)
The number of times they returned to the programme before completion	2 times		1 (11.1)
	3 times		4 (44.5)
	4 times		3 (33.3)
	5 times		1 (11.1)
Length of the STP	Too Much Short		1 (3.8)
	Short		2 (7.7)
	About right		21 (80.8)
	Long		2 (7.7)
Satisfaction of the information contained in the STP	Very Dissatisfied		1 (3.8)
	Satisfied		7 (26.9)
	Very Satisfied		18 (69.2)
Aspects they wanted to add but not covered in the STP	No		25 (96.2)
	Yes		1 (3.8)
Appropriateness of online format	Rating		Mean (SD)
	Maximum	10	9.12 (1.143)
	Minimum	7
Accessibility of additional information	Maximum	10	9.35 (0.892)
	Minimum	7

Qualitative findings

Three themes were identified: (1) Feedback and experience, (2) Limitations in the STP, and (3) The applicability of the training. A summary of the themes is provided in Table 8.

Table 8.

Summary of the themes

Theme	Sub-themes	Definition
Feedback and experiences.	Overall experiences	This theme reflected participants’ experiences with the training programme.
	Content feedback
	Particular useful aspects
Limitation of the STP.	Lack of practical content	This theme highlighted the programmes’ limitations and included suggestions for improvement.
	Short duration of the training
	Superficial explanations of specific topics
	Online delivery
Applicability of information.	Applicable content	This theme addresses how the information from the STP can be practically applied.
	Challenges to applicability
	Maintain accessibility

Theme 1: Feedback and experience.

Participants’ experiences with the STP seems to be positive. They found the training smooth, clear and simple to understand. Participant 16 stated, “It was a programme with scientific value, presented in an easy and understandable way, supported by all the latest updates in the rehabilitation of stroke patients”. Participant 24 added, “I liked the explanation, ease of access to information, presentation, and the useful and new information”. Participant 12 stated, “I liked the explanation was in Arabic, as you know not all physiotherapists have good English language”.

Participants indicated the usefulness of the content in providing them with relevant, detailed, and up-to-date information. Participant 1 said, “The ease and clarity of the information, the programme had a lot of useful information, and honestly, much of it was new to me”.

Additionally, participants suggested that the programme was useful for new physiotherapists, since it provided fundamental knowledge required for their professional development, as illustrated in Participant 2’s comment: “Most of the provided information is recent and detailed enough to help any new physical therapist understand what a stroke is and how to treat it in detail”.

The assessment section, outcome measures, and goal-setting were reported to be the most useful elements of the stroke training programme. Participants highlighted that the programme offered them a recap of information such as the assessment procedures for stroke. Participant 13 stated, “The assessment section provided a valuable recap of important information, which we need”. Additionally, the programme provided them with new information such as the G-AP approach for setting goals, self-management strategies, and GRASP. Participant 7 stated, “The sections on goal-setting and outcome measures were excellent and useful. There were many new parts, like the patient activation measure, which was also new to me”. Participant 1 added, “The self-management part was somewhat new and had excellent information”. The outcome measures information was among the most frequently identified as useful information. Participant 13 said, “Some of the outcome measures mentioned in the training were very useful”.

Theme 2: Limitations

The participants noted the following areas for improvement in the STP: lack of practical content, short duration, superficial explanations of specific topics, and online delivery. One key point was the lack of practical components and clinical scenarios, which are essential for implementing theoretical information. Additionally, the programme was short, as stated by Participant 7: “The programme was short and lacked practical aspects”. Participant 12 stated, “You could expand the information further so that it can be divided into two, three, or more lectures, in order to benefit us to a greater extent”. Participant 4 added, “The information may be more useful theoretically than practically”.

Further, there was a need for in-depth explanations on topics such as outcome measures and telerehabilitation, which were key knowledge gaps identified previously. Participant 13 said, “If the outcome measures were deeper, not just a quick overview, it would be better, because that’s the part we need the most”. Additionally, a few participants indicated that they preferred in-person workshops over online training in order to facilitate interactive learning and practical application. Participant 4 said, “It could be adding practical parts, maybe a real workshop rather than online”.

Theme 3: Applicability and adaptation

Few participants noted that the applicability of training elements in practice was simple, and some participants had successfully utilised information acquired from the training such as the outcome measures. Participant 12 stated, “It’s easy to implement the information, and with continuous practice, it could become easier”. Participant 1 added, “I used the Fugl-Meyer, and I used some outcome measures like the depression scale”. However, many participants indicated that effective application of this information requires that physiotherapists need to have adequate time, good management, and collaboration across all departments. Participant 4 stated, “Implementing these things requires time and good management, and we are under significant time pressure”. He added, “Having education sessions and goal-setting for every patient every two weeks is difficult because they require a lot of time”. Several participants asked for the supplementary file that contained all checklists and references in the training. Additionally, a few participants suggested that the programme should remain available to them beyond the research period and should be widely disseminated to those who want to improve their knowledge of stroke care. Participant 16 said, “I hope the programme remains available for those who wish to develop themselves in the future”.

Integration of findings

Integration of the findings revealed the following

Following training, knowledge about the education of patients and carers improved but did not show a statistically significant increase. Further, only one participant mentioned the patient education section as a useful part of the programme. Similarly, transition and planning of post-discharge services, such as the use of the IDEAL planning form for care post-discharge was not taken up by the participants, none of the participants mentioned planning post-discharge in the qualitative interviews.

Secondly, in terms of assessment, goal-setting, and self-management and telerehabilitation quantitative data showed statistically significant findings in all of the above domains. The positive feedback from participants in the interviews supported the quantitative findings. Additionally, most of the participants mentioned that much of the information provided in these sections was new to them. Table 9 provides quotes from participants to validate the quantitative findings.

Table 9.

Integration of quantitative and qualitative findings

Description of findings	Quantitative data	Qualitative data
Increase in knowledge (Assessment)	Knowledge of stroke assessment improved significantly in all items.	Participant 13 stated, “The assessment section provided a valuable recap of important information, which we need”. Participant 13 said, “Some of the outcome measures mentioned in the training were very useful”.
Increase in knowledge (Goal-setting)	Knowledge of the goal-setting approaches improved significantly in all items.	Participant 7 stated, “The sections on goal-setting and outcome measures were excellent and useful. There were many new parts, like the patient activation measure”.
Increase in knowledge (Self-management and telerehabilitation)	Knowledge of self-management and telerehabilitation improved significantly in all items.	Participant 1 stated, “The self-management part was somewhat new and had excellent information”.
Increase in knowledge (females demonstrated higher level)	Female participants’ knowledge level was significantly increased than that of male participants (p = 0.045), and females showed a higher participation rate in the training (17 female and 9 male participants).	Male participants expressed barriers to implementation: Participant 4 stated, “but as I said, not all of it is applicable, especially in SA. Applying some of these things is difficult, like goal-setting … it is not that easy; all patients have one goal, which is to return to normal”. Participant 4 stated: “Implementing these things requires time and good management, and we are under significant time pressure”. He added, “Having education sessions and goal-setting for every patient every two weeks is difficult because they require a lot of time”.
Increase in knowledge (females demonstrated a higher level)	Female participants who had been practising for 6 to 10 years demonstrated significantly greater knowledge acquisition than other groups (p = 0.008).	Participant 8, a female who had been practising physiotherapy for 6–10 years, stated, “The outcome measures form was excellent, the online video resources were also new and helpful, the assessment forms were straightforward to use’’. Participant 7 stated, “The programme had very advanced information, especially knowing a set of outcome measures; I will use it in monitoring neuro cases in the future”. Participant 8 said, “The programme was excellent and provided valuable information about stroke rehabilitation. The programme can have a good impact on improving specialists” skills and knowledge, which positively affects patient care”.
Change in attitude	Ratings for the importance of education, using outcome measures, setting goals and telerehabilitation all increased post-training.	Participant 1 stated, “I used the Fugl-Meyer, and I used some outcome measures like the depression scale”. Participant 11 stated, “I used the outcome measures and the assessment tools”.
Change in confidence	There was a significant increase in all items except for providing necessary support to stroke patients prior to discharge.	Participant 2 said, “Most of the provided information is recent and detailed enough to help any new physical therapist understand what a stroke is and how to treat it in detail”. Participant 24, who was in his internship, said, “It was helpful, and I learned new things that help me assist patients with strokes”.

Further, the increase in knowledge level was influenced by demographics, as female participants’ knowledge level was significantly increased than that of male participants. Qualitative data demonstrated that males voiced many more barriers to implementation of the STP than females. Additionally, males were reluctant to participate in the training, as most participants in the study were females (17). Further, the female participants who had been practising for 6 to 10 years demonstrated significant knowledge acquisition; they also indicated positive feedback on the given information, such as the outcome measures and assessment forms, which they found highly valuable for improving their skills and patient care. Females showed higher participation levels and increased perception of knowledge following STP training.

The findings regarding attitude suggested a positive change. The positive change in attitude was supported by the fact that participants had utilised some of the knowledge gained from the programme, such as the use of outcome measures, as demonstrated in Table 9. Similarly, there was a statistically significant change in the confidence level post-training. The qualitative findings highlighted that many participants felt that the training offered them comprehensive and up-to-date information, which reflects the positive impact of the training on their confidence in providing stroke care.

Additionally, the appropriateness of the online format was scored high, with a mean score of 9.12 out of 10 (SD 1.14). However, a few participants suggested that in-person workshops would be more beneficial. In terms of overall satisfaction, 26.9% of respondents were satisfied, while 69.2% were extremely satisfied with the programme. Additionally, 80% of participants believed that the length of the training was about right in the post-training questionnaire. However, some participants’ feedback contradicted this, as the shortness of the programme was one of the common comments by participants as a limitation of the training. Table 9 summarises the integration of the findings.

Discussion

This study aimed to assess an online training programme designed to improve physiotherapists’ provision of ongoing care after the discharge of stroke patients. The STP seemed to be effective overall as significant changes post-training in physiotherapists’ knowledge and confidence were found. The results for the attitude towards rating the importance of providing education, using stroke outcome measures and setting goals were not significant, but showed positive impact. Participants provided positive feedback regarding the training, with some limitations in implementing the information.

Physiotherapists’ knowledge was assessed in previous studies in SA, but only in relation to evidence-based practice [20] and telerehabilitation [49]. The studies found insufficient knowledge among physiotherapists. Given the limited training for physiotherapists in SA [15, 21, 50], it was essential to address the gap in their knowledge to enable them to deliver long-term care for patients with stroke. The quantitative findings between the pre-and post-training questionnaires demonstrated a statistically significant increase in knowledge about stroke assessment, goal-setting, self-management and telerehabilitation, but no significant difference in patient education or discharge planning. The study results are consistent with previous studies that provided training to therapists via online platforms and demonstrated an increase in knowledge [30, 31, 33]. Although the findings of these studies are not directly comparable due to differences in the assessment methods and actual contents, they demonstrated an increase in the therapists’ knowledge and confidence by delivering training through online methods.

The majority of the physiotherapists who participated in this study had no previous formal training in stroke rehabilitation. In many hospitals in SA, physiotherapists do not have specific specialisations and work across different patient populations, including musculoskeletal, paediatric, and neurological conditions. Additionally, a previous study revealed that the majority of physiotherapists identified a significant gap in training related to stroke rehabilitation and many of them were not involved in any training for stroke rehabilitation [11]. Therefore, it was expected that their knowledge test scores would improve after completing the training, particularly in areas such as self-management and goal-setting, where the information presented might have been novel to them. This was supported by the qualitative interviews, in which many participants expressed that much of the information presented in these sections was new to them. Additionally, any training programme provided to health professionals is likely to enhance their knowledge and skills by introducing new information [51].

Further, the significant increase in the knowledge scores could be due to the Hawthorne effect, where individuals perform better when they are under observation or are part of a study [52]. Another reason could include self-selection of participants. If the individuals who volunteered for the training were more motivated or already had a higher baseline interest in stroke rehabilitation, this could have influenced their engagement and subsequently, their knowledge acquisition. Another factor to consider is the content of the training. If the training content was highly relevant to the participants’ daily practice or addressed current gaps in knowledge, this could explain the high improvement in their knowledge scores.

On the other hand, the physiotherapists’ knowledge levels about providing stroke education to patients was found to be high pre-training. This finding is relevant to a recent study by Alhenaki and Shaik [53]. The study explored physiotherapists’ awareness of stroke prevention, and its findings demonstrated that physiotherapists had good levels of knowledge about stroke prevention and management. This suggests that the curriculum in SA may be effective in delivering such information. Nonetheless, gaps were identified, suggesting that physiotherapists should be provided with continuous training and education [53]. Additionally, education of patients with stroke should not only be about prevention and risk factors. Delivering education on how patients can take care of themselves and do home exercises could be more important in the community. This was supported by Mahrous [54] study, which revealed very low levels of satisfaction among patients regarding the education they had received, with most ratings ranging between 19.3% and 50%, which highlights a significant need for improvement in patient education.

Further, the standardisation of practice in delivering patient education is still lacking [10]. This inconsistency in delivering educational content can lead to different outcomes. Variations in curricula and degree programmes across countries [55] along with the country of education [7] and differences in education levels [20] contribute to diverse practices among physiotherapists. To minimise variation in the treatment of stroke patients across different regions in SA, it is essential to first establish comprehensive guidelines [56]. Following this, providing targeted training for physiotherapists will be crucial. This approach will bridge the gap between theoretical knowledge and practical application, ultimately enhancing patient outcomes [57].

Furthermore, physiotherapists may not have primary responsibility for planning patients’ care post-discharge, given the multidisciplinary nature of stroke care. Nurses are frequently responsible for planning and coordination activities [58]. However, the STP programme emphasised post-discharge planning to ensure that patients are thoroughly assessed around their physiotherapy rehabilitation needs prior to discharge. This included scheduling appointments for outpatient clinics and developing a comprehensive rehabilitation plan to manage the transition period between inpatient care and outpatient follow-up. Furthermore, it is possible that the STP did not provide sufficient depth and practical applications in key areas such as the education module and post-discharge planning, which requires further work based on these findings.

Findings on telerehabilitation on physiotherapists’ knowledge, attitude and confidence showed a significant increase post-training. Previous research has identified that the main challenges to implementing telerehabilitation in SA are insufficient skills and technical barriers [49, 59]. As a result, many physiotherapists viewed telerehabilitation as impractical and that patients tend to prefer in-person rehabilitation sessions [11]. Healthcare professionals should undergo specialised training on the safe operation of equipment and the application of safety protocols during telerehabilitation. Additionally, sufficient technical support should be made available to ensure that devices are functioning correctly and are suitable for the required software [60]. The STP provided guidance on operational and safety measures necessary for effective telehealth use, which likely contributed to the significant improvement in physiotherapists’ confidence to integrate telehealth into their practice.

In this study, male participants demonstrated reluctance to participate in the training programme. Additionally, male participants believed that implementation needs more collaboration across departments and adequate time. In SA, physiotherapy is predominantly a female profession, with 63% of physiotherapists being women [61] a figure consistent with international trends. For instance, in the UK, 70% of physiotherapists are female [62], and in the US, 64% [63]. On the other hand, stroke in SA is more common among men, with 68.4% [1]. This gender disparity could explain why male physiotherapists were more hesitant to implement the training programme, as they may face higher workloads compared to females.

The assessment of clinical skills and the practical implementation of knowledge in this study was limited because the primary goal was to evaluate changes in knowledge, confidence, and attitudes. Previous studies have similarly focused more on user satisfaction and knowledge acquisition rather than on the clinical application of the information [30, 64]. In this study, few participants believed that implementation needs more collaboration across departments and adequate time. The issue here could be that once individuals become used to a specific system, they tend to adhere to it, as changing usual practice requires time and institutional support [65]. Other common barriers to implementing stroke guidelines include difficulty accepting new treatment approaches and a lack of motivation to change [66].

Hurley et al. [33] assessed implementation of training. However, they indicated a low implementation rate and recommended a local peer mentor to facilitate the implementation. Multiple studies have emphasised the importance of organisations in the implementation of interventions [67, 68]. Organisations need to facilitate implementation by monitoring physiotherapists, auditing, and feedback [69]. Additionally, in order to ensure successful implementation, it is essential that the intervention is in line with the organisation’s missions and resources [70]. Thus, future research should focus on developing strategies to enhance the translation of knowledge from training into practice, working with institutions.

Additionally, the study lacked practical aspects, which may have an influence on translating knowledge into practice. Providing physiotherapists with knowledge is effective but not sufficient to facilitate the implementation of this knowledge. Utilising practical strategies such as role-playing to facilitate behaviour change has been shown to be effective in other settings [71]. However, this training consisted of multiple resources such as video clips, tutorials and supplementary files, which have been found to be effective in improving therapists’ practical skills [72].

The overall satisfaction, low attrition (three participants), and positive feedback could indicate that the STP was feasible and acceptable. Satisfaction is crucial to assess the feasibility of the training, as the participants are unlikely to finish the training if they find it challenging, unhelpful or impractical [31]. Additionally, engagement was another factor used to assess the success of a training programme in previous studies [33]. Engagement was demonstrated in this study by the fact that 65.4% of respondents completed the training in one setting. These findings were in line with previous studies which described a high satisfaction rate with online training [31, 33]. However, in order to enhance the completion rate, Bennett‐Levy et al. [64] compared two modes of online training: one was independent and the other had fifteen minutes of support for therapists. They found that the supported online training mode had a higher completion rate [64]. Further, a personalised message weekly was found to be effective in improving the response rate [73]. Thus, the researcher aimed to send one message per week, but the participants’ time constraint was the main reason for not completing the training.

Further, a few adaptations were recommended, although the programme received high overall satisfaction from physiotherapists. There were a few suggestions for conducting in-person workshops instead of online training. Online training was found to be no different from the in-person workshop method [74]. However, in-person training can be interactive and particularly valuable for acquiring practical skills [75]. It was evident that the online platform was effective in enhancing knowledge acquisition, but other aspects such as acquiring hands-on practical skills need in-person approaches [76]. Thus, a blended approach could be more effective. Further, a few participants suggested that the duration of the training is short. However, previous training programmes for therapists of two hours [77] and three hours [31, 78] were found to be effective in enhancing knowledge and skills post-training. Finally, the participants were under 40 years old, and the majority (22 participants) had fewer than 10 years of experience. This could be because physiotherapy educational programs are relatively new in SA. Further, younger individuals may be more familiar with online training methods than older individuals.

Study limitations

The findings from this study must be interpreted with caution due to several limitations. Firstly, the absence of a control group and randomisation reduce the accuracy of measuring the effectiveness of the current training programme. These two elements are critical for ensuring that the changes in participants’ knowledge, attitudes and confidence are truly due to the STP rather than any other external factors. The utilisation of control and comparison groups is primarily intended to prevent unwarranted interpretations (internal validity) [79]. Individuals who participated in the study might be more motivated to enhance their knowledge and skills in comparison to those who did not volunteer. This bias could influence the findings, making the programme appear more effective. Further, the study findings might have been affected by the Hawthorne effect. However, participants were not aware of the study hypothesis. In addition, triangulation of positive feedback and a very high satisfaction rate provides evidence to support the effectiveness of the programme. Additionally, the period between the pre- and post-training questionnaires was short. This limited time-frame might have affected the participants’ ability to fully process and integrate the information given in the STP, which might have led to less accurate or incomplete responses in the post-training questionnaire and limited evidence on the long-term retention of knowledge acquired through the training. The follow-up period was likely inadequate to comprehensively evaluate the changes in physiotherapists’ attitude resulting from the training. Despite the fact that the online format provided ease and accessibility for physiotherapists, it did not give the value of in-person conversations that are generally present in traditional physical workshops. The training lacked practical elements and interaction, which may have limited participants from developing the essential hands-on skills needed to treat stroke patients effectively. Another limitation of this study was the lack of consideration for participants’ diverse learning styles. The online format may have been effective for those who prefer self-directed learning, but participants who perform better in more interactive or hands-on environments may not have fully benefited. Thus, incorporating multimodal delivery methods, such as live discussions, practical demonstrations, and collaborative learning, could better accommodate various learning preferences.

Further, the short duration of the STP may have reduced the depth of information that was presented. Further, the sample in the study was restricted to a single city, limiting the generalisability and applicability of the findings to wider contexts. Thus, the above elements, such as the use of a control group and extended training duration and follow-ups, may be incorporated to improve future training programmes.

Finally, the absence of an assessment of the long-term implementation was another limitation. The study primarily focused on immediate changes in participants’ knowledge and confidence, it did not evaluate how the training translated into practice. Factors such as workplace culture, the availability of necessary resources, institutional policies, and the provision of ongoing support were not explored, despite their critical role in determining the success of long-term implementation. Future research should address these aspects to provide a more comprehensive evaluation of training effectiveness in real-world settings.

Implications for practice

The STP training provided physiotherapists who participated in this study with sufficient knowledge of stroke care. Given the STP positive feedback and effectiveness in enhancing physiotherapists’ knowledge and confidence, it’s recommended that the STP be integrated into higher education curricula. The programme provided illustration of key assessment procedures and strategies which can help standardise care and ensure care continuity. Incorporating these elements into university courses could strengthen physiotherapists’ ability to provide long-term rehabilitation. Further, the training has the potential to directly enhance their performance in clinical settings. However, this translation into practice needs to be studied in the future.

In addition, the training can promote the standardisation of practices in various physiotherapy settings by establishing a consistent knowledge base. Further, the training can act as foundational steps towards more extensive training in the future, allowing continued education of physiotherapists in SA. The programme aligns with global care standards as it primarily guided by international guidelines such the NICE, while being adapted to address the specific needs of the Saudi Arabian context. Evidence-based practice plays a vital role in healthcare across all cultural backgrounds and has been shown to have positive outcomes and enhance decision-making among practitioners [80].

Finally, the training programme not only focused on enhancing the skills of physiotherapists but also emphasised empowering patients through education, self-management, and active involvement in goal setting. Patients should be equipped with comprehensive information about all aspects of healthcare, enabling them to actively participate in decision-making regarding their treatment and access suitable services [81]. Additionally, Insufficient information provision impacts adherence to secondary prevention measures and affects the psychological and social well-being of stroke survivors and their caregivers [82].

Conclusion

The training seemed to be beneficial and acceptable to improve participants’ knowledge and confidence to some extent in delivering long-term care for patients with stroke. However, strategies for performance monitoring must be implemented to facilitate effective implementation and behavioural change. Additionally, continual training is essential to ensure that physiotherapists remain informed about the latest developments in their field. Further, providing practical training could be valuable for bridging the gap between theory and practice.

Abbreviations

SA

Saudi Arabia

STEM

Science, Technology, Engineering and Mathematics

PI

Principal Investigator

GRASP

Graded Repetitive Arm Supplementary Program

G-AP

Goal-setting and Action Planning

GAS

Goal Attainment Scale

IDEAL

Include, Discuss, Educate, Assess, and Listen

Authors’ contributions

B.T., S.R. and A.S. conceptualised the study B.T. developed methodology A.S. and S.R. supervised the study B.T. performed data collection, data analysis, and wrote the manuscript with input from A.S. and S.R. All authors have read and agreed to the published version of the manuscript.

Funding

Not funded.

Data availability

All data generated or analysed during this study are included in this published article and supplementary files. Other data are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval was sought from the Ministry of Health ethics committee, (Jazan Health Ethics Committee, Ref: 2416) on 31/01/2024 and the University of Birmingham on 29/02/2024 (Science, Technology, Engineering and Mathematics (STEM)) ethics committee, Ref: ERN_20-1836). Informed consent was obtained from all participants. Consent forms were signed and sent by email or WhatsApp by participants themselves.

Consent of publication

Not applicable.

Competing interests

The authors declare no competing interests.