Scandinavian Journal of Occupational Therapy. 2015; 22: 216–225

ORIGINAL ARTICLE

Occupational therapy with people with depression: Using nominal group technique to collate clinician opinion

DANIELLE HITCH1, MICHELLE TAYLOR2 & GENEVIEVE PEPIN1 1

Occupational Science and Therapy, Deakin University, Geelong, Australia, and 2IPAR Rehabilitation Pty Ltd, Geelong, Australia

Abstract Aims. This aim of this study was to obtain a consensus from clinicians regarding occupational therapy for people with depression, for the assessments and practices they use that are not currently supported by research evidence directly related to functional performance. The study also aimed to discover how many of these assessments and practices were currently supported by research evidence. Methods. Following a previously reported systematic review of assessments and practices used in occupational therapy for people with depression, a modified nominal group technique was used to discover which assessments and practices occupational therapists currently utilize. Three online surveys gathered initial data on therapeutic options (survey 1), which were then ranked (survey 2) and re-ranked (survey 3) to gain the final consensus. Twelve therapists completed the first survey, whilst 10 clinicians completed both the second and third surveys. Major findings. Only 30% of the assessments and practices identified by the clinicians were supported by research evidence. A consensus was obtained on a total of 35 other assessments and interventions. These included both occupational-therapy-specific and generic assessments and interventions. Principle conclusion. Very few of the assessments and interventions identified were supported by research evidence directly related to functional performance. While a large number of options were generated, the majority of these were not occupational therapy specific.

Key words: practice guidelines, occupational therapy practice, mental health, evidence-based practice, depression

Introduction Depression is a mental health disorder, diagnosed on the basis of the symptoms reported as being experienced by individuals (1). Commonly experienced symptoms include feelings of low mood, anhedonia, changes in sleep and appetite, slowed reaction times, reduced concentration, fatigue, and feelings of worthlessness (1). These can lead to feelings of decreased self-worth, thoughts of self-harm and losses in the areas of productivity, income, and functional performance (2). In this study, functional performance refers to a person’s ability to perform the tasks and activities needed in daily life (3). Depression has a major impact on the individual, his/her family, and the wider community, and substantially contributes to

disease burden globally (4). Occupational therapists have worked with people with depression since the beginnings of the profession, particularly in relation to functional performance. However, there exist few guidelines for occupational therapy practice in relation to this highly prevalent and burdensome condition. Occupational therapists seeking guidance on best practice need to access, critique, and synthesize evidence from a number of sources and disciplines. The development of evidence-based guidelines can be an effective way of providing occupational therapists with this knowledge, and recommendations that would directly impact on their use in practice. However, relatively few clinical practice guidelines are currently available for occupational therapy in mental health.

Correspondence: Danielle Hitch, Occupational Science & Therapy, Deakin University, Waterfront Campus, 1 Gheringhap Street, Geelong, Victoria 3217, Australia. Tel: +613 5227 8642. E-mail: [email protected] (Received 3 December 2013; accepted 1 January 2015) ISSN 1103-8128 print/ISSN 1651-2014 online Ó 2015 Informa Healthcare DOI: 10.3109/11038128.2015.1004366

Nominal group technique study of OT for depression The current study was undertaken as part of a larger Australian project to formulate evidence-based guidelines for improving engagement and participation for people with depression. Participation refers to the physical, overt act of performing occupations, while engagement refers to the “invisible”, tacit processes that underlie and support participation (5). The full process of their development has been published elsewhere (6); however, the following brief overview will indicate the context of this current study. There are five consecutive phases in the construction of evidence-based guidelines: evidence gathering, guideline construction, consultation, dissemination and evaluation. The first of these phases is the focus of this article, and involves five steps: (i) the formulation of an explicit statement of purpose and focus; (ii) conduct of a systematic review of all peerreviewed evidence; (iii) critique and grading of each piece of evidence with regard to its quality; (iv) formulation of consensus statements regarding aspects of practice not addressed in current evidence; and (v) conduct of secondary systematic review of non-discipline-specific literature to find any additional evidence (6). The overall purpose of the project was to provide guidance on appropriate assessment and intervention strategies with people with depression, who wish to improve their engagement and participation in daily activities. The initial systematic review of peerreviewed research published by occupational therapists on this topic yielded 87 articles from the past 12 years. As noted in the full account of this review (6), we noticed that this body of evidence was very diverse, with little consolidation around particular assessments or interventions. There were also few studies (using either quantitative or qualitative methods) that achieved a high level of scientific rigour, and many gaps where no evidence had been generated to date. The aim of this study was therefore to obtain consensus from a group of clinicians around best practices for occupational therapy for people with depression, in areas where no research currently exists for reference. This practice could be in relation to the implementation of assessment, intervention, or professional behaviours in practice. This position specifically related to the usefulness of assessments and practices not currently supported by research evidence (but directly related to functional performance) used in occupational therapy for people with depression. While many assessments and interventions for people with depression have been found to have a positive impact on symptoms, few have been the subject of research into their impact on functional performance. There is a prevalent assumption that improvement in symptoms automatically leads to an

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improvement in engagement and participation. However, social models of disability and recovery highlight that there is far more to overcoming depression than symptom relief (7). The research questions posed in this fourth step of the evidence-gathering phase are: (i) How many of the occupational therapy assessments and interventions for people with depression identified by clinicians were supported by research evidence directly related to functional performance?; and (ii) Which occupational therapy assessments and interventions for people with depression not currently supported by research evidence directly related to functional performance achieved a position of consensus amongst a group of clinicians who work in mental health? Material and methods A modified nominal group technique was used to collect data via three anonymous online surveys. Nominal group technique is used to generate guidelines where there are gaps in evidence, and expert opinion is required to assist in filling in the gaps (7). This method provides a rigorous method of solution generation and decision-making, which triangulates both qualitative and quantitative data. Usually nominal group technique is undertaken in one location, with the process comprising three parts (8). The first stage involves clinicians gathering and individually expressing ideas regarding the topic at hand. Second, the ideas are privately ranked by the clinicians, producing a list of ideas. Those ideas not reaching the pre-determined level of consensus in terms of being best practices in occupational therapy for people with depression are eliminated from the process at this point. Finally, the remaining ideas are again privately ranked by the clinicians, and those not reaching the pre-determined level of consensus are once again eliminated. The final outcome of this process is a list of ideas in order of preference (8). Some authors (9) stated that group members are allowed to interact during the process, after independently nominating and ranking ideas; however, this was not part of this modified technique. The nominal group technique used for this study was modified by the use of three online surveys, instead of gathering clinicians in one location. This modification made it similar in some ways to Delphi technique but we chose nominal group technique due to its cost effectiveness, the dispersed geographical locations of clinicians, and ease of distribution (10). Delphi technique involved resourcing requirements the research team were not able to meet and requires participants to be recognised experts in their professional field (11). Clinicians generate ideas independently in all forms of this technique, so conducting this

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process remotely does not miss anything as regards group interaction. This modification therefore has no effect on the overall conduct or potential outcomes of a study using this technique. Ethics Ethical approval for this study was sought from Deakin University Human Ethics Advisory Group (HEAG-H) prior to the commencement of this study. For each subsequent survey, a modification to the original ethics application was submitted, and revised ethical approval granted by the ethics committee. Ethical approval was provided in stages, as each stage of the method led to the design of a new survey based on the data from the previous stage. Demographic information (i.e. such as location or length of practice years) was not collected during this study, to lessen the risk of inadvertently identifying clinicians. Sample Clinicians invited to take part in this study were current practicing occupational therapists treating clients who had been clinically diagnosed with depression. They were considered to have expertise in the direct provision of occupational therapy to people with depression, as this is the focus of their work on a daily basis. Recruitment was purposefully targeted at occupational therapists who were currently working with people diagnosed with depression in Australia, and occurred via e-mail invitation. These e-mails were sent to the first author’s professional networks, with an invitation to pass the e-mail on to anyone the recipient thought might be interested. E-mail advertisements were also sent to a regional special interest group for occupational therapy in mental health, and placed in the national e-bulletin of OT Australia. Those wishing to participate sent their e-mail address to the research team, and their details were stored on a secure mailing list. The inclusion criteria were that clinicians must be English speaking (to enable successful completion of the surveys), and must reside and practice within Australia (to enable sampling throughout the nation). Clinicians were excluded if they were occupational therapists who worked in the mental health field but did not treat clients clinically diagnosed with depression. Initially, 17 clinicians were recruited to the study, but only 12 progressed to completing the first survey. Two of the clinicians declined to completed surveys two and three. One of those who declined to continue indicated by e-mail that she did not feel the method enabled her to report the client-centred practices she used. The reason for the loss of the other participant is

unknown. As the data were de-identified on receipt, these clinicians had been advised they could not withdraw after completing the first survey during the initial consent process. Therefore, their data remained under consideration by the rest of the sample in the second and third survey. This left a final sample of 10 clinicians who completed all surveys, and all of these were female. Surveys The surveys used were developed specially for this study, and were pilot tested on a small group of occupational therapy students before being sent to clinicians. A copy of the first survey was pilot tested with nine occupational therapy research students, to allow for review and clarification of the information provided. Pre-testing surveys on a small group assists in establishing validity of a survey (12). The survey was modified due to feedback by including a separate adult category. The survey took approximately 15–30 minutes to complete. The surveys were distributed using a web-based survey tool (SurveyMonkeyÒ). An e-mail was sent to all clinicians whose details were stored on the mailing list, with a web link directing them to the first survey. A plain-language statement was attached to this e-mail, and clinicians were advised that consent would be assumed if they returned each survey. The clinicians had two weeks from the date of each survey distribution to complete and return their responses. A reminder email was sent to all clinicians prior to the closing date for each survey. Following the expiry of the time period for completion, each survey was closed to clinicians. The use of SurveyMonkeyÒ assured anonymity, as there was no way of knowing who amongst the sample had returned the data being collected. The first survey was designed by the second author, and peer reviewed by the first and third authors. Its overall structure was based on a systematic review of occupational therapy assessment and intervention with people with depression completed by the first and second authors, reflecting the categories of knowledge available on this topic (13). It had six sections on six separate pages: assessments, group interventions, individual interventions, health-promotion activities, professional issues, and any other comments. The first four headings mentioned above included the following sub-categories: children and adolescents, adults, older adults, comorbid physical conditions, male or female (gender specific), forensic clients, private clients, and carers. A text dialogue box was provided next to each category to allow clinicians to record the assessment, intervention, or health-promotion activities they thought were appropriate and relevant to occupational

Nominal group technique study of OT for depression therapy practice with people with depression. On the last page, an open text box was provided for clinicians to provide any further ideas they wished to contribute. Clinicians were not required to fill in every category, and were not provided with any prompts aside from the headings and categories. The second survey listed all assessments and interventions identified by clinicians from the first survey, according to which dimension of Wilcock’s Occupational Perspective of Health – doing, being, becoming, and belonging (14) – they most related to. The findings from the first survey were categorized into these dimensions at the conclusion of the first round, with the first and second authors working on this collaboratively before the categorization was reviewed and confirmed by the third author. In this study, doing was defined as the medium through which people engage in occupations, which may involve being either actively or tacitly engaged (6). Being was defined as the sense of who someone is as an occupational and human being, encompassing the meanings they invest in life, and their unique physical, mental, and social capacities and abilities (6). Becoming was defined as the perpetual process of growth, development, and change that reside within a person throughout his/her life, and is directed by goals and aspirations (6). Finally, belonging was defined as a sense of connectedness to other people, places, cultures, communities, and times (6). These dimensions were chosen as a structural framework for the evidencebased practice guidelines to connect them with and embed them in theoretical knowledge about human occupation. The definitions of each dimension used to classify this information were developed as part of the broader process of constructing the evidence-based guidelines, and are provided in full elsewhere (15). Data from the first survey that were supported by research and categories that did not receive any responses were not included. Clinicians were asked to rank all the assessments and interventions in numerical order, with the first preference ranked as 1 (most favoured), 2 (second most favoured), and so on until all had been marked. The survey took approximately 10–15 minutes to complete. For the third survey, data from the second survey that were identified by at least 50% of the clinicians and were in the top 50% by ranking were presented. Therefore, the consensus level for this study was agreement by over half of the clinicians that (a) the assessment or intervention was appropriate and relevant to occupational therapy practice with people with depression, and (b) the assessment or intervention was in the top half of rankings for its dimension (either doing, being, becoming, or belonging). Clinicians were again asked to rank the assessments, interventions, and professional statements using the same scale, and this survey also took approximately 10–

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15 minutes to complete. A total of 35 assessments and interventions achieved a consensus from practicing occupational therapists as being appropriate and relevant for use with people with depression. Data analysis Analysis of Survey 1 commenced with all responses being downloaded via SurveyMonkeyÒ into a database. This led to an overall list of assessments and interventions, recording each individual response. This list was examined by all authors of this article, who independently reviewed the responses and consolidated those that were duplicated. The list was also compared with the systematic review that had already been completed, and responses supported by existing evidence were excluded. When the individual consolidations of the responses were compared, there was a high level of agreement between the authors. Minor and few differences in the way the responses had been consolidated were discussed and resolved in a face-toface meeting during this process. This method is known as investigator triangulation, and having more than one investigator analysing the data promoted the rigour of the analysis (16,17). Data from the second survey were downloaded to an Excel document directly from SurveyMonkeyÒ. The same process of triangulation occurred in this and the subsequent phases, with each author independently ranking and analysing the responses received. There were no disagreements concerning which responses were to be retained or discarded. The consensus level for this study was set at 50% for doing, being, becoming, and belonging, meaning that at least half the responding clinicians needed to identify an assessment or intervention. Responses were ranked by frequency for each of these dimensions, and responses had to be in the top 50% to be retained. For example, there were 26 responses about doing, so all responses ranked below 13th place were discarded. The responses that were in the top 50% of those identified were then analysed to reach a consensus of 50% of clinicians. Those assessments and interventions that were identified by five or more clinicians (having been identified by half or more of the sample) were retained. The same process occurred after the third survey, with the final list of assessments and interventions having met the consensus level through both rounds. Results Survey 1 Survey 1 generated a total of 217 distinct responses across all of the categories. As displayed in Table I,

0

0

0

Private

Carers

4

Comorbid physical conditions

0

10

Older adults

Forensic

34

Adults

Gender specific

10

Total responses

Children and adolescents

Sub-categories

Depression Anxiety and Stress Scale (DASS) (19) Kessler 10 (20) Health of the Nation Outcome Scales (HoNOS) (21) Mental state examination (22) Beck Depression Scale (23)

Depression Anxiety and Stress Scale (DASS) (19)

Assessments identified more than once

Assessments

0

4

0

0

1

20

Activity groups Cognitive behavioural therapy Mindfulness therapy Relaxation Stress management

4

5

1

2

4

4

Cognitive behavioural therapy Psycho-education Mindfulness cognitivebased therapy Mindfulness-based stress reduction Goal setting Motivational interviewing Activity analysis Couple/family therapy

27

Mindfulness therapy Art therapy Cooking Exercise/walking

27

Interventions identified more than once Mindfulness cognitivebased therapy Cognitive behavioural therapy

Total responses 14

Interventions identified more than once

Individual interventions

12

Total responses

Group interventions

Table I. Number of responses to Survey 1, highlighting those nominated more than once.

0

1

0

0

0

2

23

6

Total responses

Exercise Healthy outings Information about free support services

Interventions identified more than once

Health promotion

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Nominal group technique study of OT for depression these responses were unevenly distributed with some categories getting multiple responses and others receiving none. Only those responses identified by more than one respondent are specifically identified in this table for clarity. Of the responses received to this survey, 65 (30%) were eliminated at this point, as they were supported by research evidence directly related to functional performance. Surveys 2 and 3 Given that Survey 2 was an intermediate step of the consensus-building process, only the final results arrived at after Survey 3 will be reported here. Some of the responses that were only identified by one participant in the first survey met the agreed consensus level in the subsequent survey. This was due to clinicians agreeing with the relevance of an assessment or intervention that they did not initially identify themselves. However, some of the initial categories (i.e. children and adolescents, gender specific, forensic, and private) were eliminated as they did not reach the agreed level of consensus. Table II displays the responses that had achieved consensus at the conclusion of the nominal group technique process with this sample, along with the dimension of occupation to which they had been classified. These have been clustered into group and individual assessments or interventions, and across four other subcategories (adult, older adult, comorbid conditions, carers) to reflect occupational therapy practice. Discussion There are several findings of interest in this study, which illuminate current practices in Australia for occupational therapy with people with depression. We found that few of the occupational therapy assessments and interventions for people with depression identified by clinicians were supported by research evidence directly related to functional performance. There were also areas where research exists, but were not identified by the clinicians (e.g. falls prevention programs for people with comorbid conditions). This is congruent with the widely held view that currently practicing occupational therapists struggle to engage in evidence-based practice (26). The prevalence of generic assessments and interventions also reflects that Australian occupational therapists in mental health often work in generic positions or contexts, and this impacts on their practices. One possible explanation for this is that the occupational therapists who participated in the survey are experience-based rather than evidence-based practitioners (27). Muir Gray, Haynes, Sackett and Guyatt

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(28) suggested that occupational therapists who use experience rather than evidence as the primary decision-making tool are acting in a similar manner to other health professionals such as general practitioners. This finding may therefore be an accurate reflection of current occupational therapy practice with people with depression. Another relevant factor to this finding is the amount of evidence available to occupational therapists specifically related to functional performance for people with depression. Very little of the available evidence regarding occupational therapy with people with depression uses the robust scientific methods that occupational therapists are urged to refer to (27), which contributes to the difficulties many encounter when trying to be evidence based (29-30). However, when peer-reviewed evidence that uses non-scientific methods is taken into account, there is a substantial body of occupational-therapy-specific information for therapists to draw from. A wide range of occupational therapy assessments and interventions for people with depression that are not currently supported by research evidence directly related to functional performance achieved a consensus from clinicians. The majority of occupational therapy assessments and interventions for people with depression focused on adults. Some for older adults achieved consensus, but none for children or adolescents attracted enough support from the clinicians. Under-diagnosis of depression may be a contributing factor in older adults, as comorbid conditions (which non-mental-health occupational therapists tend to treat) can obscure the identification of depressive symptoms (31) and older adults may be less likely to report and seek treatment for depression, due to the stigma involved in mental illness (32). The sheer number of assessments and interventions that were elicited from the first survey was surprising. For example, the adult section for assessments generated 34 different responses, with only five being occupational therapy specific. As highlighted by a comment from one participant, there may be the perception there are no suitable functional assessments for people with depression. However, assessments such as the Canadian Occupational Performance Measure (COPM) (32-35), Assessment of Motor and Process Skills (36), and Occupational Circumstances Assessment Interview and Rating Scale (OCAIRS) (37) have all been used in research by occupational therapists with people with depression. It may be that clinicians are not aware that these tools have been used with this population. The majority of the assessments and interventions identified by clinicians for use with people with depression were generic. For occupational therapy

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Table II. Assessments and interventions achieving consensus at conclusion of nominal group technique. Response

Dimension of occupation

Sub-total

Group

Individual

Adults

Older adults

Assessments

Being

Beck Depression Index (22)

Being

ü

ü

Clinical observation and judgement

Being

ü

ü

General mental health assessment

Being

ü

ü

Geriatric Depression Scale (24)

Being

ü

ü

Risk assessment

Being

ü

ü

Volitional questionnaire (25)

Being

ü

Comorbid conditions

Carers

ü

ü

6 Interventions Belonging

ü

Art therapy

Doing

ü

Breathing exercises

Doing

ü

ü

Calming techniques

Being

ü

ü

Community integration activities

Belonging

ü

ü

Community outings

Belonging

ü

ü

Discussion

Doing

ü

ü

Goal setting

Becoming

Healthy lifestyle practices

Doing

Leisure activities

Doing

ü

Leisure groups

Belonging

ü

Lifestyle counselling

Doing

Linkage to community agency support

Doing

Living skills

Doing

ü

ü

Mindfulness

Being

ü

ü

Physical exercise

Doing

ü

Activity-based groups

ü ü

ü

ü

ü

ü ü ü

ü

ü

ü

ü

ü ü

ü

ü

ü

Problem-solving

Becoming

Psycho-education

Being

Psycho-education regarding carer fatigue and condition of cared-for person

Being

ü

Re-establishment of routines and roles

Doing

ü

ü

Relapse prevention

Becoming

ü

ü

ü

Relaxation

Doing

ü

ü

ü

ü

ü

Skills training

Doing

ü

ü

Sleep education and training

Doing

ü

ü

ü

Strengths identification

Being

Stress management

Doing

Structured and balanced routine activities

Doing

Symptom management

Doing

ü

Walking

Doing

ü

ü

29 Total assessments and interventions

ü

35

ü

ü

ü

ü

ü

ü

ü

ü ü

ü

Nominal group technique study of OT for depression to assert its unique role in multidisciplinary settings, both assessment and intervention must be based on occupation, whose relationship to health is the core value of our profession (38). Using generic assessments and interventions that were not developed from an occupational perspective may lead occupational therapists in a different direction, and obscure their particular skills. Limitations There are a number of limitations to this study, which reduces the possibility of generalizing these results and may have influenced its findings. As the surveys were conducted solely online, there was no opportunity for clinicians to discuss the reasons for or elaborate on their responses. While this is an accepted procedure in nominal group activities, it did lead to at least one of the clinicians being lost to follow-up. Providing opportunities for discussion and/or elaboration in a face-to-face or online nominal group, or adopting another method such as focus groups, might have produced a greater depth of data. Another limitation of the survey related to the e-mail invitations being sent to clinicians’ work addresses. Some clinicians were away on annual leave at the time of the initial survey, which may have contributed to the reduction of the sample at that point. Also, the clinicians may have had difficulties completing the survey in work hours if they had a heavy caseload or other commitments. Direct access to the website might have assisted access for these clinicians; however, this is a limitation of the survey software used. The spread of clinicians who participated in the survey may be seen as a limitation. The ideal number of clinicians for face-to-face nominal group technique has been stated as nine to 12 (39), although no standard has been established for online groups to date. The majority of survey clinicians who initially indicated their interest in participating in the project were from two of the mainland states of Australia, so clinicians were not representative of the national population of occupational therapists working in mental health. The elimination of some of the practice categories during this process may also have been a function of the sample (i.e. few child and adolescent mental health occupational therapists were recruited), and consensus of occupational therapy assessments and interventions for these populations might be possible if a different sample was sourced. All of the clinicians were also female, meaning that any gender differences or features in the data could not be discerned. While appropriate for a study of this design, the small sample size may also be considered a limitation as these clinician opinions have been drawn

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from a limited sample, whose level of experience and skill may be diverse. Further research Ideally consensus statements should be developed from representative populations of the group being consulted. In this case, further groups with occupational therapists from other nations would assist in developing the final list. The assessments and interventions identified by the clinicians also need to be the subject of more robust forms of research, to clarify their effectiveness with people with depression. A Delphi technique study could be considered in future to increase the rigour of our understanding of this topic. Further research into the role of generic assessments and interventions in supporting the functional performance of people with depression would also be of value, to clarify the role they can play in supporting occupation-focused practice. Many of these measures are used as part of multidisciplinary practices, and so it is unrealistic to expect occupational therapists to refer only to profession-specific tools. However, at present their use is independent of evidence proving their relevance to the relationship between engagement, participation, and functional performance. The use of consensus-building research as part of building evidence-based practice guidelines makes the best use of this form of evidence. By embedding these findings into guidelines, the experience of occupational therapists is represented alongside evidence obtained through research. This will lead the guidelines to reflect more accurately the nature of current occupational therapy practice with people with depression – an integration of evidence and practice to serve their needs. Conclusion The aim of this study was to obtain a consensus from clinicians regarding occupational therapy for people with depression, for assessments and practices not currently supported by research evidence directly related to functional performance. A total of 35 assessments and interventions achieved a consensus from practicing occupational therapists as being appropriate and relevant for use with people with depression. However, very few of the assessments and interventions identified were supported by research evidence directly related to functional performance. While a large number of options were generated, the majority of these were not occupational therapy specific. Attributing the findings of this study to clinicians’ lack of skill in evidence-based practice would be counterproductive, and would not reflect the complex

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factors that impact on the translation of evidence into practice. Occupational therapists do not have a lot of robust scientific evidence on which to base their practice with people with depression, and are discouraged from using the non-scientific information that is more plentiful and potentially more directly relevant to their practice. Further efforts should be made to both include occupational therapists’ practice knowledge and to place a greater focus on engagement, participation, and functional performance for people with depression in the generation of new understandings of the relationships between occupation and health. The formulation of evidence-based practice guidelines may be one means to achieve this more inclusive approach to promoting informed practice. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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