Evidence Based Practice and Notes 2022.pptx.pdf

Evidence-Based Practice in Clinical Exercise Science and Rehabilitation Dennis Hemphill (PhD) Sport and Exercise Ethics Educator Honorary Professor, Victoria University Previous Relevant Experience: Academic, Professional Ethics, Sport & Exercise Science Chair, ESSA Disciplinary and Ethics Committee...

Evidence-Based Practice in Clinical Exercise Science and Rehabilitation Dennis Hemphill (PhD) Sport and Exercise Ethics Educator Honorary Professor, Victoria University Previous Relevant Experience: Academic, Professional Ethics, Sport & Exercise Science Chair, ESSA Disciplinary and Ethics Committee Member, ESSA review/working parties (EP, ES, SS accreditation) Co-editor; Clinical Exercise: a case-based approach. Learning Outcomes • Articulate your understanding of ‘evidence-based practice’ in clinical exercise science and rehabilitation • Evaluate the foundations of ‘evidence’ in quantitative, qualitative and interpretive/critical ways of knowing in clinical practice • Examine the relevance of ‘critical thinking’, ‘emotional intelligence’, ‘cultural intelligence’ and ‘intuitive intelligence’ to clinical practice expertise Section 1. Evidence Based Practice Dot point below what you consider to be ‘evidence-based practice’ in clinical exercise science and rehabilitation. Evidence-Based Practice: what is it? • Knowledge derived from high-quality, peer-reviewed academic journals • Evidence derived from clinical experience • Knowledge shown to be transferrable and effective in practical, clinical settings What kind of evidence do you find is the most reliable, trustworthy and relevant to professional practice? And why? There tends to be more stock put in evidence from the following: • Clinical trials • Epidemiological • Quantitative surveys There tends to be, in some circles, less trust in qualitative methods and the evidence from: • Interviews, focus groups • Ethnography • Professional Experience • Professional Intuition While quantitative methods often produce more generalizable results (to large populations), qualitative methods often produce small group or individual-specific results, both of which can be complementary in clinical professional practice. Evidence Based Practice Evidence Based Practice is the integration of clinical expertise, patient values and the best evidence into the decision-making process for patient care. (Sackett, D.L., et al. (2000). Evidence-based medicine: How to practice and teach EBM (2nd ed.). Edinburgh: Churchill Livingstone). Session 1 & 2 will flesh out this diagram The aim of EBP is for health care professionals to practise based on the best research evidence available, rather than on personal opinion. This leads to: • a reduction in the variations in individual clinician’s practices • an enhancement of best practices • reduced costs • improved quality in health care • increased patient satisfaction Acknowledgements: 1. Diagram from http://www.hsl.unc.edu/Services/Tutorials/EBM/whatis.htm and Hoffmann, T. et al.(2009). Evidence based practice across the health professions. Chatswood, N.S.W.:Elsevier Australia. 2. Aim of EBP taken from MLA course "Expert searching for EBN" by Emily Partridge. All material in this and previous slide from: https://libguides.scu.edu.au/clinexphys/evidence-based-practice 5 steps of Evidence Based Practice • • • • • • Ask a question Converting the need for information (about prevention, diagnosis, prognosis, therapy, causation, etc) into an answerable question Find information/evidence to answer question Tracking down the best evidence with which to answer that question Critically appraise the information/evidence Critically appraising that evidence for its validity (closeness to the truth), impact (size of the effect), and applicability (usefulness in our clinical practice) Integrate appraised evidence with own clinical expertise and patient’s preferences Integrating the critical appraisal with our clinical expertise and with our patient's unique biology, values and circumstances Evaluate Evaluating our effectiveness and efficiency in executing Steps 1-4 and seeking ways to improve them both for next time Evidence-based medicine : how to practice and teach EBM. - 3rd ed. / Sharon E. Strauss ... [et al.]. - Edinburgh ; New York : Elsevier/Churchill Livingstone, 2005. Very often the question you ask will shape the method you choose to answer it. For each of the scenarios below, dot point what you think constitutes ‘evidence’ and what methods you might use to producing it: 1. What attitudes do Australian AEPs, physiotherapists and other allied health professionals to mandatory COVID-19 vaccination jabs? 2. Can virtual reality technology improve balance in clinical patients? For each of the scenarios below, dot point what you think constitutes ‘evidence’ and what methods you might use to producing it: 1. What attitudes do Australian AEPs, physiotherapists and other allied health professionals to mandatory COVID-19 vaccination jabs? - Large-scale quantitative survey, because it seeks Australia-wide attitudes 2. Can virtual reality technology improve balance in clinical patients? - Experiment, clinical trial, where you have controlled conditions to assess the impact of the technology on a specific variable 3. Can HITT improve motivation for exercise for older Australians? 4. What is a client’s experience of pain in the rehabilitation process? 3. Can HITT improve motivation for exercise in older Australians? - Quantitative or qualitative survey, depending on number of clients and how narrowly or widely you define ‘motivation’ 4. How do you make sense of a client’s claim to be experiencing pain in the rehabilitation process? - qualitative, individual, in-depth interview to get one client’s detailed story about the experience of pain 5. What are the perceptions of online learning effectiveness among first year Masters in Clinical Exercise Science and Rehabilitation students at VU? 6. Are there differences in interprofessional perceptions of informed consent? 5. What are the perceptions of online learning effectiveness among first year Masters in Clinical Exercise Science and Rehabilitation students at VU? - Qualitative interviews or focus groups to get student group perceptions 6. Are there differences in interprofessional perceptions of informed consent? - Quantitative survey or qualitative interviews/focus groups, depending on sample size, to get IP group perceptions 7. Are stroke stroke recovery programs more effective at home or in the clinic? 8. What makes obesity a cultural, not just a health problem? 7. Are stroke stroke recovery programs more effective at home or in the clinic? - If dealing with single client, interview and ethnography to understand client’s needs, interests, passions, hobbies, as well as some idea of the geography of, and resources available and safety considerations in the home. 8. What makes obesity a cultural, not just a health problem? - Clarification involved discussion of some of the social-cultural assumptions of the causes of obesity, for example, that the person is lazy, has no discipline (‘let themselves go’). - In ‘neo-liberal’ ideology, more emphasis is put on the individual as responsible for personal health. Less emphasis on the conditions (e.g., fashion and entertainment media images of ‘perfect’ bodies, poor education, low income) that might influence health behaviours. 9. What would it take to change a bullying culture in a university-based exercise science and rehabilitation clinic? 10. What could constitute a culturally competent inter-professional treatment plan by stakeholders at the Wyndham clinic in Melbourne’s CALD western region? 9. What would it take to change a bullying culture in a university-based exercise science and rehabilitation clinic? - Complex practice transformation involving multiple stakeholders and methods to define nature and scope of the problem, who or what groups may be impacted more than others, and to implement and evaluate change. 10. What could constitute a culturally competent inter-professional treatment plan by stakeholders at the Wyndham clinic in Melbourne’s CALD western region? - Complex practice transformation to build ‘cultural competence’ and evaluate quality of interactions and care in a culturally and linguistically diverse community. Broad number of stakeholder groups make change challenging and complex Paradigms • Positivist • Interpretive/Constructivist • Critical What direction does the cube face? If you said ‘It depends on what surface is foregrounded, you got it! Think of paradigms (systems of knowledge) as different perspectives • Positivist – there is a single, objective reality or truth that can be measured; or the restriction of ways of knowing to those aspects of physical or social reality that can be measured; value neutral • Interpretivist/Constructivist – there is no single reality/truth; reality/truth is a product of individuals in (physical, social) context. As a social construction, human reality/truth/meaning needs to be interpreted • Critical – reality/knowledge (‘common sense’ as expressed in language, practices) is socially constructed and reflects relationships of power and value Quantitative Methods • Experimental • Clinical trials - Operationalising variables so that they can be measured and correlated - Study designed to control for other variables - RCT – e.g., comparing two groups sharing similar characteristics to see effectiveness of new treatment versus a current one and control/placebo What counts as good ‘evidence’? - Validity and reliability - Randomised assignment to groups to avoid potential bias - Representative sample; large sample size - Generalisable to larger populations - Limitations: the results do not fit the uniqueness of a client or case. Knowledge Paradigm Approach Methods Examples Positivism Quantitative Surveys (longitudinal, cross-sectional, correlational) - a) The attitudes of Australian AEPs to mandatory vaccination (Context Independent) - b) The impact of HITT on clients’ motivation for exercise Experimental Randomised Clinical Trials - c) The effectiveness of virtual reality technology on improving balance Qualitative Methods • • • • Interviews Focus Groups Ethnography Case Study - Interview/focus group discussion, recordings or transcripts, including interviewer notes (e.g., pauses, hesitations, anxiety, excitement) to contextualise and help make sense of interview comments - Observed behaviours in a social setting of interest, including customs, habits, rituals, physical setting or surroundings, etc. - Researcher reflective notes on impressions, evaluations, judgements, and how these might be influence interpretations of data. What counts as good ‘evidence’? - Very detailed first-person account of a context-based experience, relationship or intervention and its results. - Richly detailed personal, subjective description of lived experience (feelings, impressions, meanings, interpretations) - Richly detailed observations and descriptions of individuals or groups of individuals in a specific setting - Depth of knowledge about a particular individual or case - Member checking, triangulation to promote rigour and robustness - Limitations: cannot generalise to large populations; nor effective when measuring physiological or biomechanical condition and changes Knowledge Paradigm Approach Methods Examples Interpretivist/ Qualitative Phenomenological - d) A client’s lived experience Constructivist Ethnographic (Context Dependent) Interviews Focus Groups Case Study of pain in rehabilitation. - e) The perceptions of online learning effectiveness among first year Masters in Clinical Exercise Science and Rehabilitation students at VU. - f) Interprofessional perceptions of informed consent. - g) Effective stroke recovery at home versus the clinic. Critical Methods • Ideology critique: Critiquing ‘common sense’ assumptions to reveal ideology/power • Participatory action research • Practitioners reflecting on and evaluating own professional practices • Value-laden inquiry: e.g., empowerment, inclusion • Research/practice with and for clients, not simply about them or on them. • Multi method (e.g., surveys, focus groups, interviews) • What counts as good ‘evidence’? • Formative style of evaluation and change responsive to current clinical practice, practitioner-client relationship, IP relationships and effectiveness, work culture. • involves collaborative spirals of planning, acting, observing, reflecting, and replanning. • Quantitative, qualitative; collaborative reflections, ‘critical friend’; practice transformation Knowledge Paradigm Approach Methods Examples Critical Critical and Transformational Ideology critique - h) Cultural assumptions underlying obesity ‘problem’. Participatory action research - i) Creating a gender-inclusive culture in a university-based exercise science and rehabilitation clinic. - j) Developing culturally competent inter-professional treatment plans by stakeholders at the Windham clinic in Melbourne’s CALD western region. Section 2. Related ‘ways of knowing’ Critical Thinking Dot point what you understand about ‘critical thinking’ and its connection, if any, to evidence-based practice. Critical Thinking • As above, a ‘critical’ paradigm and approach to knowledge starts from a recognition of power, ideology and assumptions that frame what is ’real’ and ‘valuable’ - ‘critical’ means not taking knowledge or truth claims at face value; ability to test truth or knowledge claims, asking for evidence - Analysis – breaking down complex situations or problems into smaller parts - Synthesis – creative linking or reconnecting parts to, say, solve a problem Emotional intelligence Dot point below your sense of the meaning of ‘emotional intelligence’ and how it might apply to clinical expertise. Emotional Intelligence https://www.psychologytoday.com/au/basics/emotional-intelligence • Emotional intelligence refers to the ability to identify and manage one’s own emotions, as well as the emotions of others. • Ability to identify and name one’s emotions • Ability to harness one’s emotions and apply them constructively • Ability to help others recognise, name and harness their emotions • Empathy; ability to appreciate the pain, suffering, satisfaction of others, from as much as their perspective as you can. Not taking on fully the emotions of others, but still acknowledging it before rushing in to ‘solve’ a problem. Intuition • Dot point below your sense of the meaning of ‘intuition’ and how it might apply to clinical expertise. Intuitive Intelligence Watkins, A. (2018) Intuitive Intelligence in Clinical Practice. Ausmed Online PD • • • • • • • Mystical power Direct insight Sixth sense, hunch, gut feeling Knowing something without having a logical explanation Pattern recognition; expert knowledge to quickly recognise problems Non-linear creation of knowledge through experience Experience is more than cognitive; it includes sensing (feeling, hearing, smell) • Evolves with experience allowing practitioners to perceive a situation as a whole and draw on past learning to come to a decision quickly. Clinical Intuition Brockenshaw, G. Clinical Intuition: more than rational? Australian Prescriber Vol. 25 No. 1 2002 • Rational, empathic, compassionate…clinician to whom the individual’s experience of illness is paramount, intuitively appreciates the uniqueness of the patient…the situation. • Intuition less a mystical/magical power, but a complex combination of knowledges that allows the practitioner to better (or fully) make sense of clients in clinical settings. Cultural intelligence • Dot point below your sense of the meaning of ‘cultural intelligence’ or ‘cultural competence’ and how it might apply to clinical expertise. Cultural Intelligence/Competence • Cultural intelligence or cultural quotient (CQ) is the capability to relate and work effectively across cultures. • Cultural competence is the ability to participate ethically and effectively in personal and professional intercultural or multicultural settings. [Juanita Sherwood https://sydney.edu.au/nccc/training-and-resources/resources.html • Being aware of your cultural values and beliefs • Being aware of the values and beliefs of those from other cultures • Appreciation and sensitivity to cultural similarities and differences • Being able to respond empathetically and ethically to a range of clients from diverse cultural backgrounds. Assessment Task – Article Reviews Assessment Description: Search for and select one qualitative research article (look in the Abstract of the article for mention of methods such as interview, focus group, ethnography, etc.) related to clinical exercise science and rehabilitation practice (300-500 words); and Search for and select one participatory action research journal article related to clinical exercise science and rehabilitation or related allied health profession (300-500 words). Note: there is some biomechanics type research that uses the term ‘action research’, which is not to be confused with participatory action research, which is based on an entirely different paradigm. Value: 20% Due Date: 10 October (in Collaborate Drop Box) Description (50%) Publication details: author(s), year, article title, journal name, volume, page numbers. Overview of the research article aim/purpose, methods, results, discussion and conclusion (including any author-stated limitations and implications for further research or practice). Analysis and Evaluation (50%) Briefly discuss (1-2 short paragraphs), using Session 1 materials, what counted as evidence and the strengths and limitations of the method. Briefly discuss (1-2 short paragraphs) , using Session 1 materials, the paradigm that underpins the method. Discuss (1-2 paragraphs) how the evidence presented in the article can translate to practice; that is, what you think about how the method and evidence can contribute to effective clinical practice in exercise science and rehabilitation.