Transcript Evidence-Based Practice, Theory-Based Practice, Practice

Evidence-Based Practice
and
Practice-Based Evidence
KNR 365
Rationale: ATRA Standards of Practice
▫ Standard 2: The recreational therapist plans and
develops an individualized treatment plan that
identifies goals and evidence-based treatment
intervention strategies.
▫ Standard 3: The recreational therapist implements an
individualized treatment plan, using evidence-based
practice….
▫ Snethen & McCormick, 2013
Rationale: ATRA Code of Ethics
▫ Principle 1: Beneficence
 Recreational Therapy personnel shall treat persons served in
an ethical manner by actively making efforts to provide for
their well-being by maximizing benefits and relieving,
lessening, or minimizing possible harm.
▫ Principle 2: Non-Maleficence
 Recreational Therapy personnel have an obligation to use their
knowledge, skills, abilities, and judgment to help persons while
respecting their decisions and protecting them from harm.
▫ ATRA, 2009
Rationale: ATRA Code of Ethics
▫ Principle 9: Competence
 Recreational Therapy personnel have the responsibility to
maintain and improve their knowledge related to the
profession and demonstrate current, competent practice to
persons served. In addition, personnel have an obligation to
maintain their credential.
▫ ATRA, 2009
How do we get from assessment/goals
to intended outcomes?
Appropriate Assessment/Goals
Interventions/Implementation
Intended Outcomes
Well Designed Interventions/
Implementation Strategies
Evidence-based practice (EBP)
• Systematic Reviews
• Research utilization
• Theory-based practice
Practice-based evidence (PBE)
Evidence-Based Practice
• Began as evidence-based medicine
• Research
▫ Physicians failed to recommend medications up to
10 years after they had been shown to be effective
▫ Continue to recommend treatments up to 10 years
after they have been shown to be useless
▫ Hall, 2007
• Now used with other disciplines
Definition
• Conscientious, explicit, and judicious use of
current best evidence in making decisions about
the care of individual patients
▫ Sackett, Rosenberg, Gray, Haynes, Richardson, 1996
• Evidence used to support proposed course of
treatment
• Finding treatments that work based on results
from research
Evidence-Based Practice
& Therapeutic Recreation
• Evidence-based practice is the process of applying
results of outcomes research to improve services to
clients
▫ It is the selection of treatments for which there is some evidence of
efficacy
▫ More than professional judgment
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Stumbo & Peterson, 2009
• Practitioners should not select programs because we
have always done it that way or based on out-dated
information
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Austin, 2009
• No TR program should be proposed without a serious
search of the research literature for support
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Patrick & Magnuson, 2001
Benefits
• Increased chance of getting to client outcomes quickly
• Rationale or justification of programs
• Standardize practice/reduce variability between
agencies & practitioners
• Talk with other disciplines
▫ Stumbo & Peterson, 2004
• Improves practitioner knowledge
• Accountability
▫ Bennet, n.d.
Benefits
• Improve clinical practice & client care
• May not tell us what to do but can warn us what
not to do
• Reduces risks & possible harm
• Reduce costs & unnecessary treatment
Evidence-Based Practice Goes
Beyond Google
EBP accomplished in 4 ways
• Following 5 step process
• Seeking evidence collected by others
• Adopting protocols written by others
 Stumbo, 2003
• Systematic reviews
•
Coyle, et al., 2008
Evidence-Based Practice:
5 Step Process
(Stumbo, 2009)
1. Formulate a question about a client problem
▫ Patient or problem being addressed
 What interventions work best with veterans who are homeless? Who
have substance abuse problems?
▫ Intervention being considered
 Is there sufficient evidence for the inclusion of aerobic exercise
as a treatment for people with major depressive diagnoses?
▫ Another intervention for comparison
 Will a middle-aged person with a recent spinal cord injury gain
greater stress reduction from yoga or tai chi?
▫ Possible prevention strategy
▫ Outcomes
5 Step Process
2. Search databases for relevant clinical
evidence/research
3. Appraise the evidence
▫ Level I: Strong evidence from at least 1 systematic review of multiple welldesigned randomized controlled trials
▫ Level II: Strong evidence from at least 1 properly designed, randomized controlled
trial of appropriate size
▫ Level III: Evidence from well designed trials such as nonrandomized trials,
comparative or correlational studies
▫ Level IV: Evidence from well-designed, nonexperimental studies from more than
1 center or research group
▫ Level V: Opinions of respected authorities based on clinical evidence, descriptive
studies, or reports of expert committees
Evidence-Based Practice:
Appraise the Evidence
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How strong is the research?
Is the population similar to mine?
Is the agency similar to mine?
What was used to measure outcomes?
 Reliable
 Valid
What treatment was used?
What were the results of the study?
What are the limitations of the study?
Are there resources available to implement the
program/intervention?
Ross & Ashton-Shaeffer, 2003
5 Step Process
4. Implement & use findings in practice
5. Evaluate the impact of change in practice
Evidence-Based Practice:
Search for Research Evidence – Where?
• Therapeutic Recreation
Journal
• Annual in Therapeutic
Recreation
• American Journal of
Recreation Therapy
• Palaestra
• Journal of Physical Education,
Recreation & Dance
• Leisure Sciences
• Journal of Leisure Research
Evidence-Based Practice:
Search for Research Evidence – Where?
• Not all TR research in TR journals
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Journal of Rehabilitation
New England Journal of Medicine
American Journal of Public Health
Pediatrics
• Indexes
▫ CINAHL
▫ PubMed
▫ PsycINFO
Evidence-Based Practice:
Search for Research Evidence – Where?
• Treatment Networks (ATRA Newsletter)
• Books (Sagamore, Venture, Idyll Arbor)
• Therapeutic Recreation and the Nature of Disabilities
 Mobily & MacNeil, 2002
Evidence-Based Practice:
Search for Research Evidence – Where?
• Benefits of Therapeutic Recreation: A Consensus View
 Coyle, Kinney, Riley & Shank, 1991
• Population groups
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Chemical dependency
Developmental disabilities
Gerontology
Pediatrics
Physical Medicine
Psychiatry
West, 2009
• “Until more evidence is available about specific
interventions used by recreational therapists,
evidence of the benefits of interventions used by
allied disciplines and also used by recreational
therapists should be studied to determine the
related value for recreational therapy practice.”
▫ p. 261
Evidence-Based Practice:
Search for Research Evidence – Where?
• Facilitation of Therapeutic Recreation Services:
An Evidence-Based and Best Practice Approach to
Techniques and Processes
 Stumbo & Wardlaw, 2011
Richeson, Fitzsimmons, & Buettner
(2009)
• “Currently other professions, including nursing,
psychology, social work, occupational therapy,
and others provide the majority of evidence for
recreational therapy.”
▫ P. 273
Systematic Reviews
• “Systematic reviews are
summaries of research findings
that can guide healthcare
practice. Systematic reviews
involve the use of explicit
methods to identify and
evaluate research studies in a
particular area” (Coyle et al.,
2008, p. 14).
• “Systematic reviews differ
from literature reviews.
Systematic reviews use all
relevant literature from
multiple sources, published
and unpublished, and there is
a more rigorous and
systematic appraisal and
evaluation” (Research and
Evidence Based Practice, p.
56).
Coyle, Denault, Miller, Pham, Thomas
(2008)
• Understanding systematic reviews and their
implications for evidence-based practice by
examining aerobic exercise as a recreational
therapy intervention for individuals with major
depressive disorders.
 American Journal of Recreational Therapy, 7(3)
Systematic Reviews Outcomes
• Practice-focused guidelines
• Dementia Practice Guidelines for Recreational
Therapy: Treatment of Disturbing Behaviors
▫ Buettner & Fitzsimmons, 2008
Evidence-Based Practice:
Search for Research Evidence – Where?
• Cochrane Collaboration
▫ http://www.cochrane.org/
• OT Seeker
▫ http://www.otseeker.com/
• SAMHSA’s National Registry of Evidence-based
Programs & Practices
▫ http://www.nrepp.samhsa.gov/
Evidence-Based Practice:
Search for Research Evidence – Where?
• Clinical Evidence
▫ http://clinicalevidence.bmj.com/ceweb/index.jsp
• Hooked on Evidence (PT)
▫ http://www.hookedonevidence.com/
• National Guideline Clearinghouse
▫ http://www.guideline.gov/
Evidence-Based Practice:
Search for Research Evidence – Where?
Temple University RT Wise Owls
http://rtwiseowls.com
Concerns
• Standardization
▫ Erosion of autonomy of practitioner
• Lack of relevant research
▫ Impact of using other professions research?
Pros/Cons
• Studies may not reflect “real world” conditions
• Studies may not fully describe intervention
Concerns
• Most quantitative experimental studies are
based on group means
• Practitioners have a hard time understanding
research
▫ Or doing research
• Not an easy process to do
▫ Time consuming
▫ Implementing EBP
Research Utilization
• Subset of EBP
• Use of research knowledge often based on a
single study
▫ Bennet, 2009
• Use of research findings to improve client care
Research Utilization:
Example
• The Association Between Healthy Lifestyle Behaviors and Relapse
Rates in a Homeless Veteran Population
▫ The American Journal of Drug and Alcohol Abuse
▫ LePage & Garcia-Rea,
2008
Recovery
Activities
Healthy Lifestyle
Behaviors
Recovery meetings
Leisure activities
Contact with sponsors
Social/family activities
Reading AA Big Books
Coping/spiritual activities
• Veterans participating in more Healthy Lifestyle Behaviors were associated
with lower relapse and return to homelessness
Theory-Based Practice
• “Although there is a strong argument for
evidence-based interventions, these are not
always possible or desired in all situations.
Despite that, even small, highly idiosyncratic
programs can benefit from using logic models to
specify a theory of intervention and
explanation.”
▫ Caldwell, 2003, p. 82
Theory-Based Practice
• Using theory as the basis for program design
▫ Self-efficacy
▫ Stress-coping
▫ Flow
Theory-Based Practice:
Stress-Coping Theory
• Carruthers & Hood (2002)
▫ Coping skills program for individuals with
alcoholism
Practice-Based Evidence
PBE
Practice-Based Evidence
• “In the concept of Practice-Based Evidence, the
real, messy, complicated world is not controlled.
Instead, real world practice is documented and
measured, just as it occurs, ‘warts’ and all. It is
the process of measurement and tracking that
matters, not controlling how practice is
delivered.”
▫ Swisher, 2010, p. 4
Practice-Based Evidence
• Defined: Gathering of good data from routine
practice
▫ Emphasizes outcome evidence based in the real
world
▫ Interventions that are widely practiced
▫ Gives voice to practitioners & service users
• Reflective practitioner carefully describes the
client, intervention, and outcomes.
• Aggregates approaches to look at larger trends
that work in the field
Practice-Based Evidence
• Outcomes are differences in client behaviors,
knowledge, skills, etc.
Assessment
Outcome
Intervention
Practice-Based Evidence:
Example from Literature
• Running from Homelessness
Because I participate in BOMF
Increase
My self-esteem has improved
84%
I am more motivated to live a healthy
lifestyle
95%
My self-confidence has increased
89%
I am more excited about my future
90%
I am smoking less
63%
I am more self-disciplined
96%
There is more fun & enjoyment in my life
95%
Documenting Outcomes
• Meet goals & objectives of program/treatment
plan
 Carruthers & Hood, 2002
• Self report of involvement
 LePage & Garcia-Rea, 2008
• Increased score on scale or instrument
 Wise, Ellis, & Trunneil, 2002
Documenting Outcomes:
Growing Practice-Based Evidence
• Therapeutic Recreation Journal
▫ Practice Perspectives
 Case Reports
• “It Gives Me Purpose”: The use of Dance with
People Experiencing Homelessness
▫ Knestaut, Devine, & Veriezza
▫ Vol. XLIV, No. 4, pp. 289-301
Documenting Outcomes:
Growing Practice-Based Evidence
ATRA Research Institute Practice Posters
• Poster Title
• Intervention Program
Overview
▫ Brief synopsis of program
including setting &
population. Is there support
from the literature?
• Client goals
• Assessment tools/techniques
▫ Who is appropriate for the
program? Inclusion criteria?
Referral to program?
• Staffing
• Process
▫ Describe how program is
implemented. Frequency.
Number of sessions
• Evaluation
▫ How the program is
evaluated
• Client outcomes
• Suggestions for replication
▫ How can another therapist do
this program?
PBE does not replace EBP but adds to it!
Interventions
Research
Practice
RT
Implementation
Strategies