# Presentation: 557067

## The Ottawa Model of Research Use

- Ian D Graham, PhD
- Canadian Institutes of Health Research
- School of Nursing, UOttawa
- Sept. 24, 2007

- University of Ottawa/ CIHR

## Slide 2

- University of Ottawa/ CIHR

## 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

- University of Ottawa/ CIHR

## Factors influencing uptake of innovations:

- The Innovation
- Development process
- Attributes of the innovation

- University of Ottawa/ CIHR

## Development Process

**Credible developers**
**all relevant stakeholders**
**interdisciplinary**
**Objective & rigorous method **
**Careful documentation**
**explicit & transparent process**
**Local involvement**

- University of Ottawa/ CIHR

## Characteristics of the Innovation

**Relative advantage (*****useful)***
**Low complexity (*****ease of use or do)***
**Compatible **
***(fits with current practice, norms/values)***
**(d*****oes 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)*

- University of Ottawa/ CIHR

## Factors influencing uptake of innovations:

- Potential Adopters
**awareness**
**attitudes**
**knowledge/skill**
**concerns**
**current practice/habit**

- University of Ottawa/ CIHR

## Factors influencing uptake of innovations:

- 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**

- University of Ottawa/ CIHR

## Culture & belief systems
Norms, institutionalized habits
Leadership
Politics & personalities
Peer influence

- Culture & belief systems
- Norms, institutionalized habits
- Leadership
- Politics & personalities
- Peer influence

**Practice Environment****: **Culture/social Factors

- University of Ottawa/ CIHR

**Notes:**
In addition to the structural factors, the social factors in the practice environment are considered important.  Is the practice environment a culture of change or tradition? Is there a belief in the value of research?  Leaders are critical at each level in the practice hierarchy – clinical nurses, managers, top administrators. Agency politics and personalities are important. Key individuals in the setting should be assessed for their support. These individuals may not be those in obvious positions of authority. Individuals who have something to gain or lose will play a part in any attempt to change a clinical practice. Patients or clients can influence policy makers or clinicians to consider a change in practice.  Peer influence: The influence of the peer group appears to make a difference to adopting changes in practice all though there has been scant research in this area. 

## 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

- University of Ottawa/ CIHR

## 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**

- University of Ottawa/ CIHR

## 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**

- University of Ottawa/ CIHR

## 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**

- University of Ottawa/ CIHR

## 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**

- University of Ottawa/ CIHR

## How Can We Facilitate Knowledge to Practice?

- Need a Conceptual Framework to Guide Implementation
- Planned action vs classic theories of change

- University of Ottawa/ CIHR

## Ottawa Model of Research Use

**Practice Environment**

**Potential Adopters**

** ****Innovation **

**   **
** ****Interventions**

**Adoption**

**   **
**Outcomes**

**Ottawa Model of Research Use**

- University of Ottawa/ CIHR

**Notes:**
When the barriers related to the practice environment, potential adopters and innovation have been addressed, strategies are designed to disseminate the new practice for 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)?

- University of Ottawa/ CIHR

## Ottawa Model of Research Use

**barriers & supports****                 interventions                                         outcomes**
**                                                                          ****& degree of use                                                        **

**Practice Environment**

**Potential Adopters**

**Innovation **
**(CPG, tools)**

**    ****Interventions**

**Adoption**

**   ****Outcomes**

**Ottawa Model of Research Use**

- University of Ottawa/ CIHR

**Notes:**
When the barriers related to the practice environment, potential adopters and innovation have been addressed, strategies are designed to disseminate the new practice for use.

## Ottawa Model of Research Use

**barriers & supports                 ****interventions     ****                                    outcomes**
**                                                                          ****& degree of use                                                        **

**Practice Environment**

**Potential Adopters**

**Innovation**

** ****Implementation  **
**              ****Interventions**
**barrier**
**       ****management **
**transfer**
**follow-up**

**Adoption**

**   ****Outcomes**

**Ottawa Model of Research Use**

- University of Ottawa/ CIHR

**Notes:**
When the barriers related to the practice environment, potential adopters and innovation have been addressed, strategies are designed to disseminate the new practice for use.

## Ottawa Model of Research Use

**barriers & supports               **** ****interventions****    ****                                                outcomes**
**                                                                               ****&**** degree of use****                                                        **

**Practice Environment**
**structural**
**culture/social**
**patients**
**economic**

**Potential Adopters**
**awareness**
**attitudes**
**knowledge/skill**
**concerns**
**current practice**

**Innovation (guideline)**
**development process**
**innovation attributes**

**    ****Interventions**
**barrier**
**       ****management **
**transfer**
**follow-up**

**Adoption**
**intention**
**use**
**sustained  use**

**   ****Outcomes**
**patient**
**practitioner**
**system**

**Ottawa Model of Research Use**

- University of Ottawa/ CIHR

**Notes:**
When the barriers related to the practice environment, potential adopters and innovation have been addressed, strategies are designed to disseminate the new practice for use.

## Ottawa Model of Research Use

**barriers & supports                 interventions**** ****                                        ****outcomes**
**                                                                          ****& degree of use                                                        **

**Practice Environment**
**structural**
**culture/social**
**patients**
**economic**

**Potential Adopters**
**awareness**
**attitudes**
**knowledge/skill**
**concerns**
**current practice**

**Innovation**
**development process**
**innovation attributes**

**    ****Interventions**
**barrier**
**       ****management **
**transfer**
**follow-up**

**Adoption**
**intention**
**use**
**sustained use**

**   ****Outcomes**
**patient**
**practitioner**
**system**

**Ottawa Model of Research Use**

- University of Ottawa/ CIHR

**Notes:**
When the barriers related to the practice environment, potential adopters and innovation have been addressed, strategies are designed to disseminate the new practice for 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](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**_

- University of Ottawa/ CIHR

## 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

- University of Ottawa/ CIHR

## Outline

- Background
- Purpose & Objectives
- Theoretical Framework
- Methods
- Results
- Implications for Research, Education and Practice

- University of Ottawa/ CIHR

**Notes:**
...

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

- (Magee, *WHO*, 2003)

- University of Ottawa/ CIHR

**Notes:**
Survey of patients included 500 US, 406 Canada and 400 for each of the other countries using random digit dialing.

## Slide 26

- University of Ottawa/ CIHR

## Problem: Decisional Conflict

**uncertainty about which course of action to take**
** **
- North American Nursing Diagnosis Association, 2002

**yes**

**no**

- University of Ottawa/ CIHR

## ‘Innate’ contributing factors

- 2 or more options
- Outcomes: risky/uncertain, permanent, serious
- Value tradeoffs: benefits versus harms
- Anticipated regret: ‘missed’ benefits of option not chosen

- regret

- University of Ottawa/ CIHR

## Consequences: unresolved decisional conflict & 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)

- University of Ottawa/ CIHR

## 	Compared to standard care, 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

- University of Ottawa/ CIHR

##  Value

- of coaching
- [hysterectomy]
- (Kennedy et al. JAMA 2002;
-  288: 2701-2708)

- University of Ottawa/ CIHR

## Framework for Decision Coach-Mediated   Shared Decision 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 Role*
- Communicate informed values & priorities shaped by their social circumstances

*Decision Coach Role** *
- (Ottawa Decision Support Framework)
- Assessing decisional needs
- Providing decision support tailored to needs
- Monitoring & facilitating progress in resolving needs and decision quality
- Screen for implementation needs

- (Stacey, Murray et al., _*Worldviews on Evidence-based Nursing *_in press)

- University of Ottawa/ CIHR

## Client Centred Care

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

- University of Ottawa/ CIHR

## Purpose of research

- 	A case study with an embedded randomized controlled trial (RCT), guided by the Ottawa Model of Research Use
- To explore baseline barriers and facilitators re decision support/coaching by call centre nurses
- To design and evaluate a multifaceted intervention to improve the quality of nurses’ decision support
- To describe the uptake and sustainability of decision support by call centre nurses

- Ethics approval by University of Ottawa, Research Ethics Board

- University of Ottawa/ CIHR

## BCNurseLine call centreServes 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

- University of Ottawa/ CIHR

**Notes:**
The research took place at the BCNurseLine located in Vancouver.

The goal of the BCNurseLine is to help residents of British Columbia manage personal health issues and make sound health decisions.

Unique from other call centres in Canada, the BCNurseLine is part of the BCHealthGuide self-care program and uses the Healthwise Knowledgebase. In addition to the call centre, there is a handbook and internet-based health information for the public and nurses to use. The internet information includes over 95 patient decision aids for values-sensitive decisions.

In 2003, nurses accessed patient decision aids on 803 occasions and the most common decisions were about breast vs. bottle feeding, birth control methods, treatment of miscarriage, and wisdom teeth removal.

During our study, there were several concurrent initiatives that were likely to have influenced the study results. These included: a) a major reorganization of the nurse supervisor positions; b) the organizations 3-year contract with the Ministry of Health Services was imminently due for renewal and c) high absenteeism that increased pressure to respond to calls in a shorter time frame.

## 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)

- University of Ottawa/ CIHR

## Ottawa Model of Research Use

**barriers & facilitators                   interventions                               outcomes**
**                                                                          ****& degree of use****                                                        **

- _Practice Environment_
- BCNurseLine
- organization’s policies, mandate
- callers

- _Potential Adopters: _
- Nurses
- awareness
- attitudes
- knowledge/skill
- confidence
- current practice

- _Innovation_
- Decision support

- _Multifaceted intervention_
- online autotutorial
- decision support /coaching protocol
- skill workshop
- performance feedback

- _Adoption_
- intention
- use

**   **_Outcomes_
- patient
- practitioner
- system

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

- 1. Baseline assessment

- 2. RCT of intervention

- 3. Uptake & sustainability

- University of Ottawa/ CIHR

## 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 Sources | Dec-         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-------> |  |

- University of Ottawa/ CIHR

## 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 intervention

- May 2004

- University of Ottawa/ CIHR

## Characteristics of participants

- %

- University of Ottawa/ CIHR

## 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)

- University of Ottawa/ CIHR

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

- University of Ottawa/ CIHR

## 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

- University of Ottawa/ CIHR

## Multifaceted intervention to address baseline barriers

| Barriers | Online 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)

- University of Ottawa/ CIHR

## Decision support protocol

- A process for coaching clients making decisions with 2 or more options
- Available at www.ohri.ca/decisionaid

*Based on: Ottawa Decision Support Framework*

- University of Ottawa/ CIHR

## RCT to Enhance Nurse Decision Support Coaching

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

- Time in Minutes

- University of Ottawa/ CIHR

## Health professionals’ decision support knowledge

- %

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

- University of Ottawa/ CIHR

## Coaches’ decision support skills improve (simulated calls)

- Mean quality scores

- p < 0.001

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

- University of Ottawa/ CIHR

## 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)

- University of Ottawa/ CIHR

## 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.”*

- University of Ottawa/ CIHR

## 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

- University of Ottawa/ CIHR

## 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)

- University of Ottawa/ CIHR

## 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

- University of Ottawa/ CIHR

## Key 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

- University of Ottawa/ CIHR

## 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

- University of Ottawa/ CIHR

## A mind once stretched by a new idea never regains 
its original dimension
Oliver Wendell Holmes Jr.
US jurist (1841 - 1935) 

*its original dimension*
- Oliver Wendell Holmes Jr.
*US jurist (1841 - 1935)*

- University of Ottawa/ CIHR

## www.ohri.ca/decisionaid

- University of Ottawa/ CIHR