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

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)
        - (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)

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

Practice Environment: Culture/social Factors
        - Culture & belief systems
        - Norms, institutionalized habits
        - Leadership
        - Politics & personalities
        - Peer influence

University of Ottawa/ CIHR

27

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

Assess 		+                      Monitor                  +                Evaluate

Practice Environment

Potential Adopters

 Innovation 

 Interventions

Adoption

Outcomes

Ottawa Model of Research Use

University of Ottawa/ CIHR

16

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

Assess 		+                      Monitor                  +                Evaluate

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

16

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.

Assess 		+                      Monitor                  +                Evaluate

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

16

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.

Assess 		+                      Monitor                  +                Evaluate

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

16

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.

Assess 		+                      Monitor                  +                Evaluate

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

16

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
        -    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

...

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

(Magee, WHO, 2003)

University of Ottawa/ CIHR

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

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

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 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

University of Ottawa/ CIHR

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

Assess 	           +           Monitor                  +               Evaluate

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

Ottawa Model of Research Use

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

1. Baseline assessment

2. RCT of intervention

3. Uptake & sustainability

University of Ottawa/ CIHR

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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

(Grimshaw J, et al., 2001 & 2004; Thomas L, et al., 1999)
| 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                        |

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

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

Time in Minutes

RCT to Enhance Nurse Decision Support Coaching

University of Ottawa/ CIHR

Health professionals’ decision support knowledge

%

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

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)

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) 

University of Ottawa/ CIHR

www.ohri.ca/decisionaid

University of Ottawa/ CIHR