JAMIE BENNETT, TRS, CTRS UNIVERSITY OF UTAH

Session Outcomes Understand: 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

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, Pg. 4)

Benefits Improves predictability of outcomes Assurance 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, Yesterday)

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)

Steps to Evidence-Based Practice 1. Formulate a clear clinical question from a patient’s problem. Will a middle-aged person with a recent spinal cord injury gain greater stress awareness through yoga or Tai Chi? 2. Search databases for relevant clinical evidence 3. Appraise the evidence. 4. Implement and use findings in practice. 5. Evaluate the impact of change in practice. 20

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 21

Coping Skills Application Step 1: Formulate a clear clinical question. Ask questions using PICOT format P – Population of interest I – Intervention or area of interest C – Comparison intervention or group O – Outcome(s) desired T – Time frame 22

P - Population of interest  Characteristics? Age(s)? Diagnoses?  What general needs exist within this population?  What outcomes of intervention are desired?  Example: Clients lack appropriate coping skills when stressed 23

I - Intervention or area of interest  What are best practice interventions based on needs/desired outcomes?  Example: What interventions are best used for improving coping skills? 24

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? 25

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: Possess array of effective coping skills to manage stress 26

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: Agency’s average length of stay is 3 days (or 2 weeks or 4 months, etc.) 27

Step 1: Clinical Question  What coping skills do children need in order to manage stress well and sustain a healthy lifestyle across the lifespan? 28

Step 2: Search Databases University or Hospital Library

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 30

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? 31

Coping Skills/Strategies: Specific efforts, both behavioral & psychological, people employ to master, tolerate, reduce, or minimize stressful events. Psychosocial Working Group, Step 4: Implement and use findings (cont’d)

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)

Two Types of Coping Skills  Problem-solving strategies are efforts to do something active to alleviate stressful circumstances. (Cognitive)  Emotion-focused coping strategies involve efforts to regulate the emotional consequences of stressful or potentially stressful events. (Emotion) Psychosocial Working Group,

Step 4: Implement and use findings (cont’d) Health and Lifestyle Impact  Effective coping skills are associated with positive social outcomes.  Empirical evidence suggests that coping inflexibility leads to problematic social functioning.  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) 36

Out of 72 Articles Appraised  Stress Management (59) Cognitive Restructuring (54) Interpersonal Skills Training (53) Problem Solving (51) Conflict Resolution (34) Relaxation (23) 37 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. 38 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. 39 Step 4: Implement and use findings (cont’d)

Most Common Time Frame of Interventions  weeks in length  1- 2 Sessions per week  1 – 2 hours in duration per session 40 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? 41

Steps to Evidence-Based Practice 1. Formulate a clear clinical question from a patient’s problem. Will a middle-aged person with a recent spinal cord injury gain greater stress awareness through yoga or Tai Chi? 2. Search databases for relevant clinical evidence 3. Appraise the evidence. 4. Implement and use findings in practice. 5. Evaluate the impact of change in practice. 42

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? 43 Norma J. Stumbo

Questions?

Session Outcomes Understand: 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

Thank You! Jamie Bennett TRS, CTRS jamiespeaksrt.wordpress.com