dr hazel roddam - norsklogopedlag.no · dr hazel roddam, 2013 19 exposure to research and ebp...
TRANSCRIPT
Dr Hazel Roddam
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Is EBP for everyone?
“It is not expected that all (clinicians ) will be research-active,
but it is expected that all (clinicians)
will be active users of research”
Supporting Research and Development in the NHS (Culyer, 1994)
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What is Evidence-Based Practice (EBP) ?
What are the inherent challenges of
embedding EBP into routine practice? What is Practice-Based Evidence (PBE)? ◦ Using routinely collected data ◦ Utilising appropriate research designs ◦ Developing skills & partnerships for PBE
Where are the opportunities for individuals
and professional associations?
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Research
Client Clinician
Most used definition is:
“the integration of
best research evidence with clinical expertise
and patient values”
Sackett et al 1997
Anecdotes /testimonials
“The plural of anecdotes is not evidence” (Reilly 2010)
Media headlines Cost savings Expert opinion Intuition
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◦ Trends in western medicine ◦ Political quality agendas ◦ Raised public expectations ◦ Regulation / guidance by Professional Associations ◦ Good clinical practice
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◦When you are facing unfamiliar territory ◦When things are not working as you expect
1. Frame a clinically-focused question 2. Search for the best quality evidence 3. Appraise the evidence 4. Implement changes – if appropriate 5. Evaluate effectiveness of practice
(Sackett et al 1997)
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Judging published research evidence against agreed quality criteria…
Demonstrating that you have critically evaluated a range of evidence sources and related them to your own practice…
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◦ Is the research question clear? ◦Does the design match the question? ◦ Could the study be replicated? ◦What do the results mean? ◦ Is this relevant to my own clinical setting?
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Learn new skills of searching & appraising Learn about research designs Gain confidence Focus on clinical questions Network with other colleagues Time to think!
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Addressing the barriers to changing clinical practice
Measuring the impact of practice changes
Keeping updated with new evidence sources
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Answers specific questions
Rigour
„greatest strength lies in the fact that it
removes bias‟ Reilly 2004
Does our practice work? Treatment efficacy Treatment effectiveness
How well does it work? Statistical significance Clinical significance
Is it worthwhile? Clinical effectiveness Cost effectiveness Client perceptions
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Very clearly defines the protocol Ensures the conclusions are supported by the
results Acknowledges all the limitations of the study Emphasises the clinical applications Promotes implementation of the research
findings in clinical practice
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Consistently reported barriers to EBP ◦ Personal views and attitudes ◦ Skills ◦ Time ◦ Access to research evidence ◦ Supportive context and culture ◦ Gaps in the research evidence base
Additional influences on our professional practice and decision-making
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EBP has achieved nothing like the degree of acceptance by practising clinicians that it set out to achieve
30-40% of patients do not receive care according to
current scientific standards Miles et al 2007
20-25% of care provided is not needed or harmful Eccles et al 2005
Only 10-20% of interventions achieve change and many programmes result in no change at all Treweek 2005
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Medics → Colleagues Upton & Upton 2006
Nurses → Nursing colleagues McCaughan et al 2005
Physiotherapists → Initial training. Turner & Whitfield 1999
SLTs → Colleagues & internet sources. Nail-Chiwetalu & Bernstein-Ratner 2007
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Exposure to research and EBP during training
Highest degree held
Practicality Desire for learning
Experience
Bridges et al 2007; Zipoli & Kennedy 2005; Aaron 2004; Turner 2001
How do we achieve EBP?
“EBP requires change to habits, routines,
and sometimes personal and philosophical preferences and ideals”
(Skeat & Roddam 2010)
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Establish a reading routine Selective reading, including pre-appraised
sources Use a structured checklist Discuss with colleagues Save & organise your notes
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Creating a supportive context for EBP ◦ Equipping ourselves with EBP tools and resources ◦ Building evidence-based policies for practice ◦ Influence of leadership role ◦ Valuing good practice ◦ Support for innovative practice
Making the evidence work for us ◦ Building EBP networks ◦ Service user involvement ◦ Developing evidence-based clinical resources
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It may be more helpful to consider EBP as a way of thinking,
rather than as a body of “facts”
McCurtin & Roddam, 2012
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“The first step is to become
reflective and critical reviewers
of our own practice”
Pam Enderby (in Roddam & Skeat, 2010)
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EBP Skills Experience 0-1-2-3
Confidence 0-1-2-3
Priority 0-1-2-3
Action plan
Effective strategies for keeping myself updated
Framing a specific question
Searching electronic databases
Critical appraisal
Implementing clinical change
Measuring clinical outcomes
etc
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In the next 6 months I will
Build my own skills by ... Help other colleagues by ...
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Epidemiological data across all clinical populations incl. low incidence cases
Normative data Evidence-based assessments ◦ Validated on local populations
Evidence-based interventions ◦ Direct therapy interventions ◦ Indirect / training interventions ◦ Complex interventions
Evidence-based service planning Multi-disciplinary & cross-agency delivery of services
Patient/client experience and Quality of Life
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Assumptions – or givens?
◦ Small scale ◦ Practitioner-led ◦ No external funding sources/sponsors ◦ Maximising use of routinely-collected
clinical data ◦ Limited range of research designs ◦ Empirical data collection
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How many clients/patients do you/your service
see?
How many clients/patients are identified on initial assessment as needing further input from you/your service?
How successful is the service you offer?
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Types of “evidence” Systematic approaches to gathering evidence
Levels of evidence Models of research design Sample sizes / scale of research studies
Collaborative partnerships – clinicians and
academics Multi-professional partnerships
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Types of “evidence”
◦ Evidence from systematic research ◦ Clinical expertise ◦ Patient views & preferences
(Dollaghan, 2007)
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Systematic approaches to evidence gathering ◦ Research ◦ Clinical audit ◦ Service evaluation
Maximising the use of routinely collected clinical data
“Data rich but information poor”
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Phase 1 ◦ Development of new intervention
Phase 2 ◦ Feasibility phase to pilot recruitment & outcome
measures
Phase 3 ◦ Evaluation of effectiveness (often randomised
controlled trial - RCT)
Phase 4 ◦ Implementation and long-term surveillance of
benefit/harm
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Phase 1 ◦ Identification of new intervention - single case/s
Phase 2 ◦ Refinement of intervention components – multiple single
cases, small group designs
Phase 3 ◦ Efficacy study – ideal sample under optimal conditions
(often randomised controlled trial - RCT)
Phase 4 Effectiveness study – typical sample under typical conditions
Phase 5 ◦ Cost-effectiveness studies and cost-benefit analyses
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Clinicians
Patients Academics
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Inter-Professional Learning IPL ◦ Team Journal Clubs
Multi-professional evidence-based guidelines
for practice
Multi-professional small-scale studies
Collaborative patient/client involvement
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Research skills Experience of research environment & research
processes Mentorship in specific research processes of
design, conduct, analysis and dissemination Collaborative research partnerships Support in workplace setting/s – leadership,
management, peer colleagues Funding sources for expenses/resources
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Peer support ◦ Clinical research interest groups ◦ Virtual networks
Professional body ◦ Strategic plan ◦ Operational initiatives
Strategic research capacity building
Academic lead for research themes
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Personal action-planning „doing things right‟ Skills matrix, strengths, experiences, interests Identify learning needs/skills gaps and possible
mentors Consider research degrees – but not essential Networking & collaborating – identify common
interests „match-making‟ Realistic, achievable start Be confident – don‟t undersell your professional
problem-solving skills
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Publications & conference presentations ◦ Peer review ◦ Audience ◦ Timeliness ◦ Implications for strategic service planning ◦ Clinical bottom line
Reviews & secondary sources ◦ Systematic reviews ◦ Digests of pre-appraised sources
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For your warm welcome & hospitality
For your interest today
Dr Hazel Roddam University of Central Lancashire,
Preston, UK
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