Implementing Clinical Practice Guidelines in occupational therapy practice: recommendations from the research evidence

[Orientations de facilitation pour soutenir l'application de l'Algo dans les services de soutien à domicile des personnes aînées]

Comment soutenir le déploiement de connaissances coconstruites par des personnes cliniciennes, gestionnaires ou chercheures? Ce thème est abordé à partir de l'étude de l'application de l'Algo, un algorithme clinique décisionnel conçu pour la sélection des aides techniques visant à faciliter l'hygiène corporelle des personnes aînées vivant à domicile. L'objectif de cette note sur les politiques et les pratiques est de présenter les orientations de facilitation dégagées à la suite d'un devis mixte multiphases (2015-2019) mis en œuvre dans les services de soutien à domicile au Québec (Canada). Les orientations de facilitation centrée sur la tâche et holistique sont présentées en fonction des stades d'utilisation de l'Algo, afin de soutenir les personnes cliniciennes, gestionnaires et chercheures dans la poursuite de son application auprès des personnes aînées. De plus, cette note illustre l'apport des devis mixtes à la conduite et à la compréhension de l'application des connaissances coconstruites.

Experiences with continuous quality improvement work based on the Occupational Therapy Intervention Process Model

BACKGROUND

Sustainability is an important issue in implementation processes in health care, and more knowledge is needed to facilitate improvement work in occupational therapy practice.

AIM

The aim of this study was to explore how occupational therapists experienced continuous quality improvement work based on the Occupational Therapy Intervention Process Model after 17 years.

METHOD

Two focus group interviews were conducted with a total of 12 occupational therapists. The data were analysed using qualitative content analysis.

RESULTS

The analysis resulted in three themes with related subthemes describing the occupational therapists' experiences of their model-based long-term improvement work. The themes were labelled as follows: 'sharing a safe and well-known professional reasoning', 'reaching normality and empowerment' and 'questioning and reshaping the too safe and too well-known normality'. The model functioned as a sustainable framework both for ordinary clinical practice and for continuous improvement work.

CONCLUSION

By using the model, the occupational therapists had established a safe and well-known professional reasoning in which continual quality improvement work had become sustainable.

Occupational intervention in mental health hospitals: Study of contextual impact

BACKGROUND

Recovery-promoting and occupation-oriented interventions for people with schizophrenia who receive in-patient services are scarcely investigated, limiting our understanding of the factors affecting intervention effectiveness and hindering occupational inclusion.

AIMS

To investigate the impact of contextual factors on the effectiveness of 'Occupational Connections' (OC) - occupational intervention for in-patient psychiatric settings.

MATERIALS AND METHODS

Quasi-experimental, single-blind study compared between inpatients with schizophrenia participating in OC (N = 14) and those receiving treatment as usual only (N = 16) on primary outcomes of participation dimensions and recovery-orientation of the service, and on secondary outcomes of cognition, symptom severity, and functional capacity.

RESULTS

Participation in OC in a new context appears to contribute to improvement in cognitive fluency and flexibility, schizophrenia symptoms, and functional capacity (-2.8<t < 4.32, p < 0.05) with no improvement in the participation dimensions (-1.36<t < 1.36, p > 0.05) or reduction (-2.25<t < 3.74, p < 0.05). The pattern of change in primary and secondary outcomes in a new context was distinct from previous reports on OC effectiveness.

CONCLUSIONS AND SIGNIFICANCE

These findings suggest the impact of contextual factors on OC effectiveness. Personal participants' factors, institutional features, clinician characteristics, and intervention qualities should be considered in the process of the OC further development, evidence building, and clinical implementation to ensure optimal intervention results.

Practice educators' emphasis on research in supervision of occupational therapy students

BACKGROUND

One approach to promote students' use of research in future practice involves integrating students' research use in supervision during practice placements. Studies examining this aspect of supervision in practice placements are lacking.

AIM

To explore how practice educators perceive and emphasise research in their supervision of occupational therapy students during practice placements.

MATERIALS AND METHODS

A qualitative study was conducted. A purposive sample was recruited, consisting of participants from community-based health services and hospitals in Norway. We conducted three focus groups and one individual interview with occupational therapists (n = 9). The qualitative data analysis was based on interpretive description.

RESULTS

We identified four themes: 'emphasis on research in supervision of students'; 'practice educators' research competence and awareness of research'; 'institutionalisation of research use in everyday practice'; and 'communication and cooperation between education and practice regarding research'. Despite highlighting several benefits of research use, the practice educators focused rarely on students' research use in practice placements. Conclusions and significance: Cooperation between practice educators and faculty members regarding students' training in research use seems essential. Practice educators may need additional training in how research should be emphasised in supervision.

Printed educational materials: effects on professional practice and healthcare outcomes

BACKGROUND

Printed educational materials are widely used dissemination strategies to improve the quality of healthcare professionals' practice and patient health outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines. This is the fourth update of the review.

OBJECTIVES

To assess the effect of printed educational materials (PEMs) on the practice of healthcare professionals and patient health outcomes. To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on healthcare professionals' practice and patient health outcomes.

SEARCH METHODS

We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and EPOC Register from their inception to 6 February 2019. We checked the reference lists of all included studies and relevant systematic reviews.

SELECTION CRITERIA

We included randomised trials (RTs), controlled before-after studies (CBAs) and interrupted time series studies (ITSs) that evaluated the impact of PEMs on healthcare professionals' practice or patient health outcomes. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. Any objective measure of professional practice (e.g. prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included.

DATA COLLECTION AND ANALYSIS

Two reviewers undertook data extraction independently. Disagreements were resolved by discussion. For analyses, we grouped the included studies according to study design, type of outcome and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where data were available, we re-analysed the ITS studies by converting all data to a monthly basis and estimating the effect size from the change in the slope of the regression line between before and after implementation of the PEM. We reported median changes in slope for each outcome, for each study, and then across studies. We standardised all changes in slopes by their standard error, allowing comparisons and combination of different outcomes. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format. We assessed the risks of bias of all the included studies.

MAIN RESULTS

We included 84 studies: 32 RTs, two CBAs and 50 ITS studies. Of the 32 RTs, 19 were cluster RTs that used various units of randomisation, such as practices, health centres, towns, or areas. The majority of the included studies (82/84) compared the effectiveness of PEMs to no intervention. Based on the RTs that provided moderate-certainty evidence, we found that PEMs distributed to healthcare professionals probably improve their practice, as measured with dichotomous variables, compared to no intervention (median absolute risk difference (ARD): 0.04; interquartile range (IQR): 0.01 to 0.09; 3,963 healthcare professionals randomised within 3073 units). We could not confirm this finding using the evidence gathered from continuous variables (standardised mean difference (SMD): 0.11; IQR: -0.16 to 0.52; 1631 healthcare professionals randomised within 1373 units ), from the ITS studies (standardised median change in slope = 0.69; 35 studies), or from the CBA study because the certainty of this evidence was very low. We also found, based on RTs that provided moderate-certainty evidence, that PEMs distributed to healthcare professionals probably make little or no difference to patient health as measured using dichotomous variables, compared to no intervention (ARD: 0.02; IQR: -0.005 to 0.09; 935,015 patients randomised within 959 units). The evidence gathered from continuous variables (SMD: 0.05; IQR: -0.12 to 0.09; 6,737 patients randomised within 594 units) or from ITS study results (standardised median change in slope = 1.12; 8 studies) do not strengthen these findings because the certainty of this evidence was very low. Two studies (a randomised trial and a CBA) compared a paper-based version to a computerised version of the same PEM. From the RT that provided evidence of low certainty, we found that PEM in computerised versions may make little or no difference to professionals' practice compared to PEM in printed versions (ARD: -0.02; IQR: -0.03 to 0.00; 139 healthcare professionals randomised individually). This finding was not strengthened by the CBA study that provided very low certainty evidence (SMD: 0.44; 32 healthcare professionals). The data gathered did not allow us to conclude which PEM characteristics influenced their effectiveness. The methodological quality of the included studies was variable. Half of the included RTs were at risk of selection bias. Most of the ITS studies were conducted retrospectively, without prespecifying the expected effect of the intervention, or acknowledging the presence of a secular trend.

AUTHORS' CONCLUSIONS

The results of this review suggest that, when used alone and compared to no intervention, PEMs may slightly improve healthcare professionals' practice outcomes and patient health outcomes. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.

Management of fever in Australian children: a population-based sample survey

Background

Fever in childhood is a common acute presentation requiring clinical triage to identify the few children who have serious underlying infection. Clinical practice guidelines (CPGs) have been developed to assist clinicians with this task. This study aimed to assess the proportion of care provided in accordance with CPG recommendations for the management of fever in Australian children.

Methods

Clinical recommendations were extracted from five CPGs and formulated into 47 clinical indicators for use in auditing adherence. Indicators were categorised by phase of care: assessment, diagnosis and treatment. Patient records from children aged 0 to 15 years were sampled from general practices (GP), emergency departments (ED) and hospital admissions in randomly-selected health districts in Queensland, New South Wales and South Australia during 2012 and 2013. Paediatric nurses, trained to assess eligibility for indicator assessment and adherence, reviewed eligible medical records. Adherence was estimated by individual indicator, phase of care, age-group and setting.

Results

The field team conducted 14,879 eligible indicator assessments for 708 visits by 550 children with fever in 58 GP, 34 ED and 28 hospital inpatient settings. For the 33 indicators with sufficient data, adherence ranged from 14.7 to 98.1%. Estimated adherence with assessment-related indicators was 51.3% (95% CI: 48.1–54.6), 77.5% (95% CI: 65.3–87.1) for diagnostic-related indicators and 72.7% (95% CI: 65.3–79.3) for treatment-related indicators. Adherence for children < 3 months of age was 73.4% (95% CI: 58.0–85.8) and 64.7% (95% CI: 57.0–71.9) for children 3–11 months of age, both significantly higher than for children aged 4–15 years (53.5%; 95% CI: 50.0–56.9). The proportion of adherent care for children attending an ED was 77.5% (95% CI: 74.2–80.6) and 76.7% (95% CI: 71.7–81.3) for children admitted to hospital, both significantly higher than for children attending a GP (40.3%; 95% CI: 34.6–46.1).

Conclusions

This study reports a wide range of adherence by clinicians to 47 indicators of best practice for the management of febrile children, sampled from urban and rural regions containing 60% of the Australian paediatric population. Documented adherence was lowest for indicators related to patient assessment, for care provided in GP settings, and for children aged 4–15 years.

Why Do Clinical Practice Guidelines Get Stuck during Implementation and What Can Be Done: A Case Study in Pediatric Rehabilitation

Aims: The purpose of this study was to obtain the perspectives of occupational and physical therapists working in pediatric rehabilitation about the factors that influence implementation of clinical practice guidelines (CPG) using the case of constraint induced movement therapy (CIMT). We aimed to identify factors that hinder implementation of CPGs and strategies for overcoming barriers when widespread implementation is stalled.Methods: Qualitative case study methodology was bounded within the parameters of CIMT implementation in pediatric rehabilitation in one jurisdiction. Twenty-one occupational and physical therapists participated in one of three focus groups. Data were analyzed using an inductive qualitative approach.Results: Participants viewed CPGs as useful, and emphasized the importance of consistency between guidelines and relevance to practice context. Therapists considered the "art and science" in clinical decision-making. Barriers and facilitators to CPG implementation were identified at the client, clinician, intervention location and systemic level. Potential solutions to help "unstick" guideline implementation were consistent with theories of collective knowledge exchange and mindlines.Conclusion: The presence of CPGs does not ensure evidence uptake; understanding of local barriers is required. This case study highlights the value of a collective knowledge exchange approach and attention to the social structures of knowledge development and evidence use.

The SUMAMOS EXCELENCIA Project

AIM

The gap between research and clinical practice leads to inconsistent decision-making and clinical audits are an effective way of improving the implementation of best practice. Our aim is to assess the effectiveness of a model that implements evidence-based recommendations for patient outcomes and healthcare quality.

DESIGN

National quasi-experimental, multicentre, before and after study.

METHODS

This study focuses on patients attending primary care and hospital care units and associated socio-healthcare services. It uses the Joanna Brigg's Institute Getting Research into Practice model, which improves processes by referring to prior baseline clinical audits. The variables are process and outcome criteria for pain, urinary incontinence, and fall prevention, with data collection at baseline and key points over 12 months drawn from clinical histories and records. Project funding was received from the Spanish Strategic Health Action in November 2014.

DISCUSSION

The project results will provide knowledge on the effectiveness of the Getting Research into Practice model, to apply evidence-based recommendations for the detection and management of pain, urinary incontinence, and fall prevention. It will also establish whether using research results, based on clinical audits and situation analysis, is effective for implementing evidence-based recommendations and improving patients' health.

IMPACT

This nationwide Spanish project aims to detect and prevent high-prevalence healthcare problems, namely pain in patients at any age and falls and urinary incontinence in people aged 65 and over. Tailoring clinical practice to evidence-based recommendations will reduce unjustified clinical variations in providing healthcare services. Clinical Trial ID: NCT03725774.

The experiences and perceptions of individuals diagnosed with schizophrenia regarding the challenges they experience to employment and coping strategies used in the open labor market in Cape Town, South Africa

BACKGROUND

There is limited research available regarding the coping skills of individuals living with schizophrenia and the strategies used in the open labor market, particularly from a South African context.

OBJECTIVE

The aim of the study was to explore and describe the barriers, facilitators and coping strategies that individuals with schizophrenia use when returning to the open labor market after participating in a vocational rehabilitation program to improve work skills.

PARTICIPANTS

Four individuals diagnosed with schizophrenia and two key informants (occupational therapists) participated in the study.

METHODS

The research study was positioned within the interpretive paradigm, specifically utilizing an exploratory and descriptive design. Semi-structured interviews were used in order to gather data from the participants.

RESULTS

Theme one reflects the barriers related to returning to work (i.e. society's acceptance of an individual's work potential). The second theme relates to the enabling factors related to returning to work (i.e. the usefulness of work preparation programs to enhance open labor market employability). Theme three relates to the coping skills that individuals with schizophrenia utilize (i.e. holistic support enhances participation in the worker role).

CONCLUSION

In conclusion, the findings indicate individuals with schizophrenia experience barriers that prevent them from being able to adapt to their work environments. However, with the support of the occupational therapist, family, and employer, together with improvements to the vocational rehabilitation program, these barriers may be alleviated, and there could be an improvement in the reintegration of individuals with schizophrenia into the open labor market. The findings suggest that the disclosure of an individual's medical diagnosis, in order to facilitate the return to work of an individual diagnosed with schizophrenia, could be viewed as a barrier and a facilitator.

Evidence-Based Practice in Primary Care Occupational Therapy: A Cross-Sectional Survey in Sweden

Introduction

Understanding of attitudes, knowledge, and behaviour related to evidence-based practice (EBP) and guidelines in Swedish occupational therapy is limited. The study aims were to investigate attitudes, knowledge, and behaviour related to evidence-based practice and guidelines of Swedish occupational therapists in primary care.

Methods

A web-based survey of 94 Swedish primary care occupational therapists (response rate 53.7%). Data were analysed using logistic regressions.

Results

Attitudes towards EBP and guidelines were highly positive (97%–98%). About half of the respondents reported confidence in finding and using evidence. Almost two-thirds reported being aware of guidelines and 47% knowing where to find guidelines. Four-fifths stated that they had easy access to guidelines and 75% that they used guidelines frequently. Men were more likely to feel confident to find research (OR 8.58, 95% CI 1.03 to 71.66; p = 0.047) and have easy access to guidelines (OR 9.10, 95% CI 1.94 to 42.83; p = 0.005). Occupational therapists older than 50 years were more likely to integrate patient preferences with guideline use (OR 6.44, 95% CI 1.14 to 36.57; p = 0.035). Few reported reading scientific articles, and many expressed uncertainty in finding research. The main barrier for using guidelines was reported to be lack of time.

Conclusion

Although attitudes among primary care occupational therapists towards EBP are positive and a large proportion report using guidelines, many state that they want to learn more and improve their evidence-based practice skills. The findings suggest that education measures need to be taken to address the identified shortcomings.

Implementation of an Electronic Clinical Decision Support Tool for Pediatric Appendicitis Within a Hospital Network

OBJECTIVES

Computed tomography (CT) has been widely used in the evaluation of children with suspected appendicitis, but concerns about ionizing radiation have increased interest in ultrasound for these patients. We sought to assess the effectiveness of an appendicitis electronic clinical decision support (E-CDS) system in increasing ultrasound and decreasing CT use in children evaluated in emergency departments (EDs) for suspected appendicitis.

METHODS

This was a preintervention and postintervention analysis of an E-CDS implemented into an electronic health record system shared by an academic, tertiary-care children's hospital and a community hospital. The tool consisted of a structured order set with embedded clinical advice and a link to a Web site. Emergency department patients aged 3 to 18 years with suspected appendicitis were reviewed retrospectively. Imaging use was assessed 3 months before and 6 months after implementation of the intervention.

RESULTS

Three hundred twenty-seven patients were identified, 211 at postintervention; 80% were seen in the community ED. Among community ED patients with imaging, ultrasound use increased (36%-51%, P = 0.049), and CT scan use decreased (81%-66%, P = 0.044) in the postintervention period, with no change in complications or safety outcomes. No difference was found in ultrasound rate (100%-97%, P = 1.000) or CT scan rate (13%-10%, P = 1.000) among children's ED patients with imaging.

CONCLUSIONS

An E-CDS can effectively decrease CT scanning and increase use of ultrasound in children with suspected appendicitis in a community hospital ED. Electronic clinical decision support may be an effective method of disseminating pediatric best practices from a children's hospital to affiliated community EDs.

Multiprofessional evaluation in clinical practice: establishing a core set of outcome measures for children with cerebral palsy

AIM

To develop a national consensus on outcome measures that define functional ability in children with cerebral palsy (CP) according to the International Classification of Functioning, Disability and Health (ICF) framework.

METHOD

The project started in 2008 in neuropaediatric units of two university hospitals and one outpatient clinic. Each professional group selected representatives to be knowledge brokers for their own specialty. Based on the evidence, expert opinion, and the ICF framework, multiprofessional teams selected the most valid measures used in clinical practice (2009-2010). Data from 269 children with CP were analysed, classified by the Gross Motor Function Classification System, Manual Ability Classification System, and Communication Function Classification System, and evaluated.

RESULTS

The process aimed at improving and unifying clinical practice in Finland through a national consensus on the core set of measures. The selected measures were presented by professional groups, and consensus was reached on the recommended core set of measures to be used in all hospitals treating children with CP in Finland.

INTERPRETATION

A national consensus on relevant and feasible measures is essential for identifying differences in the effectiveness of local practices, and for conducting multisite intervention studies. This project showed that multiprofessional rehabilitation practices can be improved through respect for and inclusion of everyone involved.

Do current vocational evaluation practices in traumatic brain injury align with best practices? Strengths, challenges and recommendations

Introduction

To support implementation of the Inter-professional Guideline for Vocational Evaluation Following Traumatic Brain Injury we compared current practices to best practices as outlined in the guideline.

Method

We recruited health/vocational professionals who do vocational evaluation of traumatic brain injury survivors to participate in qualitative semi-structured interviews. We also conducted a document review of internal clinical and provincial workers’ compensation insurance documents. All data were analyzed using directed content analysis.

Results

Thirteen individuals participated and three types of documents were reviewed. Practices that were found to be frequently aligned with the Inter-professional Guideline for Vocational Evaluation Following Traumatic Brain Injury included: (a) identification of evaluation purpose; (b) obtaining informed consent; (c) gathering background information; (d) assessing persistent symptoms and abilities; (e) analyzing and synthesizing results; and (f) developing return to work recommendations. Practices partially aligned included: (a) incorporating the worker’s perspectives into the evaluation; (b) observing work behaviors in naturalistic settings (c) assessing available supports; and (d) assessing occupational/job demands in context. Practices that did not align with the guideline included: (a) evaluation of the workplace environment and workplace supports; (b) accommodation potential; and (c) assessment of workplace safety.

Conclusion

To support implementation of the guideline and enhance successful vocational outcomes, additional attention and resources should be dedicated to evaluating workplace-based factors and assessing workplace-based risks.

Exploring Vocational Evaluation Practices following Traumatic Brain Injury

BACKGROUND

Individuals with traumatic brain injury (TBI) face many challenges when attempting to return to work (RTW). Vocational evaluation (VE) is a systematic process that involves assessment and appraisal of an individual's current work-related characteristics and abilities.

OBJECTIVE

The aims of this study are to (1) examine demographic and employment characteristics of vocational rehabilitation providers (VRPs), (2) identify the specific evaluation methods that are used in the VE of individuals with TBI, and (3) examine the differences in assessment method practices based upon evaluator assessment preferences.

METHODS

This exploratory case study used a forty-six-item online survey which was distributed to VRPs.

RESULTS

One hundred and nine VRPs accessed the survey. Of these, 74 completed the survey. A majority of respondents were female (79.7%), Caucasian (71.6%), and holding a master's degree (74.3%), and more than half (56.8%) were employed as state vocational rehabilitation counselors (VRCs). In addition, over two-thirds (67.6%) were certified rehabilitation counselors (CRCs). Respondents reported using several specific tools and assessments during the VE process.

CONCLUSIONS

Study findings reveal differences in use of and rationales for specific assessments amongst VRPs. Understanding VRP assessment practices and use of an evidence-based framework for VE following TBI may inform and improve VE practice.

Occupational Therapists' Attitudes, Knowledge, and Implementation of Evidence-Based Practice: A Systematic Review of Published Research

Introduction:

Evidence-based practice is the procedure whereby clinicians incorporate best research evidence, clinical expertise, and patient values to provide best patient care. Recently, there has been a significant push towards occupational therapists' adoption of evidence-based practice. This systematic review aimed to determine occupational therapists' attitudes, knowledge, and utilization of evidence-based practice.

Method:

A search of literature published between 2000–12 was conducted in relation to occupational therapists' practice. Academic Search Complete, Cumulative Index of Nursing and Allied Health Literature Plus, PsycARTICLES, Ingenta, Medline, Science Direct, and Journal Storage were systematically searched using MeSH and free-text keywords. Google Scholar and reference lists were also searched.

Findings:

Thirty-two papers were selected for review: 23 were quantitative, 8 were qualitative, and 1 used a mixed methods design. Studies demonstrated that occupational therapists hold positive attitudes towards evidence-based practice. However, these attitudes do not translate into practice, with research indicating a lack of evidence-based practice utilization. Occupational therapists perceive a number of barriers to evidence-based practice, including lack of time, lack of availability and accessibility of research, and having limited research skills.

Conclusion:

It is essential that educational and training initiatives provide therapists with the tools and support they need to engage fully with research evidence and its application within clinical care.

Determinants for the effectiveness of implementing an occupational therapy intervention in routine dementia care

BACKGROUND

A multifaceted implementation (MFI) strategy was used to implement an evidence-based occupational therapy program for people with dementia (COTiD program). This strategy was successful in increasing the number of referrals, but not in improving occupational therapists' (OTs) adherence. Therefore, a process evaluation was conducted to identify factors that influenced the effectiveness of the MFI strategy.

METHODS

A mixed-method approach of qualitative and quantitative research was used to evaluate the implementation process. The MFI strategy as planned and as executed were reported and evaluated based on the framework of Hulscher et al. (2003; 2006). Data on OTs attitudes and expected barriers were collected at baseline from 94 OTs using a 19-item questionnaire. Data on the experiences were collected after finishing the implementation using focus groups with OTs and telephone interviews with physicians and managers. For quantitative data, frequencies and correlations were calculated and qualitative data were analyzed using inductive content analysis.

RESULTS

The implementation strategy as executed had a stronger focus than planned on increasing OTs promotional skills due to an initial lack of referrals. This resulted in less attention for increasing OTs' skills in using the COTiD program as initially intended. At baseline, OTs had a positive attitude toward the program, however, 75% did not feel experienced enough and only 14.3% felt competent in using the program. Focus groups and interviews revealed various determinants that influenced implementation. Most managers were positive about the program. However, the degree of operational support of managers for OTs regarding the implementation was not always adequate. Managers stated that a well-defined place for occupational therapy within the dementia care network was lacking although this was perceived necessary for successful implementation. Several physicians perceived psychosocial interventions not to be in their area of expertise or not their responsibility. All professionals perceived inter-professional collaboration to be a facilitator for effective implementation, and general practitioners were perceived as key partners in this collaboration. However, collaboration was not always optimal. OTs indicated that increasing the referral rate was most effective when promoting OT via other disciplines within a physician's network.

CONCLUSION

Our data suggests that a first step in successful implementation should be to make sure that individual and organizational barriers are resolved. In addition, implementation should be network-based and encourage inter-professional collaboration. Initial promotion of COTiD should focus on physicians that have a positive attitude toward non-pharmacological interventions.

Translating research into prosthetic and orthotic practice

BACKGROUND

Evidence-based practice is commonly accepted as a means of improving patient outcomes; however, there is little understanding of the processes required to successfully implement it into prosthetic and orthotic practice.

OBJECTIVES

To discuss factors affecting adoption of evidence-based practice and present a theoretical framework for its implementation into prosthetic and orthotic practice.

DISCUSSION

Numerous factors that affect adoption of evidence-based practice are discussed, ranging from individual factors to those that can be attributed to administrative and environmental issues. Specific factors are likely to be context specific and are influenced by the manner in which evidence-based practice is introduced into the working environment. It is argued that successful implementation of evidence-based practice requires consideration of numerous interrelated factors. A formal translating research into practice model is presented as a means of developing a strategic plan that considers all relevant factors and maximizes acceptance of evidence-based practice into prosthetics and orthotics clinical practice.

CONCLUSIONS

The use of a theoretical model for implementation of evidence-based practice is likely to improve its adoption by prosthetic and orthotic clinicians. Clinical relevance The demand for prosthetists/orthotists to utilize evidence-based practice is increasing. Lack of strategic planning throughout the implementation phase is likely to compromise adoption of evidence-based practices by clinicians.

Implementing guidelines for follow-up after surgery with ventilation tube in the tympanic membrane in Norway: a retrospective study

Background

When clinical guidelines are being changed a strategy is required for implementation. St. Olavs University Hospital in Norway modified their guidelines for the follow-up care of children after insertion of ventilation tubes (VT) in the tympanic membrane, transferring the controls of the healthiest children to General Practitioners (GPs). This study evaluates the implementation process in the hospital and in general practice by exploring two issues: 1) Whether the hospital discharged the patients they were supposed to and 2) whether the children consulted a GP for follow-up care.

Methods

A retrospective observational study was performed at St. Olavs University Hospital, Norway and general practice in Mid-Norway. Children under the age of 18 who underwent insertion of VT between Nov 1st 2007 and Dec 31st 2008 (n = 136) were included. Degree of guideline adherence at the hospital and in general practice was measured.

Results

The hospital adhered to the guidelines in two-thirds (68.5%) of the patients, planning more patients for follow-up by their GP than recommended in the guidelines (25.8% vs. 12.4%). All except one contacted their GP for control. In total 60% were referred back to specialist health services within two years.

Conclusions

The methods for guideline implementation were successful in securing consultations for follow-up care in general practice. Lack of guideline adherence in the hospital can partly be explained by the lack of quality of the guideline. Further studies are needed to evaluate the quality of controls done by the GPs in order to consider implications for follow-up after VT surgery.

Printed educational materials: effects on professional practice and healthcare outcomes

BACKGROUND

Printed educational materials are widely used passive dissemination strategies to improve the quality of clinical practice and patient outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines.

OBJECTIVES

To assess the effect of printed educational materials on the practice of healthcare professionals and patient health outcomes.To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on professional practice and patient outcomes.

SEARCH METHODS

For this update, search strategies were rewritten and substantially changed from those published in the original review in order to refocus the search from published material to printed material and to expand terminology describing printed materials. Given the significant changes, all databases were searched from start date to June 2011. We searched: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and the EPOC Register.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-randomised trials, controlled before and after studies (CBAs) and interrupted time series (ITS) analyses that evaluated the impact of printed educational materials (PEMs) on healthcare professionals' practice or patient outcomes, or both. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. There was no language restriction. Any objective measure of professional practice (e.g. number of tests ordered, prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included.

DATA COLLECTION AND ANALYSIS

Two review authors undertook data extraction independently, and any disagreement was resolved by discussion among the review authors. For analyses, the included studies were grouped according to study design, type of outcome (professional practice or patient outcome, continuous or dichotomous) and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where the data were available, we re-analysed the ITS studies and reported median differences in slope and in level for each outcome, across outcomes for each study, and then across studies. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format.

MAIN RESULTS

The review includes 45 studies: 14 RCTs and 31 ITS studies. Almost all the included studies (44/45) compared the effectiveness of PEM to no intervention. One single study compared paper-based PEM to the same document delivered on CD-ROM. Based on seven RCTs and 54 outcomes, the median absolute risk difference in categorical practice outcomes was 0.02 when PEMs were compared to no intervention (range from 0 to +0.11). Based on three RCTs and eight outcomes, the median improvement in standardised mean difference for continuous profession practice outcomes was 0.13 when PEMs were compared to no intervention (range from -0.16 to +0.36). Only two RCTs and two ITS studies reported patient outcomes. In addition, we re-analysed 54 outcomes from 25 ITS studies, using time series regression and observed statistically significant improvement in level or in slope in 27 outcomes. From the ITS studies, we calculated improvements in professional practice outcomes across studies after PEM dissemination (standardised median change in level = 1.69). From the data gathered, we could not comment on which PEM characteristic influenced their effectiveness.

AUTHORS' CONCLUSIONS

The results of this review suggest that when used alone and compared to no intervention, PEMs may have a small beneficial effect on professional practice outcomes. There is insufficient information to reliably estimate the effect of PEMs on patient outcomes, and clinical significance of the observed effect sizes is not known. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.

Evaluation of the uptake of the Australian standardized terminology and definitions for texture modified foods and fluids

This paper discusses the uptake of standardized terminology and definitions for texture modified foods and fluids. The Australian dietetic and speech-language pathology associations endorsed national standards in 2007. This project sought to determine the barriers and enablers for use of the national standards in clinical practice. Cross-sectional online surveys were developed, including open- and closed-response questions. The surveys targeted different professional groups in Australia including speech-language pathologists, dietitians, nurses, and food service personnel. Australian accredited universities were contacted to determine penetration of the standards. A total of 574 surveys were received. Sixty-five per cent of respondents indicated full implementation, 23% partial implementation, and 10% no implementation of the standards in their workplace. Speech-language pathologists and dietitians were most likely to have championed implementation of the standards. Barriers to implementation included: lack of knowledge about the standards, time, and resistance to change. Enablers included: encouragement to use the standards and 'buy-in' from stakeholders. Benefits of implementation included: consistent terminology and perceived improvements in patient safety. It was concluded that the standards have been successfully implemented in a majority of facilities and Australian universities. This study provides insight into the complexity of introducing and managing change in healthcare environments.

Differences in Perceptions of Patient Safety Culture between Charge and Noncharge Nurses: Implications for Effectiveness Outcomes Research

The implementation of evidence-based practice guidelines can be influenced by nurses' perceptions of the organizational safety culture. Shift-by-shift management of each nursing unit is designated to a subset of staff nurses (charge nurses), whom are often recruited as champions for change. The findings indicate that compared to charge nurses, noncharge nurses were more positive about overall perceptions of safety (P = .05) and teamwork (P < .05). Among charge nurses, significant differences were observed based on the number of years' experience in charge: perception of teamwork within units [F(3, 365) = 3.52, P < .01]; overall perceptions of safety, [F(3, 365) = 4.20, P < .05]; safety grade for work area [F(3, 360) = 2.61, P < .05]; number of events reported within the last month [F(3, 362) = 3.49, P < .05]. These findings provide important insights to organizational contextual factors that may impact effectiveness outcomes research in the future.