Promoting
increased use of research evidence within
Speech
and Language Therapy departments.
Hazel Roddam (Manchester, UK)
The National Health Service
(NHS) is currently seeking to improve the clinical effectiveness of all
healthcare professionals and to promote an evidence-based practice approach.
This has been the theme of several government White Papers over the past
decade: to promote a higher quality of patient care, plus uniform standards of
care (The New NHS: Modern-Dependable,1997). The government’s agenda of Clinical
Governance emphasises the responsibility of each individual healthcare
professional to follow a model of evidence-based practice, in addition to
placing the onus on clinical departments, NHS Trusts and all the professional
bodies. As part of its cycle of inspections, the Commission for Health
Improvement seeks evidence of clinical effectiveness (CHI, 2003). Within the
scope of the RCSLT’s own accreditation standards for Speech and Language
Therapy departments, the guidance for surveyors is to ascertain that “the
service can demonstrate mechanisms to support staff in implementing
evidence-based practice” (RCSLT 2002, 1.19).
In considering the demands of these expectations upon working
clinicians, it can be anticipated that there needs to be both an effective
dissemination of the clinical effectiveness agenda, plus an unambiguous
understanding of how to appropriately implement the accepted model of
evidence-based practice. This may be either at the level of planning care for an
individual client, or in planning and reviewing service delivery issues. There
is also an overlap with continuing professional development policies, as skills
gaps or training needs for staff are highlighted.
There is now a body of evidence to show that receipt of research
evidence alone has rarely led to changes in clinical practice. Strategies to
promote increased use of research evidence in practice have been implemented
and evaluated with groups of medics and nursing staff, but none have yet been
validated for the Allied Health Professions. Strategies that have been
evaluated have included training of staff in critical appraisal of research
evidence, distribution of evidence-based clinical guidelines and the use of
clinical audit. It was concluded that the concurrent use of multiple approaches
was significantly more effective than the use of single strategies. It was also
shown that initiatives specifically planned to address assessments of potential
barriers were the most likely to be effective (Effective Health Care Bulletin
1999).
At the end of 2000, the NHS Executive-North West( NHSE -NW) funded a
three-year project to develop and deliver training packages to SLT departments
across the region (n=26), with the aim of promoting the use of research
evidence. 17 SLT departments participated in the project and were independently
randomly allocated to two strategy groups. No departments dropped out of the
project once they had begun the training sessions. Each department nominated 2
therapists to attend the training days and to subsequently disseminate the
training back to their home department. The cascade phase was explicitly
non-directive, as the participants were encouraged to tailor the feedback to
their own departments’ needs. The training package delivered to each of the
groups comprised a combination of strategies designed to promote the use of
research in clinical practice. Both packages included identical training on
critical appraisal of primary research, systematic reviews and evidence-based
clinical guidelines. Papers from both paediatric and adult clinical fields were
used for the guided appraisal exercises. The second package additionally
focused on diffusion – “selling the message” to colleagues, plus a model for
implementing and measuring clinical change. The primary outcome measure of this
randomised controlled trial (RCT) was a clinical indicator of compliance with
the published clinical guideline which was used as an exemplar in the training.
The full results of the RCT will be published on completion of analysis of the
data.
A complementary exploratory study was conducted, to investigate the
range of strategies and initiatives implemented by the SLT departments within
the period of the cascade phase. The aim was to profile indicators of
evidence-based practice activities across all the departments, plus to elicit
therapists’ perceptions of facilitating or constraining factors. The data
yielded will be used to test out and to illustrate a proposed theoretical model
for promoting research within SLT departments. The results will be submitted
for publication on completion of the interpretation of all the findings.
The first phase of the study was a survey of activities engaged in by
SLT departments throughout the initial six-month “cascade” period, following
attendance on the training days. The survey reflects the range and number of
initiatives to promote use of research evidence, within three aspects:
i) Formal training sessions: content,
timing and attendance
ii) Implementation
of recommendations from the clinical guidelines, plus clinical audits in any
aspect of the service
iii) New
or enhanced strategies to maintain ongoing use of research evidence within the
department.
Initiatives and
strategies which were recorded as supporting and promoting the use of research
included training in IT searching skills and critical appraisal, journal clubs,
clinical supervision models, plus designated roles or responsibilities. The
survey was conducted as semi-structured interviews, to provide the opportunity
to confirm whether these initiatives were already in place prior to the
department’s participation in the RCT, or had been explicitly introduced or
enhanced following attendance at the training days. Initiatives were coded as:
not in place; existing–unchanged; existing-enhanced; newly instigated.
It is acknowledged that the six-month timescale may limit the extent of
organisational change which is reported. However, the interviews afforded the
opportunity to explore the planning processes for some future initiatives.
The preliminary
findings have revealed some very wide contrasts between departments; firstly,
in the differing formats and emphasis placed on the formal feedback sessions.
Not all departments incorporated active participation elements in the sessions,
nor made attendance mandatory. Within the range of subsequent initiatives,
Information Technology (IT) training was a common strand: designated
roles were much less frequently reported. Models for journal clubs were
considerably diverse. The extent to which these issues may impact upon
therapists’ skills or confidence, or on the use of research at the department
level, was probed in the following phase of the study.
The second phase of the study comprised in-depth interviewing, to
achieve a deeper understanding of therapists’ perceptions of constraints and
facilitators to increasing their use of research within the department. A case
study method was chosen, to reflect the complex contextual issues of each
department. Four departments were selected: two from each arm of the RCT. These
departments were chosen to represent the greatest contrasts in terms of number
of therapy staff; adult-only clinical teams vs mixed paediatric and adult services;
services based in District General Hospitals (DGH) vs university teaching
hospitals. Interviews were conducted with the therapists who had attended the
project training days, the service managers and with focus groups of other
members of staff.
General perceptions expressed by therapists were coded from all the
interviews. This data set will be contrasted with an anonymous self-completion
attitude rating scale, which was collected from all staff, pre and
post-training.
Some of the
initial emergent themes include the contrasting perspectives of staff from
hospital-based teams, to those who are community-based; the influence of other
department members who are already research-active; the role of senior
management staff in creating a research-aware culture. Several strongly
distinctive issues appear to be relevant. The potential implications of these
factors will require thorough and sensitive interpretation.
The outcomes of this study will
contribute to the evaluation of the described training packages. In addition, examples of successful
strategies for promoting the use of research evidence at all levels of clinical
practice within SLT departments will be highlighted.
CHI website, http://www.chi.nhs.uk, accessed March 2003
Department of
Health (1997) The New NHS : Modern, Dependable. HMSO, London
NHS Centre for
Reviews and Dissemination (1999) Getting Evidence into Practice. Effective
Health Care Bulletin 5 (1)
RCSLT, 2002, Accreditation
Standards for Speech and Language Therapy Departments, 1.19
Upton, D, 1999,
Clinical Effectiveness and EBP 3: application by health-care professionals.
British Journal of Therapy and Rehabilitation, 6, 2, 86-90.
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