Evidence-based practice in everyday clinical practice: strategies for change in a tertiary occupational therapy department

Evidence-based practice is an approach that has gained recognition for facilitating the transfer of evidence into quality clinical practice. While occupational therapy clinicians have a professional responsibility to ensure that their practice is effective, managers also have a responsibility to implement structures and systems that will support therapists in doing so. A review of the literature demonstrated limited evidence of specific organisational models of practice to facilitate the transfer of knowledge into occupational therapy practice. This paper outlines the steps undertaken by occupational therapists in a large tertiary teaching hospital to develop and implement a model of research utilisation. The resulting Research and Evidence in Practice model and the enabling strategies for its implementation are presented. A challenge for the future is to conduct a formal evaluation of the model.     

Chronic pain following stroke: Current treatment and perceived effect

BackgroundChronic pain is common following stroke, however there is little known about the treatments for pain that are being accessed by stroke survivors, nor their perceived effectiveness.ObjectivesThe objectives were to: i) identify the number and type of treatments for pain currently used by stroke survivors with chronic pain; and ii) examine the self-perceived effectiveness of medication and non-medication treatments for pain.MethodsCross-sectional survey. Participants with stroke and self-reported chronic pain completed an online survey that measured demographics, stroke related factors, intensity of pain, treatments for pain, and perceived effect of medication and non-medication treatments for pain.ResultsOf 322 stroke survivors who completed the survey, the majority (90.1%) reported current use of pain treatment(s). Medications were accessed by 257 (79.8%), with the most common being anti-inflammatories (39.8%), anticonvulsants (29.5%) and antidepressants (24.8%). Paracetamol (12.1%) was the most common non-prescribed medication used. Polypharmacy was high, with 129 (40.1%) reporting taking 2 or more medications. Medication treatments were self-reported to be effective in 47.1% of those taking medication. Non-medication treatments were accessed by 208 (64.6%), with Physical Therapy/Physiotherapy being most common (48.1%), followed by Occupational Therapy (15.5%) and Psychology (11.8%). Use of multiple non-medication treatments was reported by 85 (26.4%). Non-medication treatments were reported to be effective by 52.4% of those receiving them.ConclusionsSurvey findings indicate that stroke survivors with chronic pain demonstrate high utilization of pain treatments, despite the perception that treatment is often ineffective. This highlights the need to develop effective pain interventions for stroke survivors.     

Organisational strategies for changing clinical practice: how trusts are meeting the challenges of clinical governance

OBJECTIVES: To describe the use, perceived effectiveness, and predicted future use of organisational strategies for influencing clinicians' behaviour in the approach of NHS trusts to clinical governance, and to ascertain the perceived benefits of clinical governance and the barriers to change. DESIGN AND SETTING: Whole population postal survey conducted between March and June 1999. SUBJECTS: Clinical governance leads of 86 NHS trusts across the South West and West Midlands regions. METHOD: A combination of open questions to assess the use of strategies to influence clinician behaviour and the barriers to clinical governance. Closed (yes/no) and Likert type ratings were used to assess the use, perceived effectiveness, and future use of 13 strategies and the predicted outcomes of clinical governance. RESULTS: All trusts use one or more of 13 strategies categorised as educational, facilitative, performance management, and organisational change methods. Most popular were educational programmes (96%) and protocols and guidelines (97%). The least popular was performance management such as use of financial incentives (29%). Examples of successful existing practice to date showed a preference for initiatives that described the use of protocols and guidelines, and use of benchmarking data. Strategies most frequently rated as effective were facilitative methods such as the facilitation of best practice in clinical teams (79%), the use of pilot projects (73%), and protocols and guidelines (52%). The least often cited as effective were educational programmes (42%) and training clinicians in information management (20%); 8% found none of the 13 strategies to be effective. Predicted future use showed that all the trusts which completed this section intended to use at least one of the 13 strategies. The most popular strategies were educational and facilitative. Scatterplots show that there is a consistent relationship between use and planned future use. This was less apparent for the relationship between planned use and perceived effectiveness. Barriers to change included lack of resources, mainly of money and staff time, and the need to address cultural issues, plus infrastructure support. The anticipated outcomes of clinical governance show that most trusts expect to influence clinician behaviour by improving patient outcomes (78%), but only 53% expect it to result in better use of resources, improved patient satisfaction (36%), and reduced complaints (10%). CONCLUSIONS: Clinical governance leads of trusts report using a range of strategies for influencing clinician behaviour and plan to use a similar range in the future. The choice of methods seems to be related to past experience of local use, despite equivocal judgements of their perceived effectiveness in the trusts. Most expect to achieve a positive impact on patient outcomes as a result. It is concluded that trusts should establish methods of learning what strategies are effective from their own data and from external comparison.     

Implementing research findings into practice using clinical opinion leaders: barriers and lessons learned

BACKGROUND: An opinion leader-driven intervention to improve practice guideline-based medication management for patients with schizophrenia was tested at four Department of Veterans Affairs health care facilities. The concept of using opinion leaders as disseminators of research evidence and internal agents of change has been widely reported. PROJECT OVERVIEW: Each intervention site received an intensive, multicomponent intervention during the course of one year. The project's process evaluation included ongoing brief surveys of physicians' attitudes and behaviors, logs of reports from opinion leader conference calls, and interviews with the opinion leaders toward the end of the implementation period. BARRIERS OR ISSUES AND POTENTIAL SOLUTIONS: Several barriers or problematic issues surfaced: (1) physicians do not always agree on who is an opinion leader; some sites may have no opinion leader; (2) some sites had poorly developed formal and informal social networks among physicians; (3) a focus on physicians only as agents of change; and (4) how much directive should be given to the opinion leaders concerning how to influence attitudes and behaviors? DISCUSSION: Four major problematic issues encountered during the project offer potential solutions for addressing them.     

Prioritization strategies in clinical practice guidelines development: a pilot study

Objective  

Few methodological studies address the prioritization of clinical topics for the development of Clinical Practice Guidelines (CPGs). The aim of this study was to validate a methodology for Priority Determination of Topics (PDT) of CPGs.     

The medical perspective towards chronic pain: biomedical model and clinical practice

This study aimed to shed light on the meanings ascribed to chronic pain in medical discourse and clinical practice in two Pain Clinics located in University hospitals in Salvador (Bahia) and S?o Paulo, Brazil. An ethnographic approach used participant observation and semi-structuralized interviews with attending and managing physicians. Data analysis drew on the clinical models developed by Byron Good and the medical rationalities project formulated by Madel Luz. The meanings emerging from the study were the recognition of chronic pain by biomedicine as a disease rather than a symptom, its invisibility to physicians, and its non-communicability and inevitability. The informants suggested the need for valorization of the human encounter in the clinic, exercise of understanding as opposed to suspicion, and negotiation of sustainable therapeutic projects.     

The impact of patient-reported outcome measures in clinical practice for pain: a systematic review

Purpose

Patient-reported outcome measures (PROMs) have increasingly been incorporated into clinical practice. Research suggests that PROMs could be viewed as active components of complex interventions and may affect the process and outcome of care. This systematic review examines PROMs in the context of treatment for non-malignant pain.

Methods

An electronic search on: MEDLINE, EMBASE, PsycINFO, PsycARTICLES, Cochrane Library and Web of Science identified relevant papers (February 2015). The inclusion criteria were: focused on implementing PROMs into clinical practice, adults, and primary data studies. Critical interpretive synthesis was used to synthesise qualitative and quantitative findings into a theoretical argument.

Results

Thirteen eligible studies were identified. Synthesis suggested that PROMs may be included in the initial consultation to assess patients and for shared decision-making regarding patient care. During the course of treatment, PROMs can be used to track progress, evaluate treatment, and change the course of care; using PROMs may also influence the therapeutic relationship. Post-treatment, using PROMs might directly influence other outcomes such as pain and patient satisfaction. However, although studies have investigated these areas, evidence is weak and inconclusive.

Conclusion

Due to the poor quality, lack of generalisability and heterogeneity of these studies, it is not possible to provide a comprehensive understanding of how PROMs may impact clinical treatment of non-malignant pain. The literature suggests that PROMs enable pain assessment, decision-making, the therapeutic relationship, evaluation of treatment and may influence outcomes. Further research is needed to provide better evidence as to whether PROMs do indeed have any effects on these domains.

     

Depression care for the elderly: reducing barriers to evidence-based practice

This paper provides an overview of five key bodies of evidence identifying: (1) Characteristics of depression among older adults -- its prevalence, risk factors and illness course, and impact on functional status, mortality, use of health services, and health care costs; (2) Effective Interventions, including pharmacologic, psychotherapies, care management, and combined intervention models; (3) Known Barriers to depression care including patient, provider and service system barriers; (4) Effective Organizational and Educational Strategies to reduce barriers to depression care; and (5) Key Factors in Translating Research into Practice. There is strong empirical support for implementing strategies to improve depression care for older adults.     

Assessment: identifying the barriers to good practice

Although much has been written about the concept of assessment, there is still no clear consensus on the characteristics of good practice. Moreover, recent studies have highlighted the fact that frameworks for assessment are often heavily influenced by particular professional perspectives, and consequently the holistic assessment of need envisaged in the National Health Service (NHS) and Community Care Act 1990 has yet to emerge. This paper identifies some of the contradictions inherent in the practice guidance relating to assessment and discusses the results of early evaluations of the implementation of the new assessment process. A possible model to structure this process is outlined and suggestions made as to the benchmarks of good assessment practice.     

Mother-infant consultation during drug treatment: Research and innovative clinical practice

Background  

This paper details a model for consulting with mothers and infants, and drug treatment staff used in a residential drug treatment program and relevant to other treatment settings. The role of parent-infant consultation based on the Neonatal Network Neurobehavioral Scale (NNNS) was evaluated.     

Evidence-based practice: strategies for its implementation in nursing

Evidence-based practice is an approach that enables the improvement of health care quality. The use of research findings on founded practice is one of the pillars of such approach; however, there are various barriers that hinder this nursing process, such as the lack of nurses' skills, lack of time and organizational support (human, material and financial resources). Therefore, based on the literature, this article presents some strategies that allow for the implementation of evidence-based practice in nursing in whatever area the nurse may perform.     

Connecting philosophy and practice: implications of two philosophic approaches to pain for nurses' expert clinical decision making

Abstract  McCaffery's definition of pain as 'whatever the patient says it is' was truly revolutionary for nursing because of its capacity to lend credibility to the patient's pain experience. However, this definition, still widely in use, represents a particular philosophic approach to pain that has limitations for nurses' expert clinical decision making. In this paper, we trace the evolution of explanations for pain and discuss two philosophic approaches to pain that are common today. The first approach, the externalist perceptual view of pain, considers pain as a perceptual experience, one that like any perceptual experience can be 'misperceived' by the person having the experience. The second approach, the non-representational view of pain, considers pain as a holistic experience, one where physical and existential aspects necessarily coincide. These two approaches, while both emphasizing the importance of believing the patient's expression, have different implications for clinical decision making. Only the first approach permits nurses to exercise the nuanced judgement that differentiates pain from other related conditions such as anxiety, suffering or meaninglessness.