Clinical questions asked and pursued

by rehabilitation therapistsAn exploratory study of information needs

Lorie KlodaMLIS, PhD candidate

School of Information StudiesJune 8, 2012Oral Defense

2

Outline

BackgroundResearch questions

MethodsFindings

ConclusionsLimitations

ContributionsFuture research

Research objective

3

4

Research objective

To explore the clinical questions of rehabilitation therapists

in the context of their everyday practice

5

Background

Information needs of this group not known

Difficulty formulating clinical questions

Research not transferred into practice

6

Information behaviour

(Wilson, 1997, p. 569)

7

Information behaviour

Information need

Person-in-context

Enablers/obstaclesInformation

seeking

Information processing and use

8

Information behaviour

Information need

Person-in-context

Enablers/obstaclesInformation

seeking

Information processing and use

9

Evidence-based practice

10

Evidence-based practice

11

Clinical question

A formalized information need related to the care of a patient.

From Taylor’s (1968) typology of information needs or questions:

Q1. Visceral need

Q2. Conscious need

Q3. Formalized need

Q4. Compromised need

12

PICO Problem/Person

InterventionComparisonOutcome

(Richardson, Wilson, Nishikawa, & Hayward, 1995)

PESICO PersonEnvironmentStakeholdersInterventionComparisonOutcome

(Schlosser, Koul, & Costello, 2007)

PICO + Problem/PersonClient’s settingClient’s valuesInterventionComparisonOutcome

(Bennett & Bennett, 2000)

Clinical question structure

13

PICO Problem/Person

InterventionComparisonOutcome

(Richardson, Wilson, Nishikawa, & Hayward, 1995)

In adults with sinusitis, does a 3-day course of antibiotics work as well as a 10-day course, with

fewer adverse effects?

Clinical question structure

14

Research questions

1

2

15

Research questions

What clinical questionsdo rehabilitation therapists ask?1

2

16

Research questions

What clinical questionsdo rehabilitation therapists ask?1a Types 1b Formulation

1

2

17

Research questions

What clinical questionsdo rehabilitation therapists ask?

How do rehabilitation therapists choose which clinical questions to pursue?

1

2

18

Rehabilitation therapist

A certified professional whose aim is to improve the functional independence of individuals with

physical or cognitive disabilities.

Physiotherapist (PT) Occupational therapist (OT) Speech-language pathologist (SLP)

19

Methods

20

Recruitment & data gathering

Interviews Clinical questions

Occupational therapists 4 26Physiotherapists 4 44

Speech-language pathologists 7 59__________ ________

15 129

21

Clinical question foci

Treatment selection 33%

Clinical manifestations of disease 17%

Prognosis 13%

Assessment tool selection 9%

Terminology 9%

Treatment procedures 9%

Etiology 5%

Practice-related self-improvement 4%

Assessment tool procedures 3%

Patient or family’s experiences and concerns 2%

Anatomy, physiology, and pathophysiology 2%

Epidemiology 1%

22

Clinical question foci

Treatment selection 33%

Clinical manifestations of disease 17%

Prognosis 13%

Assessment tool selection 9%

Terminology 9%

Treatment procedures 9%

Etiology 5%

Practice-related self-improvement 4%

Assessment tool procedures 3%

Patient or family’s experiences and concerns 2%

Anatomy, physiology, and pathophysiology 2%

Epidemiology 1%

63%

23

Treatment selection

Are compensatory strategies designed to maximize airway protection during the swallow

efficacious in reducing silent aspiration?

SLP3

“

”

24

Clinical manifestations of disease

What are the signs/symptoms of lateral medullary infarct/syndrome?

PT2

“

”

25

Prognosis

What is the prognosis for recovery in frontal cerebrovascular accidents

(compared to other types)?

PT4

“

”

26

Structural elements

Is there a role for interval training with gait re-education

post-cerebrovascular accident?

intervention

populationproblem

27

Clinical question structure

Problem 69%

Intervention 41%

Population 39%

Outcome measure 11%

Temporality 7%

Context 5%

Professional stakeholder 3%

Patient or family stakeholder 1%

28

Clinical question structure

Problem 69%

Intervention 41%

Population 39%

Outcome measure 11%

Temporality 7%

Context 5%

Professional stakeholder 3%

Patient or family stakeholder 1%

29

30

31

Why pursue clinical questions?

MemoryBelief in existence of an answer

Use of answerFeeling of responsibility

Effort requiredSelf-efficacy

Organizational support

32

Conclusions

1

2

33

Conclusions

What clinical questionsdo rehabilitation therapists ask?1a Types 1b Formulation

1

2

34

Conclusions

Therapists’ clinical questions can be characterized by 1 of 12 foci, formulated

with 8 possible structural elements1

2

35

Conclusions

How do rehabilitation therapists choose which clinical questions to pursue?

1

2

36

Conclusions

7 themes explain why therapists choose to pursue some clinical questions while

leaving others unanswered

1

2

37

Limitations

No direct observation

Recall

Not exhaustive

38

Contributions

Theoretical Contributions

• Builds on existing models of information behaviour• Supports Wilson’s (1997) revised model of

information behaviour• Links research on clinical questions to Taylor’s

definition of information needs• Adds to knowledge on the information behaviour of

health professionals• Suggests improvements to evidence-based practice

framework in rehabilitation

39

Contributions

Practical Contributions

Reference interviewInformation literacy instructionDatabase selection and design

Health sciences curricular designOrganizational support

40

Future research

Information behaviour of stroke therapists

Clinical question analysis

Information needs in allied health

41

Acknowledgements

Dissertation committeeJoan Bartlett (chair), France Bouthillier,

Nicol Korner-Bitensky, Andrew Large & Pierre Pluye

Funding Thomson Scientific / MLA Doctoral Fellowship

Fonds québecois de la recherche sur la société et la culture

Canadian Library Association World Book Scholarship

Study informants

42

Selected publications & talks

Kloda, L. A., & Bartlett, J. C. (2012). Characterizing clinical questions of occupational therapists, physical therapists, and speech-language pathologists. Medical Library Association Annual Meeting, Seattle, WA, May 18-23, 2012.

Kloda, L. A., & Bartlett, J. C. (2010). From uncertainty to answerable questions: Question negotiation in evidence-based practice. Canadian Health Libraries Association (CHLA) Annual Conference, Kingston, ON, June 7-11, 2010.

Kloda, L. A. & Bartlett, J. C. (2009). Clinical information behavior of rehabilitation therapists: A review of the research. Journal of the Medical Library Association, 97(3), 194-202.

Kloda, L. Rehabilitation therapists’ clinical questions in the context of evidence-based patient care: An exploratory study. (2009). Canadian Association for Information Science (CAIS) 37th Annual Conference, Carlton University, Ottawa, ON, May 28-30, 2009.

Kloda, L. A. & Bartlett, J. C. Rehabilitation therapists’ clinical questions (poster). (2009) American Society for Information Science & Technology (ASIS&T) Annual Meeting, Vancouver, BC, November 6-11, 2009.

Kloda, L. A. (2008). Exploring rehabilitation therapists’ clinical questions for evidence based patient care. Information Research, 13(4), paper wks07.

Supplemental Slides

44

Figure 2-1: Wilson’s revised general model of information behaviour

(Wilson, 1997, p. 569, Figure 5)

45

Table 2-2: Information behaviour investigated in research on therapists

46

Table 2-4: Comparison of question formulation structures

47

Table 2-5: Question types in medicine and rehabilitation

a(Adapted from Straus et al., 2011, p. 18); b(Adapted from Bennett & Bennett, 2000, p. 174)

48

Table 3-2: Characteristics of informants

49

Figure 3-1: Coding clinical questions for structural elements

50

Table 4-1: Clinical questions gathered

51

Figure 4-1: Clinical questions pursued and answered

52

Table 4-2: Foci of clinical questions

53

Table 4-3: Structural elements identified

54

55

Memory

“I forget about it. Time goes and I have other projects and there’s other patients and because it’s busy, I just tend to drop this as the first thing to do.” (OT2)

“Honestly, time and I forget, you know.” (PT4)

56

Belief or doubt in existence of an answer

”Well I, you know, I have great faith that every time I go to research something that there’s just so much information that I know that there is unbelievable amounts of information. I have faith that I will be able to answer, that I will find the information. But it’s not easy, you know.” (SLP2)

“I don't think that's likely to be answerable because it's a combination of things and usually that’s exclusion criteria in all the studies.” (PT1)

57

Intended use of the answer

Advance professional knowledge or understanding

“There will probably be information about what they're doing, but I think it wouldn't vary much differently from what I'm already doing. So it might give me a few new ideas, but I don't think it would really change my practice all that much.” (PT3)

58

Intended use of the answer

Establish Authority

”It would have helped. In this case, it would have helped because there was a discrepancy between what we were saying and what the family was saying.” (SLP4)

59

Intended use of the answer

Decision making

Impact on patient wellbeing

Impact on future patients

60

Feeling of responsibility

“At least, once I wrote it down. I’d better look for the answers.” (SLP1)

“I think it’s going to be really depressing because I’m not going to have time to answer it.” (OT2)

” really should look that up.” (SLP5)

”I’m notoriously... Bad bad therapist.” (OT4)

61

Effort required to find an answer

“… you have to wade through a lot of stuff.” (SLP2)

“It’s unlikely that this is the type of question I would invest time in trying to track down an answer to, especially because it’s to the extent an answer exists, it’s likely to be in books or journals or whatever that I am not familiar with so it would be extra work for me to find it.” (SLP3)

62

Self-efficacy

“That’s part of the problem because to me looking at the literature sounds like a big mountain. I don’t really know what to do although I kind of, you know, I had to do it in university but I kind of forgot. I remember the Medline and whatever but like today, if I have to go, I would be like what am I supposed to do? Where do I start? So it’s not like a fast thing because I’m not used to do it. It’s part of the problem. If it was fast, like if I knew exactly where to go and whatever, I would probably do it maybe a little bit more.” (PT4)

63

Perceived organizational support

For locating evidence– Librarian– Resources (databases)– Computer access, internet access

For implementing evidence

64

Table 5-1: Comparison of question formulation structures revisited

65

Figure 5-1: Factors influencing therapists’ decision to pursue clinical questions

66

67

Sample coding for interview transcript

68

69