University of Ottawa/ CIHR The Ottawa Model of Research Use Ian D Graham, PhD Canadian Institutes of Health Research School of Nursing, UOttawa Sept. 24, 2007

University of Ottawa/ CIHR

What do we know about research use? Uptake of research influenced by: –Perceptions of the innovation- (ie the evidence, CPGs) –The potential adopter –The practice setting or social context

University of Ottawa/ CIHR Factors influencing uptake of innovations: The Innovation Development process Attributes of the innovation

University of Ottawa/ CIHR  Credible developers  all relevant stakeholders  interdisciplinary  Objective & rigorous method  Careful documentation  explicit & transparent process  Local involvement Development Process

University of Ottawa/ CIHR Relative advantage (useful) Low complexity (ease of use or do) Compatible (fits with current practice, norms/values) (does not demand change in existing practice) Trialability (easy to try) Clear (not vague or non-specific) Evidence-based Re-invention ( Rogers 1995) (Grilli and Lomas, 1994) (Grol et al 1998) (Foy et al 2003) Characteristics of the Innovation

University of Ottawa/ CIHR Factors influencing uptake of innovations: Potential Adopters awareness attitudes knowledge/skill concerns current practice/habit

University of Ottawa/ CIHR Factors influencing uptake of innovations: Practice Environment- Structure Factors –Decision-making –Policies, rules, laws –Available technology: equipment, testing –Physical layout –Work pressure (info overload, competing demands, no time, chaotic environment) –Human resources

University of Ottawa/ CIHR Culture & belief systems –Norms, institutionalized habits Leadership Politics & personalities Peer influence Practice Environment: Culture/social Factors

University of Ottawa/ CIHR Practice Environment: Other Factors Patients/Consumers –Case mix, behavior, attitudes, preferences & demands Economic Considerations –Resources, remuneration, funding systems Medical/Legal Issues Other Organizational/System Factors

University of Ottawa/ CIHR What do we know about the effectiveness of implementation interventions? Cochrane’s EPOC (Effective Practice and Organization of Care) Group Systematic reviews of: –Professional interventions (e.g. continuing medical education, audit and feedback) –Organizational interventions (e.g. the expanded role of pharmacists) –Financial interventions (e.g. professional incentives) –Regulatory interventions

University of Ottawa/ CIHR Effectiveness of Knowledge Translation/implementation Interventions (Bero et al., 1998, Grimshaw et al., 2001, Grimshaw, 2004) Little or no effect Educational materials* Didactic educational meetings Sometimes effective Audit and feedback Local opinion leaders Local consensus processes Patient mediated interventions

University of Ottawa/ CIHR Generally Effective Educational outreach visits Reminders Interactive educational meetings Multifaceted interventions including two or more of : –Audit and feedback –Reminders –Local consensus processes –Social marketing

University of Ottawa/ CIHR Summary of Reviews on KT/Implementation Interventions No magic bullets- most interventions effective under some circumstances, none effective under all circumstances Multiple ongoing interventions are usually necessary Evidence is sparse for many interventions

University of Ottawa/ CIHR How Can We Facilitate Knowledge to Practice? Need a Conceptual Framework to Guide Implementation Planned action vs classic theories of change

University of Ottawa/ CIHR Assess + Monitor + Evaluate Practice Environment Potential Adopters Innovation Interventions Adoption Outcomes Ottawa Model of Research Use

University of Ottawa/ CIHR Getting Started Who is wanting to bring about the change in practice? Where are they located in the social system? What is their jurisdiction & scope of activities they can perform? What are their strategic alliances? What resources are available? Who is going to be the change agent(s)/facilitator(s)?

University of Ottawa/ CIHR Assess + Monitor + Evaluate barriers & supports interventions outcomes & degree of use Practice Environment Potential Adopters Innovation (CPG, tools) Interventions Adoption Outcomes Ottawa Model of Research Use

University of Ottawa/ CIHR Assess + Monitor + Evaluate barriers & supports interventions outcomes & degree of use Practice Environment Potential Adopters Innovation Implementation Interventions barrier management transfer follow-up Adoption Outcomes Ottawa Model of Research Use

University of Ottawa/ CIHR Assess + Monitor + Evaluate barriers & supports interventions outcomes & degree of use Practice Environment structural culture/social patients economic Potential Adopters awareness attitudes knowledge/skill concerns current practice Innovation (guideline) development process innovation attributes Interventions barrier management transfer follow-up Adoption intention use sustained use Outcomes patient practitioner system Ottawa Model of Research Use

University of Ottawa/ CIHR Assess + Monitor + Evaluate barriers & supports interventions outcomes & degree of use Practice Environment structural culture/social patients economic Potential Adopters awareness attitudes knowledge/skill concerns current practice Innovation development process innovation attributes Interventions barrier management transfer follow-up Adoption intention use sustained use Outcomes patient practitioner system Ottawa Model of Research Use

University of Ottawa/ CIHR Additional References Logan J, Graham, ID. Toward a Comprehensive Interdisciplinary Model of Health Care Research Use. Science Communication 1998;20(2): Graham ID, Logan J. Innovations in knowledge transfer and continuity of care. Can J Nurs Res Jun;36(2): RNAO Implementation of Practice Guidelines Toolkit Grimshaw et al Systematic review of the effectiveness and efficiency of guideline dissemination and implementation strategies. Htpp://

University of Ottawa/ CIHR Adoption and sustainability of decision support for patients facing health decisions: An implementation case study with embedded RCT Dawn Stacey RN PhD Assistant Professor, U niversity of Ottawa Funding: Canadian Institutes of Health Research September 2007

University of Ottawa/ CIHR Outline Background Purpose & Objectives Theoretical Framework Methods Results Implications for Research, Education and Practice

University of Ottawa/ CIHR Public’s view on who should make risk-related health decisions (Magee, WHO, 2003)

University of Ottawa/ CIHR

Problem: Decisional Conflict  uncertainty about which course of action to take North American Nursing Diagnosis Association, 2002 yes no

University of Ottawa/ CIHR ‘Innate’ contributing factors 2 or more options Outcomes: risky/uncertain, permanent, serious Value tradeoffs: benefits versus harms Anticipated regret: ‘missed’ benefits of option not chosen

University of Ottawa/ CIHR Consequences : unresolved decisional conflict & related factors 59 times more likely to change mind 23 times more likely to delay decision 5 times more likely to have regret 3 times more likely to fail knowledge test 19% more likely to blame practitioner for bad outcomes (Sun, Q. [MSc thesis]. University of Ottawa, 2005; Gattelari & Ward J Med Screen 2004;11: )

University of Ottawa/ CIHR Compared to standard care, patient decision aids… Improve decision quality 15% higher knowledge scores 70% more realistic expectations (probabilities) better match between values & choices Reduce decisional conflict (9 points) Help undecided to decide (50%) Patients 40% less passive in decisions Reduce over-use -25% surgery; -20% PSA; -29% HRT Potential to reduce under-use O’Connor et al., Medical Decision Making, 2007

University of Ottawa/ CIHR Value of coaching [hysterectomy] (Kennedy et al. JAMA 2002; 288: )

University of Ottawa/ CIHR Framework for Decision Coach-Mediated Shared Decision Making Primary Clinician Role to diagnose patient problem; discuss options; screen for decisional conflict; refer for decision support Goal: Informed decision making based on patients’ priorities & values Patient Role Communicate informed values & priorities shaped by their social circumstances Decision Coach Role (Ottawa Decision Support Framework) 1.Assessing decisional needs 2.Providing decision support tailored to needs 3.Monitoring & facilitating progress in resolving needs and decision quality 4.Screen for implementation needs (Stacey, Murray et al., Worldviews on Evidence-based Nursing in press)

University of Ottawa/ CIHR Client Centred Care RNAO Nurse Best Practice Guideline: Client Centred Care (2006) “Nurses have a central role in providing clinical expertise to facilitate clients’ decision making…to reach decisions that are well-informed and best for them” (p.3) Involve clients in decision making Provide structured decision support using patient decision aids and decision coaching “Providing care that is respectful of and responsive to individual patient preferences, needs and values and ensuring that patient values guide all clinical decisions” (p.6, Institute of Medicine, 2001)

University of Ottawa/ CIHR Purpose of research A case study with an embedded randomized controlled trial (RCT), guided by the Ottawa Model of Research Use 1.To explore baseline barriers and facilitators re decision support/coaching by call centre nurses 2.To design and evaluate a multifaceted intervention to improve the quality of nurses’ decision support 3.To describe the uptake and sustainability of decision support by call centre nurses Ethics approval by University of Ottawa, Research Ethics Board

University of Ottawa/ CIHR BCNurseLine call centre Serves population of 4.2 million since 2001 Goal –To help BC residents manage personal health issues and make ‘sound’ health decisions Healthwise ® Knowledgebase resources –Public access to a handbook and internet-based health information including 95+ patient decision aids Concurrent initiatives Dec 03 to June 04 –Major reorganization of nurse supervisors positions –Imminent contract renewal for call centre services –High absenteeism increased call pressure

University of Ottawa/ CIHR Decision Point Top Hits at BCNurseLine Breast or bottle feeding Birth control method Treatment for miscarriage Removing wisdom teeth Amniocentesis Antibiotics for acute bronchitis (884 hits total for 2003)

University of Ottawa/ CIHR Assess + Monitor + Evaluate barriers & facilitators interventions outcomes & degree of use Practice Environment BCNurseLine organization’s policies, mandate callers Potential Adopters: Nurses awareness attitudes knowledge/skill confidence current practice Innovation Decision support Multifaceted intervention online autotutorial decision support /coaching protocol skill workshop performance feedback Adoption intention use Outcomes patient practitioner system Ottawa Model of Research Use (Logan J & Graham ID, 1998; Graham ID & Logan J 2004) 1. Baseline assessment 2. RCT of intervention 3. Uptake & sustainability

University of Ottawa/ CIHR Case study method (Dec ‘03 to June ‘04) Analysis Conceptual content analysis of qualitative data Descriptive analysis of surveys; t-tests and ANCOVA for trial data Triangulation of results across data sources (Creswell JW, 1998; Sidani S & Braden CJ, 1998; Yin R, 2003) Data Sources Dec- Feb- Apr Jan (n) Mar (n) June (n) Key informant interviews 44 Focus groups with nurses 78 Survey: barriers/facilitators57 of 108 Quality audit simulated patient calls38 of 3939 of 39 RCT – intervention evaluation39 of 41 Survey: uptake, sustainability25 of 31 Organizational documents

University of Ottawa/ CIHR RCT methods 21 Intervention (knowledge test; acceptability surveys) 41 call centre RNs R 20 Control (knowledge test) Stratified by FTE status 41 simulated calls* 19 + simulated calls20 simulated calls (* Missed taping 1 call; + 2 dropped at the beginning of the intervention) December 2003 February 2004 April intervention May 2004

University of Ottawa/ CIHR Characteristics of participants %

University of Ottawa/ CIHR Baseline facilitators for nurses providing decision support/coaching Innovation: –Access to >95 patient decision aids Potential adopters: Nurses –Positive attitudes –Already refer to patient decision aids –Recognize callers having difficulty with decisions Practice Environment: Call centre infrastructure –supervisors/educators –classification of calls (Stacey, Graham, O’Connor, Pomey. Worldviews Evidence-based Nursing, 2005: 2: )

University of Ottawa/ CIHR Key Elements of Quality Decision Support Provided by Nurses to Simulated Callers (N=38)

University of Ottawa/ CIHR Baseline barriers to nurses providing decision support Innovation: –Inefficiency to find/use decision aids in database –No structured process to guide calls Potential adopters: Nurses –Lack knowledge, skill, confidence Practice Environment: Call centre infrastructure –Unclear program mandate –Organizational pressure to minimize call length –Low public awareness of call centre services

University of Ottawa/ CIHR Multifaceted intervention to address baseline barriers Barriers Online auto- tutorial Skill-building workshop Performance feedback (simulated call) Decision support protocol Locating & using patient decision aids Lack of structured process to guide callers X Nurses’ knowledge XX Nurses’ skills X Unclear program mandate Call length pressure (12.5 minute target) Low public awareness (Grimshaw J, et al., 2001 & 2004; Thomas L, et al., 1999)

University of Ottawa/ CIHR A process for coaching clients making decisions with 2 or more options Available at Decision support protocol Based on: Ottawa Decision Support Framework

University of Ottawa/ CIHR (Stacey et al., 2006, J Telemed & Telecare) Time in Minutes RCT to Enhance Nurse Decision Support Coaching

Health professionals’ decision support knowledge % (Stacey et al., 2006, J Telemed & Telecare; Stacey et al., ISCCN, 2006)

Coaches’ decision support skills improve Coaches’ decision support skills improve (simulated calls) Mean quality scores p < (Stacey et al., 2006, J Telemed & Telecare; Stacey et al., ISCCN, 2006)

University of Ottawa/ CIHR Adoption of decision support 25 of 31 trained nurses completed the survey Of 25 nurses, –23 plan to use decision support protocol next 3 months –21 felt comfortable using it –11 already used it with callers –14 did not receive an appropriate call “It was just plunge in, see what you do the first time…And I may not have been right on all of them but I could see where I missed. The next one I thought was better.” (Stacey et al., Implementation Science, 2006)

University of Ottawa/ CIHR Use with real callers: comments Recognized the need for decision support “It was a medication call and she had quite a few questions. But underlying it all, was her concern about how to select birth control.” Felt better prepared “I’m more likely to ask questions about the decision … instead of just making assumptions, which is a lot of what I did earlier.” Felt positive about their practice “I used to feel quite nervous that …I felt like I should know the answer. So this has given me a lot of power that you can help them, that you don’t have to sort it out for them.”

University of Ottawa/ CIHR Factors influencing sustainability of decision support by nurses Innovation: Decision support tools –usable via telephone, integrated in database, auto-charting Potential Adopters: nurses –Continuing education for ongoing skills development Practice environment: call centre –extended for all nurses –monthly call audit of decision support calls –Clear program direction/mandate –Call length guidelines tailored to decision support calls –Market decision support services to public

University of Ottawa/ CIHR Limitations of research Response biases –low response rate to survey (53%) Hawthorne effect –not blinded to simulated calls Generalizability of findings –other nurses (within call centre and other centres)

University of Ottawa/ CIHR Research, education, & policy implications Further research to study –Effect on real patient calls –Impact on nurses’ perceptions of their practice Need interventions to address unresolved practice environment barriers –Organizational mandate, call length guidelines, marketing of services –Telephone-friendly decision support resources Re-assess competencies in health professionals’ education programs

University of Ottawa/ CIHR Key Messages Effective interventions can address potential adopters’ barriers to implementing decision support in their practice –By increasing awareness, knowledge, skills Assessment of barriers and facilitators sensitizes potential adopters to innovation Interventions to manage barriers in practice environment are more challenging Environmental barriers are likely to interfere with sustainable practice changes

University of Ottawa/ CIHR Acknowledgements Appreciation is expressed to –Nurses who shared their experiences –Annette O’Connor, Ian Graham, Marie-Pascale Pomey for their expert advice and guidance throughout the study Funding –Ontario MOH and Canadian Institutes of Health Research (CIHR) Doctoral Studies Award –CIHR Group Grant on Decision Support Tools for Clinicians and Patients –In-kind support from the BC Ministry of Health Services and TCM TeleCare

University of Ottawa/ CIHR A mind once stretched by a new idea never regains its original dimension Oliver Wendell Holmes Jr. US jurist ( )

University of Ottawa/ CIHR