EBP 101 What it is. What it isn t. What to do? Mark DeRuiter, Ph.D., CCC A/SLP Michael J. Bamdad, M.A., CCC SLP Moving from a set of specific facts to a general conclusion A form of theory building in which hspecific facts are used to create a theory that explains relationships between those facts and allows prediction of future knowledge. Evidence Based Practice in Communication Disorders These facts do not ensure the truth. EBP movement seems to imply that until EBP came along, practitioners were basing their clinical decisions on something other than evidence, which is simply not true. Dollaghan (2007) 1
Evidence Based Practice in Communication Disorders definition: Infusing EBP into Clinical Education A push pull process the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients (by) integrating individual clinical expertise with the best available external clinical evidence from systematic research Typically, the push comes from course content Inspiring the pull in the clinical environment can be the challenge Students require an initial framework Sackett, Rosenberg, Gray, Haynes, & Richardson (1996) Process Track down the evidence Student weighs: Patient needs Data from research literature Data from manufacturers Evidence: Are Mice Merely Adorable or Can They Be Destructive? Does this need to be difficult? 2
Mice Can Be Destructive They do NOT want us to READ Mice Can be Destructive They will eat ALL of our FOOD Mice Can Be Destructive They will DESTROY our HOMES Mice Can Be Destructive They may inspire bad hair choices (baldness, mouse pelt sideburns) Putting Evidence and Practice Together Practice to Eliminate Mice We know mice are bad. We must now DO something. We should use practice to keep the mouse population low. This way, we take our evidence, and DO something hey! We put it into PRACTICE. 3
Example #1 : Activity Activity 2: Correct verb use. Example #1 : Rationale In terms of verb retrieval, naming therapies fail to improve production beyond the single sentence level (Chapey, 2008, p. 643). In other words, Looking specifically at verbs in terms of retrieval in a sentence fails to improve the production of a full sentence over time. Therefore, it is more beneficial to work on verbs within a subject + verb + object sequence for the production of syntactically correct sentences. (p. 644). Therefore, focus will be on production of subject + object + verb sentences. Example #2 : Activity The client will read a series of paragraphs and highlight the important pieces of each sentence. The paragraph will include vocabulary words that the client will most likely find difficult. When asked for a definition of the word, the client will be taught the concept of contextual clues to help aid in comprehension of the sentence. The client will then answer multiple choice comprehension questions about the paragraph that contain some newly learned vocabulary words. (goal 7) Example # 2 : Rationale The client has been relatively successful at picking out the most important content of each sentence. This is an important skill to have, especially for AM, because he often asks for a definition of individual words. In the past sessions, I have supplied the definitions for the client. After reading a recent piece from the literature, I think it is important to incorporate the use of context clues during this activity. Therefore, my activity will include critical words in a sentence that I believe are at a higher vocabulary level than the client is currently at. Context clues are very important for broadly comprehending text as well as for specifically learning new words. Instruction in context problem solving pays great dividends (Greenwood & Flanigan, 2007) Example #3 : Activity The clinician will place a divider in between the clinician and client and provide a set of blocks. The clinician will construct a structure out of 7 blocks and explain to the client how to re create the same structure with her own set of blocks without being able to view the clinician's structure. The client will then construct her own structure and explain to the clinician how to create the same structure. The client will then create a third structure and explain to the clinician how to create the structure without using any words that have to do with color. (3, 5, 6). Example #3 : Rationale Kaszniack, A., & Zak, M. (1996)state that self awareness of deficits provides an ideal opportunity for examining the degree to which impaired awareness is general or limited to particular aspects of cognitivedeficit deficit. Some approaches typically used for measurement of self awareness can include the following: (1) comparisons of patient self report and caregiver ratings of patient disability; (2) examination of the concordance between the patient's subjective description of abilities and objective measure of the patient's cognitive abilities. By having the client rate her performance and comparing it to the clinician's rating, the client can see the level of agreement and progression. 4
Example: Clinical Situation Mrs. Smith is 67 years old. She has worn hearing instruments for 11 years and her current set of digitally programmable hearing aids is 6 years old. Mrs. Smith complains of challenges when hearing in noise and is seeking new digital technology. She has read about directional microphones on the internet and would like to talk about this and other technologies during her appointment. Example: Initial Framework Question: Your best answer: Initial evidence resource: Example: Educational Prescription Date and place to be filled THE PATIENT PROBLEM Educational tasks to be completed before the session: Learner: Task: Presentations will cover: i. HOW you found what you found ii. WHAT you found iii. The VALIDITY & APPLICABILITY of what you found iv. How what you found will ALTER your MANAGEMENT of the patient v. How WELL you think you DID in the filing of the Rx Alternatives to EBP in Medicine (From Isaacs and Fitzgerald, 1999) Eminence based medicine The more senior the colleague, the less importance he or she placed on the need for anything as mundane as evidence. Vehemence based medicine The substitution of volume for evidence is an effective technique for brow beating your more timorous colleagues and for convincing relatives of your ability. Eloquence based medicine The year round suntan, carnation in the button hole, silk tie, Armani suit, and tongue should all be equally smooth. Sartorial elegance and verbal eloquence are powerful substitutes for evidence. Providence based medicine If the caring practitioner has no idea of what to do next, the decision may be best left in the hands of the Almighty. Too many clinicians, unfortunately, are unable to resist giving God a hand with the decision making. Diffidence based medicine Some clinicians see a problem and look for an answer. Others merely see a problem. The diffident clinician may do nothing from a sense of despair. This, of course, may be better than doing something merely because it hurts the clinician's pride to do nothing. Nervousness based medicine Fear of litigation is a powerful stimulus to overinvestigation and overtreatment. In an atmosphere of litigation phobia, the only bad test is the test you didn't think of conducting. Confidence based medicine This is restricted to surgeons. Selected References Dollaghan, C. (2007). Handbook for evidence based practice in communication disorders. Baltimore, MD: Brooks Publishing. Glasziou, P., DelMar, C., & Salisbury, J (2006). Evidence based practiceworkbook. Malden, MA:Blackwell Publishing Greenwood, S.C., Flanigan, K. (2007). Overlapping vocabulary and comprehension: context clues complement semantic gradients. The reading teacher, 61(3), 249 254. Kaszniack, A., & Zak, M. (1996). On the neuropsychology of metamemory: Contributions from the study of amnesia and dementia. Learning and individual differences, 8(4): 355 381. Mitchum, C. C., & Berndt, R. S. (2008). Comprehension and production of sentences. In Chapey, R. (Eds.), Language intervention strategies in aphasia and related neurogenic communication disorders, 5 (654 677). Baltimore, MD: Lippincott, Williams, & Wilkins. Sackett, D.L., Richardson, W.S., Rosenberg, W. & Haynes, R.B. (1997). Evidence based medicine: How to practice and teach EBM. New York, NY: Churchill Livingstone. 5