Clinical questions asked and pursued by rehabilitation therapists: An exploratory study of information needs
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Doctoral Defense, McGill University, June 8, 2012
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Clinical questions asked and pursued by rehabilitation therapists: An exploratory study of information needs
- 1. Clinical questions asked and pursued by rehabilitation therapists An exploratory study of information needs Lorie Kloda MLIS, PhD candidate School of Information Studies June 8, 2012 Oral Defense
- 2. Outline Background Research questions Methods Findings Conclusions Limitations Contributions Future research 1
- 3. Research objective 2
- 4. Research objective To explore the clinical questions of rehabilitation therapists in the context of their everyday practice 3
- 5. Background Information needs of this group not known Difficulty formulating clinical questions Research not transferred into practice 4
- 6. Information behaviour 5 (Wilson, 1997, p. 569)
- 7. Information behaviour Information Information need Enablers/obstacles seeking Person-in-context Information processing and use 6
- 8. Information behaviour Information Information need Enablers/obstacles seeking Person-in-context Information processing and use 7
- 9. Evidence-based practice Formulating Evaluating the the Process Question Searching Applying the the Results Evidence Appraising the Evidence 8
- 10. Evidence-based practice Formulating Evaluating the the Process Question Searching Applying the the Results Evidence Appraising the Evidence 9
- 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 10
- 12. Clinical question structure PICO PESICO PICO + Problem/Person Person Problem/Person Environment Client’s setting Stakeholders Client’s values Intervention Intervention Intervention Comparison Comparison Comparison Outcome Outcome Outcome (Richardson, Wilson, (Schlosser, Koul, & (Bennett & Bennett, Nishikawa, & Hayward, Costello, 2007) 2000) 1995) 11
- 13. Clinical question structure PICO Problem/Person In adults with sinusitis, does a 3-day course of antibiotics work Intervention as well as a 10-day course, with Comparison feweradverse effects? Outcome (Richardson, Wilson, Nishikawa, & Hayward, 1995) 12
- 14. Research questions 1 2 13
- 15. Research questions What clinical questions do rehabilitation therapists ask? 2 14
- 16. Research questions What clinical questions do rehabilitation therapists ask? 1a Types 1b Formulation 2 15
- 17. Research questions What clinical questions do rehabilitation therapists ask? How do rehabilitation therapists choose which clinical questions to pursue? 16
- 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) 17
- 19. Methods deductive RQ 1a diaries 12 foci thematic analysis deductive 8 structural RQ 1b diaries thematic analysis elements inductive themes explaining RQ 2 interviews why questions thematic analysis were pursued 18
- 20. Recruitment & data gathering Interviews Clinical questions Occupational therapists 4 26 Physiotherapists 4 44 Speech-language pathologists 7 59 __________ ________ 15 129 19
- 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% 20
- 22. Clinical question foci Treatment selection 33% Clinical manifestations of disease 17% 63% 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% 21
- 23. Treatment selection “ Are compensatory strategies designed to maximize airway protection during the swallow efficacious in reducing silent aspiration? ” SLP3 22
- 24. Clinical manifestations of disease “What are the signs/symptoms of lateral medullary infarct/syndrome? ” PT2 23
- 25. Prognosis “ is the prognosis for recovery in What frontal cerebrovascular accidents (compared to other types)? ” PT4 24
- 26. Structural elements intervention Is there a role for interval training with gait re-education post-cerebrovascular accident? problem population 25
- 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% 26
- 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% 27
- 29. 28
- 30. 29
- 31. Why pursue clinical questions? Memory Belief in existence of an answer Use of answer Feeling of responsibility Effort required Self-efficacy Organizational support 30
- 32. Conclusions 1 2 31
- 33. Conclusions What clinical questions do rehabilitation therapists ask? 1a Types 1b Formulation 2 32
- 34. Conclusions Therapists’ clinical questions can be characterized by 1 of 12 foci, formulated with 8 possible structural elements 2 33
- 35. Conclusions How do rehabilitation therapists choose which clinical questions to pursue? 34
- 36. Conclusions 7 themes explain why therapists choose to pursue some clinical questions while leaving others unanswered 35
- 37. Limitations No direct observation Recall Not exhaustive 36
- 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 37
- 39. Contributions Practical Contributions Reference interview Information literacy instruction Database selection and design Health sciences curricular design Organizational support 38
- 40. Future research Information behaviour of stroke therapists Clinical question analysis Information needs in allied health 39
- 41. Acknowledgements Dissertation committee Joan Bartlett (chair), France Bouthillier, NicolKorner-Bitensky, Andrew Large & Pierre Pluye Funding Thomson Scientific / MLA Doctoral Fellowship Fondsquébecois de la recherchesur la société et la culture Canadian Library Association World Book Scholarship Study informants 40
- 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. 41
- 44. Figure 2-1: Wilson’s revised general model of information behaviour (Wilson, 1997, p. 569, Figure 5) 43
- 45. Table 2-2: Information behaviour investigated in research on therapists 44
- 46. Table 2-4: Comparison of question formulation structures 45
- 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) 46
- 48. Table 3-2: Characteristics of informants 47
- 49. Figure 3-1: Coding clinical questions for structural elements 48
- 50. Table 4-1: Clinical questions gathered 49
- 51. Figure 4-1: Clinical questions pursued and answered 129 Total clinical questions 92 37 Data gathered re: No data gathered pursued/answered 43 49 Pursued Not pursued 28 15 Answered Not answered 50
- 52. Table 4-2: Foci of clinical questions 51
- 53. Table 4-3: Structural elements identified 52
- 54. 53
- 55. “forget about it. Time goes and I I have other projects and there’s other Memory 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) 54
- 56. ”Well I, you know, I have great faith that every time I go to research something that there’s just so much Belief or doubt in information that I know that there is existence of an unbelievable amounts of information. I answer have faith that I will be able to answer, that I will find the information. But it’s not easy, you know.” (SLP2) “don't think that's likely to be I answerable because it's a combination of things and usually that’s exclusion criteria in all the studies.”(PT1) 55
- 57. 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 Intended use of the me a few new ideas, but I don't think it answer would really change my practice all that much.”(PT3) 56
- 58. 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) Intended use of the answer 57
- 59. Decision making Impact on patient wellbeing Impact on future patients Intended use of the answer 58
- 60. “At least, once I wrote it down. I’d better look for the answers.” (SLP1) “think it’s going to be really I depressing because I’m not going to have time to answer it.” (OT2) really should look that up.”(SLP5) ” ”I’m notoriously... Bad bad Feeling of therapist.”(OT4) responsibility 59
- 61. “… have to wade through a lot of you stuff.”(SLP2) “ unlikely that this is the type of It’s 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) Effort required to find an answer 60
- 62. “ That’s part of the problem because to me looking at the literature sounds like Self-efficacy 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) 61
- 63. For locating evidence – Librarian – Resources (databases) Perceived – Computer access, internet access organizational support For implementing evidence 62
- 64. Table 5-1: Comparison of question formulation structures revisited 63
- 65. Figure 5-1: Factors influencing therapists’ decision to pursue clinical questions 64
- 66. 65
- 67. Sample coding for interview transcript 66
- 68. 67
- 69. 68
Notes de l'éditeur
- The title of my dissertation is Clinical questions asked and pursued by rehabilitation therapists: An exploratory study of information needs
- Here is a brief overview of the structure of my talk.
- My motivation for this research originated from my experience as a health sciences librarian. In my role as an instructor in literature searching for clinicians and students in the health professions, I realized that using artificial questions to guide online searching exercises was not a very productive teaching strategy. In my quest to use students’ and clinicians’ real questions, I encountered a lot of difficulty finding literature in the area of rehabilitation, and noticed that students struggled to conform to the strict question formulations we were teaching them to use.
- So, the objective of this dissertation was to explore the clinical questions of rehabilitation therapists in the context of their everyday practice.
- The literature in this area is rather sparse on the information needs. That is, there are no studies that report on rehabilitation therapists’ clinical questions. Though research does exist on the information needs of other health professionals, such as physicians and nurses.Research has suggested that rehab therapists struggle in formulating their clinical questions, something I remarked on as a librarian as well.Interestingly, in the rehabilitation sciences, and in stroke rehab in particular, there is a lot of research to draw on, yet it has been demonstrated that this research, or evidence, is often not used by therapists. In other words, there is high quality information out there, but clinicians are not implementing it into their decision-making as part of their everyday practice.
- This research is a study in the field of information behaviour, which is “the study of how people need, seek, give, and use information in different contexts, including the workplace and everyday living.” [Pettigrew et al, 2001]This here is Tom Wilson’s revised model of information behaviour, a widely referenced model used to DESCRIBE the process of information behaviour. And I’ve highlighted the relevant components….
- Information behaviour begins with a person in a specific context. That person become aware of their own information need, and then may decide to pursue that need OR NOT, and engage in information seeking. Once they have obtained information, the person may then use the information.
- This dissertation focuses on the recognition and formulation of info needs and the transition to info seeking (or not)
- Another important framework is that of evidence-based practice. EBP is a movement in health care which advocates for the use of evidence – or information in the form of scientific research – to inform health care decisions, and ultimately, patient care.EBP offers a PRESCRPTIVE model for how health professionals should formulate their information needs, search for information, and use that information. It’s steps parallel those of the information behaviour process. Yet, it tells people how they should behave with respect to each of these steps.
- Again, this dissertation is concerned with the first step, and the transition to the 2nd step.
- The term clinical question is a term often used in EBP. For this study, a clinical question is defined as a formalized information need relating to patient care. This definition draws from Robert Taylor’s description of information needs, or questions in his seminal paper on question negotiation in the context of reference interview, in which he described the different levels of questions.Taylor conceptualized the information need as starting with an unconscious sense of unease before being recognized by the individual. At some point, a person may choose to state their information need, either in writing or out loud. At that stage, it is considered formalized. In some cases, the person may go so far as to compromise the information need, by simplifying it or shortening it, when sharing it with someone else. For example, when sharing it with a librarian, or typing in search terms into a search engine.A clinical question, therefore, is a need that has been formalized linguistically, but not yet compromised.It does not necessarily need to be conceivably answered by published information, and in fact it doesn’t necessarily have to have an answer.
- EBP prescribes that clinical questions be formulated using a specific set of elements. This structure was and continues to be promoted as a guide to health professionals and students to ensure their questions are answerable, and lead to information seeking. A structure for clinical questions was proposed …. was composed of 3-4 elements: problem/person, intervention, an optional comparison intervention, and an outcome. This structure is known by its acronym, PICO. Other, alternative questions formulation structures have been proposed in the literature, and a couple are provided here. Yet PICO remains the dominant structure in publications and in teaching to date, including in the field of rehabilitation.
- EBP prescribes that clinical questions be formulated using a specific set of elements. This structure was and continues to be promoted as a guide to health professionals and students to ensure their questions are answerable, and lead to information seeking. A structure for clinical questions was proposed …. was composed of 3-4 elements: problem/person, intervention, an optional comparison intervention, and an outcome. This structure is known by its acronym, PICO. Other, alternative questions formulation structures have been proposed in the literature, and a couple are provided here. Yet PICO remains the dominant structure in publications and in teaching to date, including in the field of rehabilitation.
- There are two overarching questions guiding this study.
- The first research question was broken down into two narrow, sub-questions:
- A) What typesof questions do rehabilitation therapists ask?B) How do rehab therapists formulate their clinical questions?
- The population of interestin this study, includes PTs,OTs, and SLPs.This study was restricted to rehab therapists working in the context of stroke rehabilitation
- I conducted this research using an Interpretive, social constructivist approach. This entailed the careful selection of the sample, and the gathering and analysis of qualitative data resulting in categories or “themes”, which can then potentially be transferred to other settings.Therapists first recorded their questions in a diary over several weeks. This was followed by an interview in which I elicited more details about their questions, as well as their reasons for pursuing answers to questions.I conducted thematic analysis to uncover, a typology of 12 possible foci of clinical questions, 8 structural elements present in their questions, and themes explaining why some questions were pursued while other were left unanswered.
- Using purposive, snowball sampling, with the goal of maximum variation, I recruited 15 informants from different institutions includingacute medicine, and rehab hospitals, in/out-patients, with a range years of experience working with patients with stroke.Each informant was interviewed, for a total of 15 interviews, and, in total, 129 clinical questions were gathered for an average of 8-9 CQs per informant. (range 1-17)I will now present the findings.
- Each clinical question was categorized as having a focus (the plural of which of which is foci). Here is a typology of the 12 different foci identified in the set of 129 clinical questions.Most questions had a focus on treatment selection, clinical manifestations of disease, or prognosis…
- These 3 made up almost 2/3rds of the clinical questions gathered.
- These questions asked about available or best treatments, or about the effectiveness of one treatment compared to another.
- Questions with this focus were about understanding of diseases and disorders, including signs, symptoms, and clinical course. These questions asked about information to help the therapist understand what they were observing or to predict what they could expect to see in patients with a particular condition.”
- Prognosis questions were concerned with patient improvement.
- To investigate how rehab therapists formulate their clinical questions, I analyzed each question for the presence of structural elements. Here is an example:This is a question from a physiotherapist on treatment selection.(read question) (build elements)
- Here are the findings for the analysis of the structural elements in clinical questions.8 elements were identified in the set of clinical questions.Most clinical questions contained one or two structural elements:[30% included only 1 elementAlmost half included 2 elements]
- When there were 2 or more elements, these tended to be a combination of PROBLEM & INTERVENTION, or PROBLEM & POPULATIONIn the PICO question formulation structure, there is no distinction made between the elements Problem and Population (they are combined in the “P” in PICO), whereas these findings suggests these 2 elements are distinct.
- None of the clinical question structures previously proposed in the literature matches the 8 elements identified in this study.However, all of the elements have been proposed, or are similar to elements proposed in the EBP literature.
- PICO, however, does not come close to characterizing the structure of rehabilitation therapists’ clinical questions, even though it is the dominant structure recommended. It is insufficient for describing the variety of elements that can be found.
- Several themes emerged from the interviews to explain a therapist’s decision to pursue an answer to a clinical question: First, a therapist has to remember the question, since they don’t always seek information immediately. Also, the must believe that an answer may exist. If they don’t think a question has an answer, they definitely won’t spend time trying to find one. The potential use of the answer as well as their feeling of responsibility also influence the decision. Other factors include the amount of effort required to get an answer, including time as well as the therapist’s perceived self efficacy, or their perception of their capability to locate an answer. Finally, the perception support from the organization for information seeking is also a factor. This support can take several forms, including, for example, the availability of a librarian.These themes confirm Wilson’s model of information behaviour, in which he proposed that activating mechanisms and intervening variables influence whether or not information seeking takes place.
- To revisit the study’s research questions
- For the first research question…
- This presents an alternative, more comprehensive framework to describe Rehab therapists’ clinical questions.
- The themes that were uncovered elaborate on Wilson’s model of IB, by specifying the obstacles or enablers between the recognition of information needs, and information seeking..
- Some of the limitations of this study were:- there was no direct observation, as information needs are not observable behaviour. - As a result, there may have been problems with informants’ recall. However, studies have indicated the effectiveness of using diaries to mitigate recall bias.- These findings are not meant to be an exhaustive representation of all possibilities arising in stroke rehabilitation.
- This dissertation makes several theoretical contributions:The research findings from this study build on existing models of IB by highlighting the process that takes place in between the recognition of an information need and information seeking.The findings therefore support Wilson’s revised model of information behaviour and expand its reach into the area of rehabilitation.The study also contributes to our understanding of information needs, as described by Taylor’s model of question negotiation. This dissertation adds to an already large body of knowledge on the IB of health professionals, such as physicians and nurses.As well,The discrepancies uncovered in this research between proposed question-formulation structures and therapists’ clinical questions point to ways in which the EBP framework may be enhanced to better reflect this group’s clinical questions.
- This study also provides practical contributions for the fields of librarianship and rehabilitation.-------Just For info:LIS:Librarians working with students and therapists in rehab can employ knowledge of the 12 foci and the question structure to guide the reference interview.They can also suggest appropriate sources based on the focus of the question.While future research to support the utility of the question formulation structure in rehab is required, instructional designers in academic and hospital libraries can employ the new structure for question formulation, offering students and therapists an alternative to the less useful PICO structure.Information products, including biblio databases and synopses services, can tailor their interfaces according to question foci, and allow users to enter search terms corresponding to any of the 8 elements found in their clinical questions. Such enhancements to existing would allow users to pose queries that more closely match their clinical questions, and this improve the relevance of search results.Rehab:Educators in the rehabilitation sciences can incorporate knowledge of the information needs of rehab therapists in curricula for students and for professional development.Specific resources to address difference types of clinical questions can be included in workshops and courses targeting these audiences.Finally, managers of organizations can use the findings from this study to promote more effective and efficient use of information in everyday practice to inform decision-making.
- Research of an exploratory nature is bound to raise more questions than it answers. Several avenues for research would extend the findings of this study.For example: - a broader investigation of therapists’ information behaviour, including not only their information needs, but subsequent info seeking and use.- a large-scale analysis of clinical questions asked by RTs such as those which have been conducted in medicine- an exploration into the information needs of other allied health professionals, including midwives and psychologists.
- I would like to thanks my dissertation advisory committee members, and my supervisor. I would also like to acknowledge the various sources of funding.Most of all, I am very grateful to the 15 rehabilitation therapists who shared their time and experiences with me for the purpose of this research.
- Thank you.
- Table 4-4: Emergent themes in rehabilitation therapists’ pursuit of clinical questions
- Reminder of clinical question through recording – goal setting?
- Different levels of urgency/importanceIf the answer is needed for immediate decision making, or for professional role (e.g. report writing), then that takes priority over personal understanding or future patients.
- pressureHomeworkGoal setting (inadvertently)Self-derogatory comments, referring to oneself as “lazy”What I want to convey here is affect – emotion. Also, frustration came up, but not as much
- “So I think it’s like more sort of you had dedicated time to sit down and do it, I don’t think it would take that long. It’s just trying to make yourself to actually do it.” (OT4)Effort & time/workload are related concepts
- No one mentioned wireless, but clinicians did mention librarian, online resources (databases, journal subscriptions) and proximity to a computerLibrarian was mentioned as a resource available for rehab hospital clinicians. Those in acute care were unaware for the most part.Few mentioned point of care resource access, and none mentioned wireless or mobile tech
- Distinction between Problem and Population (compared to PICO and all other structures)Newer elementsVery low numbers for many elements, which suggests that these are optional, and only present when relevantWhile all the other elements have been (or are similar to those) previously proposed, none of the existing structures includes all 8 elements. In other words, I found each of these elements within the set of 129 CQs recorded by these stroke therapistsDiscuss the differences between categories/foci as well – therapy, diagnosis, prognosis & etiology/harm in medicine (EBM)[if time enough:] Importance of situating CQ research within theoretical framework of IB, and consistent definitions of CQ for cumulative and comparable research findings.
- Sample journal page for recording a clinical question
- Appendix H