Using a professional practice model to structure evidence review: the agony and the ecstasy

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

megan@uottawa.ca

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.