S TUDY III

Design: Innovative study methodology was applied. A case study was constructed and

analysed to identify possible translational challenges and possible solutions to the

challenges. This case study comprised five components (see Figure 5): (1) a physician‘s referral of a fictitious woman named Denise, described as an employee who was on long-term sick leave due to low back pain and comorbidity, and required workplace interventions; (2) a rehabilitation team at an outpatient RTW clinic that received the referral; (3) the six EBP steps; (4) the PICO framework; (5) the final component consisting of scientific evidence from a high-quality RCT, which was identified using the EBP and PICO components. In short, the initial task was to create a typical person on sick leave for the referral, which was achieved by analysing the empirical data on 30 employees on long-term sick leave. Thereafter, the six EBP steps and the PICO

approach were used to manage performance of an EBP process. Next, the challenges in the EBP process were identified by analysing the subsequent reflections. Lastly, the challenges revealed in the EBP process were isolated, presented one by one, and finally systematized into a suggested revision of the EBP steps. These five components are further described below.

C2: A REHABILITATION TEAM performing the EBP translation-process

1 ASSESS

2 ASK

3 ACQUIRE 4

APPRAISE 5 APPLY C1: A

REFERRAL FROM THE PHYSICIAN ABOUT

DENISE C3: THE

FIVE EBP-STEPS

C4:

PICO

C5: THE EVIDENCE

Identify translation challenges, and suggest possible solutions

Figure 5. Overview of the five components (C1-C5) of the evidence-based translation process in this constructed case study. These five steps are described in the text.

C1 The referral: The physician‘s referral gave information about Denise, who was described as a secretary who worked in the public sector and had high comorbidity. The case of the employee Denise was developed from analyses of the core characteristics of 30 employees on long-term sick leave, who were followed for approximately eight months each in the Rogaland RTW study

[137, 230, 231]

. Several transcripts from 135 interviews with these employees and their immediate supervisors were analysed, along with documents (n = 250) from health care, social insurance offices, and employers.

Qualitative content analysis

[215-217, 222, 223]

were used to identify typical features of the cases, such as age, gender, family situation, occupation, health status, health problems, functioning, work ability, work capacity, and aetiology. The aim was to be able to construct three typical employees on long-term sick leave, and Denise was one

THE EBP-STEPS (1) ASSESS-

acknowledge the need for information and reflect,

(2) ASK- make answerable questions, (3) AQUIRE- search for knowledge in the scientific literature, (4) APPRAISE- critically appraise the relevance and validity of information in the literature, and (5) APPLY- apply the knowledge and make the intervention decision

of these. This means that Denise could be regarded as a typical employee on long-term sick leave in the context of the working life and social security systems in Norway.

C2 The team: Denise‘s referral was sent to a hypothetical rehabilitation team that was organized in an outpatient RTW clinic and worked in close contact with the employees, employers, and workplaces. The RTW clinic had a multi-professional staff including a physician, an occupational therapist, a physiotherapist, and a psychologist. The team gave the responsibility of being Denise‘s case manager to the occupational therapist Eve, and this involved establishing and maintaining contact with the workplace, social insurance staff, and other health care services. The RTW clinic had already applied an evidence-based approach. Therefore, Eve had learned how to implement and practice EBP according to the steps of such practice and the PICO framework, and she did not encounter any of the problems that are often reported in the literature as being obstacles to EBP. In short, she was confident in performing EBP.

C3 The EBP steps: This hypothetical case study was guided by use of the EBP steps, which are further described here as they appear in the literature. The 4, 5, 6, or 7 steps have been developed to steer the process of performing EBP

[176, 179, 180, 182, 184, 232-236]

. Summarizing, they involve the following components: (1) ASSESS, acknowledge the need for information and reflect; (2) ASK, create answerable questions; (3)

AQUIRE, search for knowledge in the scientific literature, (4) APPRAISE, critically assess the relevance and validity of information in the literature; (5) APPLY, make use of good knowledge and arrive at a decision. The literature also contains a few

exceptions to the above-mentioned steps. Some investigators have also included a sixth step denoted evaluation

[184]

or dissemination to colleagues or organizations

[234]

. One publication included a step after APPRAISE, which was designated Integrate the evidence with clinical expertise and patient preferences and values

[234]

, and another article added a step in which the ASK step should be answered on the basis of

professional expertise before it is answered by the scientific literature

[185]

. Bennett and Bennett

[169]

put forward their four EBP steps (ASK, SEARCH, APPRAISE, USE) as a third frame outside two other frames, which they called (1) the client context and (2) the (occupational therapy) treatment process/therapy context.

C4 The PICO framework: The PICO framework was also used in the hypothetical case study. The ―P‖ in PICO stands for the type of patient, ―IC‖ indicates the type of interventions and co-interventions, and ―O‖ represents the outcome. The PICO

framework was developed to enable the practitioner to ask what is often referred to as a good question, an answerable question, a clinical question, an appropriate question, a searchable question, or a well-built question

[180-183, 237, 238]

. The PICO format is to be used in EBP step 2 (ASK), with the aim of targeting relevant sound evidence in the scientific literature, despite an information overload.

C5 The scientific evidence: The fifth component of the hypothetical case study comprised scientific evidence from systematic reviews, RCTs, and clinical guidelines.

Here, high-quality evidence was selected to make it possible to reveal types of

challenges other than those concerning methodological limitations and flaws in

available studies.

Applying the EBP process to the hypothetical case study: The EBP translation involved going through the EBP steps, and this constituted the context of the analytical process in this study, which was performed to identify the challenges and the solutions.

Step 1 Assess: The case manager Eve started by assessing all knowledge about the case in order to provide evidence-based treatment to the patient. Thus far, the team‘s

knowledge of Denise was derived solely from the information in the referral. Eve determined that the case was multi-factorial. In the EBP course she had attended, Eve had learned to apply scientific evidence from systematic reviews and RCTs of high quality, and that evidence is often easy to assess and apply when it is formulated as clinical guidelines. Hence Eve started her work using this type of knowledge.

Step 2 Ask: Eve had learned how to ask answerable questions by using the PICO framework. She attempted to determine which patient group Denise belonged to, remembering that the ―P‖ usually refers to the person‘s diagnosis. However, Denise had several diagnoses, whereas most of the literature was diagnosis specific. How could this discrepancy be resolved? Eve decided to choose one of the diagnoses, low back pain, which she believed was the disorder that had the most extensive impact on Denise‘s ability to work. ―P‖ could also refer to the type of job Denise had, so Eve needed to find literature on people working as secretaries in service occupations, as well studies about women in the same age group as Denise. Next, Eve considered the

―I‖ and ―C‖ components of the PICO framework, eliminating therapies that were similar to those Denise had tried previously. The referral from the physician had also indicated that more workplace-targeted interventions were needed. Considering the ―O‖

component, it was obvious what outcome was relevant, because Denise wanted to get back to work as soon as possible. Eve formulated the following PICO question: ―What interventions are effective to achieve a fast RTW for a 35-year-old female secretary with chronic low back pain?‖

Step 3 Acquire: The first thing that Eve did in this step was to look for clinical guidelines concerning chronic low back pain. She found that, for conservative treatments, the European Guidelines for chronic non-specific low back pain

[239]

recommend cognitive behavioural therapy, supervised exercise therapy, brief educational interventions, and multidisciplinary (bio-psycho-social) interventions.

Specific workplace interventions were not covered in those guidelines. Eve then conducted a literature search in the Cochrane Library. Few of the studies she found assessed the outcome of RTW, and most focused on outcomes such as pain and function. Eve used the domains of the WHO International Classification of

Functioning, Disability, and Health (ICF)

[102]

to systematize the interventions in the

identified studies, and she found that most of these were aimed almost exclusively at

the patient‘s body functions or body structures. At this stage, Eve considered these

types of interventions to be irrelevant for Denise due to her treatment history. Only a

few of the interventions included workplace components. Eve subsequently found a

review about biopsychosocial rehabilitation of chronic low back pain

[240]

, which

described conflicting evidence regarding effectiveness in relation to vocational

outcomes. Eve was not sure how to use this observation. She finally found an article

that could be relevant to Denise‘s situation, which described an intervention called a

multidisciplinary rehabilitation programme for back and neck pain

[241]

. The authors had concluded that this intervention increased RTW in women who were aged 16–60 years, working in service/care occupations, and suffering from back/neck pain. Eve decided to proceed with this promising study.

Step 4 Appraise: Eve pondered the fact that the subjects in the above-mentioned study

[241]

had been on sick leave for a maximum of 6 months due to spinal pain, whereas Denise had been on full-time sick leave for 9 months. Eve wondered whether this difference rendered the information in that study irrelevant in Denise‘s case. The third intervention in the cited investigation was called behavioural medicine rehabilitation (BM), which led to outcomes superior to those obtained with the other two

interventions and for the control group. The mean number of sick leave days for women was 201.3 less in the BM intervention group than in the control group. Eve considered this to be a good result for ―the mean person‖ in the group, but was eager to determine the effects for a specific individual such as Denise. She found that the BM group consisted of only 20 women and wondered whether the power of the study was sufficient to translate the results to Denise. Eve tried to find the spread of values for the 20 women and noted that the 95% confidence interval (CI) was extremely broad, 1.3 to 403.9. For 95% of those participating in the study, the improvement in the BM group compared to the control group consisted of a reduction of sick leave by a mean of 403.9 more days at ―best‖ and 1.3 more days at ―worst‖. Eve felt that she needed more

information about who really did or did not benefit from the intervention. For example, did only a few of the 20 women exhibit enormous improvement, and most of them experience only moderate, limited, or even adverse effects? Did they have neck or back pain? What types of occupation did they have? What kinds of companies did they work for? What types of work did they perform? Eve concluded from the confidence interval that only a few of the women—possibly only one or two—experienced a small adverse effect in the form of having more sick leave days than the average participant in the control group.

Step 5 Apply: Eve was not sure if this intervention programme would comply with Denise‘s personal preferences, health condition, type of work, occupation pattern, and workplace environment. Even if it was suitable, more information was still needed about how to apply the programme in her case, also taking into consideration the resources and competence that were available. If the intervention programme that was applied to Denise differed too much from the original programme, it would probably not produce the same positive outcome. Eve decided to contact the first author of the study to get information about the intervention programme, so that the rehabilitation team could scrutinize the content. She was eager to be guided by the scientific

literature, but felt that a decision regarding type of intervention was still a long way off,

even though the EBP steps were completed.

In document Workplace-based sick leave prevention and return to work : exploratory studies (Page 34-38)