Client-Centred Care & Ethical Dilemmas

Client-Centred Care & Ethical Dilemmas

Client-centred care (or patient-centred care or patient preference) is one of the core philosophies underpinning Occupational Therapy.  In any modern healthcare practice, it also forms part of the Evidence Based Practice (EBP) equation:

Research + Clinician Expertise + Patient Preference = EBP

How much weight each part of the formula should contribute to the overall treatment ‘answer’ is not clear cut, and when an extreme weighting from one or another element is proposed, it causes ethical dilemmas. Ethical dilemmas cannot be solved alone, but through collaboration with colleagues and professional body standards (such as the RCOT).

otter law
Source: http://www.rubberhedgehog.com

I find myself almost never listening to Radio 1 anymore instead tuning in to BBC 6, BBC 2 and even 4… is this a reflection of becoming more interesting or more boring? Or that I need talk radio to keep me awake on the more frequent long car journeys I seem to do now? Either way, in the BBC 4 programme ‘Inside the Ethics Committee’ one episode discusses a woman who wants her leg amputated in order to forego any further knee surgeries. Read more

Menu: Conducting a literature review

Menu: Conducting a literature review

Clicking on the category to the right ‘How to conduct a literature review’ does bring up all blog posts related to doing a lit review, but there were getting to be too many to keep track of the order.Otter menu

So this is just a menu of all the blog posts related to writing a literature review, and also EBP in general, so they are in some kind of order and all in one place.

EBP:

What is Evidence Based Practice? Why does it matter in everyday life?

Barriers to Evidence Based Practice

Article review: “Evidence-based medicine: a movement in crisis?” by Greenhalgh et al (2014)

Conducting a literature review:

Conducting a literature review: Where do I look for evidence to use in my Evidence Based Practice?

Conducting a literature review: creating a good question

Conducting a literature review: How to accurately evaluate any evidence before basing your practice on it

Conducting a literature review: evaluating the quality of research methods used in an article “Comparison of a traditional and non-traditional residential care facility for persons living with dementia and the impact of the environment on occupational engagement” by Richards et al. (2015)

Protected: All aboot Statistics

Conducting a literature review: Quality reviewing a research article “Strategies used by older women with intellectual disability to create and maintain their social networks: An exploratory qualitative study” by Mackenzie & White (2015)

 

 

What does Evidence Based Practice mean to me now that I have studied it at MSc level?

What does Evidence Based Practice mean to me now that I have studied it at MSc level?

Since starting the research module on my course, I have gained an understanding of the need to be critical of the evidence itself!  And also how complicated the process of creating bias-free valid evidence is, and how many opportunities for bias there are in each study.

umm not sure otter

I have gained lots of skills around the methods for gathering and analysing data. I feel that I already had a fairly questioning thought process as default, but now I am able to articulate more clearly why something is biassed or can only be trusted so far.

I never thought I would have a blog or enjoy blogging as much as I do, so I am really grateful that I was forced to start as a result of my course.  Although it is nice to see other people reading the blog it is mainly an ‘online study notes’ tool that I use; it enables me to quickly search for topics, search for module content by date, and reminds me to cover all aspects of a topic, such as the need to create a blog entry for each OT model. It is proving to be a real motivating factor (organising my thoughts, finding an otter picture that represents the topic, seeing a pretty blog page at the end) and helps make what I have typed more memorable- as well easier to link ideas together. This is probably helped by needing to categorise and tag the blogs each time; by grouping ideas from different modules or timescales together it make it easier to see how they might all connect. I suppose I probably have more technical social media knowledge now as a result, although I don’t think I was terrible to begin.

Already both when reading articles and overall in life I find myself dialoguing with myself in my head about the possible devil’s advocate outcomes of an article or a situation. I guess this could be the start of reflection-in-action!

 

Article review: “Evidence-based medicine: a movement in crisis?” by Greenhalgh et al (2014)

Article review: “Evidence-based medicine: a movement in crisis?” by Greenhalgh et al (2014)

If you need reminding what Evidence Based Practice (EBP) is, check here.

Not sure what Trish was up to but this article is printed in really small font and I had to zoom to 170% in order to be able to read it.

detective-otter

Zoom activated, I could now tell the article discusses some limitations of EBP, and the authors argue that although EBP has many benefits it has created some unintended negatives as well, which they describe as:

Drug companies controlling the research agenda, meaning evidence base is biassed according to their vested interests. Examples include fiddling inclusion criteria to make it likely people who will create desired results will participate, and only publishing positive results.

Volume of evidence has become unmanageable. We’ve all done a CINAHL search and returned 1,062 results. You don’t see how you can narrow your search terms anymore and you certainly can’t read all the abstracts…

Benefits identified as statistically significant may actually provide negligible  difference to patients in real life situations. Especially when research is carried out poorly, eg small sample size or drug company fiddling as mentioned above, the efficacy of treatment is falsely inflated for what it would actually be on a real population.

Inflexible rules risk healthcare becoming management-driven (following technical instruction) rather than client-centred (using clinical expertise). Eg creating protocols or checklists from EBP and then only following these in patient care. Like the QOF, where GPs get money for achieving health targets- Greenhalgh suggests that patients are monitored and provided check-box medication if they meet the QOF criteria, without consultation about their individual circumstances (client-centred care). This is a point Cohen & Hersh (2004)  agree with. O’Halloran et al (2010) follow on by saying that the technical guidelines produced by EBP stifle creativity.

Evidence available for individual conditions and not for co-morbidity, making it difficult to find evidence for patients with multiple diagnoses.  An aging population plus better management of chronic disease means more people have multiple conditions, which research studies don’t cover, removing individualised patient care.

 

Greenhalgh et al (2014) suggest overcoming these negatives by providing individualised care taking the context and even professional creativity into account. Patient advocacy groups should dictate areas of research more than companies. Peer-reviewed publishers should up their standards for article inclusion, and information should be disseminated in more user-friendly ways/methods (like infographics/via YouTube).

 

Note: apparently comorbidity is more than one illness in a person, and multimorbidity is more than two illnesses in the same person.

++++++++++++++++++++++++++++++++++

Source:

Cohen AM and Hersh WR (2004) Criticisms of Evidence–Based Medicine. Evidence-based Cardiovascular Medicine 8(3): 197–198.
Greenhalgh T, Howick J, Maskrey N and for the Evidence Based Medicine Renaissance Group (2014) Evidence based medicine: a movement in crisis? BMJ 348(jun13 4): g3725–g3725. Available at: http://www.bmj.com/content/bmj/348/bmj.g3725.full.pdf [Accessed on 03.05.2017]
O’Halloran P, Porter S and Blackwood B (2010) Evidence based practice and its critics: what is a nurse manager to do? Journal of Nursing Management 18(1): 90–95.
Conducting a literature review: Critical appraisal of a piece of non-research evidence (a website)

Conducting a literature review: Critical appraisal of a piece of non-research evidence (a website)

I have reviewed a piece of non-research evidence, in the form of a website http://my.clevelandclinic.org/health/diseases_conditions/stroke/hic_Eating_Well_After_a_Stroke

otter website

According to Sackett et al’s (1997) hierarchy of evidence, grey literature such as this is shouldn’t usually be the first source you turn to for evidence since there are other sources which are more reliable, for example because they have been peer-reviewed. However sometimes there may be an absence of quality sources or you are trying to gain an understanding of public opinion on a topic.

To help me assess the website I am going to use Aveyard et al’s (2001) ‘six questions to trigger critical thinking’, which are:

  1. Where does this information come from?
  2. What is being said?
  3. How did they write this?
  4. Who is telling me this?
  5. When was this written?
  6. Why has this been written?

Where does this information come from? I found this by searching for “guidelines stroke recovery eating” using the search engine DuckDuckGo to avoid any tracking cookies from Google biasing the results according to my previous search history. Read more

Conducting a literature review: How to accurately evaluate any evidence before basing your practice on it

Conducting a literature review: How to accurately evaluate any evidence before basing your practice on it

I can’t use any old piece of evidence which has an abstract and a few relevant keywords to base my clinical actions on.

wtf otter

It could be biased (such as being funded by someone with an interest in the study’s outcome), not statistically significant, methodically flawed or irrelevant to the precise patient problem I am investigating. I could be challenged by a well-informed ‘expert patient’ who has free and easy access to information themselves via the internet, so I need to make sure I can back my decisions up.

Instead I’ll need to identify the patient’s problem, find relevant studies, critically evaluate them, and then apply them to the problem taking into account the patient’s individual needs.

Research + Clinical Expertise + Patient Preference = EBP

The process of EBP has five steps, although Melnyk (2010) later added two additional ones shown in italics below. It should also be noted that sometimes ‘Health Service Restrictions’ are included in the above formula (DiCenso et al 1998), meaning that limitations due to resource cost/access are taken into account as part of pragmatic reasoning.

0. CULTIVATE SPIRIT OF INQUIRY   essential starting point

1. ASK   questions that are answerable!

2. ACQUIRE   search for the best evidence from the research available

3. APPRAISE   critically appraise/evaluate the evidence – is it relevant, valid, reliable, applicable to you clinical question?

4. APPLY   integrate the evidence with clinical expertise and patient’s preferences and values, and then implement it

5. ASSESS   evaluate and reflect on the outcomes of your decision

6. DISSEMINATE EBP RESULTS  share good practice and support other healthcare professionals Read more

Conducting a literature review: Where do I look for evidence to use in my Evidence Based Practice?

Conducting a literature review: Where do I look for evidence to use in my Evidence Based Practice?

Searching for the evidence

Lots of different information sources are available to OTs when they are searching for evidence to guide their Evidence Based Practice. The different types each have different levels of usefulness related to patient care.

otter detective
Elementary, my dear Ottson

Some example sources and their uses are:

  • Guidelines – help OTs to make decisions quickly as you do not need to search and review literature yourself. Someone eg NICE has done this (plus taken into account the cost/benefit) already for you.
  • Protocols – defined steps or rules used to describe the process for a particular treatment or assessment. Often specific to local contexts; stricter and hold more weight legally than a guideline.
  • Blogs – useful to understand public opinion around a certain issue; can read a wide range of opinions and see what evidence is used to back each up (or question whether any has!). Is this where patients have researched healthcare in the absence of journal access, and does this explain their viewpoints?. Some professional organisations also have blogs, such as this BMJ evidence based nursing blog.
  • Theories explanations of phenomena. They can be tested to see if they work in practice via research hypotheses, so in this way evidence could prove or disprove theory.

Read more

Conducting a literature review: Quality reviewing a research article “Strategies used by older women with intellectual disability to create and maintain their social networks: An exploratory qualitative study” by Mackenzie & White (2015)

Conducting a literature review: Quality reviewing a research article “Strategies used by older women with intellectual disability to create and maintain their social networks: An exploratory qualitative study” by Mackenzie & White (2015)

I’ve chosen to review the quality of a piece of qualitative research titled “Strategies used by older women with intellectual disability to create and maintain their social networks: An exploratory qualitative study” by Katharine White and Lynette Mackenzie. I chose this because prior to starting my Masters I worked for a social inclusion charity with people with learning disabilities, so I was interested in whether the results were something that could have potentially influenced my work there.

thinking otter

This article is a research paper and not an opinion piece, which you can tell by the fact that it has an Abstract, collates data methodically from a subject group (Method section), analyses it (Data Analysis/ Results sections), and then draws conclusions based on the factual results (Discussion, Implications for Occupational Therapy sections).

The authors are Katharine White who is an Occupational Therapist with the Department of Aging, Disability & Care in Sydney, and Lynette Mackenzie who is an Associate Professor at the University of Sydney. They are both interested in researching the effects of aging on disabled individuals and this is plausible as Mackenzie is part of the ‘Aging and Health Research Team’ at the university and White currently specialises in aging and disability in her job role.

They have not declared any conflicts of interests and the research was not funded by anyone, but it was given ethical approval by the University of Sydney. It’s important to check these details because if the sponsor or researcher has a vested interest in the results of the study it’s possible they will be intentionally or unintentionally biased- for example the selection criteria for subjects may be manipulated in favour of one result, or only positive findings are published. Read more

Occupational Science

Occupational Science

Occupational Science is an academic discipline concerned with the study of human occupation. science otter

It is a new discipline that emerged in the late 1980’s to provide a scientific base for Occupational Therapy practice. It has a close relationship with Occupational Therapy since OT uses evidence from Occupational Science to inform practice, and they are both concerned with occupation and how it affects people. Some examples of areas studied in Occupational Science could be identifying the nature or characteristics of occupations themselves, investigating the processes or outcomes of occupational performance, or attempting to explain how occupation affects people’s health/quality of life/social structures/identity. This can help to explain effects such as occupational deprivation or occupational justice. By studying what the  determinants of health are, it can also give weight to decisions aimed at overcoming occupational injustices (Yerxa 1993).

Like OT, Occupational Science draws on a wide range of other disciplines such as philosophy, anthropology, sociology, economics, and evolutionary biology in order to achieve this. Yerxa (2000) illustrated this in her keynote speech reflecting on her career, where she described undertaking ‘detective work’ in order to discover which elements had contributed to Occupational Therapy, and found that ideas from history, political science, disability studies and psychology had also influenced OT in addition to those mentioned above. The information created by occupational science is important to occupational therapy because it informs traditional practice whilst providing evidence for non-traditional practice areas, and has the potential to address practice dilemmas (Wilcock 2001).

OT is focussed on the individual, whereas for Occupational Science a wider view of occupation is necessary to provide a holistic understanding  of what are complicated phenomena. Occupational science can provide the underlying rationale to OT models, for example explaining the ‘identity’ in the Canadian Model of Occupational Performance & Engagement (CMOP-E). Occupational Science has shown that our experiences and motivations for occupations creates our sense of self-identity (for example Wilcock 2006, Sennet 2008 or Hocking 2000).

Occupational science can inform traditional practice as well as provide evidence for non-traditional areas of work (Hocking 2009). Additionally it can be used to study determinants of health,  address potential practice dilemmas and overcome occupational injustices (Wilcock 2001 and Yerxa 1993).

Further benefits of incorporating occupational science research into occupational therapy practice are…Occupational science: Adding value to occupational therapy’ New Zealand Journal of Occupational Therapy 58(1): 29-35

+++++++++++++++++++++++++++++++++++++

Sources:

Hocking, C (2000) Having and using objects in the western world Journal of Occupational Science 7(3), 148-157

Hocking C (2009) ‘The challenge of Occupation: Describing the things people do’ Journal of Occupational Science 16(3): 140-150

Hocking C and Wright-St. Clair V (2011) ‘Occupational science: Adding value to occupational therapy’ New Zealand Journal of Occupational Therapy 58(1): 29-35

Sennet R (2008) The Craftsman. London: Penguin books

Riley J (2012) Occupational science and occupational therapy: a contemporary relationship. Chapter 14 in Boniface G, Seymour A (eds) Using occupational therapy theory in practice Oxford: Wiley Blackwell

Yerxa EJ (2000) Confessions of an Occupational Therapist Who Became a Detective British Journal of Occupational Therapy May 2000 vol. 63 no. 5 192-199

Yerxa E J (1993) Occupational science: a new source of power for participants in occupational therapy Occupational Science: Australia 1(1) 3-9

Wilcock A (2001) Occupational Science: the key to broadening horizons British Journal of Occupational Therapy 64(8) 412-17

Wilcock A (2006) An Occupational Perspective of Health (2nd edition) Thorofare NJ: Black