From Good to Great OBJECTIVES. AOTA Centennial Vision Statement 10/14/2012

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1 From Good to Great Implementing evidence-based treatment and standardized outcome measures in in-patient rehabilitation LaMar Bolden, OTR, DPS Presented 10/28/2012 NJOTA conference OBJECTIVES Describe strategies and frameworks to facilitate research utilization in occupational therapy practice Systematically evaluate change processes related to the implementation of evidence into practice AOTA Centennial Vision Statement By the year 2017 we envision that occupational therapy is a powerful, widely recognized, science-driven and evidencebased profession with a globally connected and diverse workforce meeting society s occupational needs. Available at Accessed 10/9/

2 What is Evidence-Based Practice? Putting evidence into practice Putting knowledge into action Re search Cl i nical e xpe rtise Best Intervention Cl i ent Pre ference Knowledge Creation Researchers Clinicians Identify problem Seek knowledge Clinical reasoning Select intervention Outcomes Satisfaction Client Practice Setting Evidence Based Practice (EBP) Ask Acquire Appraise Apply Assess EBP: Limitations and Barriers Insufficient time Lack of generalization of research findings Lack of research skills Lack of understanding of statistics Application of research to unique patients Inability to critically appraise Isolation from peers Lack of information resources Lack of organizational mandate (Sa l bach, Ja glal, Korne r-bite nsky, Ra ppol t, & Da vis, 2007) 2

3 Practitioner and Organizational Barriers to Evidence-Based Stroke Rehabilitation (Salbach, Jaglal, Korner- Bitensky, Rappolt, & Davis, 2007) n=270 RESULTS indicate : Attitudes and beliefs were positive toward application and use of EBP in daily practice HOWEVER -There is a divide between research and practice Most believed they need to increase use of evidence in daily practice and are interested in learning the skills required. Education findings were neutral in regards to learning and receiving formal education to search for and critically appraise articles. 1) [P]ersonal attitudes toward, use of, and perceived benefits and limitations of EBP 2) [Confidence] in your ability to assess, interpret and apply research evidence in clinical problems 3) Availability of resources Common Criticisms of EBP Privileges clinical research findings Disregards factors that play a role in clinical decision making Only deals with the best possible evidence Methods are not applicable to questions clinicians need answered Difficult to define the typical patient Results in cookie cutter health care Is cost cutting tool Does not aid clinical decision making EBP is not evidencebased (Dijkers, Murphy, & Krellman, 2012) Bri dgi ng the gap KNOWLEDGE TRANSLATION 3

4 Knowledge Translation (KT) is a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically sound application of knowledge to improve the health of Canadians, provide more effective health services and products and strengthen the health care system. This process takes place within a complex systems of interactions between researchers and knowledge users that may vary in intensity, complexity and level of engagement depending on the nature of the research and the findings as well as the needs of the particular knowledge user. Available at Accessed October Knowledge Translation the collaborative and systematic review, assessment, identification, aggregation, and practical application of high-quality disability and rehabilitation research by key stakeholders (i.e., consumers, researcher, practitioners, and policymakers) for the purpose of improving the lives of individuals with disabilities National Center for Dissemination of Disability Research (2005) Decision Maker Groups Health care providers Patients Caregivers Managers Policy makers 4

5 Approaches to Knowledge Translation Interaction-Focused Frameworks Understanding User- Context Framework Context-Focused Models and Frameworks The Ottawa Model of Research Use The Knowledge-to-Action Process Framework The Promoting Action on Research Implementation in Health Services Framework (PARIHS) The Coordinated Implementation Model Individual-Focused Models The Stetler Model of Research Utilization (Sudsawad, P, 2007) Related Terminology Knowledge transfer Knowledge exchange Research utilization Implementation Dissemination Diffusion Evidence-based practice Competency Continuing education Continuing professional development Knowledge-to-action framework KNOWLEDGE CREATION Knowl e dge inquiry Knowl e dge synthe sis Cre a ti on of knowl edge tool s ACTION CYLCE Ide ntification of the problem Identifying, reviewing and selecting knowledge to implement Customizing knowledge to the context Asse ssi ng de terminants of use Se l e cting, ta ilori ng, i mplementing a nd monitoring knowledge uptake a nd KT i nte rve ntions Evaluating outcomes or impact of knowledge use De te rmi ning strategies for sustained use (Straus, Tetroe, & Graham, 2011) 5

6 Knowl e dge exchange, synthesis a nd application KNOWLEDGE TRANSLATION: A CONCEPT FOR OT? (LENCHUA, KOTHARI, & ROUSE, 2007) Research Utilization Facilitating Factors Education sessions on research evidence Having time scheduled for research activities Additional staff to implement research evidence Barriers Time Work load pressure Relevance to practice Inability to interpret research findings (Lenchua, Kothari, & Rouse, 2007) Refining the Fit Experiential knowledge Knowledge interpretation KT & OT Research as evidence Knowledge sharing (person to person) Practice Community (Lenchua, Kothari, & Rouse, 2007) 6

7 Analyzing barriers and supports to KT A way to develop strategies PERSON ENVIRONMENT OCCUPATION (Metzler & Metz, 2010) Strategies for Enhancing research utilization in OT Themes identified: Client-centered decision making based on OPPM Clinical expertise as source of evidence for decision making Case study method Collective study (Craik & Rappolt, 2003) TRUE-OT Theory of research utilization enhancement in occupational therapy Draws on: Kolb s experiential learning cycle Schön s research on the reflective practitioner Knott and Wildavsky s constructs of research utilization Assumes the OT: 1) Is motivated to seek out research evidence to guide decision making 2) Has the skill and maturity to critically analyze clinical actions and client outcomes 3) Has a high valuation of clinical experience and knowledge 7

8 Model of Research Utilization in Occupational Therapy Clinical decision-making and action Reflection on skill and knowledge base If need to know more then begin the research utilization process Implementation of research evidence and application to OPPM (or OT Practice Framework) Shaping Professional Thinking Re flective Pra cti ce Evi denceba sed Pra cti ce Profe ssional Thi nking (Bannigan & Moores, 2009) TRUE-OT A model of research utilization enhancement for OT Model of professional thinking Research Pyramid: A new evidencebased practice model for OT Creating Communities of Practice INSTITUTIONAL, CULTURAL, PHYSICAL & CULTURAL 8

9 KNOWLEDGE BROKER (Dobbins, et al., 2009) Initial and ongoing needs assessment, scanning the horizon & knowledge management Knowledge translation & exchange Network development, maintenance and facilitation Facilitating knowledge and skill development Facilitating individual development in evidence informed decision making Promoting and supporting organizational change REFERENCES Bannigan, K., & Moores, A. (2009). A model of professional thinking: Integrating reflective practice and evidence based practice. Canadian Journal of Occupational Therapy, Craik, J., & Rappolt, S. (2003). Theory of research utilization enhancement: A model for occupational therapy. Canadian Journal of Occupational Therapy, Dijkers, M., Murphy, S. L., & Krellman, J. (2012). Evidence-Based Practice for Rehabilitation Professionals: Concepts and Controversies. Archives of Physical Medicine and Rehabilitation, Dobbins, M., Robeson, P., Ciliska, D., Hanna, S., Cameron, R., O'Mara, L.,... Mercer, S. (2009). A description of a knowledge broker role implemented as part of a randomized controlled trial evaluating three knowledge translation strategies. Implementation Science. Egan, M. (2003). Models and evidence-based practice: You can't have one without the other. Canadian Journal of Occupational Therapy, Foley, N., Pereira, S., Salter, K., Meyer, M., McClure, A., & Teasell, R. (2012). Are Recommendations Regarding Inpatient Therapy Intensity Following Acute Stroke Really Evidence-Based? Topics in Stroke Rehabilitation, Gonzales, R., Handley, M. A., Ackerman, S., & O'Sullivan, P. S. (2012). A Framework for Training Health Professionals in Implementation and Dissemination Science. Academic Medicine, Graham, I. D., Logan, J., Harrison, M. B., Straus, S. E., Tetroe, J., Caswell, W., & Robinson, N. (2006). Lost in Knowledge Translation: Time for a Map? The Journal of Continuing Education in the Health Professions, Gwyer, J., & Hack, L. (2012). Lost in Knowledge Translation. Journal of Physical Therapy Education, 4. Lenchua, R., Kothari, A., & Rouse, M. J. (2007). Knowledge Translation: A Concept for Occupational Therapy. American Journal of Occupational Therapy, Majumdar, S. R. (2011). Successful high-quality knowledge translation research: three case studies. Journal of Clinical Epidemiology, Metzler, M. J., & A, M. G. (2010). Analyzing the barriers and supports of knowledge translation using the PEO model. Canadian Journal of Occupational Therapy, Rappolt, S., Mitra, A. L., & Murphy, E. (2002). Professional accountability in restructured contexts of occupational therapy practice. Canadian Journal of Occupational Therapy,

10 Salbach, N. M., Jaglal, S. B., Korner-Bitensky, N., Rappolt, S., & Davis, D. (2007). Practitioner and Organizational Barriers to Evidencebased Practice of Physical Therapists for People With Stroke. Physical Therapy, Straus, S. E., Tetroe, J. M., & Graham, I. D. (2011). Knowledge translation is the use of the knowledge in health care and decision making. Journal of Clinical Epidemiology, Teasell, R. (2012). Challenges in the Implementation of Evidence in Stroke Rehabilitation. Topics in Stroke Rehabilitation, Tomlin, G., & Borgetto, B. (2011). Research Pyramid: A New Evidence-Based Practice Model for Occupational Therapy. American Journal of Occupational Therapy,