Evidence-Based Practice Sioo, 8 april 2013 Utrecht

Evidence-based practice Wat is het? Waar komt het vandaan? Hoe ziet het er uit in een opleiding?

Evidence based practice: Wat is het?

Evidence based practice: Definition Evidence based practice: Improve information to support decision making

Evidence-based practice Uitgangspunt bij evidence-based practice is dat beslissingen gebaseerd dienen te zijn op een combinatie van kritisch denken en de best beschikbare 'evidence'.

Evidence based practice Met het begrip 'evidence' wordt niet meer bedoeld dan 'informatie'. Dit kan informatie zijn afkomstig uit wetenschappelijk onderzoek, maar ook interne bedrijfsinformatie en persoonlijke ervaring geldt als 'evidence’.

Evidence based practice In principe neemt iedere manager dus beslissingen op basis van 'evidence'. De meeste managers besteden echter nauwelijks aandacht aan de kwaliteit van de 'evidence' waarop ze hun beslissingen baseren.

Evidence-based practice: kritisch denken van verschillende informatiebronnen gebruik maken >> best available evidence? de evidence kritisch tegen het licht houden denken in termen van waarschijnlijkheid in plaats van 'golden bullets'.

Evidence based practice Professional expertise and judgment Best available internal evidence Stakeholders’ values and concerns Best available external evidence Evidence-based decision

Evidence based practice: Waar komt het vandaan?

What field is this? “there is a large research-user gap” “practitioners do not read academic journals” “the findings of research into what is an effective intervention are not being translated into actual practice” “academics not practitioners are driving the research agenda” “the relevance, quality and applicability of research is questionable” “practice is being driven more by fads and fashions than research” “many practices are doing more harm than good”

Medicine: Founding fathers David Sackett Gordon Guyatt McMaster University Medical School, Canada

How it all started

if you’re hyperventilating Problem I: persistent convictions breathe into a bag if you’re hyperventilating

give them a drug that reduces the number of irregular beats Problem I: persistent convictions elderly people who have an irregular heartbeat are much more likely to die of coronary disease give them a drug that reduces the number of irregular beats

How 40,000 cardiologists can be wrong In the early 1980s newly introduced anti-arrhythmic drugs were found to be highly successful at suppressing arrhythmias. Not until a RCT was performed was it realized that, although these drugs suppressed arrhythmias, they actually increased mortality. By the time the results of this trial were published, at least 100,000 such patients had been taking these drugs.

Problem II: too much information More than 1 million articles in 40,000 medical journals per year (= 1995; now probably more than 2 million). For a specialist to keep up this means reading 25 articles every day (for a GP more than 100!)

Problem I: persistent convictions Maslow, A.H. (1943). "A Theory of Human Motivation," Psychological Review 50(4) Wahba, M. A., & Bridwell, L. G. (1976). Maslow reconsidered: A review of research on the need hierarchy theory. Organizational Behavior and Human Performance, 15(2)

True or false? Incompetent people benefit more from feedback than highly competent people. Task conflict improves work group performance while relational conflict harms it. Encouraging employees to participate in decision making is more effective for improving organizational performance than setting performance goals.

How evidence-based are we? HR Professionals' beliefs about effective human resource practices: correspondence between research and practice, (Rynes et al, 2002, Sanders et al 2008) 959 (US) + 626 (Dutch) HR professionals 35 statements, based on an extensive body of evidence true / false / uncertain On average: 35% - 57% correct

Problem II: too much information HRM: 1,350 articles in 2010 (ABI/INFORM). For an HR manager to keep up this means reading 3 to 4 articles every day (for a ‘general’ manager more than 50!) BTW: most of the research is seriously flawed or irrelevant for practice

David Sackett Half of what you learn in medical school will be shown to be either dead wrong or out-of-date within 5 years of your graduation; the trouble is that nobody can tell you which half. The most important thing to learn is how to learn on your own: search for the evidence! (Remember that your teachers are as full of bullshit as your parents)

The 5 steps EBP: pull approach Formulate a focused question (Ask) Search for the best available evidence (Acquire) Critically appraise the evidence (Appraise) Integrate the evidence with your professional expertise and apply (Apply) Monitor the outcome (Assess)

Evidence-Based Practice 1991 Medicine 1998 Education 1999 Social care, public policy 2000 Nursing 2000 Criminal justice ???? Management?

Evidence based practice: Hoe ziet het er uit in de opleiding?

Evidence-based practice Fase 1: Het ontwikkelen van kritisch en wetenschappelijk denken dat leidt tot een professioneel-kritische attitude met betrekking tot organisatievraagstukken Fase 2: Het kunnen formuleren van een expliciete vraag en op basis van deze vraag kunnen zoeken in online databases naar uitkomst van relevant wetenschappelijk onderzoek. Fase 3: Het kritisch kunnen beoordelen van wetenschappelijke en organizational evidence (critical appraisal) Fase 4: Uitkomst van wetenschappelijk onderzoek kunnen toepassen in de eigen beroepspraktijk (application of science)

Evidence based practice Professional expertise and judgment Best available organizational evidence Stakeholders’ values and concerns Best available scientific evidence Evidence-based decision

Trust me, 20 years of experience

Bounded rationality

Bounded rationality

Het feilbare brein System 1 System 2 Snel, actie Intuitief, associatief shortcuts & biasses System 2 Langzaam (lui!) Rationeel Nadenken

limbische systeem en hersenstam Bounded rationality neo cortex (systeem 2) limbische systeem en hersenstam (systeem 1)

Systeem 1

Systeem 1: het feilbare brein Seeing order in randomness Mental corner cutting Misinterpretation of incomplete data Halo effect False consensus effect Group think Self serving bias Sunk cost fallacy Cognitive dissonance reduction Confirmation bias Authority bias Small numbers fallacy In-group bias Recall bias Anchoring bias Inaccurate covariation detection Distortions due to plausibility

Fase 1: Kritisch & wetenschappelijk denken Denkfouten Informatiebronnen Mythbusting Assumpties

Richard Feynman “The first principle is that you must not fool yourself - and you are the easiest person to fool”.

Dr. Michael Shermer (Director of the Skeptics Society) Seeing order in randomness Een Type I fout of een vals positief: denken dat er een patroon / verband is terwijl dat er in het echt niet is. Een Type II fout of een vals negatief: denken dat er geen patroon / verband is terwijl dat er in het echt wel is Dr. Michael Shermer (Director of the Skeptics Society)

Het feilbare brein: patern recognition Een Type I fout of een vals positief: denken dat het geritsel in de bosjes een gevaarlijk roofdier is, terwijl het gewoon de wind is (goedkoop foutje)

Het feilbare brein: patern recognition Een Type II fout of een vals negatief: denken dat het geritsel in de bosjes gewoon de wind is, terwijl het een gevaarlijk roofdier is (duur foutje)

DEFAULT Het feilbare brein: patern recognition Een Type I fout of een vals positief: denken dat het geritsel in de bosjes een gevaarlijk roofdier is, terwijl het gewoon de wind is (goedkoop foutje) DEFAULT Een Type II fout of een vals negatief: denken dat het geritsel in de bosjes gewoon de wind is, terwijl het een gevaarlijk roofdier is (duur foutje)

Het feilbare brein: patern recognition Ook ervaren mensen en experts zien patronen en verbanden waar ze niet zijn. stress & lifestyle peptic ulcer

Oct 2005 Peptic ulcer – an infectious disease! This year's Nobel Prize in Physiology or Medicine goes to Barry Marshall and Robin Warren, who with tenacity and a prepared mind challenged prevailing dogmas. By using technologies generally available (fibre endoscopy, silver staining of histological sections and culture techniques for microaerophilic bacteria), they made an irrefutable case that the bacterium Helicobacter pylori is causing disease. By culturing the bacteria they made them amenable to scientific study. In 1982, when this bacterium was discovered by Marshall and Warren, stress and lifestyle were considered the major causes of peptic ulcer disease. It is now firmly established that Helicobacter pylori causes more then 90% of duodenal ulcers. The link between Helicobacter pylori infection and peptic ulcer disease has been established through studies of human volunteers, antibiotic treatment studies and epidemiological studies. Oct 2005

more stress = more prone to biases Errors and Biases of Human Judgment superstitious rituals superstitious rituals more stress = more prone to biases

Errors and Biases of Human Judgment

“What gets us into trouble is not what we don't know, Beliefs vs Evidence “What gets us into trouble is not what we don't know, it's what we know for sure that just isn't so.” Mark Twain

(systeem 1 doet altijd mee!) Het feilbare brein: patern recognition Ook slimme mensen houden er verkeerde ideeën op na, niet omdat ze dom of eigenwijs zijn, maar omdat het de meest logische conclusie is op basis van hun eigen ervaringen. (systeem 1 doet altijd mee!)

Evidence-based practice Fase 1: Het ontwikkelen van kritisch en wetenschappelijk denken dat leidt tot een professioneel-kritische attitude met betrekking tot organisatievraagstukken Fase 2: Het kunnen formuleren van een expliciete vraag en op basis van deze vraag kunnen zoeken in online databases naar uitkomst van relevant wetenschappelijk onderzoek. Fase 3: Het kritisch kunnen beoordelen van wetenschappelijke en organizational evidence (critical appraisal) Fase 4: Uitkomst van wetenschappelijk onderzoek kunnen toepassen in de eigen beroepspraktijk (application of science)

The 5 steps EBP Formulate a focused question (Ask) Search for the best available evidence (Acquire) Critically appraise the evidence (Appraise) Integrate the evidence with your professional expertise and apply (Apply) Monitor the outcome (Assess)

Formulate a focused question

Focused question? Does team-building work? What are the costs and benefits of self-steering teams? What are the success factors for culture change? Does management development improve the performance of managers? Does employee participation prevent resistance to change? How do employees feel about 360 degree feedback?

Foreground question? Does team-building work? What is a ‘team’? What kind of teams? In what contexts/settings? What counts as ‘team-building’? What does ‘work’ mean? What outcomes are relevant? Over what time periods?

Answerable question: PICOC P = Population I = Intervention or success factor C = Comparison O = Outcome C = Context

2. Finding the best available evidence

Searching evidence What do we search?

What do we search? Current Information Overview of a subject General background Academic Information Statistical Information Theories about a subject Company information

Peer reviewed journals

Searching for evidence PRESENTATION ONE 4/04/2017 Searching for evidence Introduction to Evidence-Based Practice

Databases ABI/INFORM Business Source Elite PsycINFO Web of Knowledge ERIC Google Scholar

Searching for evidence PRESENTATION ONE 4/04/2017 Searching for evidence Introduction to Evidence-Based Practice

Searching evidence How do we search? Search Strategy

Two types of search strategies Search strategy Two types of search strategies Snowball method Building blocks method

Search strategy

Hands on instruction

Example: merger

Question Imagine you are a consultant, your client is the board of directors of a large Canadian health-care organization. The board of directors has plans for a merger with a smaller healthcare organization in a nearby town. However, it’s been said that the organizational culture differs widely between the two organizations. The board of directors asks you if this culture-difference can impede a successful outcome of a merger. Most of them intuitively sense that cultural differences matter, but they want an evidence-based advice.

What else would you like to know? Answerable question: PICOC What else would you like to know?

Answerable question: PICOC P: What kind of Population are we talking about? Middle managers, back-office employees, medical staff, clerical staff? O: What kind of Outcome are we aiming for? Employee productivity, return on investment, profit margin, competitive position, innovation power, market share, customer satisfaction? P/C: And how is the assumed cultural difference assessed? Is it the personal view of some managers or is it measured by a validated instrument?

Answerable question: PICOC According to the board the objective of the merger is to integrate the back-office of the two organizations (ICT, finance, purchasing, facilities, personnel administration, etc.) in order to create economy of scale. The front offices and primary process of the two organizations will remain separate. The cultural difference is not objectively assessed (it is the perception of the senior managers of both organizations).

Answerable question: PICOC P = back office employees in a healthcare organisation I = merger, integration back office C = status quo O = economy of scale C = different organizational culture, unequal

Evidence-based practice Fase 1: Het ontwikkelen van kritisch en wetenschappelijk denken dat leidt tot een professioneel-kritische attitude met betrekking tot organisatievraagstukken Fase 2: Het kunnen formuleren van een expliciete vraag en op basis van deze vraag kunnen zoeken in online databases naar uitkomst van relevant wetenschappelijk onderzoek. Fase 3: Het kritisch kunnen beoordelen van wetenschappelijke en organizational evidence (critical appraisal) Fase 4: Uitkomst van wetenschappelijk onderzoek kunnen toepassen in de eigen beroepspraktijk (application of science)

What is the best research design? Randomized controlled study? Grounded theory approach? Cohort / panel study? Qualitative field research? Longitudinal study? Post-test only study? Survey? Action research? Case study?

What is the best design? quants vs quallies, positivists vs post structuralist, etc

What is the BEST car?

on the research question

Which design for which question? Research designs Which design for which question?

Effect vs Non-effect

Types of questions Effect Does it work? Does it work better than ....? Does it have an effect on ....? What is the success factor for ....? What is required to make it work ...? Will it do more good than harm?

Types of questions: non-effect Needs: What do people want or need? Attitude: What do people think or feel? Experience: What are peoples’ experiences? Prevalence: How many / often do people / organizations ...? Procedure: How can we implement ...? Process: How does it work? Explanation: Why does it work? Economics: How much does it cost?

Internal validity

Internal validity internal validity = indicates to what extent the results of the research may be biased and is thus a comment on the degree to which alternative explanations for the outcome found are possible.

We are pattern seeking primates: Causal relations We are pattern seeking primates: we are predisposed to see order and causal relations in the world

When do we know there is a causal relation? Causality Are the "cause" and the "effect” related? Does the "cause" precede the "effect" in time? Are there no plausible alternative explanations for the observed effect? measurements, effect size before and after measurement randomization, control group When do we know there is a causal relation?

Bias & Confounding Research shows: Shoe size > quality of handwriting Smoking youngsters > better lung function

Levels of internal validity

Which design for which question? Explanation

Different types of research questions require different types of research designs, but ...

Best research design?

Step 3: Critical appraisal of studies

How to read a research article?

Critical appraisal: quick and dirty Is the study design appropriate to the stated aims? Are the measurements likely to be valid and reliable? Was there a relevant effect size? Is the outcome (population, type of organization) generalizable to your situation?

Critical appraisal questionnaires www.cebma.org/ebp-tools

Aantal te laat betalers neemt toe Professional expertise and judgment Best available organizational evidence Stakeholders’ values and concerns Best available scientific evidence Evidence-based decision

CAT: Critically Appraised Topic

CAT: structure Background / context Question (PICOC) Search strategy Results / evidence summary Findings Limitations Recommendation max 3 pag.

CAT-walk