Evidence based practice is a buzzword that appeared in healthcare settings in last decade. Pressure from government agencies on healthcare providers to deliver excellent clinical practice increases importance in implementation of evidence based practice. In order to sustain effective outcome in rehabilitation, is essential for clinician to manifest evidence-based practice into clinical made decision. The aim of essay is to define evidence based practice (EBP) and implementation of paradigm, EBP into occupational therapy process in Peter’s case. In order to understand Peter’s case paper draws information about his condition, multiple sclerosis (MS). Essay will explore evidence-based practice through range of researches in occupational therapy (OT) intervention, identifying possible benefits for Peter’s well-being.
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Evidence-based practice is one of most debatable process of last few decades. EBP developed and arouse from evidence-based medicine defined by Professor David Sackett and other scholars, as an attempt to find best evidence to assist healthcare professionals with making best decisions for patients (Bailey et al, 2007). EBP is process where gathered best available evidence and clinical expertise assists clinical decision-making. Decision process is understandable for client, justifiable to other healthcare professionals, where gathered evidence (through research process) allows clinician to assess current practice. Collaboration between patient satisfaction, clinical judgment, and up to date information throve EBP to become powerful toll to underpin clinical intervention (Taylor, 2000). Definition of EBP is based on best evidence, clinical expertise, patient values, and circumstances where clinician takes under consideration all those elements in practice settings. Clinician is expected in EBP process to apply criticism, educational skills and to recognise system of values meaningful for client (Hoffman et al, 2009). When applying evidence into intervention clinician is proved to use skills upon which he or she could judge and recognise best evidence for practice. Hierarchy of evidence to recognise best evidence to underpin intervention guides clinician (Taylor, 2000). Author as the strongest and most valid elevates systematic reviews and meta-analyses from all, through which clinician has access to publish and unpublished evidence. Taylor (2000) recognises ‘gold standard’ evidence in randomize control trials (RTC); they are to be considered by healthcare professionals as effective in intervention. Limited credibility is given to non-experimental studies, non-randomized trials, opinions or experts discussion where level of validity is low.
EBP takes form of several steps to address information to relevant intervention: asking the question, searching for evidence, critically appraising evidence, collaborate evidence with clinical expertise and client personal values and finally evaluate. The form of question could determine information about certain patient. Clinical question includes several components: P – patient and/or problem, I – intervention, C – comparative intervention (optional, include if relevant), O – outcome (PICO). For example, in Peter’s case clinician through formulated clinical question determines valid information about him: P -middle age male with multiple sclerosis, I – occupational therapy, C- physiotherapy, vocational therapy and O- benefit in patient well being (Hoffmann et al, 2009). Evidence research for PICO is a next step for clinician. Valid information gathered through steps of EBP process needs reliable source, where materials and references are found. Key aspect of EBP is for clinician to have access to books, journals, conferences, RCT, systematic reviews, and databases. Clinician is aided by nowadays technology in journey to find best evidence; allied tool is internet where most of databases are placed. AMED, BNI, EMBASE, HMIC, MEDLINE, PsycINFO, CINAHL, HEALTH BUSINESS ELITE, The Cochrane Database, and OTseeker are databases that assist and guide evidence based therapist to develop sufficient and explicit evidence in clinical intervention (Hoffmann et al, 2009).
Best evidence is determined by evidence-based clinician on validity of evidence through hierarchy of research (Lin et al, 2010). Critical appraisal of evidence clinician bases on RCT, where RCT could be best choice to underpin treatment options. EBP process is tailored to patient’s needs and beliefs, so client could feel empowered and included in rehabilitation process. For example, in Peter’s case client-centred occupational therapist would concentrate on Peter’s priorities, which are employment and his knowledge about MS. Although clinician in rehabilitation process manifests EBP, implementation of EBP could be a challenge for both parties (Lin et al, 2010). Process can be time consuming due to large amount of researches available. High demand to understand researches for both parties is seen as an obstacle. Therapist could have limited knowledge to conduct particular research or lack of understanding patient’s goals. However evidence based therapist could seek help from current employer in ongoing training, communicate arouse issues with other health professionals and client or collaborate to conduct small group evidence based project (Lin et al, 2010).
Peter diagnosis is relapsing- remitting form of multiple sclerosis. According to National Institute for Clinical Excellence (NICE, 2004) multiple sclerosis is chronic, progressive disease of the central nervous system, which affects young and middle-aged adults. MS causes damage to myelin, which is fatty substance surrounds the brain and spinal cord. Scare tissues within the brain or spinal cord replace myelin. Damage leads to disruption in ability of nerves to conduct electrical impulses. Individuals affected by MS experience functional loss, including weakness, fatigue, spasticity and impairments of cognition, vision, speech, swallowing, bowel, and bladder function. MS occurs with an episode from which individual recover full, after that, disease develops in certain form. NICE (2004) statistics shows that 80% individuals with MS are diagnosed with relapsing- remitting form of disease. Relapsing – remitting disease occurs when patients experience relapse, which can last from 1 day to several months. Relapse occurs in loss of mobility, loss in function of bladder, loss of vision, general paralysis of the voluntary muscles. There is no progression between relapses.
Multiple sclerosis is long-term condition with complex problems, which requires wide range of healthcare professions input: nurses, doctors, physicians, occupational therapists and many more. At the present, there is no cure for disease (NICE, 2004).
Turning now to discuss evidence-based practice occupational therapy interventions, which could be beneficial for Peter.
Peter expresses symptoms of anxiety, he does not know much about his condition, he developed negative stereotype of doctor due to insufficient amount of information about his illness.
Evidence based practitioner could build therapeutic relationship with Peter, for example by effective communicated information about his condition. Evidence based therapist would inform patient about his condition appropriate to his knowledge abilities. Ongoing support, access to information and advice on treatment could have positive influence on patient experience during rehabilitation process (Köpke et al, 2010). Köpke et al (2010) protocol highlights sufficient and adequate information through different channels (leaflets, internet and education programs) allows patient to understand illness, to develop management strategies and to avoid unrealistic expectation from rehabilitation process. Occupational therapist could develop collaborative relationship with Peter through engagement in making decisions, medical interventions, and new technological aids tailored to individual needs. For example, information process is tailored and designed for Peter’s level of understanding, Consequently Peter’s main expectations are reassured by occupational therapist – to be included in rehabilitation process, fell heard and understood. Furthermore, patient can understand complexity of disease has choice in various treatment options and feels empowered (Reynolds, 2005).
MS has impact on many areas on people life, where employment status concern individuals, many may struggle to remain in work role. Sweetland et al (2007) undertook study, where participants were tape recorded to show expectations and implications for patients with MS in vocational market. Paper demonstrated demand in MS workforce population access to vocational rehabilitation, support performance in work place, management of anxiety and fear from discrimination. Peter well-being is influenced by fear, uncertainty about employment status, insufficient money income, and deteriorating health condition. Define employment legislation to patient and employment rights, as a disable person and provide vocational support (Disability Employment Advisers and the Access to Work Scheme), could guide Peter to understand his status in work field (Sweetland et al, 2007). Evidence based practitioner could introduce Peter to legislation act. For example, Disability Discrimination Act (1995) could show Peter his rights as an employee. Information about eligibility to social benefits allows service user to feel reassured about financial aspect of life (Johnson et al, 2004). To help in employment service occupational therapist could liaise with Job Centre and local government authorities (council) to achieve financial grant for adaptation in work environment according to progression of illness. However, therapist has to be mindful about patient condition at work. Peter complains about fatigue (overwhelming tiredness) and muscle spasm. Peter is a forklift truck driver, remain in same working environment could put on risk himself and others. MS exposes individuals to risk of injury because fatigue could lead to nausea, disorientation, and loss of balance. Ongoing assessment of work conditions is important for individuals to present problems as they arise. Management of fatigue symptoms, support from employer and work colleagues, flexible work schedule, knowledge development about social benefits could have positive impact on employment performance. Informing employer about illness would be important due to health and safety issues, furthermore to set up solutions in working environment. Taking into account Peter’s expectations and needs evidence based practice therapist could develop intervention where Peter could sustain effective employment (Johnson et al, 2004).
Young and middle age adults are affected by Peter’s condition (MS). Various aspects of individual life are affected by illness. Disturbance occurs in education, employment, physical functioning or disability and important to many sexual life. Clinically effective therapist applying intervention in sexual life filed should take sensitive approach. Peter’s condition would have impact on his sexual performance, therefore therapist should concentrate on client-centred approach, adapt actions to fulfil patient needs and expectations. Often patients exhibit needs, but they do not express them, where upon that evidence based therapist should apply observation skills and intuition in rehabilitation process (Reynolds, 2005). Insufficiency in therapeutic understanding of biographical disruptions such as relationship breakdown due to poor or absence of sexual activities can be a barrier between patient and therapist. Effective communication has a significant role in active participation into rehabilitation where issues of sexual dysfunction arise. Although, sexual life is meaningful need of many individuals, embarrassing nature of issue for patient and therapist may influence patient’s adherence to long-term treatment (Reynolds 2005). Evidence based practitioner acknowledges complexity of sexual dysfunction advising patient to seek advice in collaborative services like counselling. In Peter’s case, client- centred therapist through sensitive approach could address problems with erectile dysfunction or is prepared for remark from patient side. Evidence based practitioner could address Peter with pharmacological help (Viagra); offer to see specialist in sexual problems and advice how to use sexual aids or adapt sexual position (NICE, 2004).
Multiple sclerosis is long term neurological condition. According to World Health Organization (WHO, 2008), there is no treatment that can cure MS. Evidence shows that cost of medical treatment can be expensive and it is only limited to slow down progression of disease. WHO document (2008) highlights importance of rehabilitation process in MS. For example evidence, based therapist could draw attention to management strategies for illness. Occupational therapist could show Peter how to manage fatigue through keeping daily diary of activities, regular exercise and implement schedule of brakes between activities. Evidence based therapist could liaise with other healthcare professions to promote client centred approach to MS. Result of collaboration between multidisciplinary team could be beneficial for Peter. For example, evidence-based occupational therapist could collaborate with psychologist, where psychology session could help Peter adjust to, and cope with MS. Finally yet importantly, rehabilitation process could improve quality of his life (WHO, 2008).
This overview of studies is focused on efficiency of occupational therapy for Peter, who suffers from MS. Key aspect for evidence based practice therapist is to enable Peter to remain independent and provide him with achievable goals. Occupational therapy for Peter could have problem-solving approach. Critically evaluating their practice evidence based occupational therapist would create opportunities where Peter could enhance his life quality. Evidence based therapist would seek advice from other health care professions and government agencies, local authorities to promote effective and sustainable employment status. Effective communication between occupational therapy and Peter would build profession relationship, which could be a bridge to engage patient in lifetime rehabilitation journey. Empathic, client centred occupational therapy process would be perceive as allied tool to help Peter to understand his difficult and complex illness. However, occupational therapist would not be able to treat his condition, nevertheless evidence-based occupational therapist could help Peter sustain his independence and enable Peter to regain feeling of ‘normality’.
REFERENCES:
Bailey, D., M., Bornstein, J., & Ryan, S. (2007). A case report of evidence-based practice: From academia to clinic. American Journal of Occupational Therapy, 61(1), 85-91.
Disability Discrimination Act 1995. (1995) London: HMSO
Hoffmann, T., Bennett, S., Del Mar, C. (2009). Evidence-Based Practice Across the Health Care Professions. Australia: Elsevier.
Johnson, K., L., Amtmann, D., Yorkston K., M., Klasner, E., R., Kuehn, C., M. (2004). Medical, Psychological, Social, and Programmatic Barriers to Employment for People with Multiple Sclerosis. Journal of Rehabilitation. [Online] Available at: http://proquest.umi.com/pqdweb?Ver=1&Exp=10-27-2015&FMT=7&DID=577472521&RQT=309&cfc=1 [Accessed 28 October 2010]
Köpke, S., Solari, A., Khan, F., Heesen, C., Giordano, A. (2010). Information provision for persons with multiple sclerosis. Cochrane Database of Systematic Reviews, Issue 10. Art. No.: CD008757. DOI: 10.1002/14651858.CD008757.
Lin, S., H., Murphy, S., L., Robinson, J., C. (2010). Facilitating Evidence-Based Practice: Process, Strategies, and Resources. The American Journal of Occupational Therapy, 64(1), 164-171.
National Institute for Clinical Excellence and the National Collaborating Centre for Chronic Conditions (2004) Multiple Sclerosis: National clinical guideline for diagnosis and management in primary and secondary care. London: Royal College of Physicians.
Reynolds, F. (2005). Communication and Clinical Effectiveness in Rehabilitation. London: Elsevier.
Sweetland, J., Riazi, A., Cano, S., J., Playford, E., D. (2007). Vocational rehabilitation services for people with multiple sclerosis: what patients want from clinicians and employers. Multiple Sclerosis. [Online]Available at: http://proquest.umi.com/pqdweb?Ver=1&Exp=11-09-2015&FMT=7&DID=1370288031&RQT=309[Accessed on 10 November 2010]
Taylor, M., C. (2000). Evidence- based practice for occupational therapists. Oxford: Blackwell Science.
World Health Organisation (2008). Atlas multiple sclerosis resources in the world 2008. [Online] Available at: http://www.who.int/mental_health/neurology/Atlas_MS_WEB.pdf [Accessed on 28 October 2010]
Student number: 1041133
Discuss the strengths and limitations of the educational leaflet that you developed within a small group during HH1103 seminars.
The aim of this essay is evaluation of educational and communicational material in form of leaflet based on Helen case, who suffers from Juvenile Chronic Arthritis (JCA). Essay draws definition of condition and determines how leaflet is presented and why. Moreover, paper demonstrates leaflet limitations and strengths and how well meets it purpose. The purpose of the leaflet was to inform Helen and her parents, in simple form and manner, about her condition-JCA. Furthermore, leaflet is designed to pass message about available services, form of rehabilitation, and management of JCA.
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Leaflet main topic is concentrated around solutions in life style and rehabilitation for 14-year-old girl Helen. Leaflet is designed upon Helen personal experience and her illness JCA. JCA is condition, which affects joints in children, age under 16 years old. One in 1000 children in United Kingdom is affected; in relation to gender, females are impacted more than males. Skin rush, joint swelling, fever, change in mood are symptoms associated with JCA. Rehabilitation process has successful rate in majority cases; it enables individual to preserve normal rate of growth and psychological development (Arthritis Care, 2010).
The leaflet is composed in simple form where colourful scheme would attract Helen’s attention. Choice of the colours is not patronizing, it is modern and does not have significant impact on cost of producing the leaflet (Department of Health, 2003). When it comes to graphics, pictures suggest activities in which Helen could engage and introduce to the rest of the family importance of active lifestyle. For example, picture of the family in swimming pool displayed on the front of the leaflet, illustrates meaning to rehabilitation process. Furthermore, it encourages Helen and her family to participate in activity. Swimming sessions could motivate family to spend quality time together and empower Helen in her illness. The National Health Service (NHS) logo could be discouragement for Helen, making leaflet to official. However, it could be invitation point for her parents, where it could be a source of credibility (Department of Health, 2003).
The font size is readable and information flow through the leaflet. Information is arranged in small intersections to make more understandable for children. It was important to implement bullet points where possible so leaflet draws attention and it is not boring, but has patient friendly-text aspect. Identify source of information is distinguished where it proved leaflet to be honest guide to JCA (Department of Health, 2003).
It was priority to locate information about medical treatment. Helen compliance with medication is insufficient. Information introduced in leaflet could persuade her to follow guidelines from GP related to her medical treatment. There is some evidence, where written information about medication has benefits on patients’ outcomes: like knowledge or compliance (Nicolson et al, 2009). Compliance with medication could be beneficial for Helen by reducing level of pain; subsequently medication would reduce swelling of the joints and enable Helen in active participation in physical form of treatment. The area where leaflet informs patient about medication could be less informative. Information about medications could be to formal for Helen by putting her off. However, leaflet could guide Helen into different source of information (internet or other leaflets), where medication is explained in simple language, and details possible side effects (Nicolson et al, 2009).
It is a challenge to develop leaflet for the patient with low readability and those who expect information that is more specific. Determine whether the leaflet language is comprehensible and suitable for majority of population is based on Reading Ease score (Reynolds, 2005). Language used in leaflet is readable to average 13-14 year old child. Simple and plain language could be easy to remember. Verbal information could be easily forgot or misunderstood during patient consultation session. Written information could hence patient participation in rehabilitation (Dixon-Woods, 2001). Medical jargon is reduced to minimum when explaining JCA. Adequate knowledge about condition explained in plain language could be a form of education. Available treatment options for Helen’s condition could empower her parents in decision-making process (Dixon-Woods, 2001). However, if patients who would like to explore condition in more details, leaflet should provide more adequate information in last section of leaflet.
Overall, concept of the leaflet is good. Leaflet is not only about patient information, but has numerous advice and solutions for Helen and her family. Therefore, it seems sensible that leaflet guides reader to seek advice in additional services. Group could implement few improvements in some areas. Where needed team could concentrate on board public and made it leaflet less official. Moreover, would be beneficial if leaflet explore more about occupational therapy and physiotherapy rehabilitation for Helen. Nevertheless, leaflet achieved it main purpose: to communicate information about Helen’s condition to her and family.
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