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

1. 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 megan@uottawa.ca

2. 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

3. We are dedicated to educating our students to be evidence-based practitioners, but what does it mean to be evidence-based?

4. 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

5. 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

6. 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

7. 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.

8. This works well for common, well-delineated problems with linear solutions:e.g., severe chest pain, sweating

9. How many of these types of problems do we have in nursing, midwifery and allied health?

10. 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?

11. The process of occupational therapyOPP Model (Fearing, Law & Clark, 1997) Select theoretical lens Name & prioritize « occupations » (things people want to do or need to do) Determine aspects of each that could facilite the « occupation » Determine aspects of the person, the environment or the occupation that are blocking the « occupation » Evaluate – can the person now do it? Carry out plan Make a plan to try new ways of doing based on this analysis

12. Could this process model be used as a 7-drawer filing cabinet for evidence based OT? Alzheimer disease chosen as a test case.

13. 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

14. Filling the filing cabinetA. the search

15. 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

16. Literature Search • Data bases • CINAHL • Cochrane • Current Contents • Dissertation Abstracts • Embase • Health Star • Medline and Premedline • OTDBase • PsychInfo

17. Literature Search • Limits • French & English • 1990- present • Inclusion • Descriptions of theory/application of theory • Research reports (inc systematic reviews) • Quantitative or qualitative • > 50% AD

18. 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

19. Filling the filing cabinetC. Selection of articles to keep • Appraised – using our own quality cut-offs

20. Quantitative study criteria (>4) • Methods clearly stated • Participants adequately described • Validated tools • Analysis appropriate • At least two measurement points

21. Qualitative study criteria (>4) • Methods clearly stated • Participants adequately described • Analysis adequately described • Analysis appropriate • At least one check for trustworthiness

22. 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

23. 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

24. 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

25. 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)

26. 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

27. 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

28. 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

29. 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)

30. Occupational goals • Both affected individuals and their caregivers can and do form occupational goals.

31. 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

32. 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”.

33. Findings to dateOPP Stage 2. Select theoretical approaches • Searched for literature • Theory related to “enabling occupation” and persons with Alzheimer disease

34. Sorting the theories OT Other professions Dementia specific General Dementia specific General 3 7 1 1

35. 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

36. 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

37. Best practice recommendations • ????

38. 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

39. OPP Stage 3. • OCCUPATION affected by (cont’d) • Intrusion into personal space • Background noise • Communication difficulties (sender/recipient) • Problems with cognition and executive function

40. 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)

41. 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

42. OPP Stage 5. Negotiate targeted outcomes and develop action plans • Goal Attainment Scaling (GAS) can be used by individuals/caregivers

43. 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.

44. OPP Stage 7. Evaluate occupational performance outcomes • Builds on stage 5 (identify goals)

45. A good idea? • Massive undertaking • Unknown reproducibility AND… • Is this a « penetrating analysis of the obvious »?

46. 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

47. And • Does our process model really describe what we do? • For example, where does dealing with grief/transformation enter?

48. 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?)

49. But the biggest thing…. Process highlighted how to more profoundly link evidence-based practice as « rational » practice with evidence-based practice as « rationed » practice.

50. 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.