A conceptual framework to increase usability of outcome research for evidence-based practice.

Although evidence-based practice is the current practice approach recommended for use in occupational therapy, practitioners often report difficulties in using research evidence because of its content and presentation. This paper discusses a conceptual model that researchers can use to create research evidence that is easier for practitioners to understand and use. The Diffusion of Innovations Theory is used as a framework to identify desirable characteristics that may facilitate practitioners' adoption and utilization of research evidence. The concepts of social validity, ecological validity, and clinical significance are presented and discussed as ways to create those desirable characteristics that could make research information more usable for evidence-based practice. Examples for implementation of the conceptual model are also discussed.     

Clinical reasoning strategies in physical therapy

BACKGROUND AND PURPOSE: Clinical reasoning remains a relatively under-researched subject in physical therapy. The purpose of this qualitative study was to examine the clinical reasoning of expert physical therapists in 3 different fields of physical therapy: orthopedic (manual) physical therapy, neurological physical therapy, and domiciliary care (home health) physical therapy. SUBJECTS: The subjects were 6 peer-designated expert physical therapists (2 from each field) nominated by leaders within the Australian Physiotherapy Association and 6 other interviewed experts representing each of the same 3 fields. METHODS: Guided by a grounded theory method, a multiple case study approach was used to study the clinical practice of the 6 physical therapists in the 3 fields. RESULTS: A model of clinical reasoning in physical therapy characterized by the notion of "clinical reasoning strategies" is proposed by the authors. Within these clinical reasoning strategies, the application of different paradigms of knowledge and their interplay within reasoning is termed "dialectical reasoning." DISCUSSION AND CONCLUSION: The findings of this study provide a potential clinical reasoning framework for the adoption of emerging models of impairment and disability in physical therapy.     

Introducing OTseeker (Occupational Therapy Systematic Evaluation of Evidence): a new evidence database for occupational therapists.

This clinical scenario illustrates how OTseeker can be used by occupational therapists to locate research that may inform clinical decisions. Beyond the clinical arena, this database also has potential to greatly enhance the ability of researchers to perform systematic reviews of RCTs and eventually, development of clinical guidelines. In conclusion, OTseeker is a new Web-based database that provides fast access to evidence of therapeutic effectiveness for clinicians, academics, and students, as well as consumers and providers of occupational therapy services. OTseeker will be able to be used by clinicians to guide dinical practice, by researchers to perform systematic reviews of RCTs, by students, and by consortiums of stakeholders to develop evidence-based guidelines for occupational therapy practice.     

EVIDENCE – BASED MEDICINE/PRACTICE IN SPORTS PHYSICAL THERAPY

A push for the use of evidence‐based medicine and evidence‐based practice patterns has permeated most health care disciplines. The use of evidence‐based practice in sports physical therapy may improve health care quality, reduce medical errors, help balance known benefits and risks, challenge views based on beliefs rather than evidence, and help to integrate patient preferences into decision‐making. In this era of health care utilization sports physical therapists are expected to integrate clinical experience with conscientious, explicit, and judicious use of research evidence in order to make clearly informed decisions in order to help maximize and optimize patient well‐being. One of the more common reasons for not using evidence in clinical practice is the perceived lack of skills and knowledge when searching for or appraising research. This clinical commentary was developed to educate the readership on what constitutes evidence‐based practice, and strategies used to seek evidence in the daily clinical practice of sports physical therapy.     

Professional Reasoning and Occupational Therapist's Use of a Multi-Sensory Environment for Clients with Dementia

ABSTRACT

Aims: To examine the professional reasoning process of occupational therapists using multi-sensory environments (MSEs) to treat clients with dementia. Methods: This was a qualitative study design which used interviews to uncover the multi-faceted professional reasoning process used by occupational therapists when implementing MSE interventions for individuals with dementia. Results: Qualitative data analysis yielded three themes regarding the professional reasoning process of occupational therapists that use MSEs to treat clients with dementia. Clinicians use MSEs because the intervention emphasizes client-centered care; facilitates neural changes; and promotes emotional connections. Conclusions: Current evidence does not support the professional reasoning process which occupational therapists use when integrating the MSE into the occupational therapy plan of care. Further qualitative research is indicated to explore why occupational therapists continue to use interventions that are not evidence-based and to examine the process in which clinicians abandon current practice methods when research evidence does not support their use.     

Neurorehabilitation: are we doing all that we can?

Occupational therapists have many intervention tools available for working with clients having a neurological injury; however, some of the most innovative and effective methods have not gained acceptance by many clinicians. Emerging research and new technologies provide occupational therapists with a multitude of treatment strategies and novel devices, but incorporation of those tools into clinical practice appears to be limited by the time necessary to learn about the intervention, educational requirements associated with implementation, or lack of awareness regarding the evidence supporting the use of such tools. Strategies to combat this trend include educating clinicians on evidence-based methods for neurological rehabilitation, aligning academics with practitioners to translate evidence into practical treatment strategies, and accepting that occupational therapy can use these innovations as a means toward state-of-the art, occupation-based practice.     

Implementing evidence in clinical practice: the ‘therapies’ dilemma

Evidence-based practice involves the application of the best available evidence, often from research findings, into the clinical setting to ensure best practice. This paper discusses some of the issues faced by allied health therapists when attempting to integrate research evidence into their own clinical practice. Of particular concern in allied health research are the methodological flaws, which may seriously affect the capacity of the allied health therapist to use the evidence in their clinical practice. Single therapy intervention research, or research based on an occasion of service does not replicate the model of clinical reasoning that underpins the clinical process, nor the notion of an episode of care that characterizes the allied health therapies. Other issues such as the relevance of outcome measures used in allied health research to potential stakeholders, and the differences between therapy diagnostic criteria and research diagnostic criteria used will also adversely affect the capacity for therapists to use the research evidence. It is imperative that research paradigms begin to address the therapy paradigms, allowing research evidence to reflect the real-world situation. Allied health therapists must take a pro-active stance in the process, through undertaking organized reflective practice and forging links with researchers. Barriers associated with the implementation of evidence-based practice in the allied health professions may be reduced with the publishing of relevant clinically directed research.     

An emerging view of mastery, excellence, and leadership in occupational therapy practice.

The recent focus on clinical reasoning in occupational therapy, specifically on how therapists solve complex problems, has stimulated interest in how master clinicians think in practice. By gaining insight into how clinicians think and what they think about when they identify and solve problems, we may be able to identify clinical reasoning patterns and processes that occupational therapy students and novice therapists need to experience in order to progress in their practice or to emerge as leaders in their field. Observation of the way in which clinical masters and leaders view challenges and solve problems as manifested in their clinical reasoning may provide new and potential therapists with clues as to how to best bone their skills and knowledge for future success in practice. This paper describes a study that examined the relationship of mastery, excellence, and leadership in occupational therapy. Ten master clinicians were interviewed to determine the characteristics of their mastery and excellence in practice and to explore the degree to which they engaged in leadership behavior. The findings revealed that mastery, excellence, and leadership are independent of one another but that some characteristics are common to all of these phenomenas.     

Nursing students’ knowledge,attitude and readiness to work for clients with sexual health concerns

Aims. To investigate nursing students’ knowledge, attitude and readiness to work for clients with sexual health concerns and to identify strategies to help students develop as they take up their role in sexual health‐related care. Background. There is an increasing global demand for improving sexual health. A better understanding of nursing students’ attitude and readiness to work for clients with sexual health concerns is the beginning of this endeavour. The need to explore strategies for developing competent health care practitioners is timely. Design. A cross‐sectional survey. Methods. Nursing students (n = 377) studying in pre‐ and postregistration programmes were surveyed at a university in Hong Kong using a questionnaire with open‐ and closed‐ended questions about their knowledge, attitude and self‐perception on readiness to work for clients with sexual health concerns. Results. Students’ knowledge of sexual health was satisfactory. They were positive in acknowledging the nursing role in sexual health care, but hesitant in taking up an active role in practice. Students’ readiness to participate in related activities was below satisfactory. Their perception of inadequate knowledge, feelings of anxiety, worries about colleagues’ and clients’ possible adverse responses and inadequate exemplars were major factors affecting their readiness. This paper also highlighted some important learning areas and strategies that could help in enhancing students’ knowledge and confidence in sexual health care practices. Conclusion. Improving the educational programme and clinical practice for nursing students is necessary but may not be adequate. Valuing the affective aspect of education, formal recognition of this extended role and advancing related education to a postexperience level would also benefit the development of sexual health care. Relevance to clinical practice. Preparing more mentors as exemplars, inviting clinicians and managers as partners in sexual health‐related care would help nursing students to work efficiently for clients with sexual health concerns.     

The role and position of passive intervertebral motion assessment within clinical reasoning and decision-making in manual physical therapy: a qualitative interview study

Passive intervertebral motion (PIVM) assessment is a characterizing skill of manual physical therapists (MPTs) and is important for judgments about impairments in spinal joint function. It is unknown as to why and how MPTs use this mobility testing of spinal motion segments within their clinical reasoning and decision-making. This qualitative study aimed to explore and understand the role and position of PIVM assessment within the manual diagnostic process. Eight semistructured individual interviews with expert MPTs and three subsequent group interviews using manual physical therapy consultation platforms were conducted. Line-by-line coding was performed on the transcribed data, and final main themes were identified from subcategories. Three researchers were involved in the analysis process. Four themes emerged from the data: contextuality, consistency, impairment orientedness, and subjectivity. These themes were interrelated and linked to concepts of professionalism and clinical reasoning. MPTs used PIVM assessment within a multidimensional, biopsychosocial framework incorporating clinical data relating to mechanical dysfunction as well as to personal factors while applying various clinical reasoning strategies. Interpretation of PIVM assessment and subsequent decisions on manipulative treatment were strongly rooted within practitioners’ practical knowledge. This study has identified the specific role and position of PIVM assessment as related to other clinical findings within clinical reasoning and decision-making in manual physical therapy in The Netherlands. We recommend future research in manual diagnostics to account for the multivariable character of physical examination of the spine.     

How do practising clinicians and students apply newly learned causal information about mental disorders?

Rationale, aims and objectives New causal theories explaining the aetiology of psychiatric disorders continuously appear in the literature. How might such new information directly impact clinical practice, to the degree that clinicians are aware of it and accept it? We investigated whether expert clinical psychologists and students use new causal information about psychiatric disorders according to rationalist norms in their diagnostic reasoning. Specifically, philosophical and Bayesian analyses suggest that it is rational to draw stronger inferences about the presence of a disorder when a client's presenting symptoms are from disparate locations in a causal theory of the disorder than when they are from proximal locations. Method In a controlled experiment, we presented experienced clinical psychologists and students with recently published causal theories for different disorders; specifically, these theories proposed how the symptoms of each disorder stem from a root cause. Participants viewed hypothetical clients with presenting proximal or diverse symptoms, and indicated either the likelihood that the client has the disorder, or what additional information they would seek out to help inform a diagnostic decision. Results Clinicians and students alike showed a strong preference for diverse evidence, over proximal evidence, in making diagnostic judgments and in seeking additional information. They did not show this preference in the control condition, in which they gave their own opinions prior to learning the causal information. Conclusion These findings suggest that experienced clinical psychologists and students are likely to use newly learned causal knowledge in a normative, rational way in diagnostic reasoning.     

Connecting with clinicians: Opportunities to strengthen rehabilitation research

Purpose. This article examines the distinctive opportunities and challenges involved in connecting with clinicians to strengthen rehabilitation research.

Method. The relevant literature on various factors that link researchers and clinicians is summarized and discussed.

Results. Links between researchers and clinicians are demonstrated by evidence-based practice, common conceptual background and the development of research capacity. Sustainable partnerships can evolve throughout the research process by using various enduring strategies such as experts' committee as well as novel approaches like communities of practice.

Conclusion. This paper reflects the conviction that reducing the gap between research and clinical practice will be facilitated by implementing partnerships originating from both researchers and clinicians.     

An introduction to the multisystem model of knowledge integration and translation

Many nurse researchers have designed strategies to assist health care practitioners to move evidence into practice. While many have been identified as "models," most do not have a conceptual framework. They are unidirectional, complex, and difficult for novice research users to understand. These models have focused on empirical knowledge and ignored the importance of practitioners' tacit knowledge. The Communities of Practice conceptual framework allows for the integration of tacit and explicit knowledge into practice. This article describes the development of a new translation model, the Multisystem Model of Knowledge Integration and Translation, supported by the Communities of Practice conceptual framework.     

A longitudinal framework for fostering critical thinking and diagnostic reasoning

Nurses' reasoning skills are of interest to nurse researchers, managers, clinicians, educators and students. Recent emphasis on critical thinking has raised important questions regarding the modes of reasoning necessary for practice and appropriate measures to improve nurses' cognitive skills. This paper analyses critical thinking and diagnostic reasoning. A longitudinal framework for promoting both modes of reasoning, beginning with nursing students through to experienced clinicians, is proposed as a model worth testing in nurse samples.     

Reflexivity and metapositions: strategies for appraisal of clinical evidence

According to Sackett, evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. In this article, clinical reasoning is depicted as multilayered processes of evidence construction by means of social interaction and human interpretation. A basic set of knowledge is the doctors initial capital at the onset of the individual encounter. This is a necessary, but insufficient, presumption for the elaboration of clinical knowledge required to solve the particular problem. A diagnostic conclusion may appear to constitute the most obvious part of knowledge. Yet the formulation of hypotheses and the choice of adequate strategies for the pursuit of evidence are perhaps even more significant dimensions of clinical knowledge. Potential biases affect the ways in which evidence is gathered and used. When clinicians are not committed to appraising the evidence constituting the foundations of their enterprise, quality assessment of clinical practice becomes casual and unreliable. Reflexivity implies having a self-conscious account of the production of knowledge as it is being produced. From metapositions, critical questions can be asked and sometimes answered. Evidence-based practice in the original sense requires that doctors reflect upon their own positions as knowers, in the process of situated knowing, where certain rhetorical spaces rule.     

How should the effectiveness of problem-based learning in occupational therapy education be examined?

Our aim in discussing the issue of educational outcomes of PBL has been to provoke discussion among occupational therapy educators and researchers. Future collaboration and research should involve occupational therapy educational programs that use PBL and those who have yet to access this teaching-learning method. Multisite studies would allow the evaluation of different teaching methods of clinical reasoning and their respective efficacies. Germane instruments that are easy to use and that effectively measure clinical reasoning in occupational therapy must be developed to supplement the qualitative research that is being undertaken. Such research will support and validate the use of resources and constructively contribute to accountability. PBL may be valuable for promoting adaptive learning in students, which will help them and the profession stay informed and proactive and ensure best practice in a rapidly changing health care environment. This article is a call for educators to collaborate in educational outcome research studies. The traditional methods of evaluation, such as pass rates on national certification examinations, may not demonstrate the multidimensional learning and cognitive growth acquired in PBL; therefore, there is a need to generate validating research about the efficacy of PBL in occupational therapy education. If we are to undertake the challenging task of measuring the development of clinical reasoning, research will require creativity and reflection, hallmarks of the PBL process.     

Realising the potential of Q methodology in nursing research

BackgroundMixed methods research designs are becoming increasingly popular in nursing to explore complex clinical issues and to generate knowledge useful to improve the quality of nursing practice and clients’ health outcomes. Q methodology is one such research design that combines the strengths of both qualitative and quantitative approaches to examine scientifically peoples’ subjectivity towards a subject area.AimThis paper aims to provide an introduction to Q methodology and outlines the steps taken when conducting research on clinical issues.MethodsA clinical example of nurses caring for clients with a risk for aggression is used to illustrate how Q methodology was used to examine this subject area. The five sequential phases of Q-methodology integrate both approaches in a continuous interaction in a single study design, enabling researchers to explore the breadth and depth of factors that influence participants’ responses towards the topic under investigation.FindingsQ methodology is a unique mixed methods design as it does not require the researcher to spend time triangulating two or more research approaches into one single study or to conduct a qualitative and a quantitative study separately. The unique characteristics of Q methodology can be advantageous for nurses who have complex clinical workloads but also want to conduct research. Moreover, Q methodology does not require a large sample size, hence it is resource- and cost-effective.DiscussionQ methodology allows both nurse clinicians and nurse academics to explore new dimensions of staff and clients’ subjectivity which is important for the development of evidence based practice.ConclusionAdding Q methodology to the nursing research repertoire can facilitate nurse researchers to expand clinical research opportunities, to improve client care and to build capacity in early career nurse researchers.     

Perceptions of research utilization: comparisons between health care professionals, nursing students and a reference group of nurse clinicians

The study reported in this paper was carried out to investigate a group of nursing teachers' (n=37), nursing students' (n=166), nursing administrators' (n=33) and physicians' (n=127) perceptions of barriers to and facilitators of nurses' use of research findings in clinical practice. The results were compared with the corresponding figures for a reference group of nurse clinicians (n=237). The Barriers Scale and a questionnaire for the demographic issues were used for data collection. The organization and the communication of research were seen as barriers to research utilization by the nursing teachers, students and administrators in agreement with the nurse clinicians. The nurses' research-related competence and awareness were seen as barriers by the nursing teachers, students and administrators to a greater extent than by the nurse clinicians themselves. The physicians perceived barriers to a lesser extent than the other groups did. The students' perceptions were closest to the nurse clinicians, while the physicians' perceptions differed most. Education to increase the nurses' knowledge of research and to develop their competence to evaluate research results, increased resources for education, more staff, support from the administration and research presented in a user-friendly way were the most frequently suggested facilitators. The nurses' isolation from knowledgeable colleagues with whom to discuss the research was seen as a barrier by the majority of the participants. This indicates a need for positions in clinical practice for nursing researchers, in order to promote a research-based, nursing practice.     

Conceptual models for implementing biopsychosocial theory in clinical practice

The integration of the biopsychosocial model into manual therapy practice is challenging for clinicians, especially for those who have not received formal training in biopsychosocial theory or its application. In this masterclass two contemporary models of health and disability are presented along with a model for organizing clinical knowledge, and a model of reasoning strategies that will assist clinicians in their understanding and application of biopsychosocial theory. All four models emphasise the importance of understanding and managing both the psychosocial and the biomedical aspects of patients' problems. Facilitating change in patients' (and clinicians') perspectives on pain and its biopsychosocial influences requires them to reflect on their underlying assumptions and the basis of those beliefs. Through this reflective process perspectives will be transformed, and for clinicians, in time, different management practices will emerge.     

Integrating evidence-based practice in nurse practitioner education

This column normally focuses on a specific clinical practice guideline (CPG). This month's column deviates from that practice to demonstrate how evidence-based practice (EBP) was integrated into the nurse practitioner (NP) curriculum at the University of Texas at Austin School of Nursing. Processes of EBP were linked to student clinical assignments across core NP clinical courses, culminating in a student-published CPG. When students research and analyze available scientific evidence for a CPG, they learn to critically evaluate and logically organize knowledge for use in clinical practice, and those critical-thinking skills can lead to improved clinical reasoning and decision making.