There has been a long-standing need in the field of psychotherapy to document progress and show effectiveness. The evidence-based practice (EBP) movement has had considerable influence in the field of psychology as evidenced by the APA task force that adopted the stance of evidence-based practice in psychology (EBPP) to ensure quality and accountability for psychological services as well as the integration of science and practice. One of the primary components of EBPP is the use of routine outcome measures (ROMs), which seek to integrate research with practice while simultaneously documenting progress and enhancing treatment. Despite the wave of ROM in the field, implementation rates have remained low. Research has brought forth many practical and philosophical concerns of therapists using these measures in routine practice including time burden and local validity. The Clinically Adaptive Multidimensional Outcome Survey (CAMOS) was created to directly address clinicians' concerns with a specific focus on concerns of local validity. The CAMOS was designed to monitor several dimensions of functions, thus covering a wide range of issues. In this study the item pool proposed for the CAMOS was factor analyzed, and acceptable fit was found for a 6-factor model that contained 42 items. The 6 factors include (a) psychological distress, (b) relationship distress, (c) therapy expectations, (d) spiritual distress, (e) physical health distress, and (f) work/school distress. It is of note that spirituality emerged as a distinct factor with this data set and the implications and applications are discussed. With this multidimensional foundation, clinicians could more flexibly use the CAMOS to increase local validity. Clinical applications and future directions are discussed.

Background When planning evidence‐based intervention services for children with phonology‐based speech sound disorders (SSD), speech and language therapists (SLTs) need to integrate research evidence regarding service delivery and intervention intensity within their clinical practice. However, relatively little is known about the optimal intensity of phonological interventions and whether SLTs’ services align with the research evidence. Aims The aims are twofold. First, to review external evidence (i.e., empirical research evidence external to day‐to‐day clinical practice) regarding service delivery and intervention intensity for phonological interventions. Second, to investigate SLTs’ clinical practice with children with phonology‐based SSD in Australia, focusing on service delivery and intensity. By considering these complementary sources of evidence, SLTs and researchers will be better placed to understand the state of the external evidence regarding the delivery of phonological interventions and appreciate the challenges facing SLTs in providing evidence‐based services. Methods & Procedures Two studies are presented. The first is a review of phonological intervention research published between 1979 and 2016. Details regarding service delivery and intervention intensity were extracted from the 199 papers that met inclusion criteria identified through a systematic search. The second study was an online survey of 288 SLTs working in Australia, focused on the service delivery and intensity of intervention provided in clinical practice. Main Contributions There is a gap between the external evidence regarding service delivery and intervention intensity and the internal evidence from clinical practice. Most published intervention research has reported to provide intervention two to three times per week in individual sessions delivered by an SLT in a university clinic, in sessions lasting 30–60 min comprising 100 production trials. SLTs reported providing services at intensities below that found in the literature. Further, they reported workplace, client and clinician factors that influenced the intensity of intervention they were able to provide to children with phonology‐based SSD. Conclusions & Implications Insufficient detail in the reporting of intervention intensity within published research coupled with service delivery constraints may affect the implementation of empirical evidence into everyday clinical practice. Research investigating innovative solutions to service delivery challenges is needed to provide SLTs with evidence that is relevant and feasible for clinical practice

Preterm birth (PTB) and low birthweight (LBW) babies are the source of a large burden of infant, neonatal, and childhood morbidity. The purpose of this project was to expand the use of the CenteringPregnancyTM Group Prenatal Care Model as an evidence-based intervention for management of both medical and psychosocial risk in low-income, ethnic and racial minorities in New York City. The standardized model developed by Schindler Rising decreases the incidence of preterm birth and low birthweight and increases the rate of breastfeeding. A CenteringPregnancyTM program implementation plan, customized to meet the needs of a multisite urban hospital system, was coordinated with the Centering Healthcare Institute to ensure method fidelity while allowing for an individual site's needs based upon patient demographics and provider mix. Program evaluation showed that the logic models supported implementation and expansion of Centering Groups at 2 federally qualified health centers, with adequate progress toward site approval, method fidelity scores, and favorable patient and staff satisfaction ratings using the CenteringCountsTM data collection system. After a total of 4 Centering group cohorts with 26 women, 7 at high medical risk, 4 delivered preterm (11.5%), 2.3% less than the institutional average PTB rate of 13.8%. One out of 26 women delivered a LBW infant. Twenty-two of 24 women (92%) initiated breastfeeding compared to the institutional average of 89%. To foster a change in policy toward Centering as the default option for prenatal care, ongoing evaluation is required to assess the reduction of and fiscal impact on preterm and low birthweight rates to offset the cost of implementation.

Evidence-based practice (EBP) is used worldwide to improve the quality of patient care to provide cost-effective care. EBP is a mandate for nursing practice combining individual clinical judgment with available expertise to generate a positive outcome for the patient. Investigators have documented that nurses have varying degrees of confidence and knowledge about EBP. The purpose of this project was to improve knowledge of EBP among registered nurses (RNs). The ACE Star Model of Knowledge transformation was used as the conceptual model. The key project question was to assess the level of knowledge and confidence about EBP among RNs in a cardio-thoracic (CT) intensive care unit (ICU) before and after viewing a computer-based EBP educational module. The quasi-experimental project used a 1 group pretest-posttest design. In the pretest, a convenience sample (n = 29) completed ACE-ERI competencies to self-assess confidence in EBP and an EBP Knowledge Test. The participants then viewed an EBP educational module based on major steps in EBP practice. Afterward, they repeated both tests. As a group, the paired t test showed a significant increase in scores for the ACE-ERI competencies between pretest and posttest scores. Using the Wilcoxon Signed Rank Test, knowledge scores increased but were not statistically significant. These findings suggested that there was improvement in both confidence and knowledge supporting the use of the educational module. In order to effectively implement EBP, nurses require knowledge to assess the quality and evidence for improved patient outcome. These results can guide administrators and educators to enhance RN EBP by the use of educational modules to improve the quality of patient care creating positive social change.

Anterior knee pain (AKP) is a common, chronic lower limb musculoskeletal overuse condition that represents substantial morbidity to those affected, and has a significant impact on the health care industry. Health practitioners frequently prescribe foot orthoses in the management of AKP as an alternative or adjunct to multimodal physiotherapy. The primary aim of this thesis was to investigate the clinical efficacy of foot orthoses in AKP, utilising high-quality research methodologies. The two systematic reviews conducted have identified a significant gap in the literature regarding evidence from randomised clinical trials (RCTs) for foot orthoses in AKP and other lower limb overuse conditions. While the best evidence for AKP management was for multimodal physiotherapy, there was insufficient evidence to support or refute the use of foot orthoses in the treatment of lower limb overuse conditions, including AKP. Meta-analysis provided evidence to support the use of foot orthoses in the prevention of the first incidence of lower limb overuse conditions. An interesting finding was evidence from pooled and individual study data of no difference between custom and prefabricated foot orthoses in both treatment and prevention of lower limb overuse conditions, inferring that either type of orthosis may be utilised. Both systematic reviews highlighted substantial methodological flaws of the included studies, and recommended that future studies include larger participant numbers, longer participant follow-up, more consistent use of reliable and valid outcome measures and reporting of outcome data, and utilisation of the CONSORT guidelines in the design and reporting of RCTs. A 12-month prospective RCT investigated the short- and long-term clinical efficacy of prefabricated foot orthoses in the treatment of 179 participants with AKP. Foot orthoses were more effective than flat shoe inserts in the short term, implying that their contoured form has some therapeutic effect. Foot orthoses were not significantly different to multimodal physiotherapy over 12 months, nor was there any benefit in adding foot orthoses to physiotherapy. Considering that all groups experienced clinically meaningful long-term improvements in pain and function, clinicians may prescribe foot orthoses for AKP to hasten recovery. Findings of post-hoc analyses to develop a clinical prediction rule indicate that those of older age and shorter height, who have a lower severity of AKP and a more mobile midfoot, are more than twice as likely to experience a successful outcome with foot orthoses. As a secondary aim, this thesis has provided a more comprehensive profile of AKP as a condition. Baseline data from the RCT participants confirms previous reports of higher rates of AKP in females, and a tendency towards bilaterality and chronicity. This AKP sample did not differ from asymptomatic individuals in terms of body mass index, physical activity level, general and mental health, and foot posture, although they tended to have a more mobile foot under load. These characteristics tend to be homogenous across a number of published RCTs, indicating that the findings of the RCT described above are likely to be generalisable to the broader population with AKP. An additional finding in this group was that those with AKP of long duration, higher pain levels, lower functional levels, and an overall lower score on a specific measure of AKP have a poorer prognosis over 12 months, irrespective of their age, gender or morphometry. These findings suggest that, in order to improve prognosis and the chance of a successful outcome, the primary goals of intervention should be to reduce the severity and duration of AKP, through the use of early intervention with foot orthoses, multimodal physiotherapy, or a combination of the two.

Students with autism spectrum disorders present deficits in social interaction skills that may prevent their successful inclusion in general education placements. Considering the increasing number of children with autism spectrum disorders (ASD) being educated in inclusive settings and recent requirements on the use of research-based interventions in schools, the purposes of this study were (1) to evaluate the quality of single-case research and determine whether behaviorally-based interventions to improve social interaction skills of children with ASD in inclusive settings can be considered evidence-based practices and (2) to conduct a meta-analysis investigating whether specific factors such as participants' age, behavioral components used in the intervention, target social interaction skills, intervention implementer, and peer training moderate effectiveness of the interventions. Specific criteria for quality of single-case research were used to classify studies according to their certainty of evidence. Tau-U, a non-parametric index of effect size in single-case research, was used to measure the intervention's magnitude of change on target outcomes. Differences between levels of the moderators were analyzed using statistical significance test (p = .05) through the use of 83.4% confidence intervals. Results indicate that the use of behaviorally-based interventions to improve social interaction skills of students with ASD in inclusive settings can be considered evidence based practices. In addition, the interventions produced overall high effect size, indicating their effectiveness based on studies meeting minimum standards of methodological quality. More specifically, the interventions are demonstrated to be effective for preschool and elementary school children between the ages of 2 and 10 years. Studies targeting social interaction initiations or responses in isolation were more effective than studies focusing on both skills. While interventions using planned reinforcement were shown to be more effective, no differential effects were found regarding the use of planned modeling. No differences were found regarding intervention implementer. Finally, the use of peer training did not appear to increase effectiveness of the behaviorally-based social skill interventions. The results and their implications for practice and future research are discussed.

Pain management in hospitalized infants in the Neonatal Intensive Care Unit continues to be substandard despite the development and availability of evidence-based guidelines. The Evidence-based Practice Identification and Change (Lee et al., 2009) strategy is a multifaceted tailored intervention that has been used to promote evidence-based practice. However, the process of delivering the components of the intervention is not well understood and no valid measure for evaluating the fidelity of intervention implementation exists. The overall objective was to develop and determine the face validity, content validity, construct validity, feasibility, and clinical utility of the Process Evaluation Checklist. Three prospective studies were conducted. In Study 1, the face and content validity of the Process Evaluation Checklist was determined. In Study 2, the construct validity of the Process Evaluation Checklist was examined by assessing the fidelity of implementing the Evidence-based Practice Identification and Change intervention in a clinical setting. In Study 3, the feasibility and clinical utility of the Process Evaluation Checklist was determined. Overall, the face and content validity of the Process Evaluation Checklist was achieved. The intervention was implemented with high fidelity, supporting the construct validity of the measure. A Research Practice Council, with assistance from an external facilitator and internal facilitators, implemented multifaceted knowledge translation strategies in the form of constant reminders to improve sucrose administration practices. Post intervention admission orders were significantly more likely to include sucrose, and odds of being administered sucrose were 13 times greater compared to baseline. Beginning support was provided for the content and construct validity, feasibility, and clinical utility of the Process Evaluation Checklist for use with complex interventions. Using this measure to monitor intervention fidelity in different contexts and with different users over longer periods of time will provide additional support to the validity of the Process Evaluation Checklist.

Pain management in hospitalized infants in the Neonatal Intensive Care Unit continues to be substandard despite the development and availability of evidence-based guidelines. The Evidence-based Practice Identification and Change (Lee et al., 2009) strategy is a multifaceted tailored intervention that has been used to promote evidence-based practice. However, the process of delivering the components of the intervention is not well understood and no valid measure for evaluating the fidelity of intervention implementation exists. The overall objective was to develop and determine the face validity, content validity, construct validity, feasibility, and clinical utility of the Process Evaluation Checklist. Three prospective studies were conducted. In Study 1, the face and content validity of the Process Evaluation Checklist was determined. In Study 2, the construct validity of the Process Evaluation Checklist was examined by assessing the fidelity of implementing the Evidence-based Practice Identification and Change intervention in a clinical setting. In Study 3, the feasibility and clinical utility of the Process Evaluation Checklist was determined. Overall, the face and content validity of the Process Evaluation Checklist was achieved. The intervention was implemented with high fidelity, supporting the construct validity of the measure. A Research Practice Council, with assistance from an external facilitator and internal facilitators, implemented multifaceted knowledge translation strategies in the form of constant reminders to improve sucrose administration practices. Post intervention admission orders were significantly more likely to include sucrose, and odds of being administered sucrose were 13 times greater compared to baseline. Beginning support was provided for the content and construct validity, feasibility, and clinical utility of the Process Evaluation Checklist for use with complex interventions. Using this measure to monitor intervention fidelity in different contexts and with different users over longer periods of time will provide additional support to the validity of the Process Evaluation Checklist.

The overall aim of the present thesis was to explore and compare professional co-operation in child welfare investigations, explore the psychometric properties, and describe the clinical utility from different perspectives of a translated Swedish version of the standardized assessment instrument the Home Observation for Measurement of the Environment (the HOME Inventory). Social workers in Sweden, Denmark, Britain, Germany, and Texas (USA) co-operated with different professionals around a fictitious child welfare case. Differences were found between and within country-based samples, indicating an unsystematic work procedure in the social work agencies studied. The psychometric properties of the translated Early Childhood version (EC-HOME) and Middle Childhood version (MC-HOME) of the HOME Inventory were explored in terms of inter-observer reliability and by Rasch analysis. The samples were authentic Swedish child welfare cases recruited from a field setting. Inter-observer reliability was satisfactory. Results were ambiguous regarding measurement construction of the two versions studied. Because of the differentiating ability of the EC-HOME and MC-HOME, total scores could provide an indication of inadequate home environments. Experiences of social work practitioners of the clinical utility of the HOME Inventory suggested that they considered the instrument to be comprehensive and have explicit potential benefits, i.e. to be clinically useful. Correspondingly, caregivers’ overall perceptions of the HOME Inventory were positive, determining the content relevant and the format acceptable. However, certain flaws have to be rectified before the HOME Inventory is to be implemented and used successfully. Further, education and the possibility to practice administering the instrument seemed to be essential conditions for future use according to social workers. When social workers and teachers’ apprehensions about support and stimulation provided by caregivers to children in their home environments were compared, preschool teachers’ apprehensions correlated poorly with the social workers’ assessment. These results suggest that the HOME Inventory is promising but cultural adaptation and further studies of psychometric properties are necessary. Different forms of support to practitioners and agencies for successful implementation are required. Awareness of the type of information provided by different sources is important when co-operating in child welfare.

Nearly two decades of research on translating evidence-based care guidelines into practice has resulted in a considerable body of primary and secondary evidence about guideline implementation strategies and the individual, organizational and environmental challenges associated with closing the evidence to practice gap in primary care. Interventions to improve professional performance are complex and a disentangling of the various independent, intervening and constraining variables is required in order to be able to design and implement interventions that can improve primary care practice performance. The PRECEDE-PROCEED planning model (Green & Kreuter, 1999) provides a step-wise theoretical framework for understanding the complexity of causal relationships among the variables that affect the adoption of evidence-based practice and may assist in the design and implementation of practice-based interventions. Knowledge of an evidence-based practice guideline is important, but a consensus has emerged that having knowledge is rarely sufficient to change practice behaviour. Didactic education or passive dissemination strategies are ineffective, whereas interactive education, reminder systems and multifaceted interventions tailored to the needs of the practice are effective. Outreach or practice facilitation is a proven effective multifaceted approach that involves skilled individuals who enable others, through a range of tailored interventions, to address the challenges in implementing evidence-based care guidelines within the primary care setting. The challenges to implementing evidence-based chronic illness care practice guidelines are thought to be similar to the other contextual, organizational and individual behavioural challenges associated with the uptake of research findings into practice. A multifaceted guideline implementation strategy such as practice facilitation may be well-suited to improving the adoption of these guidelines within rural primary care settings. However, research has not systematically reviewed, through meta-analysis, the published practice facilitation trials to determine overall effects and an implementation research study of practice facilitation that has considered fidelity of implementation within the rural Ontario setting for a complex practice guideline such as chronic illness management has not been done. The systematic review in the thesis incorporated an exploratory meta-analysis of randomized and non-randomized controlled trials of interventions targeted towards implementing evidence-based practice guidelines through practice facilitation, and was conducted to gain an understanding of the overall effect of practice facilitation and the factors that moderate implementation success. The results were the identification of an improvement overtime in the methodological rigour of practice facilitation implementation research based on a critical appraisal of methods, a significant moderate overall effect size of 0.54 (95% CI 0.43 – 0.65) for 19 good quality practice facilitation intervention studies and several significant effect size modifiers; notably, tailoring to the needs of the practice, using multiple intervention components, extending duration, and increasing the intensity of practice facilitation were associated with larger effect sizes. As more practices were assigned to the practice facilitator, the effect diminished. A significant positive association between the number of PRECEDE predisposing, enabling and reinforcing strategies employed by the facilitator and the effect size was detected. The implementation research study utilized mixed methods for data collection as part of an embedded case study of four rural primary care practices to determine the implementation fidelity of the practice facilitation of chronic illness care planning and the factors that impeded and contributed to implementation success. The feasibility of and potential cost savings of practice facilitation via videoconferencing was also implemented for two of the practices. For those practices that successfully implemented care planning, fidelity was achieved for the implementation of care plans. On the other hand, the dosage, duration, component delivery of the practice facilitation intervention was low in comparison to other published studies, and tailoring of the intervention to the practice was inconsistent. Based on the qualitative analysis of physician interviews, the moderating factors for successful implementation were categorized into the broad themes of pessimism and tempered optimism. Pessimistic physicians were unsuccessful at implementation, lacked a willingness to engage and were uncomfortable with the patient-centred approach to chronic illness care. Optimists were positive about the psychosocial, patient-centred assessment aspects of the chronic illness care protocol and provided anecdotes of success in resolving patient problems. However, this was tempered as both pessimists and optimists reflected on the time intensive aspect of the protocol and the unlikelihood of widespread implementation without additional supports. Participating physicians were satisfied with the facilitator and the videoconferencing experience, and the intervention cost analysis revealed opportunities for cost saving via the use of videoconferenced facilitation. Improvements to the intervention suggested by participants included integrating chronic illness management with medical information systems, involving other health disciplines, and forming networks of community health resources and support services for health providers and patients. This work has demonstrated that although practice facilitation can successfully result in moderate significant improvements in practice behaviour, it is not necessarily singularly effective in all contexts or for all targeted behaviours. A complex practice guideline such as the chronic illness care management model is unlikely to be adopted in the current context of primary care in rural Ontario and as a consequence to have any impact on the health of chronically ill patients without further intervention supports, adaptation, and implementation research undertaken to demonstrate successful execution of chronic illness care management. Alternative care delivery models are required to address barriers and improve the delivery of chronic illness care management.