Using a professional practice model to structure evidence review: the agony and the ecstasy Mary Egan, PhD, OT Reg. (Ont.), FCAOT Associate Professor School of Rehabilitation Sciences University of Ottawa [email protected]
Jan 23, 2016
Using a professional practice model to structure evidence review:
the agony and the ecstasy
Mary Egan, PhD, OT Reg. (Ont.), FCAOTAssociate Professor
School of Rehabilitation Sciences
University of Ottawa
Lessons from “Client-centred evidenced based occupational therapy for persons with dementia”
Egan, Hobson & Fearing
With grateful acknowledgment to:
Canadian Occupational Therapy Foundation
Ontario Ministry of Health and Long-term Care
We are dedicated to educating our students to be evidence-based practitioners, but what does it mean to be evidence-based?
Plan of presentation
A brief history of being evidence-based How we got to the diagnose + treat filing cabinet
for evidence
Our experience working with a filing cabinet based on steps in the OT process
What working with an OT filing cabinet taught us about Evidence and knowledge
Evidence-based medicinein context
Physician as guild master replaced by physician as scientist model (Europe 17th-18th centuries to Flexner report early 20th century) Good practice is “rational” i.e., scientifically sound
Physician as contractor to the state (Cochrane) Good practice is good rationing of care
Under the latter perspective
Areas where practice could be more efficient are identified
Most efficient procedure(s) in this area identified (“innovation”)
Measures implemented to “encourage” adoption of innovation
Under the classic medical model practice is defined as:
DIAGNOSE TREAT
In these situations « diagnose » and « treat » become natural filing drawers for evidence required to provide « rational » care.
This works well for common, well-delineated problems with linear solutions:
e.g., severe chest pain, sweating
How many of these types of problems do we have in nursing, midwifery and allied health?
What if most of your work involves iterative processes that deal as much in mysteries as in problems?
What would your filing cabinet look like?
The process of occupational therapyOPP Model (Fearing, Law & Clark, 1997)
Name & prioritize « occupations » (things people want to do or need to do)
Select theoretical lens
Determine aspects of the person, the environment or the occupation that are blocking the « occupation »
Determine aspects of each that could facilite the « occupation »
Make a plan to try new ways of doing based on this analysis
Carry out plan
Evaluate – can the person now do it?
Could this process model be used as a 7-drawer filing cabinet for evidence based OT?
Alzheimer disease chosen as a test case.
Preparatory work Who is the client?
Individual/family or institutional caregiver
Where does theory fit in exactly?
Biomedical information on AD? Where does that fit?
Questions we thought would be addressed in the evidence
Filling the filing cabinetA. the search
Literature Search Key Words
Alzheimer disease/dementia Caregivers Occupation/self-care/leisure/work
Supplemental Key Words Per OPPM stage
Performance components Environmental components
Specific Topics
Literature Search Data bases
CINAHL Cochrane Current Contents Dissertation Abstracts Embase Health Star Medline and Premedline OTDBase PsychInfo
Literature Search Limits
French & English 1990- present
Inclusion Descriptions of theory/application of theory Research reports (inc systematic reviews)
Quantitative or qualitative > 50% AD
Filling the filing cabinetB. Selection of articles to read
4451 references identified
Reviewed title, abstract and determined: theory description or research report pertinent to a model stage?
If so, which one
Filling the filing cabinetC. Selection of articles to keep
Appraised – using our own quality cut-offs
Quantitative study criteria (>4)
Methods clearly stated Participants adequately described Validated tools Analysis appropriate At least two measurement points
Qualitative study criteria (>4)
Methods clearly stated Participants adequately described Analysis adequately described Analysis appropriate At least one check for trustworthiness
Summarizing the contents of each of the 7 drawers of the filing cabinet
We planned to:Summarized key findings by stageMade best practice
recommendations
Findings to dateStage 1. Name, validate, priorize occupational performance issues
We thought we would find evidence of: potential problems with things people with AD
needed to do or wanted to do how to explore these
Findings to dateOPP Stage 1. Name, validate, priorize occupational performance issues
What we actually found The experience of occupation
Affected individuals Caregivers
How to explore occupational performance issues
26 studies
Experience of occupation (individuals)
Progressive difficulty with occupations, although speed of decline varies greatly
Difficulty with occupations threatened control, identity
Occupations first provided pleasure, later threat
Yet, continued desire to “be useful”
Egan, Hobson & Fearing (2006)
Experience of occupation (individuals) (cont’d)
Felt caregivers limited their activities in early stages
Identified strongly with work roles early in disease, later identified with sick role
Experience of occupation (informal caregivers)
Caregiving itself is a valued occupation
Problem behaviours increased caregiving difficulty
Lack of occupation as troubling to caregivers as many problem behaviours
Shared recreation source of happiness, even respite, for caregivers
Experience of occupation (informal caregivers cont’d)
Caregiving interferes with other occupations – particularly work
the results of this interference may be perceived differently by spouses than by other caregivers
Experience of occupation (formal caregivers)
“Preventing harm” the guiding principle of occupation for formal caregivers
Staff cherished moments of connecting with residents during activities
Institutional residents may spend <20% of the day in occupation (including nursing care)
Occupational goals
Both affected individuals and their caregivers can and do form occupational goals.
Best practice recommendations:
Know that participation in daily activities is highly valued by individuals and caregivers
Be sensitive to multiple risks associated with occupation
Appreciate caregiving as valued and/or problematic occupation
Ask about occupational goals Use ethnographic-style interviewing
At this point we decided that this should be a multidisciplinary review of theory and research regarding “how to facilitate meaningful activity among people with dementia”.
Findings to dateOPP Stage 2. Select theoretical approaches
Searched for literature Theory related to “enabling occupation”
and persons with Alzheimer disease
Sorting the theories
OT Other professions
Dementia specific
General Dementia specific
General
13
17
To be organized by:
Orientation to care (medical, social, personhood)
Underlying theory/theories Consideration of
person/environment/occupation How well each addresses issues
identified in stage 1
REFLECTION
2 2-year breaks between 1st and 2nd stage
Roadblocks due to difficulties: Conceptualizing role of theory Determining what to do when the available theory
addresses your main purpose only indirectly
Best practice recommendations
????
OPP Stage 3. Identify personal and environmental conditions
From literature found evidence that OCCUPATION affected by
Cognitive processing problems Visual and visual perceptual problems Anxiety, depression, apathy Comorbidity Gait and balance problems
OPP Stage 3.
OCCUPATION affected by (cont’d) Intrusion into personal spaceBackground noiseCommunication difficulties
(sender/recipient)Problems with cognition and executive
function
OPP Stage 3. Identify personal and environmental conditions
From literature found evidence for ASSESSMENT
Functional Performance Measure Other measures (to follow) Location of assessment (to follow)
OPP Stage 4. Identify strengths and resources (preliminary)
From literature found evidence that OCCUPATION facilitated by
Individual’s personal strategies Caregiver personal knowledge of the individual Caregiver strategies Environmental modifications Opportunity to attempt occupations Physical rather than verbal assistance
OPP Stage 5. Negotiate targeted outcomes and develop action plans
Goal Attainment Scaling (GAS) can be used by individuals/caregivers
Preliminary findings to dateOPP Stage 6. Implement plans through occupation
What are effective methods to enhance performance of occupations
Work now being led by Lori Letts at McMaster University
NOTE: 6 years later we are finally doing a tradition evidence-based review.
OPP Stage 7. Evaluate occupational performance outcomes
Builds on stage 5 (identify goals)
A good idea?
Massive undertaking Unknown reproducibility
AND…
Is this a « penetrating analysis of the obvious »?
Other potential problems
Insistence on a link to occupation focused/restricted the filing cabinet contents at each stage Not everyone thought that was a great idea
They moved our cheese CAOT switched to a 6 stage model
And
Does our process model really describe what we do? For example, where does dealing with
grief/transformation enter?
On the other hand
Allows us to include important information we would not have found using only « diagnose » and « treat » filing drawers
Helps us reflect on whether the model accurately describes what we do (e.g. where does transformation fit in?)
But the biggest thing….
Process highlighted how to more profoundly link evidence-based practice
as « rational » practice
with
evidence-based practice
as « rationed » practice.
Miettinen (2007)
Evidence vs knowledge
There may presently be too great a focus on evidence as currently defined and too little focus on the foundational knowledge we have and the further foundational knowledge we need.
The time will have to come, soon, when clinical professors come to grips with their true responsibility, that of being supreme authorities on the aggregate of applied-science evidence bearing on at least the most common challenges of practice in their respective specialties. … it will guide the professor away from the time-consuming travails of original gnosisoriented research, to merely fostering it where needed; and above all, it will engender a devotion to the synthesis of original evidence and the dissemination of its results….
Miettinen (1998)
Mere technicians, however skilled they may be, will not succeed in [working though places where they have no knowledge]; they are practitioners, not theorists. The aporia calls for thinking, for theory. This is all the more urgent in a world where technicity stands in for thought and Google searches stand in for knowledge.
Murray et al. (2007)
This may be particularly critical at a time when basic science information is presumed (e.g., masters level entry professional training).
Back to the future…?
Multidisciplinary foundational education highlighting state of theory and science underlying how we conceive of intervention related to our prime mandates.
Doidge, N. (2007). The brain that changes itself.
returning to Sackett“The practice of EBM means integrating
individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice... By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centred clinical research [regarding] diagnostic tests, … prognostic markers, and … therapeutic, rehabilitative, and preventive regimens."
Perhaps
A practice model-defined filing cabinet, that includes theory and state of the science knowledge, could help us ensure that practice is both rational and well-rationed.