Transcript Methods

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]
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 medicine
in context
 Physician as guild master replaced by
physician as scientist model (Europe 17th18th 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 therapy
OPP Model (Fearing, Law & Clark, 1997)
Name & prioritize
« occupations »
(things people
want to do or
need to do)
Select
theoretical
lens
Evaluate – can
the person now
do it?
Carry out plan
Make a plan
to try new
ways of doing
based on this
analysis
Determine aspects
of the person, the
environment or the
occupation that are
blocking the
« occupation »
Determine aspects
of each that could
facilite the
« occupation »
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 cabinet
A. 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 cabinet
B. 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 cabinet
C. 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 stage
 Made best practice
recommendations
Findings to date
Stage 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 date
OPP 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
 Problem
itself is a valued occupation
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 date
OPP 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 General
specific
3
1
Dementia
specific
1
General
7
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
 Intrusion
affected by (cont’d)
into personal space
 Background noise
 Communication 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 date
OPP 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 timeconsuming 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.