Putting research to work : It is all about changing our behavior

1. Putting research to work :It is all about changing our behavior Kathy O’Leary, RN, MN Faculty of Nursing, University of Alberta May 18, 2010

2. The current landscape • Society’s ‘love affair’ with science and the promise of medical breakthroughs • A fundamental challenge in health care is the effective management of innovation and change • Unfortunately, there has been much “breakthrough” (knowledge development) but not enough “follow through” (application in clinical practice)

3. The current landscape • Juxtaposition of increased amounts of research with glaring needs has led to growing clamor in both clinical and policy circles about the need to “translate research into practice” (Simpson, 2004). • Failing to use the latest health care research is costly and harmful and leads to overuse of ineffective care, under-use of effective care and potential errors.

4. The current landscape • Reality is that clinical practice does not always reflect the latest research • New advancements fail to be translated into tangible human benefits (return-on- investment) • This is unfortunate as health care is rich in research advancements and the past decade has witnessed widespread interest in the development of practices better informed by evidence

5. The current landscape • This enthusiasm has been tempered by understanding the challenges of devising effective strategies to ensure that research informs practice • Putting research ‘into action’ or ‘to work’ – knowledge translation • Having research inform our behavior/actions as clinicians • Having research shape the decisions by leaders/decision-makers and healthcare consumers

6. The current landscape • Knowledge translation (KT) is one of two major goals of the Canadian Institutes of Health Research “….the exchange, synthesis and ethically-sound application of knowledge within a complex system of interactions among researchers and users, to accelerate the capture of the benefits of research for Canadians through improved health, more effective services and products and a strengthened health care system.”

7. The current landscape • Generally accepted, though not well substantiated that the majority of practitioners do not base their practice on research • Studies from the US and the Netherlands suggest that 30%- 40% of patients do not receive care complying with current research evidence • 20-25% of the care provided is not needed and may be potentially harmful

8. Knowledge translation • To increase the use of relevant knowledge (a.k.a. research) among clinicians, managers, administrators, and policy makers • KT issues are challenging because they involve behaviour change among providers working in complex and high velocity health care organizations.

9. Knowledge translation • While both new science about health issues (knowledge development) and increased clinician knowledge about health issues are important, neither increasing research nor deploying strategies aimed at increasing clinician knowledge will solve the challenges of getting clinicians to use research in their practice

10. Knowledge translation • Previous research demonstrates that KNOWLEDGE is NOT enough • Let’s consider: • Majority of staff (72%) identified the supine position as the placement that most lowers SIDS risk, yet only 30% reported most often placing infants to sleep in that position Stastny, P. et al., (2004). Nursing Research, 53(2), 122-129.

12. What does KT science tell us? • Individual determinants • Include factors that reside in individual practitioners and are amenable to interventions aimed at changing individual behavior • Individual determinants of research utilization: A systematic review*. • Categories of determinants: • Beliefs & attitudes • Involvement in research activities • Information seeking • Professional characteristics • Education • Socioeconomic factors *Estabrooks CA; Floyd JA; Scott-Findlay S; O'Leary KA; Gushta M; Journal of Advanced Nursing, 2003 Sep; 43 (5): 506-20

13. Strategies from medical perspective • General approaches to KT • Development & dissemination of CPGs • Computerized decision support systems • Continuing medical education • SRs of the effectiveness of interventions for modifying physician behavior concluded that: • no guaranteed approaches for ensuring practitioner behavior change • Most interventions are effective under particular conditions • And no interventions are effective under all circumstances or in all contexts.

14. The organization – what we know from the literature • Organizational complexity • Centralization • Organizational size • Innovation champions • Traditionalism • Organizational slack • Time • Access to research and resources • Professional autonomy • Support • Unit-level Uncertainty

15. So what needs to be done? • Need to understand other KT influences – most importantly work environment • Development of organizational KT interventions • The research I am involved in tackles this gap

16. What have I learned about getting clinicians to use research in practice? • MDI spacer project (Scott & Osmond) • Barriers and facilitators to research use • CIHR Team in Children’s Pain (Stevens et al.,) • Implementation of strategies to increase research use

17. A Qualitative Study of Barriers and Supports to Implementation of MDI/Spacer Use in Canadian Pediatric Emergency Departments • Barriers: • Lack of leadership in the form of a research champion • Lack of consensus about the benefits of MDI/spacers • Perceived resistance from parents • Perceived increased cost and workload • Successful strategies: • Active participation of all professional groups • Well-planned and well-executed educational component for staff, patients, and families • Early adopter sites were more likely to have the MDI/spacer included in a clinical protocol/pathway

18. In palliative care… Goepp MD, et al. (2008). Provider insights about palliative care barriers and facilitators: Results of a rapid ethnographic assessment. American Journal of Hospice & Palliative Medicine, 25(4),309-314. • Underutilization of palliative care in the US • Looked at healthcare providers at one institution (physicians, nurses, social workers, pastoral care professionals) • Barriers to inpatient palliative care utilization: • Need for consistent and uniform education • Training • Policy-making • Procedural standards • Facilitators: • Absence of resistance to change • Strongly expressed desire to overcome barriers that they identified

19. CIHR Team in Children’s Pain • Getting a snapshot of pain experienced in 8 Canadian Children’s Hospitals • Exploring how work environment shapes how research is used or not in practice • Testing effectiveness of unit-level ‘research practice councils’ in improving how children’s pain is managed in hospital

20. In palliative care… Harris D, Hillier LM, Keat N. (2007). Sustainable Improvements: Impact of the Comprehensive Advanced Palliative Care Education (CAPCE) Program. Journal of Palliative Care, 23(4), 262-303. • How do you make practice change sustainable? • Development of a ‘Palliative Care Resource Role’ • Direct provision of care • ‘Champions’ for the core concepts of palliative care • Mentorship and support to colleagues • Advocacy • Identification of palliative care issues within the organization

21. In palliative care… Harris D, Hillier LM, Keat N. (2007). Sustainable Improvements: Impact of the Comprehensive Advanced Palliative Care Education (CAPCE) Program. Journal of Palliative Care, 23(4), 262-303. • Barriers: • Limited management support • Lack of peer support • Limited physician support • Facilitators • Management support • Peer support • Physician support • PCR characteristics • Family support • Mentor support

22. CIHR Team in Pediatric Emergency

23. KT to healthcare consumers • An increase in consumerism, an expansion in the number of viable treatment options and the substantial growth of the Internet and availability of health information have all contributed to greater patient involvement in health care decisions. • Provision of health information to patients is challenging in light of ensuring that the information is relevant, based on the best available science and presented in a form that is understandable.

24. KT to healthcare consumers • Traditionally the provision of information to consumers has be according to a medico-centered model where the information flow is unidirectional • More patient-centered approaches are becoming more prevalent – health beliefs, knowledge of the patient are considered equal • Examples…..

25. So what is next? • Through these studies I have learned: • KT is challenging because multiple players • Dealing with patients and families • KT needs to be happening at many different levels (individual, organizational, regional, etc.) with all players (physicians, nurses, families, etc.)

26. So… what can we do? • Understand that knowledge is not enough • Importance of creating and sustaining work environments that value using research in clinical practice • Consider how your work environment shapes your behavior • Accept that we all have a role to play in decreasing this gap between what we know and what we do!

27. I suggest that the extent to which research can improve health outcomes for patients depends on our ability to translate knowledge into practice • Those patients receiving end-of-life care and their families are counting on us! • Improving their quality of life is our ultimate goal!

28. In theory, there is no difference between theory and practice. In practice there is. Yogi Berra