OCC2022 Class Test 1

Week 1-4 Content

Evidence-Based Practice (EBP)

• Definition

A practice that is supported by scientific evidence, clinical expertise and client values. The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients

What are the 3 components of EBP?

1. Best research evidence

2. The clinical expertise of a therapist

3. The patient perspectives and values

EBP

• Factors that influence the context of application

• Increasing choices in healthcare and treatment

E.g. Going into public or private health care

• Large number of sources of information available to clients

E.g. Using AI

• Much of the information is out of date but it depends on the specific field

E.g. 10+ years is deemed as out of date information

• Scientific quality of information is variable, information may be based on false or misinformation, biased or small number of quality research studies

• Clinicians are time poor and have limited time available to read the number of articles published each week so it is hard to stay up to date

Why is EBP important?

• Contributing impacts

• Improve client outcomes and client care that is provided

  • Prevents ineffective interventions

  • Ensures services provided are cost effective, high quality and harmful to the client

• Client's expect EBP as there is increasing consumerism

  • People are paying for healthcare services and they expect value for money

• Improves clinicians knowledge and highlights the strengths and weaknesses about interventions which assists in clinical reasoning

• It emphasises the importance of OT professions and helps to establish our expertise

• Excessive use of inappropriate treatments and interventions currently

• Poor uptake of research evidence and its effect on practice

  • OTs need to become research consumers and be able to evaluate the quality of evidence

• There is an exponential growth in research evidence

  • Many studies being published each week

• It helps to link theory to practice

  • Model (CMOP-E) each have a body of research evidence which demonstrates its relevance to different clinical areas

• Helps ensure cost effectiveness and efficacy to funding bodies

  • You want to be able to demonstrate that the services being provided are based on sound evidence

Approaches practitioners are using instead of EBP

2. Decision making by press cutting

   • Press cutting refers to taking evidence and advice off an article or source that may or may not be credible

   • Many health professionals fail to go through a checklist prior to making press cutting decisions

3. Decision making by expert opinion  

   • Serious harm can be caused when applying interventions and treatment without the support of EBP

4. Decision making by cost minimisation

   • Healthcare is provided from a limited budget, resulting in the need to consider economic costs of interventions for clients

   • Making decisions based on cost minimisation and no regard for effectiveness is ethically unjustified

What information is provided in EBP?

• Some information needs are general knowledge or background questions

E.g. what causes autism?

• Other information needs must be met by interaction with the client

E.g. what type of leisure activities do you enjoy?

• Research can provide information about the management, treatment, follow-up and experience of clients

What does PICO stand for?

What are the best forms of evidence for:

• Treatment

• Patient experiences/concerns/perspectives

• Course of disease progress

• Cost effectiveness

Tips for searching evidence

• Aim to find clinical research evidence that is relevant to your topic

• Aim to find papers using the best methods for a particular type of clinical question

• Search for a variety of sources of credible information including peer reviewed journals, books, conference proceedings, google scholar and websites

Critical Appraisal of Evidence

• Definition

• A process of formally reviewing a paper, manuscript or journal article to find information of value

  • Is the evidence valid?

  • Is the evidence important?

Critical Appraisal of Evidence

• Things to consider/questions to ask yourself (methods)

• Was the method appropriate to the question? Qualitative or quantitative?

• Was the sampling strategy appropriate?

E.g. random sampling, volunteers

• Were all participants who entered the study properly accounted for at its conclusion?

E.g. often studies are conducted where people may drop out or people may be found that people do not meet the inclusion criteria

• Were measures taken to reduce bias and confounding factors? These are internal and external factors that can influence the types of results that are obtained

• Were the methods for data analysis appropriate?

How to determine strength of evidence

• Variables to consider

• Size of the effect

• How confident we are of the observed effect, in the results

• Number of studies confirming the results

• Findings from other studies

• Mix method studies gives you a much richer overview of the topic being investigated

  • Looks at both qualitative and quantitative data

Higher level EBP

• Definition

Involves studies with large sample sizes or they take a large number of individual studies and merge them together

Limitations of higher level EBP

• Inappropriate for many research questions

• Usually done with clearly defined and delimited populations (excludes many people who are involved in OT interventions)

• When working with a large number of people it creates a picture of "average" construction that bares little resemblance to many people seen by OT, leading to the inability to find the best evidence for our clients

E.g. people who have rare conditions, atypical presentations or people who have multiple conditions at once

• To produce findings that can be generalised, individuals differences in clients and context is controlled for

  • There is a need to re-contextualise for our own client group

  • Which may contradict what we know about the health condition

  • Human experience of health cannot and should not be measured from an ethical perspective

How to implement EBP

• Process

• Requires significant behaviour and systems change

• Using change management principles helps organisations to take up evidence at a systems level

• Once people are aware of the evidence it must be accepted, applicable, available, acted on, agreed to and adhered to

• Clinicians need access, time, employer support and modelling of skills

What are the 5 steps in the emerging science of EBP?

1. Convert our information needs into answerable questions (ask)

2. Track down the best evidence to answer these questions with maximal efficiency (acquire)

   • May come from clinical examination, diagnostic laboratory or published literature 

3. Assess the validity and usefulness of the evidence (appraise)

4. Implement the results of this appraisal into our clinical practice (apply)

5. Assess our performance (evaluate)

Barriers to EBP

• Attitude of question and inquiry

  • Some work places may not value EBP

• Know-how in finding, appraising and applying evidence

  • Individuals need the skills to implement EBP which may be lacking

• Information resources on tap

  • Having access

• Lack of time with time pressure and high case loads

  • Therapists lack time available to dedicate time to engaging in EBP

• Lack of professional development

  • This can be in terms of funding time allocated to professional development activities

• Clinicians unsure of EBP and how to use the evidence

  • There are very few practice guidelines that currently exist

Clinical reasoning in practice

• Health professionals needs to use their clinical reasoning to collect and interpret different types of information from a range of sources to make judgements and decisions regarding complex situations under conditions of uncertainty

• In addition to the logical decisions that health professional need to make, they also have to make ethical and pragmatic ones

  • This is due to resource limitations or time constraints

  • Having to make the best informed decisions in consultation and collaboration with clients that are ethical, sound and safe

Relationship between EBP and clinical reasoning

• To practice in an evidence-based way OTs need to integrate research with their clinical experience, the preference of their clients and the demands of the practice context

• Engaging in different types of EBP and finding answers to clinical questions

• Clinical reasoning is used to determine whether the evidence 'fits' with each feature of the client's context (person, occupation and environment)

  • Particular attention should be given to the preferences and the values of the client

  • Consideration must also be given to the practice setting, clinical expertise and resources available to the therapist

What are the 4 main sources for identifying research topics?

1. Theory, an organised body of concepts, generalisations and principles that can be subjected by investigation E.g. MOHO, CMOP-e

   • Essentially anything related to the daily occupations, facilitators or barriers and ways to rehabilitate those types of occupations

2. Personal experience/professional work contexts

   • You may find topics that you are curious about or areas that require from investigation

3. Replication, repeat what has been done previously

   • This can be done with a different group of people, in another context or with a different set of assessment tools or another profession

4. Literature and previous research studies

What are the 3 main problems with broad topics?

1. Enlarges the scope of the review of literature beyond reason

E.g. the impact of culture on children's play skills, requires you to look at studies in English and other languages

2. Complicates the organisation of the review of the literature itself, it is important to come up with some inclusion and exclusion criteria when conducting the literature review

3. Creates studies that are too general, too difficult to carry out and too difficult to interpret

How to narrow a topic down

• Talking to experts in the field

E.g. lecturers, tutors or unit coordinators

• Read credible secondary sources that provide overviews of your topic E.g. textbooks, journal articles and conference proceedings

Qualitative vs Quantitative research topics

• Mixed methods

• The main difference between the two include:

  • Qualitative studies tend to narrow the topic throughout the research process itself

  • Quantitative studies tend to narrow the topic initially

• Often the topic can help guide which approach may be more appropriate

  • Sometimes a combined approach can also be done, known as a mixed methods approach

Factors that determine whether a topic is researchable

• Funding, some topics require large amounts of funding and without this funding it is not feasible to investigate that topic

• A topic may fall outside your scope of practice

Topics classified as researchable

• Topic dealing with people's occupations, performance and engagement

• Can be investigated through the collection and analysis of data, generally quantitative data

• Theoretical or practical significance

E.g. OT interventions that may decrease hospital admissions

• Contribute to the educational process

• Must be adequately research given the expertise, resources and time constraints for the researcher

Topic classified as non-researchable

• Address philosophical or ethical issues which cannot be resolves through collection and analysis of data (qualitative and quantitative)

• Addresses an opinion or "should" questions, these are matters of opinion for the individual or organisation to decide

What should a formal statement of a quantitative research topic include?

• Identify the variables of interest

• Describes the specific relationship between the variables (inverse or correlation)

E.g. what type of equipment is in the playground and how big is it?

• Identifies the nature of the participants

E.g. preschool children with autism

What is a literature review?

The review of literature involves the systematic identification, location and analysis of documents containing information related to the research problem or question

What to document in a literature review

• Reports on primary or original sources of scholarship

  • It describes, summaries, evaluates, clarifies, compares, contrasts and integrates the content of primary reports

• You must describe in detail the process that you went through to obtain the studies you are citing

• The inclusion and exclusion criteria

• The types of sources of information, where it was obtained from

What are the functions of a literature review?

• Determines what has already been done

• It can help you form the research design for your topic

• Provides insight necessary to develop a logical framework into which the topic fits

• Provides the rationale for the hypothesis being investigated and the justification of the significance of the study

• Identifies potentially useful methodological strategies

• Facilitates the interpretation of the results

• Assists to contextualise the collected research results with already published studies

• Helps to inform future research recommendations

• Identifies any limitations or potential biases within your own research study that you have conducted

What is the purpose of a literature review?

• It can help you develop the structure and format of your design

• Provides a strong rationale for why your study should be completed

Recommendations for the scope of the review

• Bigger does not always mean better

E.g. there is no need to go back 50 years when the last 20 years is enough

• Heavily researched topics provide enough references to focus only on the major studies

• Lesser researched topics require reviewing any study related in some meaningful way even if it means searching related fields for additional information

What are the 4 stages of conducting a literature review?

1. Identifying key words to guide the search

2. Identifying sources

3. Abstracting the information found in the references

4. Analysing, organising and reporting the literature

What is involved in identifying key words to guide the search?

• Looking at synonyms and established key words

• Experiment with key words and combinations of them to find the most relevant information

• Using legal key words for particular databases

What is involved in identifying sources?

• Books, journal articles, conference abstracts, lecturers, credible websites, databases and OTs

• It is important to look at the different characteristics of sources, primary, secondary, empirical and opinion

  • Secondary sources help you to identify what some of the key search terms you may consider and provide a broad overview of your research topic

E.g. secondary sources are encyclopedias, handbooks

What is primary research?

• Single research study 

E.g. Databases, Google Scholar

• Found through reference lists and hyperlinks from secondary sources 

• Identified directly from journal alerts 

What is secondary research?

• Meta-analysis

• Meta-synthesis

•  Synthesised findings, literature reviews 

  • Examine and summarise multiple primary research papers 

    • Meta-analysis: literature of quantitative articles

    • Meta-synthesis: literature of qualitative articles 

• Useful to quickly understand what is already known about a topic

What is involved in abstracting the information found in the references?

• Involves locating, reviewing, summarising and classifying references

• Abstracting the relevant facts and summarising the information

What are the 7 steps involved in abstracting the information found in the references?

1. Read the article abstract

2. Skim the entire article

3. Record complete bibliographic information

4. Classify and code the article, based on what topic focuses on what its participant group is and what journal that it is published in

5. Summarise the article

6. Identify thoughts about the article you believe are important

7. Indicate direct quotes properly

What are the 3 main methods of finding evidence?

1. Informally, general google search

   • Sources may be unreliable

2. Focused, looking for answers, related to questions that have occurred in a clinical setting

   • More detailed approach

   • Uses more credible sources

3. Surveying the existing literature before embarking on a research topic

Considerations when writing a literature review

• What does the literature say, to date about the topic?

• Has there been much literature published about that topic?

• Has this literature been published by any specialised researchers?

• What are the 'landmark' or seminal studies within that body of knowledge?

• How has the evidence been gathered in the past?

• Have there been any studies published with inconclusive findings?

• Are there any unanswered questions related to your topic?

• What are the main identifiable gaps in the research area?

• Who are the main authors, educators and researchers in the area?

What are the reasons for literature reviews?

• Identify gaps in the already published literature

• Avoid re-inventing the wheel and repeating the mistakes made previously

• Identify people working in the same field, can facilitate collaborative links with others in the same field

• Increases breadth of knowledge of the subject field

• Identify seminal works

  • These are key studies that have provided the basis of knowledge for different areas

• Intellectual context of work, your position your own work against others

• Identify opposing views

• Put your work into perspective

What are some strategies for abstracting?

• Begin with the most recent references and move towards the most dated

• Record all bibliographic information

  • This includes the author, date of publication, title, journal name or book title or website name, volume and issue, pages, URL and DOI

• Identify direct quotes and record page numbers, this information will be required when citing

• Identify and summarise the main ideas

What technical details in a literature review require reporting?

• What is the referencing style you will be using?

E.g. APA 7

• What is the formal language being used?

E.g. Active or passive

• Adherence to prescribed referencing styles

What is included in the overall review of the literature?

• You may consider to organise the articles you've selected based on different characteristics or subtopics

E.g. country, method or age group

• Analyse for similarities and difference within your subheadings

• Discuss the least relevant studies first, followed by the most relevant studies

• Discuss the most recent studies first and then mention the older dated studies afterwards

• Summarise the review and discuss the implications related to your research problem

E.g. how does the previously completed and reported research results and findings complement, back up or provide a rationale for your proposed research topic

What is a systematic review?

One of the precursor step to conducting a meta analysis

What are the protocols for selecting studies in a systematic review?

• They select studies on a strict inclusion and exclusion set of criteria

• These are summarised and there may be a written summary about the findings that are common

What is a meta-analysis?

A statistical approach to summarising the results of many studies that have investigated the same problem

• Have the advantage of being an overall summary and much more of a definitive statement

What are the 2 unique characteristics of a meta-analysis?

1. The review is inclusive as possible

   • There is still strict inclusion criteria

2. The results of each study are translated into a statistic called an effect size

What is a limitation to meta-analysis?

Tend to focus on randomised controlled trials and do not include other types of research designs

Effect size

• Definition

The difference between the means for the experimental group and a control group in control group standard deviation units

What is the purpose of effect sizes?

• The average of all effect sizes for all of the studies, summarises the overall effect of the studies

  • Involves taking the results from many different studies and then comparing the experimental and control groups in those studies

  • An overall "macro" effect size that is recorded in the meta-analysis published

Interpreting effect sizes

• Range of effect sizes

• Effect size indices generally range from 0.00 to slightly more than 1.00

• An indicator of whether a certain research approach, treatment or finding is found to be strong, moderate or weak

  • Gives a more definitive answer on the studies' effectiveness

• There are some general guidelines when interpreting effect sizes but there is no single standard

What are the 2 types of hypothesis?

1. Inductive

2. Deductive

What is an inductive hypothesis?

• A generalisation made from a number of observations

  • Typically of qualitative studies

What is a deductive hypothesis?

• Derived from theory and aimed at providing evidence to support, expand or contradict aspects of that theory

  • Typically of quantitative studies

What are some characteristics that define a good hypothesis?

• Provides a reasonable explanation for the predicted outcome of the results

• Clearly and concisely states the expected relationships between the variables (independent and dependent)

• It must be testable, approved by the ethics committee, decide on a research design and have participants willing to take part

What are the 3 types of quantitative hypotheses?

1. Non-directional

2. Directional

3. Null

What is a non-directional hypothesis?

A statement that no relationship or difference exists between the variables

What is a directional hypothesis?

 A statement od the expected direction of the relationship or difference between variables

What is a null hypothesis?

A statistical statement that no statistically significant relationship or difference exists between the variables

How to test a hypotheses

• Involves the statistical analysis of data

• Results support or fail to support hypotheses, but they never prove or disprove hypotheses

What 3 groups developed the national statement document?

1. NHMRC

2. Australian Research Council (ARC)

3. Universities in Australia (39), affected by the statement

What is the purpose of the ethical conduct?

• It clarifies the responsibilities of institutions and researchers for the entire research process

• This spans from design through conduct to the dissemination of the results

• It aims to helps us identify issues of ethics that arise, deliberate those ethical issues and justify decisions we make about them

• It also acts as a decision aid to help research and committees predict and respond to ethical issues

Human research

• Definition

Any research activity that includes the involvement of human

What are some forms of human research?

• Taking part in surveys, interview or focus groups, this can occur in many different research designs

• Undergoing psychological, physiological or medical testing or treatment, occurs in medical and feasibility trials

E.g. effectiveness of a treatment or intervention is tested

• Observation

E.g. ethnographic studies of culture or qualitative study on children's social interactions in a playground

• Researchers accessing personal documents or other materials

E.g. analysing medical records, diaries or emails

• Collection and use of body organs, tissues, fluids or exhaled breath

E.g. blood samples, saliva or hair

• Accessing information as part of an existing published or unpublished database

E.g. hospital, mental health, disability or aged care data stored by the Australian Institute of Health and Welfare

Where do human research ethics committees (HREC) exist?

• In universities, hospitals and other sites where research takes place

• Small institutes may have a local research governance function, but that do not provide for ethics reviews 

What people are included in a HREC?

1. Chairperson with suitable experience

   • Previous member of a HREC who can guide the deliberations of the committee

2. 2 independent lay people

   • Bring community or consumer perspective and have no affiliations with the institution

3. A health professional

   • A person with knowledge of current experience in the professional care or treatment of people

   • Help to assess the risk of the project to individuals, especially for health or clinical research

4. A person with pastoral care role

E.g. an Aboriginal or Torres Strait Islander elder or community leader, a chaplain or minister of religion

• Bring important ethical approaches to the research and help assess some of the core ethical principles

5. A qualified lawyer

   • Preferably not employed by the institution

   • Provides advice on legal aspects of the research

6. 2 people with current research experience who are directly relevant to the proposals being considered at the meeting

   • Assess the merit and integrity of the research

What are some other considerations of a HREC?

• Diversity

• Gender diversity

• At least 1/3 of the members are from outside the institution

What are some other specialists that may be called upon?

• Aboriginal and Torres Strait Islanders, for research conducted in their communities

• Research method specialists, help assess the research, merit and integrity

• Technical specialists, understand the research processes and data management

E.g. statisticians and data security experts

• Participant advocates

• Research content experts, to consider the appropriateness of the research for a particular participant group or context

What are the 4 core ethical principles?

1. Merit and integrity

2. Justice

3. Beneficence

4. Respect

What are the 6 criteria outlined under merit?

1. Potential benefit

   • Has the potential to contribute to knowledge, social welfare, individual well-being or researchers skills and expertise

2. Methods used are appropriate for the research question

3. Comprehensive and thorough literature review

   • Helps to identify how the research has potential benefit and the gaps in the literature this research is attempting to address 

4. Research aims, process or results do not compromise respect for participants

5. Conducted by people who has the necessary skills, experience and qualifications

6. Research must be conducted using appropriate facilities and resources

What behaviours must be adhered to under integrity?

• Knowledge and understanding

• Following established and recognised research principles, involves following the norms of our areas research procedures and methods

• Conducting research honestly

• Research dissemination and communication of results

What is publication bias

• The tendency for researchers and journals to publish significant results

  • This means that many researchers can breach this last criteria by failing to publish unfavourable results

  • We must also publish all collective outcomes, not just the favourable ones

  • In qualitative research we need to present the multiple views of the research topic

What is a clinical registry?

• This ensures all authors are held accountable for reporting on any changes to their research methods

• Also the reason behind why academics are expected to publish in reputable journals to allow for further scrutiny when reviewed by peers

What is procedural justice?

The processes of research are fair

• Clear exclusion and inclusion criteria that is appropriate for the research question, ensure it is fair and well communicated in the results

• Apply the criteria above when recruiting participants and document the process

Procedural justice

• Examples

• Selection criteria is fair and accurately reported

• Recruitment process is fair

• Fair access to benefits

• Timely and clear access to research outcomes

What is distributive justice?

• Research benefits and burdens are fairly distributed between participants

• Ensure not to exploit participants

E.g. failing to reimburse them for their times in cost or using their information for our benefit

• Ensure there is a fair distribution of benefits

Distributive justice

• Examples

• No unfair burden of participation

• Fair distribution of benefits

• No exploitation

What is involved under beneficence?

• Involves balancing the benefits and risks of participants, ensuring the benefits always out weigh the risks

  • It is okay to have a study with no benefits but there can be no more than a mild discomfort for the participants

• Research must be suspended if the risks change and outweigh the potential benefits

Respect

• Definition

The recognition of a human being's intrinsic value

What is involved under respect?

• Involves showing regard for the welfare, beliefs, perceptions, customs and cultural heritage for the individual and any community they belong to

• The researcher must respect privacy (having control of your own information), confidentiality (having confidence in researchers not sharing this information), anonymity (not being identifiable in the research) and cultural sensitivities of an individual participant and their communities

  • Honouring any specific agreements made with the individuals or communities as part of the research

• Empowerment of participants to make their own decisions and the protection of those unable to

  • Key principle of informed consent

Autonomy

• Definition

Patients and clients are free to determine their own actions

Non-maleficence

• Definition

Avoiding or minimising harm

Confidentiality

• Definition

Maintenance of privileged information, including right to privacy and anonymity

Confidentiality

• Right to privacy

• Gives participants the right to choose and control what happens to their personal information

  • Done through collection of anonymous data (like from a survey)

Confidentiality

• Right to confidentiality

• Encompasses responsibility for others to respect another person’s privacy 

  • Removing identifying information, such as names and dates of birth

Veracity

• Definition

Obligation to tell the truth

• Not to leave out or minimise results that don’t prove/support 

• Not to Deliberately use jargon/terminology to cloud meaning

Consent

• Key aspects

• Researchers must provide sufficient information in a way suitable for each specific participant that ensures they adequately understand the purpose, methods, demands, risks and potential benefits of the research

• It is important to modify the consent process to ensure everyone can understand

  • We must consider children, people with intellectual disabilities and people with low vision etc

• Formal consent can happen verbally, in writing or even through the submission of a form or survey

What must the consent form include?

• Aims and requirements of the participation

• What will the people need to do and how long will it take?

• Benefits and risks

• Services available if they experience adverse events

E.g. medical or counselling services

• How we protect them from their privacy and confidentiality

• Reimbursement for time

• Accessibility of research for the participants

• Explanation of who is conducting and funding the study

• Any conflicts of interest

• How to contact the researcher and ethics committee if there is a problem

• Ensure participants are aware of their right to withdraw from the study and what happens to their data if they do

• No negative consequences should be given if participants withdraw from the study

Deception

• Requirements

Requires additional ethical oversight and important debrief criteria

Risk and benefit

• Considerations

1. How likely it is to happen? (likelihood)

2. How much harm will occur if it does? (severity and consequences)

What can risk be caused by?

• Delaying or withholding a treatment

• Humiliation, manipulation, disrespect or injustice

• Research process

• Through interactions with people

What are the various types of harm?

• Cultural harm, failing to respect the participants

• Social harm, to their relationships, workplaces or service providers

• Economic harm, financial loss

• Legal harm, if the research exposes them to criminal proceedings

Level of risk

• Minimal risk

• Minimal risks including inconvenience

  • Can be referred to as negligible risk or quality assurance projects

Level of risk

• Low risk

• Low risk including discomfort

E.g. natural sense of anxiety when being interviewed or some discomfort

• Most commonly used

• Leads to a low risk ethics approval process

Level of risk

• High risk

• How to determine high risk

• High risk requires a full ethics review

• To determine if a high risk or full ethical review is required, the researchers are asked a series of questions

  • It focuses on 2 things:

    1. The types of participants being targeted for recruitment

    2. The types of procedures involved

Participant specific considerations

• Key aspects

• The national statement provides a list of populations that have specific issues to be considered when conducting research

• When it involves foreign individuals and Aboriginal and Torres Strait Islanders it is important that the researcher has specialist expertise and connection with community groups in areas to ensure that the research is done in a culturally safe way

Collection, use and management of data and information

• Definition

• Key considerations for the managing and storing plan

• Relates to the dissemination of the research and merit of the research

• All research projects require a plan for how to manage and store data, key considerations when developing this plan include:

  • Thinking about data identifiability

  • Actual data management

  • Secondary uses of data

  • Data sharing

What is identifiable data?

• Identify of individual participants can be determined

  • Any data that is collected in audio or visual mediums is automatically identifiable

  • Majority of surveys conducted are identifiable as we routinely collect demographic information and we know where we have recruited people