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History of EBP in Medicine
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Implementing Evidence-Based Practice: Coping Skills as an Example
JAMIE BENNETT, TRS, CTRSUNIVERSITY OF UTAH
Session Outcomes
2
Identify the history of EBP
Identify 3 reasons why EBP is important to your practice and profession
Identify the relationship between EBP and outcomes
List five steps of EBP
Understand Coping Skills program as example
Explain how to transfer to your programs and practices
History of EBP in Medicine
Middle Ages
Medicine – Technically did not heal you, faith healed you.
Neo-Classical Period
Mid 1800’s“The fastest knife in the West End”
Johns Hopkins Hospital – Mid 1800’s
Early 1900’s
The End Result Concept
Earnest Amory Codman
Definition:“Evidence Based Practice means conducting or using research to inform the design and delivery of therapeutic recreation practice.”
(McCormick & Lee, 2001)
Purpose: “The overall aim of EBP is to reduce wide (and unintended) variations in practice, and instead use the best, accumulated evidence possible to inform, enlighten, and direct practice.”
(Stumbo, 2011. Pg. 4)
Benefits Improves predictability of outcomesAssurance of quality of care
Regulators Payers Patient/client/participant and family
Efficient Increased ability to reach desired outcomes Best practices
Why?
More likely to reach desired
Outcomes!
What are Outcomes? Observable changes that result from
intervention (Client status, functional status, well-being, care satisfaction, cost/resource utilization
Changes over specified time Clinical results Results of performance
(Stumbo, Yesterday)
What are Outcomes? Direct effects of service Difference between input (assessment
baseline) and output (discharge) Straightest line between A and B Both planned and unplanned Both beneficial and harmful
(Stumbo)
Client Outcomes!
Intervention
Entry Exit
Difference between Point A/Entry and Point B/Discharge
= Outcomes
(Stumbo, 2003)
Client Outcomes!
Intervention
Entry Exit
Difference between Point A/Entry and Point B/Discharge
= Outcomes
EBP 5 Steps!
(Stumbo, 2003)
What Do We Know For Sure? Outcome measurement depends on:
Specification of outcomes
Standardized practice
Client assessment
Documentation/records
Systematic program evaluation and efficacy/effectiveness research
(Adapted from Norma Stumbo)
20
Steps to Evidence-Based Practice
1. Formulate a clear clinical question from a patient’s problem.
2. Search databases for relevant clinical evidence3. Appraise the evidence.4. Implement and use findings in practice.5. Evaluate the impact of change in practice.
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Coping Skills Application
STEP ZERO: Cultivate a spirit of inquiry
TR is more than just activity provision!
TR is Process that starts with:○ Specifying outcomes (don’t start with activity first!)○ Looking at research○ Choosing and implementing best practice interventions○ Documenting and evaluating outcomes of interventions
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The Flea Complex Fleas are the longest and highest
jumper among all animals compared to body size.
Fleas can jump: 220 times their body length
○ 13 inches 150 times their body height
○ 7 inches vertical
You Make the Difference!
“The best way to predict the future is to create it!”
– Peter Drucker
Coping Skills Application
Step 1: Formulate a clear clinical question.
Ask questions using PICOT formatP – Population of interestI – Intervention or area of interest C – Comparison intervention or groupO – Outcome(s) desiredT – Time frame
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P - Population of interest
Characteristics? Age(s)? Diagnoses? What general needs exist within this
population? What outcomes of intervention are desired?
Example: Who do you want to create a program for?
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I - Intervention or area of interest
What are best practice interventions based on needs/desired outcomes?
Example: What do you plan to do for the population? What is currently happening for this
population?
27
C - Comparison intervention or group
What population studied in the research is closest to my group?
Are skills specific to this group or are they universal?
Example:Are coping skills unique to at-risk youth or are they
universal for everyone needing to manage stress?
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O - Outcome(s) desired
What change(s) are possible with this group? What are the target behaviors of the
interventions? What should clients understand as a result of
these interventions?
Example: What change do I want to generate?
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T - Time frame
How long are the programs described in the research?
How long are clients at my facility? What can realistically be accomplished within this
time frame?
Example:How long does the program need to be in order to impact
change?What time frame do I realistically have, in working with my
population?
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Step 1: Clinical Question
What coping skills do children need in order to manage stress well and sustain a healthy lifestyle across the lifespan?
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Step 2: Search Databases
University or Hospital Library
www.scholar.google.comwww.guideline.govwww.findarticles.comwww.cochrane.org www.clinicalevidence.comwww.ncbi.nlm.nih.govwww.samhsa.govwww.ahrq.govwww.bmj.comwww.MedScape.comwww.jstage.jst.go.jpwww.doaj.org
www.samhsa.govwww.ahrq.govwww.bmj.comwww.MedScape.comwww.jstage.jst.go.jpwww.doaj.org
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Coping Skills: Keywords Searched Coping Skills Coping Skills AND Children Coping Skills AND Healthy Lifestyles Coping Skills AND Adolescents Coping Skills AND Adults Coping Skills AND People with Disabilities Coping Strategies Life Skills Self-Efficacy Perceived Control Coping Flexibility Coping Skills AND School Systems Coping Skills AND Stress
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Step 3: Appraise the evidence Articles Appraised: 72
What did the evidence suggest? Was there a theory used in the research? Was there an intervention implemented?
What was implemented? With who? What duration? What techniques were used to facilitate the intervention? Was there a statistical significance? What OUTCOMES did they find?
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Coping Skills/Strategies: Specific efforts, both behavioral & psychological, people employ to master, tolerate, reduce, or minimize stressful events.
Psychosocial Working Group, 1998
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Step 4: Implement and use findings in practice
Significant stress in early childhood can trigger amygdala hypertrophy and result in hyperresponsive or chronically activated physiologic stress response, along with increased potential for fear and anxiety.
Tottenham, Hare, Quinn, et al.
Step 4: Implement and use findings (cont’d)
This can then result in some children appearing to be both more reactive to even mildly adverse experiences and less capable of effectively coping with future stress.
Compas BE.
Step 4: Implement and use findings (cont’d)
Step 4: Implement and use findings (cont’d)
Two Types of Coping Skills Problem-solving strategies are efforts to do
something active to alleviate stressful circumstances.
Emotion-focused coping strategies involve efforts to regulate the emotional consequences of stressful or potentially stressful events.
Psychosocial Working Group, 1998
38
Step 4: Implement and use findings (cont’d)
Health and Lifestyle Impact Effective coping skills are associated with positive social outcomes. Evidence suggests a relation of coping strategies to health outcomes. (Mayeux & Cillessen, 2003; Richard & Dodge, 1982)
Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
(World Health Organization)
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Out of 72 Articles Appraised Stress Management (59)
Cognitive Restructuring (54)Interpersonal Skills Training (53)Problem Solving (51)Conflict Resolution (34)Relaxation (23)
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Step 4: Implement and use findings (cont’d)
Overall Outcomes: Increase perceived control over managing daily behaviors and emotions. Increase ability to manage stressors. Increase ability to communicate effectively with peers and support system. Increased coping flexibility.
41
Step 4: Implement and use findings (cont’d)
Specific Outcomes: Client will self-identify physiological signs of stress (increased heart rate, shallow breathing, etc.) Client will initiate controlled breathing within one minute. Client will remove self from situation within two minutes. Client will initiate one cognitive-based coping strategy (e.g., thought stopping, redirection, etc.) within two minutes.
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Step 4: Implement and use findings (cont’d)
Most Common Time Frame of Interventions 8 - 10 weeks in length 1- 2 Sessions per week 1 – 2 hours in duration per session
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Step 4: Implement and use findings (cont’d)
Step 5: Evaluate impact of intervention in practice
How well did the intervention work? What percentages of clients reached their intended outcomes?
For what groups did it work best? Least? What part of the intervention still needs to be modified?
44
Steps to Evidence-Based Practice
1. Formulate a clear clinical question from a patient’s problem.
2. Search databases for relevant clinical evidence3. Appraise the evidence.4. Implement and use findings in practice.5. Evaluate the impact of change in practice.
45
So what?
What did you learn about the PROCESS? What did you learn about OUTCOMES? What impact could EBP make on your services? What impact could EBP make on client
outcomes? How will you apply this to your daily practice? What other resources are needed to implement EBP? What is your next step?
46Norma J. Stumbo
Questions?
Session OutcomesUnderstand:
EBP historically Definition of EBP Outcomes The purpose and benefits of EBP How to create an evidence based program How to implement EBP to generate
outcomes in your facility
