PROTOCOLS /
CLINICAL PRACTICE
GUIDELINES
KNR 365
WHAT ARE PROTOCOLS?
Provide link between addressing client
needs & evaluating the effects of service
delivery
 Document the purposeful procedures used
to deliver intervention to clients
 Provide a basis for evaluating the efficacy
of those procedures

WHAT ARE PROTOCOLS?
Major factor in being able to standardize
care & produce predictable client
outcomes
 When researched and validated, may
provide a common basis of TR treatment
procedures used across the country
 “Common practice”

WHAT ARE PROTOCOLS?
Purpose is to provide a defensible and
consistent way of treating or serving client
needs
 Help improve quality of care

PROTOCOLS DEFINED
Connolly & Keogh-Hoss, 1991
 Given a specific diagnostic need or
problem, a particular protocol may be
developed and tested and used with
consistency to lead to a predetermined
outcome that is defined as alleviating or
remediating the diagnostic related need or
problem

PROTOCOLS DEFINED
Stumbo & Peterson, 2009
 “Documents that describe the ‘best
practice’ of specific interventions as
applied to a specific group of clients or
client needs that have been standardized
and result from recent research evidence,
literature reviews, or professional
consensus.” (p. 231)

2 TYPES OF PROTOCOLS
Treatment or intervention (program)
 Diagnostic (client)

 what
Connolly & Keogh-Hoss defined
HOW ARE THESE
DIFFERENT?
Formats in Stumbo & Peterson, 2009

Treatment (intervention or program)
 Based
on 1 area of care
 Stress management, social skills

Diagnostic (or problem based)
 Specific
diagnosis
 TBI, depression, etc.
 Related problem clusters
 Confusion & disorientation
CLINICAL GUIDELINES DEFINED
Stumbo & Peterson, 2009
 “Systematically developed statements to
assist practitioner and patient decisions
about appropriate health care for specific
clinical circumstances.” (p. 231)
 Test that s/b ordered, how long stay in
hospital, etc.

CLINICAL GUIDELINES DEFINED
Hood, 2001
 Term most widely used & accepted in
health-care
 “Distillation of the best collective thinking
from the literature, from practicing
clinicians, from academics on how to treat
a particular medical situation.” (p. 193)

Clinical Practice Guidelines
Richeson, Fitzsimmons, & Buettner in Stumbo, 2009
Evidence-based Guidelines
 Manual of systematic statements
developed to assist practitioners on
selecting appropriate healthcare for
specific situations.
 Summarize & evaluate strength of
evidence related to a healthcare problem
 Make practice recommendations

Clinical Practice Guidelines
Richeson, Fitzsimmons, & Buettner in Stumbo, 2009

Development process includes
 Verifiable,
systematic literature review of
research in peer-reviewed journals
 Must be current
 Revised within last 5 years

Written in way to help practitioners digest
most current research so they can apply
the research to practice
HISTORY OF TR PROTOCOLS

1989 NTRS Protocols in Therapeutic
Recreation
 Sample
protocols
 Efficient tool for quality treatment
 Tool to market TR services & programs
 No info on how to develop or use protocols
HISTORY OF TR PROTOCOLS

1990-1993
 Serious
ATRA Protocol Committee
attempt to collect protocols from
around country to develop library & database
 Goal to have system where TR practitioners
could go to request protocols
 Only a handful of protocols were gathered
 Therapists didn’t know how to write up or use
protocols
HISTORY OF TR PROTOCOLS

1991 Riley edited Quality Management
Applications for Therapeutic Recreation
 ATRA
publication
 Connolly & Keogh-Hoss
 Knight & Johnson
 Provided some direction to protocol
development
HISTORY OF TR PROTOCOLS

1993
ATRA Protocol Committee
 Developed
a 2 year strategy for moving
protocols forward
 5 major diagnostic categories
Substance abuse
 Aging/geriatrics
 Mental health/psychiatry
 Pediatrics
 Rehabilitation

HISTORY OF TR PROTOCOLS
1997 Kelland, Protocols for Recreation
Therapy Programs (Canada)
 1997/98 Hood & Krinsky

 ATRA
Development Committee
 Identify priority needs in alcoholism treatment
 Delphi procedure
 Used experts
HISTORY OF TR PROTOCOLS

Hood & Krinksy cont.
 Findings
Fairly wide range of opinions from a select panel of
experts on needs s/b viewed as priority for TR
intervention
 Underestimate impact of philosophical differences

HISTORY OF TR PROTOCOLS

1999 Personal conversation with Cyn
Carruthers
 Current
work is on alcoholism and depression
 Being tested with varying success
 Legal implications
 Untested protocols s/b called Clinical Practice
Guidelines
HISTORY OF TR PROTOCOLS

2000
Peterson & Stumbo
 Provide
sample formats for treatment and
diagnostic protocols
HISTORY OF TR PROTOCOLS

2001 Hood in Stumbo
 Little
consensus on usefulness of protocols
 Variety of terms
Protocol
 Practice Standards
 Critical Pathways
 Clinical Practice Guidelines

HISTORY OF TR PROTOCOLS

Hood Cont.

What process of development should be followed?
Extensive literature review, panel of experts
 Efficacy research
 In TR little evidence of efficacy of services provided


What kind of information is required for practice
guidelines?
Debate about level of detail & what s/b included
 How make accessible & useable to practioners

HOOD’S CONCERNS
The kinds of problems addressed in TR
tend to be more psychosocial and not as
amenable to standardization as biomedical
needs. (p. 194)
 May be hard to design step-by-step
procedures to address psychosocial
issues or secondary effects of disability (p.
204)

OTHER CONCERNS

2001 Sylvester, Voelkl, & Ellis
 People
may share dx, but have different
beliefs, values, backgrounds, & experiences
 Not consistent with multicultural approach

1 size does not fit all
Other Concerns
Richeson, Fitzsimmons, & Buettner in Stumbo, 2009

Few interventions published for TR

Research evidence from other disciplines
may drive our clinical practice guidelines
 30
pages of reference for TR guideline but
less than 20% TR
 Raises concerns about validity
Clinical Practice Guidelines Today
Richeson, Fitzsimmons, & Buettner in Stumbo, 2009

Dementia Practice Guidelines for Recreational
Therapy: Treatment of Disturbing Behaviors


Wheelchair Biking for the Treatment of
Depression


Buettner & Fitzsimmons, 2003
Fitzsimmons, 2001
Only 2 in National Guideline Clearinghouse
Dementia Practice Guidelines for Recreational
Therapy: Treatment of Disturbing Behaviors

Contains
 Evidence-based
practice explanation
 Complexity of problem
 Models & theories
 Literature review
 Recreation therapy and assessments
 Considerations
 82 RT protocols
Dementia Practice Guidelines for
Recreational Therapy: Treatment of
Disturbing Behaviors

Each protocol
 Ratings
R = shows protocol effective for this behavior
 RU = research is underway to examine the effect
of the protocol
 E = expert opinion feels this protocol is effective
 Blank = no research or expert opinion

 Dementia
stage appropriate for protocol
Clinical Practice Guidelines
Today

Efficacy of Prescribed Therapeutic Recreation
Protocols on Falls and Injuries in Nursing Home
Residents with Dementia


Buettner, 2001
Being developed according to Stumbo &
Peterson, 2009



Effect of animal-assisted therapy on distress in oncology
patients being treated for pain
Therapeutic recreation and the treatment of obesity
Therapeutic recreation and pain management
What’s next?

Stumbo & Peterson, 2004
 “Protocols
are among the most powerful and
the most needed tools in the therapeutic
recreation profession. Only in the last decade
or so have therapeutic recreation specialists
become active in developing protocols for
intervention purposes: a significant amount of
work remains to be done in this area.” (p. 246)