Research to Practice Contemplating the connections Margaret Hamilton adapting and presenting from a

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Research to Practice Contemplating the
connectionsMargaret Hamilton adapting and
presenting from a paper by Trevor King
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Whats the issue?

• Rhetoric of research-based-evidence.
• it is striking how little is known about the
  effectiveness and cost effectiveness of
  interventions that aim to change the practice or
  delivery of health care (Bero et al 1998, p
  467).
• Practice what we preach (?)

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Perspectives

• Research
• Practice
• Organisation
• Consumer/client
• Policy

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1. Research Perspective

• Why doesnt research lead to practice change?
• Purpose of research need to understand

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Source WHO (1996) Investing in Health Research
Development, p3
 
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Key points research

• - Research - different purposes - disseminate
  differently
• - Applied research (to improve practice) not
  passive dissemination (ineffective in
  changing practice)
• - Research must specifically target key audiences
  (involve
• them in the process provide accessible
  reports)
• - Consider ways to value such targeted research
• equal peer reviewed publication as a researcher
• performance measure.

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Effective Practice Change Strategies

•    Least effective behaviour change strategies -
  most commonly used (didactic education,
  dissemination of practice guidelines)
•    Most effective strategies - multidimensional
  and interactive
•    Need to understand what factors contribute to
  the persistent use of these ineffective
  strategies

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Effectiveness of transfer

• Consistently effective
• Variable effectiveness
• Little or no effectiveness
• Bero et al (1998) Davis et al (1995) Freemantle
  et al (1998) Soumerai et al (1998) Thompson et
  al (1998) a, b,c

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Effective Transfer strategies

• Educational outreach visits (academic detailing)
  - trained personnel visit providers in their
  practice settings - information / support.  
• Interactive educational sessions (adult learning
  principles) - health care providers participating
  in interactive learning sessions (eg.
  problem-based learning or discussing practice
  issues in small groups).
•  Decision support and reminder systems (automated
  or manual prompts to perform clinical tasks)
•  Multifaceted interventions (any combination of
  audit feedback, reminders, local consensus
  processes, or marketing) 

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Variable effectiveness

• Audit and feedback - clinical performance
  observations, medical records or patient
  feedback.
•  The use of local opinion leaders - Practitioners
  identified by their colleagues as influential in
  modelling and transmission of norms.
• Local consensus processes Health providers in
  discussions designed to reach consensus on
  appropriate management strategies for specific
  health problems
•  Patient mediated interventions intervention
  designed to change the performance of healthcare
  providers for which specific information was
  sought from or given to patients (such as
  clinical information collected directly from
  patients)
•  

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Little of no effect

• Educational materials - Distribution of
  recommendations for clinical care, including
  clinical practice guidelines, audiovisual
  materials, and electronic publications. (May be
  justification if small effect /low cost. Research
  needed).
•  Didactic educational meetings - Lectures
  conferences (if no explicit effort re practice
  change). Workshops - include practice rehearsal
  reinforcement can effect change.

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Why persist with ineffective?

• Yet to be convinced
• Unaware of the research
• Structural issues
• Incentive systems different
• Only part funding
• (and other motives)

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2. Practice perspective

• Evidence-based practice - limited by gaps in the
  evidence base.
• Clinical personal experience component of
  evidence based practice / issue (further
  workforce professionalisation is required
  ideology can be strong).
• Transfer of research into practice - more likely
  in environment - physically intellectually
  supportive.
• Cont/.        

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Practice perspective (cont)

• Difficult to estimate extent of change needed
• Research needs to be synthesised to ease access
  by practitioners.
• Development of practice guidelines - be more
  effective change strategy if stakeholders are
  engaged in the development process and there is a
  commitment to active dissemination.

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Facilitating factors.

•  Perception of local ownership
•  Support of senior clinicians, health
  professionals and patients
•  Support of senior administration
•  Promotional programs for guidelines
• Source Best, J, Clarkson, D and Stanfield, A.,
  (2002) Implementing evidence-based clinical
  practice The way forward, NHMRC

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Barriers

• Lack of consensus on best practice too many
  guidelines
• Lack of skills to implement new practice
• Additional workload to implement change
• Patient preference
• Source Best, J, Clarkson, D and Stanfield, A.,
  (2002) Implementing evidence-based clinical
  practice The way forward, NHMRC

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Who are we trying to influence?

• USA research on workforce (?applicable)
• Australia Wolinski et al (2003)
•  77 of agencies reported that harm-minimisation
  (definition included abstinence) was the
  dominant treatment approach.
•  15 of agencies reported an exclusive
  abstinence orientation
•  47 provided self-help programs
•  29 provided Alcoholics Anonymous
•  3 provided Narcotics Anonymous.

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• Evidence
• Reports from managers and research
• gt Resources () 72 84NGOs (M)
• Remuneration (M, R)
• Education/Training gt Professionalisation
  (M,Reward)
• Career pathways (M, R)
• Fulfilling work (R)

From Wolinski et al (2003) Pitts (2001) NOTE
Rousseau (1997)
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Who is the workforce (Aust)?

• Nursing (26)
• Psychology (8)
• Social Work (5)
• Other (Wolinski et al, 2003)
• Victoria unqualified
• 1996 (30)
• 2000 (25)
• 2003 (17)

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Implications (?)

• include
• Proportion with research education low
• Does it matter ?
• Approach rational evidence based
• Other frames
• Bill Miller (therapist/counsellor factors)
• Donald Schön (espoused ? / in-action)

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Other elements gt transfer

• Physical and intellectually supportive
• gt education levels gt early adopt innovation
  (Rogers, 1995 Roman et al 2002)
• Research debated and valued (Gray, 1998)
• Managerial commitment to using it (Ibid)
• Shared beliefs, education, social status and
  networks (Haines Jones, 1994)

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3. Organizational perspective

• Change - often difficult to achieve (ind/org)
• Principles to guide - transfer of research to
  practice
• Match intensity of the selected intervention
  complexity (issue or environment)
• Readiness to change assess (? Enhance)
• Monitor change (org. practitioner) to estimate
  return on research investment.

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the principles for effective technology transfer
  Relevant - have obvious practical
application Timely - there is a need for the
technology Clear - easily understood by the
target audience Credible - audience has
confidence in the proponents and sources
of the technology Multifaceted - formats
suited to different targets Continuous -
supported until it becomes accepted practice
Bi-directional - target audience must be
involved in the change initiative from the
outset     Source Addiction Technology Transfer
Centers, The Change Book A Blueprint for
Technology Transfer, 2001, p 8.  
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Readiness to change

•    What internal and external resources are
  available to support a change process?
•    What factors may impede or enhance the
  process?
•    How is the organisation functioning?
•    What quality and support systems are in place
  (communication, supervision, practice
  guidelines, quality improvement, program
  evaluation etc.)? (various)
•  Reflections from TP (constant in parts
  infrastructure support cultures
  survival/business and care/commitment respect)

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4. Consumer/client perspective

•   Provide and opportunity for input -
  development delivery
•   adapt research findings for this audience
  make available
•   secondary benefit gt accountability - health
  care providers to align services with the
  available evidence
•  Wouldnt it be good if .. (service/product
  information regarding expected results and
  factors that influence this)

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5. Policy perspective

•   Research is only one factor ( often not
  the most important)
•   Many programs retain funding though
  evaluations suggest they are ineffective
•   Engage decision makers in all aspects of
  research process if expect them to use findings
•   Present research findings to decision makers
  in a compelling way.
•  

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Conclusions

• still substantial gaps in the evidence-base for
  drug and alcohol interventions
• In some instances we have the research evidence
  but uptake/practice change has not occurred
• The body of literature on effective research
  dissemination and practice change remains quite
  limited.

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Making the connections

• Priority driven research agenda needed
• Incentives for researchers for policy and
  practice research transfer needed
• Research into incentives and barriers still
  needed
• Passive dissemination has limited effect
• Resourcing an issue re staffing
• Science (and art?) needed

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A TP case study

• The TP Text Book
• We will write a book as a staff development
  activity
• We did
• Many had never written .
• Second edition now OUP
• Change over 5 years
• Title and sub-title
• Thanks other editors and authors .
• We did it!

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Researcher incentives

• Effort needed to translate research for key
  audiences
• Few incentives - as scientific journals dont do
  it (Policy domain - short term contracts and
  ownership/authorship issues)
• Journals and previous reports (?)
• Synthesising efforts have value but . (eg
  Cochrane Collaboration)

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