Facilitating interprofessional evidence-based practice

http://informahealthcare.com/dre ISSN 0963-8288 print/ISSN 1464-5165 online Disabil Rehabil, Early Online: 1–9 ! 2015 Informa UK Ltd. DOI: 10.3109/09638288.2015.1041616

PERSPECTIVE IN REHABILITATION

Facilitating interprofessional evidence-based practice in paediatric rehabilitation: development, implementation and evaluation of an online toolkit for health professionals Stephanie M. N. Glegg1,2,3, Roslyn Livingstone1,2, and Ivonne Montgomery1,2

Disabil Rehabil Downloaded from informahealthcare.com by 70.68.177.83 on 04/29/15 For personal use only.

1

Therapy Department, Sunny Hill Health Centre for Children, Vancouver, BC, Canada, 2Department of Occupational Science & Occupational Therapy, The University of British Columbia, Vancouver, BC, Canada, and 3Child & Family Research Institute, Vancouver, BC, Canada Abstract

Keywords

Purpose: Lack of time, competencies, resources and supports are documented as barriers to evidence-based practice (EBP). This paper introduces a recently developed web-based toolkit designed to assist interprofessional clinicians in implementing EBP within a paediatric rehabilitation setting. Methods: EBP theory, models, frameworks and tools were applied or adapted in the development of the online resources, which formed the basis of a larger support strategy incorporating interactive workshops, knowledge broker facilitation and mentoring. Results: The highly accessed toolkit contains flowcharts with embedded information sheets, resources and templates to streamline, quantify and document outcomes throughout the EBP process. Case examples relevance to occupational therapy and physical therapy highlight the utility and application of the toolkit in a clinical paediatric setting. Workshops were highly rated by learners for clinical relevance, presentation level and effectiveness. Eight evidence syntheses have been created and 79 interventions have been evaluated since the strategy’s inception in January 2011. Conclusions: The toolkit resources streamlined and supported EBP processes, promoting consistency in quality and presentation of outputs. The online toolkit can be a useful tool to facilitate clinicians’ use of EBP in order to meet the needs of the clients and families whom they support.

Education, evidence-based practice, knowledge translation, online, paediatric practice, practice change History Received 5 December 2014 Revised 8 April 2015 Accepted 13 April 2015 Published online 29 April 2015

ä Implications for Rehabilitation

A comprehensive online EBP toolkit for interprofessional clinicians is available to streamline the EBP process and to support learning needs regardless of competency level. Multi-method facilitation support, including interactive education, e-learning, clinical librarian services and knowledge brokering, is a valued but cost-restrictive supplement to the implementation of online EBP resources. EBP resources are not one-size-fits-all; targeted appraisal tools, models and frameworks may be integrated to improve their utility for specific sectors, which may limit them for others.

Background Health care professionals have a responsibility for evidencebased practice (EBP) to ensure their interventions are effective and safe [1]. EBP requires clinicians to access, appraise and integrate research literature with clinical experience and their clients’ perspectives [2]. This process begins with the generation of clinical queries that can guide clinical practice and drive the development of research and knowledge products [3]. Clinicians also engage in EBP when searching for, synthesising and sharing evidence in a format that is suitable for clients, managers or fellow clinicians [4]. However, the volume of

Address for correspondence: Stephanie M. N. Glegg, Therapy Department, Sunny Hill Health Centre for Children, 3644 Slocan Street, Vancouver, British Columbia, V5M 3E8, Canada. Tel: +1 604 453 8300x8268. E-mail: [email protected]

evidence can be overwhelming; clinicians may lack the knowledge, skills or resources to find, manage and apply the most relevant high-quality evidence to practice [5]. Efficiency in EBP requires practical supports and strategies for clinicians, including EBP competency development, access to evidence, tools to facilitate information management and appraisal and structured support to implement and evaluate evidence in practice [5]. These support needs vary across individuals and professions; as such, challenges exist in developing appropriate supports to meet the needs of novice and experienced EBP practitioners, while addressing the diverse EBP preferences of various disciplines [6–8]. Theory and research about EBP and knowledge translation (KT) can inform the processes, tools and strategies used to develop EBP competencies, to establish consistent methods of EBP, and ultimately to foster an EBP culture. This latter goal, which may be strengthened through such strategies as competency


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S. M. N. Glegg et al.

development, mentoring, consensus-building, emphasising outcome measurement and fostering teamwork and creativity, is important for sustainability [5]. The application of theory is also important for conveying the focus of a resource being developed, for enabling replication and evaluation of outcomes, and for identifying appropriate learning strategies [9,10]. Web-based learning is one strategy that has gained momentum for continuing professional development and education [11,12]. E-learning affords busy clinicians access to updated information and resources and the opportunity for self-paced, self-directed learning [12,13]. Clinically-relevant case examples and tools can be incorporated into online resources and skill-based activities to ensure they are meaningful and applicable [14]. Such learning resources can build foundational knowledge and support competency development [15]; however, research suggests that possessing EBP knowledge and skills may not be enough to generate practice changes that positively influence patient outcomes [16]. The KT literature has much to offer educators in terms of identifying strategies to promote behaviour change. For example, multifaceted KT strategies involving active methods, such as interactive workshops, consensus-building, social mobilisers (e.g. knowledge brokers) and quality improvement initiatives targeting different barriers to change, have demonstrated success in various practice contexts [17,18]. Combining online resources with interactive KT strategies delivered within group and individual formats may thus increase the likelihood of successful outcomes in EBP knowledge, skills and behaviour. The context for this EBP initiative is a provincial paediatric health centre providing specialised inpatient rehabilitation and tertiary services for children with developmental disabilities, within a family-centred, program-based model. The centre’s mandate for education, research and professional development is supported in part by the onsite Child Development and Rehabilitation (CDR) Evidence Centre [19]. The purpose of this paper is to introduce the Evidence Centre’s recently developed strategy to support interprofessional EBP using online resources and to describe its implementation and evaluation. While a plethora of online EBP resources exist, the aim of this initiative is to improve efficiency of access through the provision of a single integrated website housing context-specific resources of relevance to clinicians’ paediatric rehabilitation practices, their learning needs and the organisational context, while providing consistency in language, frameworks and the quality and formatting of outputs.

Toolkit development and implementation process Through literature searches and online research, EBP and KT theories, frameworks and models (Table 1) were sought and integrated by Alyssa Barrie and the first author, to create a comprehensive framework for EBP at the centre. These primary developers of the toolkit are staff of the Evidence Centre, and occupational therapists by training, with paediatric clinical experience, as well as facilitation and education experience related to interprofessional EBP. The first author also coordinates the Knowledge Brokering Initiative [19] at the centre and conducts research in KT; both have led program development and coordination of the Student EBP Initiative that customizes EBP learning opportunities for fieldwork students and their supervisors at the centre. The Adapted Fresno Test (AFT) of Competence in EBP [6], previously administered to an interprofessional group of 43 clinicians at the centre, was used to identify EBP learning and resource needs. Professions represented included occupational therapy (n ¼ 10), speech-language pathology (n ¼ 8), physical therapy (n ¼ 7), nursing (n ¼ 5), physicians (n ¼ 4), therapeutic

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recreation (n ¼ 3), rehabilitation technician (1), social work (1), management (1) and three unknown. Mean years clinical experience of the group was 14.9 years; 28 reported receiving previous continuing education in EBP. An informal needs assessment, consisting of tracking verbal requests for support, as well as the knowledge and skill gaps identified by all Evidence Centre staff and by internal knowledge brokers during one-to-one and group interactions with clinicians, also informed toolkit development. Existing resources were then compiled by the two toolkit developers, and adapted to fit the context, with input from other Evidence Centre staff; resource gaps were addressed through the development of novel tools and templates. The two toolkit developers obtained feedback from local content experts prior to pilot testing the resources internally with individual clinicians and discipline groups in order to improve their utility [9]. To support the toolkit’s implementation, three workshops were provided by the toolkit developers, to a total of 12 knowledge brokers and 14 professional practice leaders and program managers at the centre. The purpose of these workshops was to introduce the resources and to discuss how they could be used to facilitate or lead EBP within different sectors. A second workshop series was then offered to all clinicians by the toolkit developers, with 30 clinicians attending the Step 1 workshop, 36 attending Step 2 and 17 and 13 clinicians attending the two Step 3 workshops. Represented health professions included occupational therapy, physical therapy, social work, speech-language pathology, nursing and therapeutic recreation. A pilot workshop for Step 4 was offered to a single discipline group (therapeutic recreation), with eight participants in attendance. Small group activities within the larger group workshops afforded collaborative EBP learning opportunities, practical experience in applying the tools using case-based scenarios, and face-to-face facilitation and support to answer questions and engage clinicians in the EBP process. Knowledge brokers attending the Steps 1–4 workshops facilitated these processes within the small groups in collaboration with the toolkit developers. Following the workshops, the existing infrastructure of the Knowledge Broker Initiative [19] enabled a forum for ongoing collaborative EBP learning, facilitation and consensus-building within clinical teams and discipline groups. Interactive e-learning modules [31] developed by the first author afforded additional orientation to the resources and the group processes these individuals would be facilitating, along with more practice opportunities with the tools. Knowledge brokers, leaders and clinicians could also access individual and group mentoring support by Evidence Centre staff, including the clinical librarian. The timeline for toolkit development and implementation is depicted in Figure 1.

Description of the EBP toolkit Designed for interprofessional clinicians in the child development and rehabilitation field, the EBP resource toolkit is based on Sackett’s five steps of EBP [20] (Figure 2). A flowchart for each EBP step houses embedded resources designed to address the learning and EBP process needs of both novice and experienced EBP practitioners. As a self-serve toolkit, clinicians can select the specific resources they need for the tasks they are undertaking, based on their prior knowledge of the topic or process and on the intended outcome. As the flowcharts are reviewed below, real case examples (Table 2) from the Occupational Therapy Department and the Positioning and Mobility Team at the centre highlight their application to daily practice. The Step 1 flowchart (Formulating a Clinical Question) provides a framework for prioritising daily clinical queries [20] and tools to turn them into answerable clinical questions to

Online EBP toolkit

DOI: 10.3109/09638288.2015.1041616

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Table 1. Incorporated theories, frameworks and models. Title

EBP step

Resource(s)

Sackett’s 5 steps of evidence-based practice [20]

All

PICO (Population, Intervention, Comparison, Outcome) framework [21]

Step 1

Research, clinical experience, client perspective [22]

Step 2

International Classification of Functioning, Disability and Health (ICF) framework [23]

Step 2

American Academy of Cerebral Palsy and Developmental Medicine (AACPDM) appraisal framework [24]

Steps 2, 3 and 4

Stetler Model of Research Utilization [25]

Steps 3 and 4

Knowledge-To-Action Cycle [26]

Step 4

6s Hierarchy of Pre-appraised Evidence [27]

Steps 2 and 3

Traffic Lighting Framework [28]

Steps 1, 2 and 4

Center for Evidence Based Medicine (CEBM) Levels of Evidence framework [29] Lean Methodology [30] Knowledge-to-Action Cycle [26] Traffic Lighting Framework [28] Stetler Model of Research Utilization [25]

Step 3

Home page Steps 1–5 flowcharts Clinical Question Guidelines Clinical Question Worksheet Critically Appraised Topic (CAT) Template & Guidelines Step 2 flowchart Considerations for Selecting Sources of Evidence Documenting Your Current Practice Worksheet Traffic Lighting Synthesis Traffic Lighting Record Evidence for Practice (E4P) Templates & Guidelines Documenting Your Current Practice Worksheet CAT Template & Guidelines Choosing Your Best Evidence Study Design Identification Flowchart Traffic Lighting Overview Traffic Lighting Process Traffic Lighting Synthesis Traffic Lighting Record Evidence for Practice (E4P) Templates & Guidelines Clinical Applicability Form Determining How to Apply Evidence Practice or Process Change Plan Practice or Process Change Plan Knowledge Translation Plan CAT Template & Guidelines Step 3 Flowchart Sources of Evidence Table Sources of Evidence Search History Form Choosing Your Best Evidence CAT Template & Guidelines Documenting Your Current Practice Worksheet Traffic Lighting Overview Traffic Lighting Process Traffic Lighting Synthesis Traffic Lighting Record Evidence for Practice (E4P) Templates & Guidelines Step 3 flowchart

Step 5

structure an efficient search of the research literature. See Table 2 for the PICO [21] questions generated by the team of clinicians for each case example. The Step 2 flowchart (Searching for Evidence) supports rapid literature searches by busy clinicians, as well as more robust and systematic searches to develop evidence syntheses. Several resources incorporate the 6s Hierarchy of Pre-Appraised Evidence [22] as a means of improving the efficiency of searching to yield pre-appraised, synthesised evidence. Multiple means of accessing the literature are presented to address some of the challenges confronted by clinicians in this area. See Table 2 for the search strategies and the best evidence for each case example. The Step 3 (Appraising the Evidence) flowcharts for each 6s pyramid level [27] provide tools and considerations for determining the level of evidence (i.e. study design), the quality of the evidence and its clinical applicability using the American Academy of Cerebral Palsy and Developmental Medicine (AACPDM) level and quality of evidence rating scales [24]

Evaluating Clinical Implementation Evaluating Knowledge Translation Measuring Yellow Light Interventions Step 5 Flowchart

because of their inclusion of single-subject and group research designs prevalent in child development and rehabilitation [36], and their demonstrated psychometric properties [37]. The International Classification of Functioning, Disability and Health (ICF) [23] was applied to classify outcomes as a means of promoting a common language. A unique feature of the EBP toolkit is the integration of the Traffic Lighting Classification Scale, adapted in 2010 from Dr. Iona Novak’s work [28], which categorises interventions as green (go), yellow (measure) or red (stop) light; criteria are provided in Table 3. Table 2 shows the appraisal tools and summary of results obtained for each case example. The Step 4 (Applying Evidence to Practice) flowchart guides clinical implementation (e.g. use, discontinue or change how an intervention is used), knowledge transfer/education to various stakeholders and/or research linkage to explore research questions or gaps that have been identified. Organisational quality improvement terminology and tools were incorporated (see Supplemental Materials) for consistency across clinical and


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Figure 1. Timeline for EBP resource development and facilitation.

Figure 2. Evidence-based practice (EBP) resources [20].

organisational applications. See Table 4 for the Traffic Lighting Record for each case example, Table 2 for their clinical bottom lines, and the Supplemental Materials for their detailed Practice or Process Change Plans (Supplemental Materials). The Step 5 (Evaluating Evidence Use) flowchart supports the evaluation of the effectiveness of clinical implementation and knowledge transfer efforts, the identification of appropriate outcome measures for the evaluation of yellow light interventions, and the tracking of linkage and exchange activities within

research and professional networks. Table 2 describes the preliminary evaluation results of the practice change implementations described in the Supplemental Materials.

Evaluation Traffic lighting of interventions is vetted by Evidence Centre staff and results are entered into an internal database that is searchable by population, intervention, outcome, ICF [23] component,

Therapists report that families and community therapists are willing to provide mobility experience through the use of mainstream toys and loaned equipment, reducing barriers to early implementation of power mobility equipment. The evidence synthesis on infant/preschool-aged power mobility prescription represents the second most highly accessed synthesis on the centre’s resource website

Step 5: Evaluating Evidence Use – Preliminary Results

Example 2

AMSTAR Tool:[35] High – 8/11

Quality of evidence

Green – proven effective

Traffic light code

Therapists report that school therapists and teams are very open to learning and using these resources and knowledge products to inform and carry out evidence based handwriting intervention. The handwriting resources represent the most highly accessed web pages of any kind on the centre’s resource website

The active ingredient in handwriting interventions appears to be practice intensity at levels necessary for neuroplastic change. These interventions must allow for taskspecific handwriting practice at a minimum twice per week (time per session varied from 20 to 60 min) for a total of at least 20 sessions to improve handwriting legibility; speed improvements may require even higher intensities. Lack of clarity exists about whether practice requires a cognitive or sensorimotor component or some combination although preliminary evidence suggests cognitively focused interventions may be more effective

* Findings apply only to children with handwriting difficulties (likely ‘‘mild highincidence’’ diagnostic categories). Coded as yellow light for other populations (e.g. Autism spectrum disorder, Down Syndrome) and thus outcomes must be measured with these populations * Daily practice using well-designed worksheets is a user-friendly low-cost method of integrating handwriting teaching and intensive task-specific practice into the classroom

Subjects were diagnosed with handwriting difficulties but no specific diagnoses were provided. Functional category of handwriting difficulties matched the population of students serviced broadly through our school therapy program. Subjects mainly received services through their school intervention programs, similar to our school-aged clinical practice context

Systematic review: AACPDM Scale: Group Level II

Level of evidence

An electronic search was performed in March 2012 of TRIP, McMasterPlus, OTSeeker, ERIC, PubMed and MEDLINE using keywords: child*, students and handwriting intervention. Best evidence: ‘‘A systematic review of interventions to improve handwriting.’’[33]

For elementary-aged students with handwriting difficulties, does regular handwriting practice improve handwriting legibility?

AACPDM, American Academy of Cerebral Palsy and Developmental Medicine; AMSTAR, Assessment of Multiple Systematic Reviews.

Children as young as 14 months can begin to use power wheelchairs. Power mobility experience appears to have a positive impact on overall development and no difference in motor skills was found between participants and controls suggesting no negative impact on motor skill development. In order to prevent or mitigate secondary effects of ineffective mobility on other areas of development (e.g. socialisation, cognition, visual-perceptual and language development), power mobility should be considered a routine intervention for infants and children who do not have the ability to move and explore independently in early childhood

* Small study – lacks power * Developmental change may be underreported in older children because of outcome measure limitations * Low-cost alternatives (e.g. powered ride-on toy cars) or loan/sharing may reduce cost barrier * Another review’s [34] yellow light rating of this RCT, for independent mobility outcomes only, used a less discriminating rating scale for this body of research * Negative impact of lack of mobility supports upgrading strength of recommendation for use with young children

Evidence Appraisal Key Messages

Step 4: Applying Evidence to Practice – Clinical Bottom Line

Subjects closely match our clinical population (cerebral palsy and other complex conditions, cognitive/communication limitations, require alternate access methods, e.g. switches, head-controls). Subjects received services through community earlyintervention programs similar to our clients, who also receive our specialised services on a consultative basis

Clinical Applicability

Green – proven effective

AACPDM Scale: Strong – 6/7

Randomised controlled trial (RCT): AACPDM Scale: Group Level II

Level and quality of evidence

Traffic light code

Quality of evidence

An electronic search was performed in April 2012 of MEDLINE, CINAHL, Embase and Google Scholar using keywords: child*, power* mobility, power* wheelchair and wheelchair/powered. No systematic reviews or guidelines were identified. Best evidence: ‘‘Effects of power wheelchairs on the development and function of young children with severe motor impairments.’’ [32]

Step 2: Search Strategy & Outcome

Level of evidence

In children under three years-of-age with physical disabilities, does a power mobility intervention have a positive impact on overall development?

Step 1: PICO Question

Step 3: Evidence Appraisal

Example 1

Clinical query results

Table 2. Clinical query results for both case examples.


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Table 3. Traffic lighting classification scale. Colour code

Criteria

State of the evidence

a

Group design Level I or II evidence of good quality demonstrating negative outcomes (e.g. absence of change compared to no treatment)

Proven ineffective

Group design Level I or II evidence of poorb quality regardless of outcome Group design Levels III–V evidence of any quality regardless of outcome Single study research design Levels I–V of any quality regardless of outcome Inconclusive results No evidence about the intervention’s effectiveness Group design of either Level I or II evidence, where both studies of the same level of evidence show conflicting results

Insufficient evidence

No evidence Conflicting evidence Proven effective


Group design Level I or II evidence of gooda quality, demonstrating statistically significant positive outcomes

a

Moderate or Strong quality (Group Design AACPDM Conduct Rating Scale2 score of 4–7 or AMSTAR score of 4–11). Weak quality (Group Design AACPDM Conduct Rating Scale2 or AMSTAR score of 1–3).

b

discipline, team or program and Traffic Lighting colour code. Eight evidence syntheses have been created and 79 intervention outcomes have been classified using the Traffic Lighting Classification System since its inception in 2011. As part of program evaluation by the Evidence Centre, web usage statistics were tracked as an indicator of use and utility of the resources. Web usage statistics for the EBP toolkit, knowledge products and resources generated by the case example team members are provided in Figure 3. Note that these data represent compiled internal and external visitors to the web pages, as isolated internal data were not available for the time period presented. Participant feedback from workshops was also obtained to evaluate utility, applicability and presentation of content, as well as to identify areas for improvement. Figure 4 presents average learner ratings for the EBP workshops. Application of the A pRoject Ethics Community Consensus Initiative (ARECCI) Ethics Screening Tool (http://www.aihealthsolutions.ca/arecci/guidelines/) identified minimal potential risk related to reporting of this program evaluation.

Discussion The vast selection of KT theories and models and EBP tools available create a significant challenge for those facilitating EBP in terms of resource selection, consistency of approach, terminology and criteria on which to propose basing clinical reasoning regarding evidence implementation in practice. This paper provides a concrete example of the targeted selection and application of frameworks and models (as illustrated in Table 1) to organise the EBP process, as a means of supporting the knowledge and efficiency needs of clinicians. Practically applying the elements of these frameworks and tools within the resources and flowcharts has made them more accessible to clinicians by implicitly cueing clinicians to consider the important constructs inherent in the frameworks. Examples include the reinforcement of the 6s hierarchy levels by embedding them within specific resources, increasing awareness of different types of evidence (e.g. research, clinical experience and the client perspective) in

the Step 2 flowchart, and prompting the targeting of barriers and facilitators of practice change during planning as per the Knowledge-To-Action Cycle [26]. The many challenges in conducting RCTs in childhood disability research, and often, the paucity of research at this level, necessitate developing specific methods of appraising broader types of evidence and creating recommendations for this field [38]. Decisions to implement practice change need to be based not merely on the most rigorous research, but on the best available evidence, while considering its generalisability and applicability to the intended population and clinical setting [38]. The appraisal tools and classification scheme presented here were developed in response to these challenges. These decisions acknowledge a less robust definition of applicable evidence than might be considered in more thoroughly studied fields; as such, the resources tailored for child development and rehabilitation may be less applicable than those making up the balance of the toolkit. Furthermore, while overall the resources were developed with a broad audience in mind, several resources are specifically tailored for our internal clinicians and will have poor generalisability in other contexts as a result. Supports to facilitate EBP exist at our centre [19]; however, lack of time, and the pressures of large clinical caseloads present challenges to participating in EBP activities. Lessons learned through this initiative to enhance clinician engagement in EBP include: (1) the scheduling of regular EBP work meetings; (2) the use of small group sessions whose format and direction are tailored by knowledge brokers in order to prioritise and address meaningful clinical questions together and (3) the support of a clinical librarian. Web usage statistics presented suggest that the highly accessed resources are useful. Participant feedback and learning outcomes of the EBP learning activities were positive overall. The Traffic Lighting Framework provides a method for facilitating communication, for achieving consensus among stakeholders and for adapting research evidence for application to the local context. Although the Traffic Lighting Database is growing as an important evidence resource to improve efficiency of access to

Online EBP toolkit

Participation

Activity

Functional mobility skills

Social function

Written output – legibility Task-specific handwriting practice at least 2x/week (20–60 minutes) for at least 20 sessions Example 2

Elementary-schoolage children with handwriting difficulties

Activity

Receptive language Children 14–30 months, GMFCS Level IV or V or similar Standard power wheelchair in home and community settings for year Example 1

GMFCS, Gross Motor Function Classification Scale; BDI, Battelle Developmental Inventory; PEDI, Pediatric Evaluation of Disability Inventory; ETCH, Evaluation Tool of Children’s Handwriting; THS, Test of Handwriting Skills; BHK, Concise Assessment Scale for Children’s Handwriting; HHE, Hebrew Handwriting Evaluation; MHA, Minnesota Handwriting Assessment.

Printing like a Pro! download-able resources 1 or more of: ETCH; THS; BHK; HHE; MHA

PEDI April 2012

August 2012

PEDI April 2012

Evidence for practice (E4P) synthesis: early power mobility April 2012 Body function

Outcomes Population Define treatment

ICF component Case example

Table 4. Traffic lighting record for the case examples.

Traffic light code

Date of synthesis


BDI

Outcome measure(s) to use

Knowledge synthesis products

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pre-appraised, synthesised evidence of relevance to clinicians at the centre, its scope is limited by the ongoing resources available to populate it, and pales in size compared to the one established for cerebral palsy interventions in Australia [Iona Novak OT PhD, personal communication, September 29, 2010]; partnerships are being explored to expand the reach of these similar initiatives, although differences in appraisal methodology pose a challenge. While a number of other web-based resources are available to support EBP, some provide critical appraisal tools only (e.g. [39–41]), others provide tools in addition to guidelines or pre-synthesized evidence focused on specific disciplines (e.g. [42–44]) and others focus on evidence summaries specific to particular client populations only (e.g. [45,46]). In contrast, the Evidence Centre initiative was designed to incorporate tools and resources to address all steps of EBP and is applicable to a wide range of clinical disciplines and client groups. In addition, the toolkit provides a more comprehensive approach incorporating different models and theories unlike other initiatives that are based on a single model (e.g. [47]). From a research perspective, questions of value emerging from this initiative include evaluating the reliability of Traffic Lighting appraisals, conducting mixed-methods evaluations of utility and usability of the website and its individual resources with respect to clinicians both internal and external to the organisation, formally evaluating change in EBP competencies and measuring practice change resulting from answering specific clinical queries. Future clinical directions include the ongoing Traffic Lighting of interventions, dissemination of the results of clinical queries and the collaboratively planned implementation of recommendations within the health centre as well as with community partners and clients. Dynamic customisability of the flowcharts has been suggested as a way to reduce their information overload on novice users, and to streamline them for more advanced users who do not require access to introductory information sheets or other specific resources. The development of a formal EBP curriculum incorporating e-learning and more comprehensive interactive workshops for clinicians and leaders are also of priority. While some of the appraisal tools and frameworks were identified because of their applicability to the child development and rehabilitation literature base, overall, the resources and their founding frameworks are based on general theories of KT and EBP that apply to an interprofessional audience. As such, we propose that their utility should be highly transferable to other health centres and individual clinicians engaging in evidence informed health care. Our experiences in implementing the toolkit at our centre using a multi-faceted approach suggest that additional supports may be valued, if not merited, to facilitate its use across programs in a consistent and prevalent manner. Pairing the online resources with facilitation activities, e-learning, group and individual education or other supports, may assist in their application to different contexts, as well as help to identify the need for context-specific modifications to the resources to ensure their relevance. However, these strategies are resource-heavy; our initiative was developed using approximately 0.5 full-time equivalent over more than a year, and entails ongoing online maintenance, resource updates and development, as well as facilitation support by Evidence Centre staff and knowledge brokers. This level of support is not accessible in a majority of health care settings; for this reason, the toolkit has been made freely accessible at http://www.childdevelopment.ca/Evidencecentre.aspx, the power mobility synthesis and associated resources at http://www.sea tingandmobility.ca/WheeledMobility.aspx, and the handwriting resources at http://www.childdevelopment.ca/SchoolAgeTherapy/ SchoolAgeTherapyClassResources.aspx.

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Figure 3. Web usage statistics for online toolkit, knowledge products and resources. *Projected annual estimate based on first six months’ data.

Figure 4. EBP workshop participant evaluation mean scores. 1 ¼ low/poor, 5 ¼ high/ excellent except * where 1 ¼ too elementary, 3 ¼ just right, 5 ¼ too challenging.

Conclusion The EBP toolkit provides highly accessed online tools and supports to assist clinicians in gaining EBP knowledge and skills, in determining the state of the evidence for priority clinical questions, in creating consistently high-quality knowledge syntheses and in implementing evidence into practice using consistent processes. While some of the tools and frameworks were developed specifically for child development and rehabilitation practice, they could be readily applied to practice by other health professionals and clinical populations. By participating in this guided EBP process and utilising the online toolkit, clinicians are better equipped to effectively meet the needs of the children and families they support.

Acknowledgements The authors would like to acknowledge the significant contributions of Alyssa Barrie to the development of the EBP toolkit, the resource development assistance of Monica Lauriente, Mark Dilabio and Evidence Centre staff, the support of Evidence Centre

Coordinator Lori Roxborough, the input on the final manuscript by Dr. Jill Zwicker and the technical assistance provided in relation to this submission by Shannon Smith.

Declaration of interest The first author is employed by the Child Development and Rehabilitation Evidence Centre and co-developed the toolkit described in the article. The authors have no external funding source or sponsor involvement to report.

References 1. Caldwell E, Whitehead M, Fleming J, Moes L. Evidence-based practice in everyday clinical practice: strategies for change in a tertiary occupational therapy department. Aust Occup Ther J 2008; 55:79–84. 2. Dijkers MP, Murphy SL, Krellman J. Evidence-based practice for rehabilitation professionals: concepts and controversies. Arch Phys Med Rehabil 2012;93:S164–76.

Online EBP toolkit


DOI: 10.3109/09638288.2015.1041616

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