Being an occupational therapy
researcher
and collaborating on the current study:
Lifestyle Matters
OT
Educator's
conference
SHU
18.06.14
1
Aim of this talk
• Picture a career of an OT involved in research
• Look at the many ways and levels OTs can be
involved in research
• Stress that collaboration is vital
• Demonstrate the importance of OT informed
research for our clients and populations
• use the Lifestyle Matters study as an example
2
It starts with
curiosity
As children we all
engage in the
occupation of
research
3
Save the Children Fund programme evaluation:
Community Based Rehabilitation in Zanzibar
4
Improving Anxiety Management Groups
Together with Jan Duffy, Clinical Psychologist
Learning to use a
standardised
outcome measure
DESCRIPTION
• Service evaluation in a Community Mental Health Team. 1990?
• Problems with staffing, timing, poor attendance
Methods:
• Staff discussion groups; standardised symptom questionnaire completed
by clients.
Results:
• As a team we changed things:
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–
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rolling programme of anxiety management courses,
day time and an evening course; and a woman only and a mixed courses
paired inexperienced staff with experienced group leaders
Routinely measured clients' outcomes
5
A study of outcomes of Occupational Therapy in
mental health services
Masters
dissertation
DESCRIPTION
Research Question:
– What outcomes do clients attribute to their experiences of the
therapy process?
– How do these outcomes relate to any goals or expectations?
Methods:
• Qualitative
• researcher’s fore-understandings in generating interpretations
• focussed interviews with 7 former clients of mental health OT
Results
• Intermediate outcomes:
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Engagement in activity
Learning, and regaining confidence in abilities
Achievement of satisfying results
Contribution to other people
Creative expression
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Final outcomes of OT
Intrapersonal Outcomes:
Subjective outcomes:
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Lifting of mood
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Reduction of distress
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Reduction of feeling isolated
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Feeling in control
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Experience of pleasure
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Feeling physically fit and reduction of pain
Increased motivation
Release of emotional pressure
Changes in attitudes and beliefs
Increased self awareness
Improved self value or acceptance
Adaptive Outcomes:
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Acquisition of skills
Acquisition of knowledge
Management of time and routines
Acquisition of coping strategies concerning:
– Altering negative habits of thinking
– Controlling and expressing emotions
– Solving problems
– Coping with disabilities
– Managing anxiety and panic attacks
– Pacing time spent on work, leisure and rest
– Being assertive
Performance outcomes:
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Changed roles
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Improved ways of relating to others
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Functional competence and independence in
the community
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Engagement in productive and creative activities
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Interaction with the local environment and
community
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Trent Region Occupational Therapy Clinical Audit and
Outcomes Project.
a research
job!
DESCRIPTION
• With my job share partner, Penny Spreadbury, Trent Region Head
OTs employed us to stimulate, support and study clinical audits
across the region, in a wide range of OT teams.
Methods:
• Literature searching and putting on a database
• Participant observation,
• Developing tools for outcome measurement,
• Group interviews evaluating the process, thematic analysis
Results:
• Several barriers and enablers were established.
• Individualised goal setting way forward
• Development of a tool: Binary Individualised Outcome Measure.
• Alternative to SOAP notes: ACTOR notes (Activity, Client’s
observations, Therapist’s observations Overall analysis, Replanning.)
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Mental Health Advocacy Group evaluation
DESCRIPTION
Paid
consultancy
work
group of service users had set up their own organisation, commissioned an
evaluation.
Methods: qualitative analysis of:
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Individual interviews, group interviews,
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Observed meetings,
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Evaluation workshop (including a roving microphone).
Results: recommendations on
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policy and implementation for the organisation
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staff roles,
•
clarification of different types of advocacy
9
Primary Mental Health Care Project
DESCRIPTION
a research-practitioner job,
gave me the data for my PhD
Job as a research practitioner in an inner-city GP surgery. About 100 patients
with psychotic conditions, became my PhD study.
Methods:
• 1) Needs Assessment Survey using standardised assessments
• Development of new service
•
2) Case study of the new primary care mental health service
– Single cohort, before and after quasi-experimental study using
standardised assessments
– Qualitative interviews with staff (interviews carried out by a student
OT)
– Survey of patient satisfaction (interviews carried out by service user
interviewers)
– Economic evaluation of costs
10
Dancing for Living
DESCRIPTION.
Worked as a
volunteer
Mental Health Foundation promoting service user led research, What was the
impact of dance on emotional wellbeing, as a health promotion activity,
and what helps people take part.
Methods: Participatory research with members of the public and service user researchers
•
5 Rhythms dance – free classes
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Quantitative survey questionnaire,
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Qualitative diaries, peer-pair interviews, focus groups, and feedback on
draft report
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Dancing for Living
Results
• Themes:
• Specific to the dance group: A safe place; freedom of expression;
structure of the rhythms; power of music; group connections.
• Transformation through dance: moving from being stuck; releasing
powerful feelings; integrating parts of ourselves.
• Effects on day to day living: Part of life now; physical wellbeing;
dancing as a strategy for emotional wellbeing; appreciating music.
• What helps people take part: Out of 19 women, top scores:
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Can go on your own without a partner (18),
Toilet nearby (17)
Friendly and welcoming (16)
Able to express self in own way (16)
No spectators watching (15)
Don’t need special clothes or equipment (14)
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Occupational Therapy for people with psychotic conditions
I won the award
to pay for my
salary and
DESCRIPTION
research costs
• Post doctoral award from the Dept of Health research capacity awards.
• 4 years funding (75% time), a programme of research, + local research
grants, funded a small research team.
• http://www.nihr.ac.uk/Lists/Research%20Training%20Awards/awards_curr
ent.aspx
• Research team:& collaborators: Julie Coleman, Eleni Chambers, Melanie
Hart, Sally Bramley, Nicky Watson, Helen Tompkins, Steve McGrath.
Methods
• Delphi survey, asking OTs to help define the intervention
• Pilot Randomised Controlled Trial & economic evaluation using
standardised outcome measures, in community mental health teams.
• Qualitative study, individual interviews of people with psychotic
conditions, carried out by a service user-researcher, using Framework
analysis.
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Occupational Therapy for people with psychotic conditions
Results:
Intervention schedule for OT for people with psychosis, 11 stages listing 82 actions
(obligatory & optional components).
Pilot RCT showed that:
•
no difference between the intervention and control groups, except
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OT group had more clinical improvement in relationships, independence
performance, independence competence and recreation, and reduced negative
symptoms.
Qualitative study showed that:
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Some non OTs did OT, probably due to inter-disciplinary team working
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Wide range of factors impacted on what people wanted in their daily lives.
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OT was appreciated as focussing on achievement or independence; overcoming
fears; organising time and widening horizons.
•
This was different from having things done for you, or having someone as a
companion or coming along for re-assurance.
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My recent collaboration in large
research studies
Improving Quality and
Effectiveness of Services Therapies
and Self-management on longer
term depression (IQUESTS).
•
•
a literature review and qualitative
study of self-management strategies
used by people with long term
depression and development of a
Guide.
Sarah's contribution:
– co-leading Work Package 2.
– 10 Qualitative interviews and analysis
– helping to write report and article
This study is within the Collaboration and Leadership
in Applied Health Research and Care for South
Yorkshire (CLAHRC-SY). 2010 - 2011.
Rehabilitation Effectiveness and
Activities for Life (REAL):
•
•
a multicentre study of rehabilitation
services and the efficacy of
promoting activities for people with
severe mental health problems.
Sarah's contribution:
– a co-applicant on the bid
– member of the steering group
– developing the intervention for the
cluster randomised trial,
– supervising the therapists
– monitoring fidelity to the intervention.
January 2009 - March 2014.
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Lifestyle Matters:
A large collaborative study involving OTs at every level
Principle investigators:
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Prof. Gail Mountain (University of Sheffield) and Gill Windle (Bangor University)
Research Teams:
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Sarah Cook and Claire Craig (Sheffield Hallam University)
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Bob Woods, Cath Brannan, (Bangor University)
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Kirsty Sprang, Danny Hind, Anju Keetharuth, Lauren O'Hara, Katy Treherne, Maggie
Spencer, Tim Chater, Lauren Powell, Stephen Walters, John Brazier (University of
Sheffield)
Facilitators delivering the intervention:
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Johanna Warren & Samantha Bryan (Sheffield) + OT clinical supervisor
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Elaine Hughes & Jessica Shirley (Bangor) + 2 OT clinical supervisors
Thanks to Prof. Gail Mountain for being an inspiring
research leader, and Clair Craig for her creativity - both
developed and piloted 'Lifestyle Matters' and both are OTs.
Gail produced the following slides.
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The importance of ageing well
Active ageing and prevention of ill health in older
people is a priority for policy makers across Europe
But also…
Beautiful Old Age
It ought to he lovely to be old
To be full of the peace that comes of experience
And wrinkled life fulfilment………….
DH Lawrence
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The Well Elderly study of Lifestyle Redesign
Clark, et al (1997) Occupational Therapy for
independent older living adults: a randomised
controlled trial. Journal of the American Medical
Association, 278, 1321-1326
• Participants experienced benefit; health, function
and quality of life
• Benefit was sustained six months later
• The interventions were cost effective
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Lifestyle Redesign
Would this programme from the USA work with
community living older people in the UK?
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Outputs from the feasibility study
Results used to inform national guidance
alongside well elderly study:
http://guidance.nice.org.uk/PH16
Intervention published
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Lifestyle Matters
Programme Ethos
– A preventive health approach which focuses on the
benefits of activity
– Underpinned by the belief that what we do on a day
to day basis is central to our health and wellbeing
– And that positive changes can only be sustained if
they are embedded within what a person does on a
day to day basis
Programme Delivery
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The older person is the expert
peer support
sharing information and positive coping
rooted in the local community
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Lifestyle Matters:
selecting from a menu of activities
Beginnings: celebration
Activity and health
The ageing process and activity
Personal energy, time and activity
Goals; realising hopes and wishes
Pulling things together – how is activity related
to health
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Lifestyle Matters:
Ideas continued…
Maintaining mental wellbeing
Sleep as an activity
Keeping mentally active
Memory
Maintaining physical wellbeing
Nutrition
Pain
Keeping physically active
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Lifestyle Matters:
More ideas…..
Occupation in the home and community
• Transportation
• Opportunities for new learning
• Experiencing new technologies
Safety in and around the home
• Keeping safe in the community
• Keeping safe in the home
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Lifestyle Matters:
yet more…..
Personal circumstances
• Dealing with finance
• Social relationships and maintaining
friendships
• Dining as an activity
• Interests and pastimes
• Caring for others, caring for self
• Spirituality
Endings
Ideas for group outings and further
activities; some examples
• T’ai chi
• Exploring community resources – yoga,
relaxation courses at community colleges
• Aromatherapy, hand massage
• Outing to a spa or leisure centre
• Problem solving techniques –
assertiveness, saying no
• Individual sessions
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Lifestyle Matters trial
• A pragmatic, two-arm, parallel group,
individually randomised controlled trial in two
study sites funded by LLHWB (6)
• Included an evaluation of clinical and cost
effectiveness of the intervention (Lifestyle
Matters) and a process evaluation (fidelity
checks and qualitative interviews)
• Is examining the long term benefits of the
intervention through a 2 year follow up
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Intervention delivery & participants
Target reached: 270 randomised
participants
16 weekly meetings (11 groups ran)
Monthly 1:1 sessions to pursue
individual goals
Groups supported by 2 trained
facilitators (Band 4 NHS Equivalent)
Attended by 8-16 individuals
Central, accessible venues with
appropriate facilities
Activities and outings designed to
help people achieve or maintain a
happy, healthy and fulfilling later life
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Outcome measures
For all participants, at baseline (after cognitive screening, 6 months after
randomisation and once more two years later
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Mental health dimension of the SF36 (primary)
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Other dimensions of the SF-36 to measure all aspects of health including physical health;
EQ-5D (for health economic analysis (Brazier et al, 2007);
The Brief Resilience Scale (Smith et al, 2008);
General Perceived Self Efficacy (GSE) Scale (Schwarzer & Jerusalem, 1995);
Patient Health Questionnaire to determine extent of depressive symptomology (PHQ-9)
(Spitzer et al, 1995);
de Jong Gierveld loneliness scale (de Jong, 1985);
An adapted Client Services Receipt Inventory (CSRI) to collect participants’ use of health,
social care and community services for health economic analysis;
A simple socio-demographic questionnaire constructed for the purposes of the study
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•
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No measure of participation!
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Fidelity assessment
Showed that on the whole fidelity to the intervention was good
Goal
Standardised training
Fidelity
 Participant observation of 2 day training, using content
checklist
Facilitator skill
acquisition
 Monitoring of attendance and delivery numbers
 Audit of records
Standardised delivery  Observation of a purposive sample of video recorded
Minimise drift in
skills/ delivery
weekly sessions using a content checklist
 Participant and facilitator semi-structured interviews
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Fidelity assessment &
process evaluation
• Qualitative interviews and Framework data analysis
– Interviewed all 4 facilitators, 2 time points
– Interviewed all 3 OT supervisors post intervention
– Interviewed 13 participants (10% purposive sample) post
intervention
• Participants from 6 groups across all 3 cycles
• Both sites (Sheffield n=7, Bangor n=6)
• Selection criteria included age, sex, geographical area, attendance as
individual or part of a couple, education, previous occupation, level of
current activity, number of sessions attended
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Emergent results from process
evaluation (participants)
Most of those interviewed indicated that with the support of
the group and the facilitators they had found the impetus to
pursue one or more activities or interests since taking part in
the programme
I think what we’re going to do now, [wife] and I have decided
that on Thursdays it should be an activity day for us…Erm but
we’ve said, ‘OK, Thursday, we’ve enjoyed it so much, why
don’t we go out and make Thursday an activity day’. We’ve
nothing else to worry about, we’ve no dependents as such, we
can go, go out any day, but Thursday ‘cause we’ve got into a
routine, ‘yeah, let’s go and try so-and-so.
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Emergent results from process
evaluation (10% of participants)
• Main reasons for not attending were illness or being ‘too
busy’ but non attendance was also viewed negatively
• Initial concerns over male/ female mix
"I remember when I went in there that first day and, oh
god, I was the only bloke there and I thought, what the
hell have I let myself in for here? And when I was going,
the last one [group meeting], I was quite, I was quite sad
that it was over with, you know, because the group had
joined in…as a gel, yeah, you know.
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Emergent results from process
evaluation (participants)
Challenges were posed by transport and the climate;
Shall we go, shan’t we go because of the snow and one
thing and another, which again was unfortunate...when
er, you know, we had two out of the, three out of the
sixteen weeks...where I couldn’t go, er, and I mean I only
live a couple of hundred yards away”.
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Emergent results from process
evaluation (facilitators)
• Over time, the facilitators did not change attitudes and understanding
but did develop and improve their skills and confidence
• Rather than the facilitators instructing and directing, they encouraged
the group to make decisions and enabled people to contribute and for
some, to take leadership.
• Group dynamics were very important. Group facilitation needed to
include subtle and nuanced responses to complex relationships and
behaviour including conflict. This enabled trust and respect for
difference, expression of feelings and knowledge, and for the group to
gel.
• Older people shared and developed coping strategies for managing the
challenges of ageing. This included increased assertiveness at home
and with GPs, balancing occupations and routines, and finding new
ways to be active.
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Emergent results from process
evaluation (facilitators)
• The programme provided opportunities to try out new activities and
community facilities, which led to changes in routines and behaviour
• There was little evidence of the older people taking over and continuing
the organisation of the whole group by the end of the programme
• People built new friendships which they planned to continue after the
programme, and do activities together.
• It may have needed longer than 16 weeks, and a gradual withdrawal of
facilitation, for groups to take over running themselves
• Facilitators found it challenging to engage people in the 1:1 sessions which
were initially seen as optional
• The clinical supervision was much appreciated, but in future supervisors
should have experienced delivering the programme themselves.
• Recruitment challenges – how to reach those in most need? Some people
took part to help the researchers, not because they were isolated or
inactive. But they did say they benefited from the programme.
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What have we learnt??
•No definitive trial results due to 2 year follow up –
interim analysis not allowed
•From the feasibility study to the major trial
– Methodological contribution - evaluation of complex, group
based interventions
– Have we measured the right dimensions? – would have liked
a measure of participation
– Need to target recruitment to those most in need
– Need to establish 1:1 sessions as essential.
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Future Research and You
• Two feasibility studies have been started: Lifestyle Matters for
older people with dementia, and for older people with
depression.
• Could Lifestyle Matters be modified for other client groups in
your settings?
• and with other age groups?
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How can you see yourself as an occupational
therapist contributing to research?
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•
•
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Evidence based practice - implementation in routine services
Funding bids need clinical expertise
Development of new or modified OT interventions
Delivery and supervision of new interventions being
researched
Fidelity checking (to monitor adherence to the intervention)
Research steering or management group
Member of a research team collecting and analysing data.
MSc or PhD study to learn research skills
• and if this is not for you, SUPPORT your
colleagues and students to get involved.
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Thank you!
42
References
1. Clark F, Azen S, Zemke R, Jackson J, Carlson M, Mandel D: Occupational Therapy for Independent-Living Older Adults. Journal of the
American Medical Association 1997, 278(16):1321-1326.
2. Clark F, Azen S, Carlson M, Mandel D, LaBree L, Hay J: Embedding Health-Promoting Changes Into the Daily Lives of Independent-Living
Older Adults: Long-Term Follow-Up of Occupational Therapy Intervention. Journal of Gerontology: Series B Psychological Sciences 2001,
56(1):60-63.
3. Hay J, LaBree L, Luo R, Clark F, Carlson M, Mandel D: Cost-Effectiveness of Preventive Occupational Therapy for Independent-Living
Older Adults. Journal of the American Geriatrics Society 2002, 50(8):1381-1388.
4. Clark F, Jackson J, Carlson M, Chou C, Cherry B, Jordan-Marsh M, Knight B, Mandel D, Blanchard J, Granger D et al: Effectiveness of a
lifestyle intervention in promoting the well-being of independently living older people: results of the Well Elderly 2 Randomised
Controlled Trial. Journal of Epidemiology & Community Health 2011.
5. National Institute for Health and Care Excellence (NICE): Guidance on occupational therapy and physical activity interventions that
promote good health and wellbeing in older people. In. London: National Institute for Health and Care Excellence; 2008.
6. Sprange, K. Mountain, GA. Brazier J. Cook, SP. Craig, C. Hind, D. Walters, SJ. Windle, G. Woods, R. Keetharuth, AD. Chater, T. Horner, K.
(2013) Lifestyle Matters for maintenance of health and wellbeing in people aged 65 years and over: study protocol for a randomised
controlled trial. Trials 14:302
7. Bellg A, Borrelli B, Resnick B, Hecht J, Minicucci D, Ory M, al. e: Enhancing treatment fidelity in health behavior change studies: best
practices and recommendations from the NIH Behavior Change Consortium. Health Psychology 2004, 23(5):443-451
8. National Institute for Health and Care Excellence (NICE): Public Guidance 6: Behaviour change at population, community and individual
levels. In.: London: National Institute for Health and Care Excellence; 2007.
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