translating current research in rehabilitation post stroke ... · • the process of translating /...
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TRANSLATING CURRENT RESEARCH IN REHABILITATION POST STROKE INTO OUR
DAILY PRACTICE
Natasha A. Lannin@NatashaLannin
November 19 CONFIDENTIAL 2
I would like to acknowledge that this meeting is being held on Aboriginal land and recognise the strength, resilience and capacity of Noongar People.I acknowledge that I grew up on the lands of the Noongar People. I express my gratitude in the sharing of this land, my sorrow for the personal, spiritual and cultural costs of that sharing and a hope that we may walk forward together in harmony and in the spirit of healing.
ACKNOWLEDGEMENTS
Peter Bragge, Monash UniversityTammy Hoffmann, Bond UniversityRussell Gruen, Singapore Laura Jolliffe, Latrobe University & Alfred HealthLiana Cahill, La Trobe University & Florey NeurosciencesAmanda Baker, Queensland HealthPetrea Cornwell, Griffith UniversityMeg Morris, La Trobe University & HealthscopeLeeanne Carey, La Trobe University & Florey Neurosciences Adam Scheinberg, Royal Children’s Hospital Sarah Knight, Murdoch Children’s Research InstituteJacqui Wheatcroft, Alfred Health
Project FundingTransport Accident Commission, Department
of Health & Human Services, NHMRC
I acknowledge that my work is supported by National Heart Foundation of Australia fellowship (GNT102055, 2019-2022)
STROKE REHABILITATION – MIND THE GAP
Australia “remains at substandard levels of adherence to the Clinical Guidelines” for key areas of rehabilitation
(Stroke Foundation, 2010)
WHAT DO WE NEED?• Ensuring stakeholders* are AWARE of and USE
research evidence to inform their health & healthcare decision-making
• Ensuring research is informed by current best evidence AND the experiences AND information needs of stakeholders*
* Stakeholders include: - Healthcare professionals- Consumers (i.e. patients, family members, carers)- Policy makers- Educators- Research Funders- Researchers
Best Evidence / Knowledge
Patient Experience
Information Needs
A ROSE BY ANY OTHER NAME?Implementation Science: scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine clinical care
Knowledge Translation: to enhance the use and usefulness of research
WHAT ABOUT MODELS? FRAMEWORKS? APPROACHES?
Availability, Responsiveness & Continuity (ARC) Model
Behaviour Change Wheel
Canadian Institutes of Health Research Knowledge Translation within the Research Cycle Model or Knowledge Action Model
Collaborative Model for Knowledge Translation Between Research and Practice Settings
Community Based Participatory Research (CBPR)
Conceptualizing Dissemination Research and Activity: Canadian Heart Health Initiative
Consolidated Framework for Implementation Research (CFIR)
Contextual Frameworks for Research on the Implementation of Complex System Interventions
Coordinated Implementation Model
Determinants of Innovation within Health Care Organizations
Diffusion of Innovation
Dynamic Sustainability Framework
Explaining Behavior Change in Evidence-Based Practice
Facilitating Adoption of Best Practices (FAB) Model
Framework for Analyzing Adoption of Complex Health Innovations
Framework for Dissemination of Evidence -Based Policy
Framework for the Dissemination & Utilization of Research for Health-Care Policy & Practice
Framework for the Transfer of Patient Safety Research into Practice
Framework of Dissemination in Health Services Intervention Research
General theory of implementation
Health Promotion Research Center Framework
Health Promotion Technology Transfer Process
Implementation Effectiveness Model
Intervention Mapping
Iowa Model of Evidence-Based Practice
Joint Venture Model of Knowledge Utilization
Knowledge Exchange Framework
Knowledge Transfer and Exchange
Knowledge Translation Model of Tehran University of Medical Sciences
Marketing and Distribution System for Public Health
Model for Improving the Dissemination of Nursing Research
Model for Locally Based Research Transfer Development
Multi-level Conceptual Framework of Organizational Innovation Adoption
Normalization Process Theory
Organizational Theory of Innovation Implementation
Ottawa Model of Research Use
Outcomes-Focused Knowledge Translation
OutPatient Treatment in Ontario Services (OPTIONS) Model
Pathways to Evidence Informed Policy
Policy Framework for Increasing Diffusion of Evidence-based Physical Activity Interventions
Practical, Robust Implementation and Sustainability Model (PRISM)
Precede-Proceed Model
Promoting Action on Research Implementation in Health Services (PARIHS)
Pronovost's 4E's Process Theory
Push-Pull Capacity Model
RAND Model of Persuasive Communication and Diffusion of Medical Innovation
RE-AIM Framework
Research Development Dissemination and Utilization Framework
Research Knowledge Infrastructure
Rosswurm & Larabee 'Research Utilization Model'
Stages of Research Utilization Model
Stetler Model of Research Utilization
Streams of Policy Process
Theoretical Domains Framework
US Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI)
Utilization-Focused Surveillance Framework
Vratny & Shriver Model for Evidence Based Practice
• PROBLEM: We are not making the best use of research to inform clinical care
• Part of the solution: Research Translation / Exchange
INFORMED DECISIONS FORIMPROVING OUTCOMES
Knowledge to action cycleGraham et al (2006). Lost in Knowledge Translation. Time for a Map? Journal of Continuing Education for Health Professionals
Knowing what we should be doing• Science is cumulative- the
results of individual studies needs to be interpreted & translated alongside the totality of evidence
WHAT RESEARCH SHOULD WE TRANSLATE?
Clinical Practice Guidelines• www.clinicalguidelines.gov.au/re
gister
• www.guidelinecentral.com/summaries/
• Professional associations
Systematic Reviews
WHAT RESEARCH SHOULD WE TRANSLATE?
Doing what we know we should be doingClinicians come to work to do the right thing… the know-do gap gets in the way
HOW SHOULD RESEARCH BE TRANSLATED?
Doing what we know we should be doingClinicians come to work to do the right thing… the know-do gap gets in the way
HOW SHOULD RESEARCH BE TRANSLATED?
• Difficulty in changing current practice model
• Resistance and criticism from colleagues
• Lack of trust in evidence or research
• Lack of time
• Lack of up-to-date evidence
• Lack of clear answers to clinical questions
• Contradictory information in the guidelines
• Lack of training
• Lack of accountability
Doing what we know we should be doingSelect your Implementation Interventions with care…
HOW SHOULD RESEARCH BE TRANSLATED?
IMPLEMENTATION STRATEGIES“Methods or techniques used to enhance adoption, implementation, & sustainability of a clinical program or practice” (Proctor et al., 2013)
Proctor EK, Powell BJ, McMillen JC. Implementation Strategies: Recommendations for Specifying and Reporting. Implementation Science. 2013;1(8):139
Identify objectives for implementation•Facilitate improved patient outcomes•Assist in monitoring patient progress and determining presence of a plateau
•Standardize care • Improve communication between levels of care, patients, and funders
Select strategies that will assist in overcoming specific barriers • Lack of understanding: tailored education, mentoring, etc. • Lack of time: locate a file in clinic with copies of instrument with details of how to use/interpret them, explain value of measures
• Lack of equipment: specific boxes with equipment, identify space in clinic, etc.
•Forgetting when to administer: alter documentation to incorporate measurements, timing, etc
SELECT, TAILOR, IMPLEMENT INTERVENTIONS
Straus, Tetro and Graham, 2009
SUSTAINING KNOWLEDGE USEDocumentation•Set up routine tests & common interventions in the clinic•Agree on documentation templates•Create “cheat sheets” with meaningful interpretations•Create clinical pathways
Equipment•Create kits for assessments & treatments
Working PartiesMonitoring•Audit & Feedback at Service Level•Unmet needs survey at Individual Clinician Level
Educational outreach visits•Expert visits your site and provides education tailored to address your clinic’s barriers
• Involves survey of clinicians to determine barriers & tailors education to address barriers
•Education provided by a respected person
FIVE THINGS TO KNOW BEFORE YOU START
1. LACK OF A CLEAR AIM FOR YOUR IMPLEMENTATION PROGRAM• What are you trying to achieve?
• What changes do you want to make that will result in improvement?
• What is the evidence to support changes to practice or service?
2. LACK OF UNDERSTANDING OF CONTEXT
Because the interaction of factors at multiple levels may influence the success or failure of implementation, an understanding of these factors is crucial to an effective intervention
Ferlie and Shortell, 2001; Grol and Wensing, 2004; van Bokhoven, Kok,vander Weijden, 2003
3. NOT INCLUDING PEOPLE IN THE PLAN OR THE PLANNINGStakeholders…
• Are anyone with an interest in the outcomes of your project
• Have something to gain or lose
• Are involved in or affected by the project
4. BAD PLANNING
Implementation plans should:
• Be well designed, well prepared and preferably pilot tested before use
• Guided by a theory of change
“Theories are like toothbrushes.
Everyone has their own and no one wants to use anyone else's” Campbell & Zazkis 2002
Theoretical approaches
1. Describing / guiding a process
Process models
2. Explaining what influences
outcomes
Determinant frameworks
Classic theories
Implementation theories
3. Evaluating the process
Evaluation frameworks
Adapted from: Nilsen, Implement Sci, 2015
Adapted from: Nilsen, Implement Sci, 2015
Theoretical approaches
1. Describing / guiding a process
Process models
2. Explaining what influences
outcomes
Determinant frameworks
Classic theories
Implementation theories
3. Evaluating the process
Evaluation frameworks
KNOWLEDGE-TO-ACTION FRAMEWORK
RE-AIM FRAMEWORK
PARIHSTHEORETICAL DOMAINS FRAMEWORK
CIFR
THEORY OF DIFFUSION
COM-B (Capability, Opportunity, Motivation and Behaviour)
5. FAILING TO BUILD SUPPORT FOR SUSTAINABILITY AND SCALE UP
• Evaluation of process and outcome
• Addressing contextual barriers
• Keeping people engaged and informed of progress
• Fidelity to the innovation and the implementation plan
FINAL REFLECTIONS
• The process of translating / moving our guidelines into practice is challenging
• Clinicians can translate guidelines into practice locally by taking a Knowledge Translation Approach to Quality Improvement
• Use of Implementation Science with the assistance of an Implementation Science Researcher/Theorist is likely to improve uptake into practice
• Training in Implementation Science Models, Theories and Frameworks is highly beneficial
TRAINING OPPORTUNITIES
https://training.cochrane.org/online-learning/knowledge-translation
