Being an occupational therapy researcher and collaborating on
the current study: Lifestyle Matters OT Educator's conference SHU
18.06.14 1
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Aim of this talk Picture a career of an OT involved in research
Look at the many ways and levels OTs can be involved in research
Stress that collaboration is vital Demonstrate the importance of OT
informed research for our clients and populations use the Lifestyle
Matters study as an example 2
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It starts with curiosity As children we all engage in the
occupation of research 3
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Save the Children Fund programme evaluation: Community Based
Rehabilitation in Zanzibar 4
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Together with Jan Duffy, Clinical Psychologist DESCRIPTION
Service evaluation in a Community Mental Health Team. 1990?
Problems with staffing, timing, poor attendance Methods: Staff
discussion groups; standardised symptom questionnaire completed by
clients. Results: As a team we changed things: rolling programme of
anxiety management courses, day time and an evening course; and a
woman only and a mixed courses paired inexperienced staff with
experienced group leaders Routinely measured clients' outcomes
Improving Anxiety Management Groups 5 Learning to use a
standardised outcome measure
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DESCRIPTION Research Question: What outcomes do clients
attribute to their experiences of the therapy process? How do these
outcomes relate to any goals or expectations? Methods: Qualitative
researchers fore-understandings in generating interpretations
focussed interviews with 7 former clients of mental health OT
Results Intermediate outcomes: Engagement in activity Learning, and
regaining confidence in abilities Achievement of satisfying results
Contribution to other people Creative expression A study of
outcomes of Occupational Therapy in mental health services Masters
dissertation 6
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Final outcomes of OT Intrapersonal Outcomes: Increased
motivation Release of emotional pressure Changes in attitudes and
beliefs Increased self awareness Improved self value or acceptance
Adaptive Outcomes: Acquisition of skills Acquisition of knowledge
Management of time and routines Acquisition of coping strategies
concerning: Altering negative habits of thinking Controlling and
expressing emotions Solving problems Coping with disabilities
Managing anxiety and panic attacks Pacing time spent on work,
leisure and rest Being assertive Subjective outcomes: Lifting of
mood Reduction of distress Reduction of feeling isolated Feeling in
control Experience of pleasure Feeling physically fit and reduction
of pain Performance outcomes: Changed roles Improved ways of
relating to others Functional competence and independence in the
community Engagement in productive and creative activities
Interaction with the local environment and community 7
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DESCRIPTION With my job share partner, Penny Spreadbury, Trent
Region Head OTs employed us to stimulate, support and study
clinical audits across the region, in a wide range of OT teams.
Methods: Literature searching and putting on a database Participant
observation, Developing tools for outcome measurement, Group
interviews evaluating the process, thematic analysis Results:
Several barriers and enablers were established. Individualised goal
setting way forward Development of a tool: Binary Individualised
Outcome Measure. Alternative to SOAP notes: ACTOR notes (Activity,
Clients observations, Therapists observations Overall analysis, Re-
planning.) Trent Region Occupational Therapy Clinical Audit and
Outcomes Project. a research job! 8
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DESCRIPTION group of service users had set up their own
organisation, commissioned an evaluation. Methods: qualitative
analysis of: Individual interviews, group interviews, Observed
meetings, Evaluation workshop (including a roving microphone).
Results: recommendations on policy and implementation for the
organisation staff roles, clarification of different types of
advocacy Mental Health Advocacy Group evaluation Paid consultancy
work 9
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DESCRIPTION Job as a research practitioner in an inner-city GP
surgery. About 100 patients with psychotic conditions, became my
PhD study. Methods: 1) Needs Assessment Survey using standardised
assessments Development of new service 2) Case study of the new
primary care mental health service Single cohort, before and after
quasi-experimental study using standardised assessments Qualitative
interviews with staff (interviews carried out by a student OT)
Survey of patient satisfaction (interviews carried out by service
user interviewers) Economic evaluation of costs Primary Mental
Health Care Project a research-practitioner job, gave me the data
for my PhD 10
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DESCRIPTION. Mental Health Foundation promoting service user
led research, What was the impact of dance on emotional wellbeing,
as a health promotion activity, and what helps people take part.
Methods: Participatory research with members of the public and
service user researchers 5 Rhythms dance free classes Quantitative
survey questionnaire, Qualitative diaries, peer-pair interviews,
focus groups, and feedback on draft report Dancing for Living 11
Worked as a volunteer
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12
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Results Themes: Specific to the dance group: A safe place;
freedom of expression; structure of the rhythms; power of music;
group connections. Transformation through dance: moving from being
stuck; releasing powerful feelings; integrating parts of ourselves.
Effects on day to day living: Part of life now; physical wellbeing;
dancing as a strategy for emotional wellbeing; appreciating music.
What helps people take part: Out of 19 women, top scores: Can go on
your own without a partner (18), Toilet nearby (17) Friendly and
welcoming (16) Able to express self in own way (16) No spectators
watching (15) Dont need special clothes or equipment (14) Dancing
for Living 13
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DESCRIPTION Post doctoral award from the Dept of Health
research capacity awards. 4 years funding (75% time), a programme
of research, + local research grants, funded a small research team.
http://www.nihr.ac.uk/Lists/Research%20Training%20Awards/awards_curr
ent.aspx
http://www.nihr.ac.uk/Lists/Research%20Training%20Awards/awards_curr
ent.aspx Research team:& collaborators: Julie Coleman, Eleni
Chambers, Melanie Hart, Sally Bramley, Nicky Watson, Helen
Tompkins, Steve McGrath. Methods Delphi survey, asking OTs to help
define the intervention Pilot Randomised Controlled Trial &
economic evaluation using standardised outcome measures, in
community mental health teams. Qualitative study, individual
interviews of people with psychotic conditions, carried out by a
service user-researcher, using Framework analysis. Occupational
Therapy for people with psychotic conditions 14 I won the award to
pay for my salary and research costs
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Results: Intervention schedule for OT for people with
psychosis, 11 stages listing 82 actions (obligatory & optional
components). Pilot RCT showed that: no difference between the
intervention and control groups, except OT group had more clinical
improvement in relationships, independence performance,
independence competence and recreation, and reduced negative
symptoms. Qualitative study showed that: Some non OTs did OT,
probably due to inter-disciplinary team working Wide range of
factors impacted on what people wanted in their daily lives. OT was
appreciated as focussing on achievement or independence; overcoming
fears; organising time and widening horizons. This was different
from having things done for you, or having someone as a companion
or coming along for re-assurance. Occupational Therapy for people
with psychotic conditions 15
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My recent collaboration in large research studies Improving
Quality and Effectiveness of Services Therapies and Self-management
on longer term depression (IQUESTS). a literature review and
qualitative study of self-management strategies used by people with
long term depression and development of a Guide. Sarah's
contribution: co-leading Work Package 2. 10 Qualitative interviews
and analysis helping to write report and article This study is
within the Collaboration and Leadership in Applied Health Research
and Care for South Yorkshire (CLAHRC-SY). 2010 - 2011.
Rehabilitation Effectiveness and Activities for Life (REAL): a
multicentre study of rehabilitation services and the efficacy of
promoting activities for people with severe mental health problems.
Sarah's contribution: a co-applicant on the bid member of the
steering group developing the intervention for the cluster
randomised trial, supervising the therapists monitoring fidelity to
the intervention. January 2009 - March 2014. 16
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Lifestyle Matters: A large collaborative study involving OTs at
every level Principle investigators: Prof. Gail Mountain
(University of Sheffield) and Gill Windle (Bangor University)
Research Teams: Sarah Cook and Claire Craig (Sheffield Hallam
University) Bob Woods, Cath Brannan, (Bangor University) Kirsty
Sprang, Danny Hind, Anju Keetharuth, Lauren O'Hara, Katy Treherne,
Maggie Spencer, Tim Chater, Lauren Powell, Stephen Walters, John
Brazier (University of Sheffield) Facilitators delivering the
intervention: Johanna Warren & Samantha Bryan (Sheffield) + OT
clinical supervisor Elaine Hughes & Jessica Shirley (Bangor) +
2 OT clinical supervisors
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Thanks to Prof. Gail Mountain for being an inspiring research
leader, and Clair Craig for her creativity - both developed and
piloted 'Lifestyle Matters' and both are OTs. Gail produced the
following slides. 18
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The importance of ageing well Active ageing and prevention of
ill health in older people is a priority for policy makers across
Europe But also Beautiful Old Age It ought to he lovely to be old
To be full of the peace that comes of experience And wrinkled life
fulfilment. DH Lawrence 19
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The Well Elderly study of Lifestyle Redesign Clark, et al
(1997) Occupational Therapy for independent older living adults: a
randomised controlled trial. Journal of the American Medical
Association, 278, 1321-1326 Participants experienced benefit;
health, function and quality of life Benefit was sustained six
months later The interventions were cost effective 20
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Lifestyle Redesign Would this programme from the USA work with
community living older people in the UK? 21
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Outputs from the feasibility study Results used to inform
national guidance alongside well elderly study:
http://guidance.nice.org.uk/PH16 http://guidance.nice.org.uk/PH16
Intervention published 22
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Programme Ethos A preventive health approach which focuses on
the benefits of activity Underpinned by the belief that what we do
on a day to day basis is central to our health and wellbeing And
that positive changes can only be sustained if they are embedded
within what a person does on a day to day basis Programme Delivery
The older person is the expert peer support sharing information and
positive coping rooted in the local community 23 Lifestyle
Matters
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Lifestyle Matters: selecting from a menu of activities
Beginnings: celebration Activity and health The ageing process and
activity Personal energy, time and activity Goals; realising hopes
and wishes Pulling things together how is activity related to
health 24
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Lifestyle Matters: Ideas continued Maintaining mental wellbeing
Sleep as an activity Keeping mentally active Memory Maintaining
physical wellbeing Nutrition Pain Keeping physically active 25
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Lifestyle Matters: More ideas.. Occupation in the home and
community Transportation Opportunities for new learning
Experiencing new technologies Safety in and around the home Keeping
safe in the community Keeping safe in the home 26
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Lifestyle Matters: yet more.. Personal circumstances Dealing
with finance Social relationships and maintaining friendships
Dining as an activity Interests and pastimes Caring for others,
caring for self Spirituality Endings
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Ideas for group outings and further activities; some examples
Tai chi Exploring community resources yoga, relaxation courses at
community colleges Aromatherapy, hand massage Outing to a spa or
leisure centre Problem solving techniques assertiveness, saying no
Individual sessions 28
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Lifestyle Matters trial A pragmatic, two-arm, parallel group,
individually randomised controlled trial in two study sites funded
by LLHWB (6) Included an evaluation of clinical and cost
effectiveness of the intervention (Lifestyle Matters) and a process
evaluation (fidelity checks and qualitative interviews) Is
examining the long term benefits of the intervention through a 2
year follow up 29
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Intervention delivery & participants Target reached: 270
randomised participants 16 weekly meetings (11 groups ran) Monthly
1:1 sessions to pursue individual goals Groups supported by 2
trained facilitators (Band 4 NHS Equivalent) Attended by 8-16
individuals Central, accessible venues with appropriate facilities
Activities and outings designed to help people achieve or maintain
a happy, healthy and fulfilling later life 30
Slide 31
Outcome measures For all participants, at baseline (after
cognitive screening, 6 months after randomisation and once more two
years later Mental health dimension of the SF36 (primary) Other
dimensions of the SF-36 to measure all aspects of health including
physical health; EQ-5D (for health economic analysis (Brazier et
al, 2007); The Brief Resilience Scale (Smith et al, 2008); General
Perceived Self Efficacy (GSE) Scale (Schwarzer & Jerusalem,
1995); Patient Health Questionnaire to determine extent of
depressive symptomology (PHQ-9) (Spitzer et al, 1995); de Jong
Gierveld loneliness scale (de Jong, 1985); An adapted Client
Services Receipt Inventory (CSRI) to collect participants use of
health, social care and community services for health economic
analysis; A simple socio-demographic questionnaire constructed for
the purposes of the study No measure of participation! 31
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Fidelity assessment Showed that on the whole fidelity to the
intervention was good GoalFidelity Standardised training
Facilitator skill acquisition Standardised delivery Minimise drift
in skills/ delivery Participant observation of 2 day training,
using content checklist Monitoring of attendance and delivery
numbers Audit of records Observation of a purposive sample of video
recorded weekly sessions using a content checklist Participant and
facilitator semi-structured interviews 32
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Fidelity assessment & process evaluation Qualitative
interviews and Framework data analysis Interviewed all 4
facilitators, 2 time points Interviewed all 3 OT supervisors post
intervention Interviewed 13 participants (10% purposive sample)
post intervention Participants from 6 groups across all 3 cycles
Both sites (Sheffield n=7, Bangor n=6) Selection criteria included
age, sex, geographical area, attendance as individual or part of a
couple, education, previous occupation, level of current activity,
number of sessions attended 33
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Emergent results from process evaluation (participants) Most of
those interviewed indicated that with the support of the group and
the facilitators they had found the impetus to pursue one or more
activities or interests since taking part in the programme I think
what were going to do now, [wife] and I have decided that on
Thursdays it should be an activity day for usErm but weve said, OK,
Thursday, weve enjoyed it so much, why dont we go out and make
Thursday an activity day. Weve nothing else to worry about, weve no
dependents as such, we can go, go out any day, but Thursday cause
weve got into a routine, yeah, lets go and try so-and-so. 34
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Emergent results from process evaluation (10% of participants)
Main reasons for not attending were illness or being too busy but
non attendance was also viewed negatively Initial concerns over
male/ female mix "I remember when I went in there that first day
and, oh god, I was the only bloke there and I thought, what the
hell have I let myself in for here? And when I was going, the last
one [group meeting], I was quite, I was quite sad that it was over
with, you know, because the group had joined inas a gel, yeah, you
know. 35
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Emergent results from process evaluation (participants)
Challenges were posed by transport and the climate; Shall we go,
shant we go because of the snow and one thing and another, which
again was unfortunate...when er, you know, we had two out of the,
three out of the sixteen weeks...where I couldnt go, er, and I mean
I only live a couple of hundred yards away. 36
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Emergent results from process evaluation (facilitators) Over
time, the facilitators did not change attitudes and understanding
but did develop and improve their skills and confidence Rather than
the facilitators instructing and directing, they encouraged the
group to make decisions and enabled people to contribute and for
some, to take leadership. Group dynamics were very important. Group
facilitation needed to include subtle and nuanced responses to
complex relationships and behaviour including conflict. This
enabled trust and respect for difference, expression of feelings
and knowledge, and for the group to gel. Older people shared and
developed coping strategies for managing the challenges of ageing.
This included increased assertiveness at home and with GPs,
balancing occupations and routines, and finding new ways to be
active. 37
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Emergent results from process evaluation (facilitators) The
programme provided opportunities to try out new activities and
community facilities, which led to changes in routines and
behaviour There was little evidence of the older people taking over
and continuing the organisation of the whole group by the end of
the programme People built new friendships which they planned to
continue after the programme, and do activities together. It may
have needed longer than 16 weeks, and a gradual withdrawal of
facilitation, for groups to take over running themselves
Facilitators found it challenging to engage people in the 1:1
sessions which were initially seen as optional The clinical
supervision was much appreciated, but in future supervisors should
have experienced delivering the programme themselves. Recruitment
challenges how to reach those in most need? Some people took part
to help the researchers, not because they were isolated or
inactive. But they did say they benefited from the programme.
38
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What have we learnt?? No definitive trial results due to 2 year
follow up interim analysis not allowed From the feasibility study
to the major trial Methodological contribution - evaluation of
complex, group based interventions Have we measured the right
dimensions? would have liked a measure of participation Need to
target recruitment to those most in need Need to establish 1:1
sessions as essential. 39
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Future Research and You 40 Two feasibility studies have been
started: Lifestyle Matters for older people with dementia, and for
older people with depression. Could Lifestyle Matters be modified
for other client groups in your settings? and with other age
groups?
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How can you see yourself as an occupational therapist
contributing to research? 41 Evidence based practice -
implementation in routine services Funding bids need clinical
expertise Development of new or modified OT interventions Delivery
and supervision of new interventions being researched Fidelity
checking (to monitor adherence to the intervention) Research
steering or management group Member of a research team collecting
and analysing data. MSc or PhD study to learn research skills and
if this is not for you, SUPPORT your colleagues and students to get
involved.
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Thank you! 42
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References 1.Clark F, Azen S, Zemke R, Jackson J, Carlson M,
Mandel D: Occupational Therapy for Independent-Living Older Adults.
Journal of the American Medical Association 1997,
278(16):1321-1326. 2.Clark F, Azen S, Carlson M, Mandel D, LaBree
L, Hay J: Embedding Health-Promoting Changes Into the Daily Lives
of Independent-Living Older Adults: Long-Term Follow-Up of
Occupational Therapy Intervention. Journal of Gerontology: Series B
Psychological Sciences 2001, 56(1):60-63. 3.Hay J, LaBree L, Luo R,
Clark F, Carlson M, Mandel D: Cost-Effectiveness of Preventive
Occupational Therapy for Independent-Living Older Adults. Journal
of the American Geriatrics Society 2002, 50(8):1381-1388. 4.Clark
F, Jackson J, Carlson M, Chou C, Cherry B, Jordan-Marsh M, Knight
B, Mandel D, Blanchard J, Granger D et al: Effectiveness of a
lifestyle intervention in promoting the well-being of independently
living older people: results of the Well Elderly 2 Randomised
Controlled Trial. Journal of Epidemiology & Community Health
2011. 5.National Institute for Health and Care Excellence (NICE):
Guidance on occupational therapy and physical activity
interventions that promote good health and wellbeing in older
people. In. London: National Institute for Health and Care
Excellence; 2008. 6.Sprange, K. Mountain, GA. Brazier J. Cook, SP.
Craig, C. Hind, D. Walters, SJ. Windle, G. Woods, R. Keetharuth,
AD. Chater, T. Horner, K. (2013) Lifestyle Matters for maintenance
of health and wellbeing in people aged 65 years and over: study
protocol for a randomised controlled trial. Trials 14:302 7.Bellg
A, Borrelli B, Resnick B, Hecht J, Minicucci D, Ory M, al. e:
Enhancing treatment fidelity in health behavior change studies:
best practices and recommendations from the NIH Behavior Change
Consortium. Health Psychology 2004, 23(5):443-451 8.National
Institute for Health and Care Excellence (NICE): Public Guidance 6:
Behaviour change at population, community and individual levels.
In.: London: National Institute for Health and Care Excellence;
2007. 43