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,

University of Ottawa/ CIHR

The Ottawa Model of Research Use

Ian D Graham, PhD

Canadian Institutes of Health ResearchSchool of Nursing, UOttawa

Sept. 24, 2007



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


Factors influencing uptake of innovations:

The Innovation

•Development process

•Attributes of the innovation


Credible developersall relevant stakeholders

interdisciplinary

Objective & rigorous method

Careful documentationexplicit & transparent process

Local involvement

Development Process


• 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



Potential Adopters• awareness

• attitudes

• knowledge/skill

• concerns

• current practice/habit



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


• Culture & belief systems

– Norms, institutionalized habits

• Leadership

• Politics & personalities

• Peer influence

Practice Environment: Culture/social Factors


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


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


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


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


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


How Can We Facilitate Knowledge to Practice?

• Need a Conceptual Framework to Guide Implementation

• Planned action vs classic theories of change


Assess + Monitor + Evaluate

Practice Environment

Potential Adopters

Innovation

Interventions

Adoption

Outcomes

Ottawa Model of Research Use


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)?


Assess + Monitor + Evaluatebarriers & supports interventions outcomes & degree of use


Potential Adopters

Innovation

(CPG, tools)

Interventions Adoption Outcomes





Potential Adopters

Innovation

Implementation

Interventions

• barrier

management • transfer• follow-up

Adoption Outcomes





• structural• culture/social• patients• economic

Potential Adopters

• awareness• attitudes• knowledge/skill• concerns• current practice

Innovation (guideline)

• development process

• innovation attributes

Interventions• barrier


Adoption• intention• use• sustained

use

Outcomes• patient• practitioner• system





• structural• culture/social• patients• economic

Potential Adopters

• awareness• attitudes• knowledge/skill• concerns• current practice

Innovation• development

process• innovation

attributes

Interventions• barrier


Adoption• intention• use• sustained

use




Additional References• Logan J, Graham, ID. Toward a Comprehensive

Interdisciplinary Model of Health Care Research Use. Science Communication 1998;20(2):227-246.

• Graham ID, Logan J. Innovations in knowledge transfer and continuity of care. Can J Nurs Res. 2004 Jun;36(2):89-103.

• RNAO Implementation of Practice Guidelines Toolkit http://www.rnao.org/bestpractices/PDF/BPG_Toolkit.pdf

• Grimshaw et al 2004. Systematic review of the effectiveness and efficiency of guideline dissemination and implementation strategies. Htpp://www.ncchta.org/project.asp?PjtId=994

http://www.rnao.org/bestpractices/PDF/BPG_Toolkit.pdf


Adoption and sustainability of decision

support for patients facing health decisions:

An implementation case study with

embedded RCT

Dawn Stacey RN PhD

Assistant Professor, University of Ottawa

Funding: Canadian Institutes of Health Research

September 2007


Outline

• Background

• Purpose & Objectives

• Theoretical Framework

• Methods

• Results

• Implications for Research, Education and Practice


Public’s view on who should make risk-related health decisions

5%

6%

6%

3%

10%

4%

26%

29%

36%

33%

38%

36%

69%

63%

57%

64%

51%

60%

0% 20% 40% 60% 80% 100%

USA

Canada

UK

Germany

S. Africa

Japan

MD makes decision MD gives options & his/her opinion

MD gives options & lets pt decide Not Sure

(Magee, WHO, 2003)



Problem: Decisional ConflictProblem: Decisional Conflict

uncertainty about which course of action to take

North American Nursing Diagnosis North American Nursing Diagnosis Association, 2002Association, 2002

yesyes

nono


‘‘InnateInnate’ ’ contributing factorscontributing factors

2 or more options

Outcomes: risky/uncertain, permanent, serious

Value tradeoffs: benefits versus harms

Anticipated regret: ‘missed’ benefits of option not chosen


ConsequencesConsequences: : unresolved decisional unresolved decisional conflict & related factorsconflict & 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;11:165-169)


Compared to standard care, Compared to standard care, patient decision aids…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


ValueValueof coachingof coaching[hysterectomy]

(Kennedy et al. JAMA 2002; 288: 2701-2708)


Framework for Decision Coach-Mediated Shared Framework for Decision Coach-Mediated Shared

Decision MakingDecision 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 RoleCommunicate 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)


Client Centred CareClient Centred Care

RNAO Nurse Best Practice Guideline: Client RNAO Nurse Best Practice Guideline: Client Centred Care Centred Care (2006)(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)


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


BCNurseLine call centreServes 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


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)


Assess + Monitor + Evaluatebarriers & facilitators interventions outcomes & degree of use


BCNurseLine• organization’s policies,

mandate• callers

Potential Adopters:

Nurses• awareness• attitudes• knowledge/skill• confidence• current practice

Innovation

Decision supportMultifaceted intervention

• online autotutorial

• decision support /coaching protocol

• skill workshop

• performance feedback

Adoption• intention• use



(Logan J & Graham ID, 1998; Graham ID & Logan J 2004)

1. Baseline assessment

2. RCT of intervention

3. Uptake & sustainability


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 SourcesDec- Feb- Apr

Jan (n) Mar (n) June (n)

Key informant interviews 4 4

Focus groups with nurses 7 8

Survey: barriers/facilitators 57 of 108

Quality audit simulated patient calls 38 of 39 39 of 39

RCT – intervention evaluation 39 of 41

Survey: uptake, sustainability 25 of 31

Organizational documents <-------Continuous------->


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 calls 20 simulated calls

(* Missed taping 1 call; + 2 dropped at the beginning of the intervention)

December 2003

February 2004

April 2004

12 interventionMay 2004


Characteristics of participants

%


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: 184-195)


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


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


Multifaceted intervention to address baseline barriers

BarriersOnline 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 X X

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)


A process for coaching clients making

decisions with 2 or more options

Available at www.ohri.ca/decisionaid

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 RCT to Enhance Nurse Decision Nurse Decision

Support CoachingSupport Coaching


Health professionals’ decision support Health professionals’ decision support knowledgeknowledge

%

(Stacey et al., 2006, J Telemed & Telecare; Stacey et al., ISCCN, 2006)


Coaches’ decision support skills improveCoaches’ decision support skills improve (simulated

calls)

Mean quality scores

p < 0.001

(Stacey et al., 2006, J Telemed & Telecare; Stacey et al., ISCCN, 2006)


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)


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.”


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


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)


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


Key MessagesKey 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


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


A mind once stretched by a new idea never

regains

its original dimensionOliver Wendell Holmes Jr.

US jurist (1841 - 1935)

University of Ottawa/ CIHRwww.ohri.ca/decisionaidwww.ohri.ca/decisionaid

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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,