Australian occupational therapists' use of an ... - Wiley Online Library

Australian occupational therapists’ use of an online evidence-based practice database (OTseeker) Blackwell Publishing, Ltd.

Kryss McKenna*1, Sally Bennett*1, Zoe Dierselhuis*†, Tammy Hoffmann*1, Leigh Tooth‡1 & Annie McCluskey§1, *Division of Occupational Therapy, School of Health and Rehabilitation Sciences, University of Queensland, Qld, †Royal Brisbane and Women’s Hospitals, Herston, Qld, ‡School of Population Health, University of Queensland, Qld and §School of Exercise and Health Sciences, University of Western Sydney, New South Wales, Australia

Abstract Introduction: Online databases can support the implementation of evidencebased practice by providing easy access to research. OTseeker (www.otseeker.com), an electronic evidence database, was introduced in 2003 to assist occupational therapists to locate and interpret research. Objectives: This study explored Australian occupational therapists’ use and perceptions of OTseeker and its impact on their knowledge and practice. Methods: A postal survey questionnaire was distributed to two samples: (i) a proportionate random sample of 400 occupational therapists from all states and territories of Australia, and (ii) a random sample of occupational therapists working in 95 facilities in two Australian states (Queensland and New South Wales). Results: The questionnaire was completed by 213 participants. While most participants (85.9%) had heard of OTseeker, only 103 (56.6%) had accessed it, with lack of time being the main reason for non-use. Of the 103 participants who had accessed OTseeker, 68.9% had done so infrequently, 63.1% agreed that it had increased their knowledge and 13.6% had changed their practice after accessing information on OTseeker. Conclusion: Despite OTseeker being developed to provide occupational therapists with easy access to research, lack of time was the main reason why over half of the participants in this study had not accessed it. This exploratory research suggests, however, that there is potential for the database to influence occupational therapists’ knowledge and practice about treatment efficacy through access to the research literature.

Introduction A new paradigm, evidence-based practice (EBP), has emerged over the past two decades, emphasizing the importance of integrating research evidence Correspondence: Kryss McKenna, Division of Occupational Therapy, School of Health and Rehabilitation Sciences, University of Queensland, Queensland, 4072, Australia. E-mail: [email protected] 1Member

of the OTseeker team.

into clinical decision making.1 While the medical profession initially drove EBP, the philosophy of using research evidence in clinical decision making has since influenced the policies and practices of other health professions, including occupational therapy. However, like their counterparts worldwide, Australian occupational therapists have experienced barriers to embracing EBP, largely as a result of difficulties accessing and interpreting research evidence.2,3

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Occupational therapists’ use of OTseeker, Kryss McKenna et al.

This paper begins by reviewing studies that have identified the barriers to occupational therapists’ participation in EBP. It then provides a description of an electronic database, Occupational Therapy Systematic Evaluation of Evidence database or OTseeker, introduced in 2003 by the authors (KM, SB, TH, LT, AM) to help occupational therapists integrate research evidence into practice. The remainder of the paper reports the results of a postal survey that explored a sample of Australian occupational therapists’ use of OTseeker and its impact on their knowledge and practice. Literature review Despite the opportunities that EBP provides to improve client outcomes, not all occupational therapists readily integrate scientific evidence into clinical decision-making.2,3 In a survey of 66 British occupational therapists, 86% read research studies in professional journals, but only 11% indicated there was time to do so during work hours.3 Other barriers that impacted on therapists’ ability to undertake EBP were a lack of resources and a limited ability to critically appraise research findings. In Australia, similar findings have been reported. McCluskey4 administered a questionnaire to 67 participants before they attended an introductory workshop on EBP and found that 53% reported a low level of knowledge about and skills in critically appraising research literature. Most (79%) reported limited knowledge of electronic databases and only 15% had attended a previous course on EBP. The six main barriers to implementing EBP reported were: lack of time (88%), large caseloads (67%), limited searching skills (50%), limited appraisal skills (44%), difficulty accessing journals (44%), and lack of evidence to support occupational therapy practice (41%). In a randomly selected sample of 649 members of OT AUSTRALIA, Bennett and colleagues5 found that, while respondents were positive about EBP, most relied more on their clinical experience (96%), continuing professional development (82%) and colleagues (80%) than on published research findings (56%) when making clinical decisions. Lack of time (91.8%)

was again the main reason why therapists were not using an evidence-based approach to practice. Background and aim of the study In response to these difficulties, an online database was developed to provide evidence about the effectiveness of interventions relevant to occupational therapy. 5,6 The Occupational Therapy Systematic Evaluation of Evidence (OTseeker) database contains the bibliographic details of relevant systematic reviews and randomized controlled trials and, where publisher approval has been obtained, abstracts are displayed. The randomized controlled trials are independently appraised and scored by two trained occupational therapists to help users evaluate a study’s validity and its usefulness in informing clinical decision-making. The PEDro scale7 is used to score the randomized controlled trials. In OTseeker, scores on the PEDro scale are displayed in two categories: internal validity and statistical reporting. Internal validity is expressed as a score out of eight, reflecting the extent to which the trial meets the criteria of random allocation; concealed allocation; similarity of study groups at baseline; blinding of participants, therapists, and assessors; outcome measures obtained from more than 85% of participants; and intention-to-treat analysis. Statistical reporting is scored out of two, that is whether the paper reported between-group statistical analysis and point measures with variability data. The database has been freely available at www.otseeker.com since March 2003. The current study explored whether OTseeker was being accessed by Australian occupational therapists and whether it had impacted on their practice. The research questions addressed were: 1 In a randomly selected sample of Australian occupational therapists, what proportion has heard of and accessed OTseeker? 2 Of those in the sample who have accessed OTseeker, what proportion state that their knowledge and clinical practice have been impacted? 3 What are users’ perceptions of the utility of OTseeker?

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Method Design This was a postal survey of two random samples of Australian occupational therapists. Sample Two sampling methods were used. 1 A national sample. Members of the Australian national occupational therapy association, OT AUSTRALIA, were randomly sampled in June 2004. OT Australia has an approximate membership of 4500. Using a random numbers list, a proportionate (by state /territory) random sample of 400 members was selected. This sample size was chosen on the basis of resources available for the initial survey mail out and follow-up reminders. 2 A State sample. Following a low response from the national sample, a second sampling strategy was implemented, focusing on occupational therapists from the two Australian states in which OTseeker team members were based (Queensland and New South Wales). It was considered likely that occupational therapists in these two states may have greater awareness of the database. Occupational therapists working in 95 randomly selected facilities from across these two states were invited to complete the survey questionnaire in November 2004. In Queensland, 59 (11.7%) of the 504 facilities listed in a directory of facilities employing occupational therapists who are members of OT AUSTRALIA Queensland were selected using a random numbers list. In New South Wales, 36 (10%) of the 366 facilities listed in a university’s directory of facilities that provide fieldwork placements for occupational therapy students were selected using a random numbers list. Procedure Approval to undertake this study was provided by the School of Health and Rehabilitation Science’s Research and Postgraduate Studies Committee at the University of Queensland, Australia. Survey packages consisted of a participant information

sheet, survey questionnaire and a reply paid envelope. Consent to participate was assumed if the questionnaire was returned. For the national sample, OT AUSTRALIA staff conducted the sampling process and mail-out of the survey packages to maintain participant confidentiality. For the State sample, facilities rather than individual occupational therapists were targeted to preserve participant anonymity. An initial telephone call was made to the senior occupational therapist at the facility to explain the purpose of the study and to ascertain whether occupational therapists at that facility would be willing to participate. The senior occupational therapist indicated the number of occupational therapists who worked at the facility and corresponding numbers of survey packages were sent. To increase the response rate, generic follow-up letters were sent to all potential participants in the national sample at approximately 2- and 4-week intervals after the initial mail out. In the state sample, a follow-up telephone call was made to the senior occupational therapist approximately 3 weeks after the survey packages were mailed to encourage their return. The instrument The survey questionnaire used in the study was modelled on two previous surveys. The first aimed to determine Queensland health professionals’ awareness and use of the Clinicians’ Knowledge Network (http://ckn.health.qld.gov.au). The second sought to establish Australian occupational therapists’ knowledge, skills and involvement in EBP.4 The questionnaire contained three sections: (i) participants’ demographic information; (ii) participants’ awareness of and access to OTseeker, reasons for accessing OTseeker, sources of information for clinical decision making both before and after OTseeker became available, whether they had changed practice and if their knowledge about the effectiveness of occupational therapy interventions had increased as a result of information on OTseeker; (iii) participants’ perceptions of the utility of the database including their understanding of the PEDro scale and usefulness of the tutorial and website links on OTseeker.


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Most questions could be answered using dichotomous or multiple fixed-response categories. Where appropriate, an ‘other’ category was included. For the question regarding sources of information used for clinical decision making, participants ranked fixed response categories from 1 to 10, with 1 being the source most relied on. The questionnaire was piloted on three occupational therapists who were not members of OT AUSTRALIA. Minor adjustments were made to enhance the clarity of the wording of some questions in response to pilot feedback. Data analyses Data were analysed descriptively using the Statistical Package for Social Science (SPSS) for Windows (version 11, SPSS, Chicago, IL, USA). Results Characteristics of participants A total of 213 questionnaires was completed. In the national sample, of the 400 questionnaires distributed, 124 were completed, representing a 31.0% response rate. Five questionnaires were returned uncompleted because the participant was overseas (n = 3), no longer practising (n = 1), or did not have time to participate (n = 1). In the state sample, based on the number of occupational therapists who worked in the facilities as indicated by the senior occupational therapists, 326 survey packages were distributed, 165 to the 59 facilities in Queensland and 161 to the 36 facilities in New South Wales. Eighty-nine completed questionnaires were returned and one questionnaire was returned uncompleted because the therapist did not have time to participate. This represents a response rate of 27.3%. When compared using chi-square analyses and an independent samples t-test, there were no statistically significant differences between the two samples in terms of their gender, work location, setting and role, postgraduate qualifications, participation in EBP training, awareness of OTseeker and years worked as an occupational therapist. Therefore, the data from both samples were pooled. Most participants were female and

worked in a metropolitan area, full-time, as a clinician in the public sector in an adult physical caseload. Participants had been working for a mean of 11.9 years (SD = 9.3, range < 1–44). Approximately one-quarter had postgraduate qualifications and almost three-quarters had participated in EBP training. Table 1 provides participant details. Access to OTseeker Of the 183 (85.9%) participants who had heard of OTseeker before receiving the questionnaire, 103 (56.3%) had accessed the database. The reasons why participants who had heard of OTseeker had not accessed it are provided in Table 2. Of the 103 participants who had accessed OTseeker, most did so at work (n = 79, 76.7%), with the remainder accessing the database at home or university. Most who accessed OTseeker visited the site infrequently (less than monthly; n = 75, 72.8%). Thirty-one (30.1%) participants accessed OTseeker occasionally (monthly) while three (2.9%) accessed the database frequently (daily/ weekly). Participants ranked their reliance on sources of information that informed clinical decision making both before and after OTseeker became available in March 2003. Based on the mean rank, the top five sources of information before and after OTseeker became available are presented in Table 3. After March 2003, OTseeker was the fourth ranked source of evidence. After OTseeker became available, participants’ reliance on journal articles for evidence moved from third to first rank. Incorporation of evidence into clinical practice Of the 103 prior users, their reasons for accessing OTseeker are summarized in Table 4. Sixty-five (63.1%) participants indicated that accessing OTseeker had contributed to their knowledge base. Of the other 38 who did not report an increase in knowledge, 23 (57.5%) stated that there was not enough information about their topic of interest on OTseeker, 15 (37.5%) indicated that they had not used OTseeker enough, and two (5.0%) responded that more useful information was available on other electronic databases.


Occupational therapists’ use of OTseeker, Kryss McKenna et al. Table 1 Participant demographic information (n = 213)

Characteristics

Number (%)

Gender Female Male

203 (95.3%) 10 (4.7%)

Work location* Capital city Metropolitan centre (population ≥ 100 000) Large rural centre (population > 25 000) Small rural centre (10 000 –25 000) Remote (population < 10 000)

98 (46.0%) 63 (29.6%) 33 (15.5%) 11 (5.2%) 5 (2.3%)

Employment status Full-time Part-time Not currently employed

146 (68.5%) 62 (29.1%) 5 (2.3%)

Work role Clinician/consultant Manager Academic/researchers Other†

185 (86.9%) 17 (8.0%) 4 (1.9%) 7 (3.3%)

Area of practice* Adult physical Mixed caseload Other‡ Child/adolescent physical Adult mental health Child/adolescent intellectual disability Academic/researcher Child/adolescent mental health Adult intellectual disability Work setting* Public Private Other (charitable organizations) Undertaken evidence-based practice training Postgraduate education Workplace computers with Internet access available

90 (42.3%) 41 (19.2%) 30 (14.1%) 17 (8.0%) 15 (7.0%) 12 (5.6%) 3 (1.4%) 2 (0.9%) 2 (0.9%) 149 (70.0%) 50 (23.5%) 13 (6.1%) 152 (71.4%) 48 (22.5%) 177 (83.1%)

*Some missing data; †managerial and clinical duties; ‡hand therapy and occupational rehabilitation.

Fourteen (13.6%) of the 103 participants who had accessed OTseeker indicated that they had changed their practice, management, or teaching in the last 3 months as a result of information on OTseeker. Examples of changes included using more economical foam cushions to prevent pressure sores over more expensive brands (clinical practice), incorporating an EBP course into a 3rd-year occupational therapy university curriculum (teaching) and commencing an EBP in-service group (management). Of the other 89 participants who did not report practice

changes, most stated that this was as a result of there not being relevant or enough information on OTseeker (55, 53.4%), followed by changes to practice being constrained by work environment or policies (22, 21.4%) and information on OTseeker confirming current practice (22, 21.4%). Utility of OTseeker Participants who had not accessed OTseeker before completing the questionnaire were asked to


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Occupational therapists’ use of OTseeker, Kryss McKenna et al. Table 2 Reasons why participants who had heard of OTseeker had not accessed it (n = 80)

Table 4 Reasons why participants accessed OTseeker (n = 103)

Reason

Number (%)

Reason

Number (%)*

Lack of time No reason to use it Did not know what it could offer No access to OTseeker on a computer No access to a computer Other Missing

31 (38.8%) 23 (28.8%) 12 (15.0%) 5 (6.3%) 2 (2.5%) 4 (5.0%) 3 (3.8%)

Clinical information Preparation of teaching/in-services Private study Research Assignment Other

90 (87.4%) 62 (60.2%) 59 (57.3%) 56 (54.4%) 40 (38.8%) 3 (2.9%)

*Participants could choose more than one reason.

Table 3 Top five sources of information relied on for clinical decision making in practice Rank

Before OTseeker launch*

After OTseeker launch

1 2 3 4 5

Colleagues Experience with similar clients in the past Journal articles Short courses/continuing professional development Textbooks

Journal articles Experience with similar clients in the past Colleagues OTseeker Short courses/continuing professional development

*OTseeker was launched in March 2003.

do so to enable them to comment on the utility of the database. Most participants (91.9%) indicated that using the OTseeker search page was easy or relatively easy. Participants were less uniform in their perception of the ease with which the internal validity and statistical reporting components of the PEDro scale could be interpreted, with 29.6 and 34.8%, respectively, finding these somewhat difficult or difficult to understand. Discussion This study aimed to explore whether a sample of Australian occupational therapists had heard of and accessed OTseeker, and its impact on their knowledge and clinical practice. Use of OTseeker Most participants (86%) had heard of OTseeker. This finding may in part be because of the extensive promotion of OTseeker in journals,5,6 at conferences and online, with links to OTseeker being provided by numerous occupational

therapy, health-service, library and EBP websites, as well as Australian health department intranets. Of the participants who had heard of OTseeker, over half (56.3%) had accessed it. The main reason why participants had not accessed OTseeker was lack of time, despite the database being developed to provide quick and easy access to high-quality research findings. Previous studies support that lack of time is the main barrier to implementing EBP.5,7−9 OTseeker has been designed to save users time when searching for evidence. It is freely available online, giving users fast access to research literature. As in other studies,4 most participants in this study had access to a computer and the Internet at work, indicating their ability to access online resources. Studies have shown that clinicians tend to rely on electronic databases such as ,  or  when searching for clinical information.2,3,10  is available free online through PubMed, and therapists may have access to  and  through institutional subscriptions.10 These databases do not contain all research findings relevant to physiotherapy10 and



the same is likely to be true for occupational therapy. When searching these databases, clinicians may need to peruse many citations before finding papers containing high-quality evidence that will assist in answering their clinical question. OTseeker contains research findings from multiple databases, including  ,  ,  , : Rehabilitation and Physical Medicine, AMED, PsycINFO, the Cochrane Library, CancerLit and Ageline8 providing users with fast access to research relevant to occupational therapy from many sources. This feature decreases the need for users to search multiple electronic databases, ultimately saving time. Only systematic reviews and randomized controlled trials are contained on OTseeker so users can be assured that the articles they retrieve have the potential to provide strong evidence about the effectiveness of a given intervention.11 Further, all randomized controlled trials on OTseeker have been critically appraised for internal validity and statistical reporting. This enables users to more easily interpret the quality of study conclusions and determine applicability to clinical practice. Although OTseeker has the potential to save users time when searching for high-quality research, there are some limitations to the database. Due to copyright laws, abstracts of some papers on OTseeker are not available. Users cannot then determine whether a study is applicable to their clinical question unless they locate the abstract elsewhere. A difficulty that applies to both OTseeker and traditional databases is that, once a study of interest has been identified, users must retrieve the full-text paper either from the online or printed journal. Problems accessing journal articles such as proximity to libraries have been well documented in previous studies investigating occupational therapists’ perceptions of EBP.2,4,12 Another limitation that may deter use of OTseeker is that only papers regarding the effectiveness of interventions are contained on the database. If users have questions about assessments or prognosis, other databases need to be accessed. Sources of evidence Participation in EBP does not rely solely on accessing research literature. It involves the

integration of clinical expertise and client preferences with the best available evidence.13 When these three components are combined, clinicians are able to make informed decisions that can optimize client outcomes.13 Participants ranked sources used to make clinical decisions both before and after the launch of OTseeker. After the introduction of OTseeker, participants ranked the database after journal articles, clinical experience, and colleagues, and before continuing education courses. After OTseeker became available, reliance on journal articles as a source of evidence rose from third to first rank. This finding suggests a change in behaviour from past research where occupational therapists placed greater emphasis on knowledge from clinical experience and colleagues than on information from research.2,12 While reliance on the opinion of experienced colleagues for clinical decision making can be biased by personal preferences and experiences, reference to the research literature can also be problematic. Reading journal articles may not necessarily provide clinicians with appropriate information on which to base clinical decisions.14 A large proportion of published research either lacks relevance or the methodological rigour to adequately answer clinical questions. Critical appraisal of key studies is essential to determine a study’s validity and applicability to practice. In this study, just over one-third of participants expressed difficulty understanding the critical appraisal scores on OTseeker, despite explanations of each criteria being provided in the help pages on the website. McCluskey9 found that critical appraisal skills could be improved with training. Increasing clinicians’ understanding of research terminology such as ‘meta-analysis’ and ‘intentionto-treat’ can enhance their ability to determine the quality of research and to further engage in EBP.10 Changes to knowledge and practice Almost two-thirds of participants who had accessed OTseeker reported that using information from the database had changed their knowledge, while only 13.6% indicated that the database had impacted on their practice. There are


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a number of potential reasons why OTseeker did not impact on the practice of more users. For some, the information contained on the database may confirm rather than increase their current practice. For others, the database may not contain enough information relevant to their clinical questions. As OTseeker is a relatively new resource, there may be studies available that have not yet been entered into the database. In addition, users may not have access to full-text articles to enable them to follow up on OTseeker search yields. Occupational therapy is a diverse profession with clinicians working in many practice areas. Studies in specific areas of practice may not yet exist, requiring clinicians to generalize findings from less relevant research. Copyright permission to display abstracts of all citations has not been obtained. This limits users’ ability to determine if a particular citation would be useful in answering their clinical question. A number of issues impact on a clinician’s ability to change their clinical practice. Incorporating evidence into clinical practice must take place at both a system and individual level.15 At the system level, clinicians require administrative support, access to research literature and time to conduct searches.16,17 At the individual level, clinicians need to prioritize time for research utilization9 have high-level critical appraisal skills to combine and synthesize research findings from multiple articles,18 in addition to having confidence in their ability to change practice. McCluskey4 reported that only 30% of participants in her study were confident in their skills and ability to change clinical practice in response to new evidence. Study implications While OTseeker was developed to address identified barriers that limit occupational therapists’ participation in EBP, namely lack of time, difficulty finding appropriate research evidence, and difficulty critically appraising the research literature, OTseeker has not yet been wholly embraced by Australian occupational therapists. To raise therapists’ awareness of OTseeker, the database will continue to be promoted nationally

and internationally. Future developments that are planned for OTseeker including an alert system and an online tutorial may assist therapists to optimize use of the database. New studies are continually being added to the database to increase the quantity and range of available research. An analysis of search terms and strategies used by users of OTseeker is currently underway to prioritize the addition of future entries to the database. OTseeker displays only those abstracts of systematic reviews and randomized controlled trials for which copyright permission has been obtained from the publishers. In the future, a structured summary of the study, including an overview of the results, will be added to citations where an abstract is unavailable or does not contain a detailed synopsis of the article. This summary feature should help users to determine if a study is relevant and likely to answer their clinical question. Limitations The main limitation of this study was the low response rate. Although the response rates in this study are within the acceptable limits for a postal survey,19 they are still low and may have resulted in a highly select sample. A further limitation of this study was sampling bias, with all participants in the national sample and from Queensland facilities being OT AUSTRALIA members. Therefore, the results may not be representative of non-members or occupational therapists in other countries. Participants were all volunteers. Those who were aware of and had accessed OTseeker may have been more likely to respond. Participants in the state sample may have been more aware of OTseeker because OTseeker originated from these states. Conclusion Although most participants in this study had heard of OTseeker, only approximately half had accessed the database. Lack of time was the main reason reported for not accessing the database, despite the database being specifically designed to address this very problem. Two-thirds of participants reported that information on



OTseeker had improved their knowledge. Participants’ reliance on journal articles as a source of evidence increased after OTseeker became available. Only a small proportion of respondents reported changes to practice as a direct consequence of accessing OTseeker. As awareness of OTseeker increases and refinements are made to the database, it may have a greater impact on clinicians’ practice and participation in EBP. Research is required to explore the use of OTseeker by occupational therapists in other countries and its impact on their practice. Acknowledgements The support of OT AUSTRALIA in the distribution of the survey packages is gratefully acknowledged. A brief outline of the results from this study was presented at the OT AUSTRALIA Qld 8th State Conference, Sunshine Coast, 16– 18 September 2004. OTseeker is currently funded by the Motor Accident Authority of New South Wales, Australia, and OT Australia. LT was supported by a National Health and Medical Research Council of Australia Capacity Building Grant (no. 252834) while this research was undertaken.

Key Messages Implications for Practice • Information on OTseeker contributes to improvements in knowledge of occupational therapy interventions and, to a small extent, changes in practice. • Participants’ reliance on journal articles as a source of evidence increased after OTseeker became available. Implications for Policy • Lack of time persists as the main barrier to accessing research from databases such as OTseeker. Further research is needed to address this issue. • Ongoing marketing is needed to increase awareness of OTseeker. • Research is required to explore the use of OTseeker by occupational therapists in other countries and its impact on their practice.

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