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

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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_at_uottawa.ca

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Lessons from Client-centred evidenced based
occupational therapy for persons with
dementiaEgan, Hobson Fearing

• With grateful acknowledgment to
• Canadian Occupational Therapy Foundation
• Ontario Ministry of Health and Long-term Care

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

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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

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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

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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

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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.
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This works well for common, well-delineated
problems with linear solutionse.g., severe
chest pain, sweating
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• How many of these types of problems do we have in
  nursing, midwifery and allied health?

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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?
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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 the person, the environment
or the occupation that are blocking the
 occupation 
Evaluate can the person now do it?

• Determine aspects of each that could facilite the
   occupation 

Carry out plan
Make a plan to try new ways of doing based on
this analysis
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Could this process model be used as a 7-drawer
filing cabinet for evidence based OT? Alzheimer
disease chosen as a test case.
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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

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Filling the filing cabinetA. the search
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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

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Literature Search

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

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Literature Search

• Limits
• French English
• 1990- present
• Inclusion
• Descriptions of theory/application of theory
• Research reports (inc systematic reviews)
• Quantitative or qualitative
• gt 50 AD

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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

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Filling the filing cabinetC. Selection of
articles to keep

• Appraised using our own quality cut-offs

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Quantitative study criteria (gt4)

• Methods clearly stated
• Participants adequately described
• Validated tools
• Analysis appropriate
• At least two measurement points

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Qualitative study criteria (gt4)

• Methods clearly stated
• Participants adequately described
• Analysis adequately described
• Analysis appropriate
• At least one check for trustworthiness

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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

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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

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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

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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)

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Experience of occupation (individuals) (contd)

• Felt caregivers limited their activities in early
  stages
• Identified strongly with work roles early in
  disease, later identified with sick role

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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

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Experience of occupation (informal caregivers
contd)

• Caregiving interferes with other occupations
  particularly work
• the results of this interference may be perceived
  differently by spouses than by other caregivers

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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 lt20 of the day
  in occupation (including nursing care)

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Occupational goals

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

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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

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• 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.

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Findings to dateOPP Stage 2. Select theoretical
approaches

• Searched for literature
• Theory related to enabling occupation and
  persons with Alzheimer disease

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

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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

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Best practice recommendations

• ????

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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

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OPP Stage 3.

• OCCUPATION affected by (contd)
• Intrusion into personal space
• Background noise
• Communication difficulties (sender/recipient)
• Problems with cognition and executive function

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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)

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OPP Stage 4. Identify strengths and resources
(preliminary)

• From literature found evidence that
• OCCUPATION facilitated by
• Individuals personal strategies
• Caregiver personal knowledge of the individual
• Caregiver strategies
• Environmental modifications
• Opportunity to attempt occupations
• Physical rather than verbal assistance

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OPP Stage 5. Negotiate targeted outcomes and
develop action plans

• Goal Attainment Scaling (GAS) can be used by
  individuals/caregivers

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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.
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OPP Stage 7. Evaluate occupational performance
outcomes

• Builds on stage 5 (identify goals)

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A good idea?

• Massive undertaking
• Unknown reproducibility
• AND
• Is this a  penetrating analysis of the
  obvious ?

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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

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And

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

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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?)

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But the biggest thing.

• Process highlighted how to more profoundly link
  evidence-based practice
• as  rational  practice
• with
•  evidence-based practice
• as  rationed  practice.

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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.

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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)
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• 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)

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• This may be particularly critical at a time when
  basic science information is presumed (e.g.,
  masters level entry professional training).

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Back to the future?

• Multidisciplinary foundational education
  highlighting state of theory and science
  underlying how we conceive of intervention
  related to our prime mandates.

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Doidge, N. (2007). The brain that changes itself.
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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."

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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.