Evidence-based practice and rehabilitation: occupational therapy in Australia and New Zealand experiences

A strategic initiative to facilitate knowledge translation research in rehabilitation

BACKGROUND

While there is a growing body of literature supporting clinical decision-making for rehabilitation professionals, suboptimal use of evidence-based practices in that field persists. A strategic initiative that ensures the relevance of the research and its implementation in the context of rehabilitation could 1) help improve the coordination of knowledge translation (KT) research and 2) enhance the delivery of evidence-based rehabilitation services offered to patients with physical disabilities. This paper describes the process and methods used to develop a KT strategic initiative aimed at building capacity and coordinating KT research in physical rehabilitation and its strategic plan; it also reports the initial applications of the strategic plan implementation.

METHODS

We used a 3-phase process consisting of an online environmental scan to identify the extent of KT research activities in physical rehabilitation in Quebec, Canada. Data from the environmental scan was used to develop a strategic plan that structures KT research in physical rehabilitation. Seven external KT experts in health science reviewed the strategic plan for consistency and applicability.

RESULTS

Sixty-four KT researchers were identified and classified according to the extent of their level of involvement in KT. Ninety-six research projects meeting eligibility criteria were funded by eight of the fourteen agencies and organizations searched. To address the identified gaps, a 5-year strategic plan was developed, containing a mission, a vision, four main goals, nine strategies and forty-two actions.

CONCLUSION

Such initiatives can help guide researchers and relevant key stakeholders, to structure, organize and advance KT research in the field of rehabilitation. The strategies are being implemented progressively to meet the strategic initiative's mission and ultimately enhance users' rehabilitation services.

Content analysis to locate assistive technology in Queensland's motor injury insurance rehabilitation legislation and guidelines

INTRODUCTION

Reforms to Australia's disability and rehabilitation sectors have espoused the potential of assistive technology as an enabler. As new insurance systems are being developed it is timely to examine the structure of existing systems. This exploratory study examined the policies guiding assistive technology provision in the motor accident insurance sector of one Australian state.

METHODS

Policy documents were analyzed iteratively with a set of qualitative questions to understand the intent and interpretation of policies guiding assistive technology provision. Content analysis identified relevant sections and meaningful terminology, and context analysis explored the dominant perspectives informing policy.

RESULTS AND DISCUSSION

The concepts and language of assistive technology are not part of the policy frameworks guiding rehabilitation practice in Queensland's motor accident insurance sector. The definition of rehabilitation in the legislation is consistent with contemporary international interpretations that focus on optimizing functioning in interaction with the environment. However, the supporting documents are focused on recovery from injuries where decisions are guided by clinical need and affordability.

CONCLUSION

The policies frame rehabilitation in a medical model that separates assistive technology provision from the rehabilitation plan. The legislative framework provides opportunities to develop and improve assistive technology provision as part of an integrated approach to rehabilitation.

Supporting evidence-based practice: Changes in service provision and practitioners’ attitudes following EBP Service Centre consultation – a qualitative study / Evidenzbasierte Praxis unterstützen: Veränderungen der Arbeitsweise und der Einstellungen von Ergotherapeuten/-innen durch die Nutzung eines EBP Service Centers - eine qualitative Studie

Evidence-based practice (EBP) aims at optimal fulfilment of clients´ needs, but also plays an essential role in establishing an effective and efficient health care system. It is no longer a question whether EBP is essential and valued, but rather how to sustainably implement it into clinical practice. A new implementation strategy of an EBP workshop in combination with a CAT (critically appraised topic) service was established and investigated.

The aim of this study was to explore post EBP Service Centre consultation effects regarding occupational therapists’ changes in service provision, professional viewpoints and attitudes and job satisfaction. The second aim was receiving feedback on the EBP Service Centre for its further development.

For the evaluation of the EBP Service Centre the qualitative approach of content analysis by Gläser and Laudel was chosen. Two focus group discussions with 13 participants were conducted.

The combination of an EBP workshop and a CAT service, as provided by the EBP Service Centre, seems to be an effective tool to facilitate EBP implementation. The service was used intensively. Participants reported changes in service provision, e.g. increased client-centredness and occupation-based practice and changed professional attitudes like increased reflection and critical questioning.

A division of resources and strengths between research staff and practitioners seems to be reasonable. Hence research staff takes over literature search and appraisal and produces CATs, whereas practitioners focus on asking clinical questions and integrating the knowledge from the CAT into their clinical decisions.

Organisational support for evidence-based practice: occupational therapists perceptions

BACKGROUND

Barriers to the use of evidence-based practice extend beyond the individual clinician and often include organisational barriers. Adoption of systematic organisational support for evidence-based practice in health care is integral to its use. This study aimed to explore the perceptions of occupational therapy staff regarding the influence of organisational initiatives to support evidence-based practice on workplace culture and clinical practice.

METHODS

This study used semi-structured interviews with 30 occupational therapists working in a major metropolitan hospital in Brisbane, Australia regarding their perceptions of organisational initiatives designed to support evidence-based practice.

RESULTS

Four themes emerged from the data: (i) firmly embedding a culture valuing research and EBP, (ii) aligning professional identity with the Research and Evidence in Practice model, (iii) experiences of change: pride, confidence and pressure and (iv) making evidence-based changes to clinical practices.

CONCLUSION

Organisational initiatives for evidence-based practice were perceived as influencing the culture of the workplace, therapists' sense of identity as clinicians, and as contributing to changes in clinical practice. It is therefore important to consider organisational factors when attempting to increase the use of evidence in practice.

Determining the barriers and facilitators to adopting best practices in the management of poststroke unilateral spatial neglect: results of a qualitative study

BACKGROUND

A gap exists between best and actual management of poststroke unilateral spatial neglect (USN). Given the negative impact of USN on poststroke recovery, knowledge translation efforts are needed to optimize USN management. To date, no study has investigated the specific barriers and facilitators affecting USN management during the acute care process.

OBJECTIVE

To identify the facilitators and barriers that affect evidence-based practice use by occupational therapists (the primary discipline managing USN) when treating individuals with acute poststroke USN.

METHODS

Focus group methodology elicited information from 9 acute care occupational therapists.

RESULTS

Key barriers identified included lack of basic evidence-based practice skills specific to USN treatment and personal motivation to change current practices and engrained habits. Key facilitators included the presence of a multidisciplinary stroke team, recent graduation, and an environment with access to learning time and resources. Synthesized Web-based learning was also seen as important to uptake of best practices.

CONCLUSION

It is estimated that upwards of 40% of patients experience poststroke USN in the acute phase, and we have evidence of poor early management. This study identified several modifiable factors that prepare the ground for the creation and testing of a multimodal knowledge translation intervention aimed at improving clinicians' best practice management of poststroke USN.

Differences and similarities between functional and personal recovery in an Asian population: a cluster analytic approach

This study gathers empirical data to test whether two forms of recovery are related: (1) the traditional outcome-based notion of recovery from a mental illness, which is called "functional recovery," and (2) the more recent, consumer-based concept of recovery in mental illness, which is called "personal recovery." A total of 150 Chinese outpatients were recruited, 75 with bipolar disorder and 75 with schizophrenia, as determined by structured clinical interview. Participants were reported to be in clinical remission for at least the previous 6 months by treating psychiatrists. Personal recovery was measured with the Stages of Recovery Scale, and functional recovery was measured with residential and employment status. In addition to clinical and demographic data, self-report measures included functioning (confirmed through chart review) and a survey of the participant's assessment of the importance of various elements of recovery. Personal recovery was significantly correlated with functional recovery; small effect size suggested that the two domains are far from identical. The strength of this correlation was stronger for participants with schizophrenia than for those with bipolar disorder. A cluster analysis also suggested that residential and employment statuses, along with personal recovery scores, were useful in differentiating participants. Patients were more likely to reach better recovery outcomes if they were female, married, had higher family income, and perceived social roles as less important to their recovery. Consistent with the consumer literature, personal recovery is related but still distinct from functional recovery. Personal recovery has more to do with life circumstances than with functioning status alone.

Evidence-based practice behaviours: a comparison amongst occupational therapy students and clinicians

BACKGROUND

Occupational therapy graduates are expected to demonstrate entry-level competencies in evidence-based practice. To support students during the course of professional education in developing the knowledge, skills, and attitudes for integrating scientific findings into clinical practice, educators must identify the process by which these competencies are developed.

PURPOSE

To identify the differences in evidence-based practice decisions amongst occupational therapy students and experienced clinicians.

METHODS

Using a vignette depicting an older client with a history of falls, participants' evidence-based practice decisions were compared to a reference model.

RESULTS

In the initial steps of the process, knowledge of evidence-based practice concepts appeared to be dependent upon formal instruction, whereas expert-like behaviours in the integration of evidence for decision-making seemed to be a function of clinical experience.

IMPLICATIONS

Academic and clinical educators can use identified gaps in knowledge and synthesis of concepts to update the evidence-based practice content in occupational therapy curricula and fieldwork.

Creation of an evidence-based practice reference model in falls prevention: findings from occupational therapy

PURPOSE

This study attempted to capture the evidence-based practice (EBP) behaviours of expert occupational therapy (OT) clinicians in order to develop a reference model of EBP in falls prevention.

METHODS

Expert clinicians participated in the creation of a clinical vignette through focus group discussions. Using the vignette as the stimulus case, the same clinicians answered questions that reflected the EBP process. Validation of original responses and data synthesis occurred through a second focus group. This validation process resulted in the elaboration of a tree structure EBP decision model.

RESULTS

Findings show that clinicians are not expert evidence-based practitioners. Although some of the experts' clinical decisions were based on a combination of professional experience and research evidence, clinicians relied primarily on clinical experience for more complex aspects of decision-making. When explicitly instructed to answer questions corresponding to the five EBP steps, experts were compelled to think about the use of evidence and could proceed through the EBP process.

CONCLUSIONS

The model represents the expert clinical decisions in each of the EBP steps and illustrates what aspects of the decision-making process are in line with EBP versus aspects that are driven primarily by experience. This research has the potential to assist clinicians working in prevention of falls in geriatric rehabilitation who can use the model as a practice framework to guide them through the EBP process.

Integrating evidence-based practice and information literacy skills in teaching physical and occupational therapy students

BACKGROUND

To ensure that physical and occupational therapy graduates develop evidence-based practice (EBP) competencies, their academic training must promote EBP skills, such as posing a clinical question and retrieving relevant literature, and the information literacy skills needed to practice these EBP skills.

OBJECTIVE

This article describes the collaborative process and outcome of integrating EBP and information literacy early in a professional physical therapy and occupational therapy programme.

METHODS

The liaison librarian and a faculty member designed an instructional activity that included a lecture, workshop and assignment that integrated EBP skills and information literacy skills in the first year of the programme. The assignment was designed to assess students' ability to conduct a search independently.

RESULTS

The lecture and workshop were successful in their objectives, as 101 of the 104 students received at least 8 out of 10 points on the search assignment.

CONCLUSIONS

The teaching activities developed for the students in this course appear to have achieved the goal of teaching students the EBP research cycle so that they might begin to emulate it. The collaboration between the faculty member and the librarian was integral to the success of this endeavour. Future work will include the evaluation of students' long-term retention of information literacy objectives.

Evaluating Psychosocial Interventions in First-Episode Psychosis

Little is known about what influences the success of psychosocial interventions for first-episode psychosis. One possible explanation for the mixed results of clinical trials is the influence of confounders on outcome. Psychosocial functioning prior to the onset of psychosis (premorbid adjustment) is one possible confounder. In order to examine the importance of premorbid adjustment to occupational therapists providing and evaluating psychosocial interventions, this study compared the baseline characteristics and premorbid adjustment of the people with first-episode psychosis referred to psychosocial rehabilitation with those of the people not referred, and the outcomes of both groups.

All people with first-episode psychosis (n = 171) were assessed at baseline, including their premorbid adjustment. The participants were followed up 4 years later. A subgroup (n = 44) had been referred to psychosocial rehabilitation. The baseline presentation, premorbid adjustment and outcomes (symptoms and functioning) at 4 years of both groups were compared.

The results showed that the people referred to a psychosocial rehabilitation programme had a poorer premorbid adjustment and fewer years in education than those not referred. Unsurprisingly, those not referred had better outcomes 4 years after initial presentation. It was concluded that premorbid psychosocial functioning is influential in determining the likelihood of referral to psychosocial rehabilitation and can influence evaluations of psychosocial interventions.