Evidence based practice is a vital component of professional development as it provides a framework in which practitioners can incorporate clinical expertise, best research evidence and patient values to provide the most appropriate and efficient service to their patients (Upton and Upton, 2006). A rigorous development process is required to develop an evidence based guideline (EBG) which is a valuable and accurate guidance on best clinical practice. This paper is a reflection of an Occupational therapy student who developed an Evidence based guideline (EBG) with a team. It will include the process that was undertaken to develop the guideline, the methods of assessing and appraising articles with a team to highlight any significant events that impacted my learning. The guideline is aimed at Occupational Therapists (OTs) who provide service to patients with Chronic Fatigue Syndrome (CFS).
It has been continuously emphasised that teamwork is a fundamental component of health-care delivery which has been supported by numerous frameworks and policy documents (Willard et al., 2009; Health & Care Professionals Council, 2016). Our team consisted of Occupational therapy students who had established a rapport with each other due to the social dynamic of our cohort. During the formation of our group, we all completed a Belbin (1993) team role questionnaire to characterise each member’s key attributes. The results from Self-perception Inventory (SPI) determined my role as the coordinator and resource investigator, which emphasised my role of delegating work and finding innovative ideas. However, it is difficult to conclude whether the roles that we were given from the test accurately reflected our attributes as some team role descriptions had similar features (Mathieu et al., 2014). We identified that we had a variety of Belbin roles in the group which allowed us to designate our project tasks depending on each member’s strengths. Our team consisted of seven members and we decided to pair up in groups of twos and threes for the appraisal process based on our confidence in using the Critical Appraisal Skills Programme tool (CASP, 2013). Due to the odd number of people in our group I teamed up with two fellow peers.
The group work required for this project has developed my ability to work collaboratively within a large team as well as enhanced my organisational and delegation skills. To ensure each team member understood the expected behaviour and contribution required towards the project, we created a group contract to set fundamental rules; with precautions for failing to meet the final deadlines of individual tasks. Formation of a group contract has shown benefits as it allows a team to develop a written agreement to formalise how a team will manage and organise the tasks throughout the process (Levi, 2016). Two members of the team were also assigned to complete the minutes due to their previous experience and to maintain consistency in quality. Smith (2013) suggests minutes can assist teams to keep track of progression, make decisions and develop action plans based on team development.
At the beginning of the project during the “norming” phase based on the Tuckmans model (Tuckman, 1965), the team agreed to delegate equal amounts of work for each individual. Equal distribution of work can maximise the success of group projects (Yang et al, 2012). However it became apparent midway through the project that some members were struggling with their workload and were unable to complete their tasks prior to the deadline. This resulted in my appraisal group picking up the additional work load which affected our morale; leading to disorganisation and lack of communication. This caused conflict and dissatisfaction within the team during the “Storming phase” (Klein et al., 2011). The team acknowledged that the lack of leadership may have caused the disorganisation. Beccaria et al (2014) states that the “Storming” phase (Table 1) enhances an individual’s problem solving skills, communication strategies and develops a perceptive understanding of team dynamics, which I believe reflects my experience.
|(Table 1) Gibbs Reflective Model (Gibbs 1988) Lack of leadership in the team|
|Description (What happened)||Team leaders play a fundamental role in influencing shared norms, helping the team manage their environment, and coordinating actions (Hanson and Ford, 2010). This reflection is based on the lack of leadership in our team throughout the process which affected the progression of our guideline. Due to the lack of leadership there were many disagreements regarding workload and the allocation of work to match individual strengths. The deadlines set by the group during the creation of our contract also diffused our focus and slowed down the progression of our project. In this case, the lack of leadership affected the team’s morale and caused conflict with the production of our guideline.|
|Feeling (What were you feeling)||As the beginning of this module a team leader was not assigned as we agreed that we would share the team leader role. This is based on the Alimo-Metcalfe and Alban-Metcalfe model (2001) on transformational leadership which focuses on the team having a shared goal and a distribution of leadership power to everyone in the team. I felt that it was ideal to take this approach so that everybody has the opportunity to experience the leadership role, as it would allow us to practice our skills in management, organisation and delegation of work and ensure that all opinions are taken into consideration. Research support the benefits of a transformational leadership approach, explaining that professionals who embrace the values of such leadership create teams with higher levels of motivation, performance and satisfaction, in addition to lower levels of burnout and stress (Pieterse et al., 2010).
According to the Belbin team roles (1993) my role was the co-ordinator therefore I thought it would be ideal if I took on the leadership role with setting realistic deadline of completing individual work. However due to attendance issues with fellow team members I felt that I had to take on more work of creating and developing the guideline design as well as inputting and organising the information on the guideline. During the process we were split into group of twos and threes for our appraisal groups and I felt that my appraisal group were very supportive as we had to pick up extra work in order to complete the guideline on time.
I often felt that my appraisal group felt overwhelmed with the amount of work we had to complete when other team members were absent. In order to be an effective team leader in healthcare, it is important to be supportive, compassionate and fair in order to promote effective collaborative work (West, 2015). I believe that during the process I was able to provide emotional support when the morale was low and empowered team members through encouragement.
|Evaluation (What was good and bad about the experience)||I felt that the experience was useful for me to develop my leadership skills as it taught me the importance of time management and keeping an open communication with my team. In order to support my team members we decided to use a social media “Whatsapp” and created a group which allowed us to communicate outside the university and provide advice to each other. However I often felt that the conversations were misinterpreted which caused tension within our group. In research it has been recommended conflict management and negotiation should be discussed face to face rather than through an electronic medium as it requires complex interaction, observation of non-verbal communication and the need to build trust (Desivilya et al, 2010). I therefore found it useful to arrange a group meeting where we discussed the reasons of why we need to distribute our work load and importance of attendance in each session.
I felt that the core reasons of the conflict in our group were due to some members had to contribute extra towards the development of the guideline. Two members of the team were unable to attend many sessions and in order to make sure that we were on track my appraisal group were picking up extra workload.
|Analysis (What sense can you make of the situation)||Throughout the process I felt that we were rushing to finish the guideline therefore everyone felt quite pressured. I assume that as we split the articles up for each pair to CASP and grade, some pairs were completing their tasks quicker than others. I consider that we didn’t spend enough time in organising our deadline to understand how much time each member required and if any additional support was needed.
Weberg (2012) suggests that traditional leadership which presume a top-down power dynamic are no longer effective for dealing with the increasing adaptive challenges which face the health care. Therefore it is important to incorporate leadership styles which values individual contribution and creates an atmosphere where desirable behaviours such as attention to detail and mutual respect is reinforced (NHS Leadership Academy, 2013). Due to the lack of leadership we were unable to support each other during a stressful period as we were worried about completing our individual work. This prevented the group from discussing the progressive steps required to complete the guidelines.
|Conclusion (What else could you have done)||In order to overcome disagreement and reduce confusion, the team could have arranged more group meetings to set deadlines which suited everyone’s needs. We could have clarified whether additional support was required to other pairs with appraising and grading, as some team members found grading their articles confusing and stressful.|
|Action Plan (What would you do if it occurred again?)||
The topics of interest were gained from a group brainstorm and personal placement experiences. The final topic was chosen by a majority vote which created a guideline for Occupational Therapists to provide service to patients with chronic fatigue syndrome. In order to ensure that the systematic literature search that we conducted was thorough with a clear focus, we developed a PICO (See table 2). The PICO helps professionals articulate the important aspects of the clinical question that is most applicable to the patient. This assists the searching process by identifying the key terms for an effective search strategy (Houser, 2013). It has been identified that to create an effective guideline the literature search should be transparent and reproducible to minimise distribution biases (Brink, Walt and Rensburg, 2012).
|P (Population)||I (Intervention)||C (Comparison)||O (Outcome)|
|Adults 18-65 males/females with chronic fatigue syndrome||Occupational Therapy approach on all available interventions||No treatment, Patient who have received treatment and the outcomes||Increased awareness for OTs on the service they could provide for CFS patient
Reduced fatigue for CFS patient
Educating CFS patient
In order to carry out the systematic literature search the PICO helped us identify clear search terms along with our inclusion and exclusion criteria (Table 3).
We carried out a comprehensive search using multiple databases (including hand searches) in order to provide us with numerous articles which have been published in the last 10 year which are in English language. Lisa (2009) highlights that it vital to have an inclusion/exclusion criteria, as it provided a baseline set of standards of the research articles that are being collected. The breakdown of our search results in included in (Table 4).
|(Table 3): Databases used, Key words searched with inclusion and exclusion criteria|
|Databases to search||MEDLINE, AMED, CINAHL, Pyscarticles, Psycinfo, OT journals, Assia|
|Key words to search||Patient (Component of PICO)
Chronic fatigue syndrome
|Intervention (Component of PICO)
|Inclusion/Exclusion criteria (Filters)||Inclusion||Exclusion|
English only language
Have the condition longer than 3 months
Chronic fatigue syndrome
|Paediatrics and teenagers (19 and under)
Older adults (Aged 65 and over)
ME / Myalgic encephalomyelitis
No studies before the year 2006
Exclude existing conditions
|(Table 4) : Total number of search results with application of filter of Year and Language|
|Articles found though database with filters
(CINAHL, MEDLINE, AMED, Pyscarticles, Psycinfo, OT journals, Assia)
|Total number of articles after duplicate articles removed from database search||43|
|Remaining articles after application of PICO/Inclusion criteria||26|
|Articles found through Hand search||7|
As a team we screened the articles by title and abstract and then delegated an equal number of articles to each member of the group. We decided that every member would appraise 5 articles and then swap the articles within their appraisal team. The aim was to improve precision and reduce any details which may have been overlooked. We recognised that there was a high level of irrelevant articles included such as book abstracts and news articles which should have been eliminated during the screening stage. As we were able to identify this problem at an early stage of the process we were able to hand search articles which were relevant and inclusive to our PICO. We decided to use the CASP tool to appraise our articles as all team members had previous experience of using this appraisal tool. The CASP allowed us to organise our review; as research shows that the tool assesses both internal and external validity as well as the relevance and reliability of the literature (Aveyard, H, 2010; Krainovich-Miller et al., 2009).
We created a front sheet to summarise our CASP findings of each article which outlined the findings, strengths, weaknesses, a grade and our rational for including/excluding the article. Grading the quality of the evidence of each article indicates the extent to which our team were confident that the estimated results from the study are adequate to support particular recommendations (Balshem et al., 2011). The team struggled when grading the articles as we had mixed methodology articles and some members wanted to use two grading systems; The hierarchy of evidence for assessing qualitative health research (Daly et al., 2007) and the SIGN grading system (Harhour and Miller, 2001). I recommended using one grading system since this would make our guideline more precise and understandable for the target audience. Therefore to overcome the confusion the team collectively assigned a level of evidence and strength to the recommendation using the SIGN criteria (Harhour and Miller, 2001).
Midway through the process, the team realised that each appraisal group used a different approach during the appraisal process. We recognised that some groups were sharing their front sheets with their appraisal partner which may have caused confirmationbias and reduced consistency of the quality of our appraisals. This may have impacted the reliability of the evidence base for our guideline since consistency in the process is crucial when developing an EBG; only then can we ensure that the recommendations are explicitly linked to the clinical evidence available (Heselmans et al., 2013). I reflected (Table 5) on how the appraisal process could have been more rigorous if the team communicated openly to improve the validity of our appraisals.
|(Table 5) Gibbs Reflective Model (Gibbs, 1988) Validity of appraising|
|Description (What happened)||As a team, we decided to create a front sheet for each article we reviewed which summarises the Methodology, sample size, findings, strengths, weaknesses and the reasons why we should include or exclude the study in our guideline. My article group included three team members due to the odd number in the whole group. We decided to appraise our five individual articles and then exchange our articles within the group including the front sheet. However, one pair in the team informed us that they didn’t share their front sheet with their appraisal pair to keep the information blinded. In contrast, my group shared the front sheet which may have caused confirmation bias as we may have read what a peer has reviewed about an article and altered our view on the article to support their decision. This affected the quality of our assessment as we were unable to review the articles with consistency.
We were aware that high-quality evidence does not essentially imply strong recommendations (Balshem et al., 2011). Therefore it was important that we reviewed the articles thoroughly in order to find recommendations which had shown a beneficial result.
|Feeling (What were you feeling)||I felt that the pair that did review each article blinded (not knowing what their partner has written in their appraisal) was a more valid way of conducting the review. The reviewing process was challenging as we were not able to establish consistency during the appraisal process. It would have been ideal to discuss with the team prior to appraising the article on the technique that we would be using within our pairs. In order to do this the team could have had an open conversation with ideas regarding the appraisal process.|
|Evaluation (What was good and bad about the experience)||The good thing about this experience is that when we were informed about how a pair blinded their appraisal from their partner, we were able to reflect on this as a group. We discussed how it would have been useful to have had a protocol on how to appraise the articles within pairs. The National Institute for Health and Care Excellence (2012) (NICE) emphasise using two or more reviewers to independently assess the quality of studies in order to reduce bias and risk errors. Although my group did independently appraise the articles, we were still able to read the analysis carried out by a peer. However, I felt that this experience has taught me a valuable lesson on how to reduce/minimise the risk of bias during the appraisal process by ensuring that in future project my group is more systematic with our method.|
|Analysis (What sense can you make of the situation)||I recognised that precision and consistency during the appraisal process is significant for the quality of our guideline and the level of evidence. Dearholt et al (2012) empathise the importance of having a transparent method during the appraisal process in order to maintain reliability. However due to the lack of communication during the beginning of the process this affected our appraisal method as we were unable to discuss the use of the front sheet.
The World Health Organization (2012) recommend that the quality of each article should be assessed by one reviewer and then rechecked by another reviewer. I believe that my appraisal group did incorporate this strategy however the only difference was that we had the front sheet which contained the review of a peer.
The group reflected on the value of effective communication via either face to face or mobile messaging and highlighted the importance of having a set procedure for everyone to follow. We were able to learn from this process for future guideline development.
|Conclusion (What else could you have done)||To sustain the reliability of our appraised articles it would have been ideal for the team to discuss the procedure of how we were going to use the front sheet and whether we were going to share them with our pairs. Krainovich et al (2009) emphasised how communicating is a key attribute in a group project as it helps build a team’s focus and provides a clear idea of what is expected from each individual. It also aids individual goals which affects the overall objective for a successful project (Brown et al., 2011). I believe that I could have arranged a team meeting to discuss how we were going to use the front sheet as well as suggested to the whole group to CASP one study (same one) individually to determine the quality and their confidence in appraising.|
|Action Plan (What would you do if it occurred again?)||
I appraised 15 articles altogether which are listed below in (table 6). The articles were appraised using the CASP tool and then rechecked by designated appraisal group members. This prevented any article being unjustifiably accepted or rejected. Any articles that had differences in opinion relating to the grading of the evidence resulted in a discussion with the whole team.
In order to aid the interpretation of our recommendations, we wanted to use the best available evidence to create our guidelines using the hierarchy of evidence. We were all aware that high-quality evidence does not essentially imply strong recommendations (Balshem et al., 2011).The hierarchy of evidence have been developed in health care to rank research according to validity (Hoffman et al., 2013) Most of our evidence were qualitative studies which were well-conducted with consistent key findings and themes. Qualitative methods are useful as they can access people in real life situations to gain an in-depth understanding of participants behaviour and the effects of an intervention (Yin, 2010). We also researched NICE guidelines to gain an overview of the standards and protocol of their clinical guidelines in order to improve the quality of our guidelines.
When grading the articles a team member assigned (Pinxsterhuis, 2015) a 2- which was considered too weak to include in our guideline as she identified that there could be possible response bias, however I disagreed and explained that the authors involvement in the development and piloting of the programme could have produced a richer and deeper evaluation compared to an external moderator. The article was discussed with the whole team who decided to grade it a 2++. Discussing the opinions of other team members ensured that our decision was comprehensive which caused some stress in our team however improved our clinical reasoning skills. Farh and Lee (2010) acknowledged that moderate levels of conflict for team projects have been shown to be beneficial for group performance as it increases divergent thinking and improves decision quality
We established the emerging themes from our articles which were collated to develop a body of evidence for our recommendations. We were able to collate evidence for four recommendations which include: Education, Referral for Cognitive behavioural therapy (CBT), Self-management groups and Pacing. We recognised that it was difficult to grade the “Mindfulness” recommendation due to the varying level of evidence. Therefore a team member suggested to include a disclaimer so that the OTs would consider the recommendation with consultation from health professionals.
|(Table 6) Articles critically appraised||Study Metholody and level of evidence||Included and Excluded and the reasons why|
|Pinxsterhuis, I., Hellum, L.L., Aannestad, H.H. and Sveen, U. (2015) ‘Development of a group-based self-management programme for individuals with chronic fatigue syndrome: A pilot study’, Scandinavian Journal of Occupational Therapy, 22(2), pp. 117–125.||Qualitative research method
|Drachler, M. de L., Leite, J.C. de C., Hooper, L., Hong, C.S., Pheby, D., Nacul, L., Lacerda, E., Campion, P., Killett, A., McArthur, M. and Poland, F. (2009) ‘The expressed needs of people with chronic fatigue syndrome/Myalgic Encephalomyelitis: A systematic review’, BMC Public Health, 9(1).||Systematic review
|Gray, M.L. and Fossey, E.M. (2003) ‘Illness experience and occupations of people with chronic fatigue syndrome’, Australian Occupational Therapy Journal, 50(3), pp. 127–136.||N/A||Excluded:
|Chambers, D., Bagnall, A.., Hempel, S. and Forbes, C. (2006) ‘Interventions for the treatment, management and rehabilitation of patients with chronic fatigue syndrome/myalgic encephalomyelitis: An updated systematic review’, Journal of the Royal Society of Medicine, 99(10), pp. 506–520. doi: 10.1258/jrsm.99.10.506.||Systematic review
Good level of evidence:
|Mellin, T. and Anne, H. (2010) Sick and Tired. Occupational Health 62(8), 24-27.||N/A||Excluded :
This was not a study but a published article which discussed the prevalence of CFS and the legal aspects around the condition.
|Moore, L. (2000) Chronic Fatigue Syndrome: All in the Mind? An Occupational Therapy Perspective. British Journal of Occupational Therapy 63(4), 163-170.||N/A||Excluded:
|Damme, V. S., Crombex, G., Houdenhove, V. B., Mariman, A., Michielsen, W. (2006) Well-being in patients with chronic fatigue syndrome: The role of acceptance. Journal of Psychosomatic research 61(1), 595-599.||Qualitative research method
Good level of evidence:
|Reynolds, F., Prior, S., Vivat, B. (2008) Women’s experiences of increasing subjective well-being in CFS/ME through leisure based arts and crafts activities: A qualitative study. Disability and Rehabilitation, 30(17), 1279-1288.||Qualitative research method
|Mallet, M., King, E., White, D. D. (2016) A U.K. based review of recommendations regarding the management of chronic fatigue syndrome. Journal of psychosomatic research 88(1), 33-35.||Qualitative research method
Good level of evidence:
|Goudsmit, E. M., Jason, L. A., Nijs, J. and Wallman, K. E. (2012) Pacing as a strategy to improve energy management in myalgic encephalomyelitis/chronic fatigue syndrome: a consensus document. Disability and Rehabilitation 34 (13), 1140 – 1147||N/A||Excluded:
|Jason, L., Benton, M., Torres-Harding, S. and Muldowney, K. (2009) The impact of energy modulation on physical functioning and fatigue severity among patients with ME/CFS. Patient Education and Counselling 77 (2), 237 – 241.||N/A||Excluded:
|Johnson, S. K. (2008) Treatment approaches to chronic fatigue syndrome. Medically unexplained illness: Gender and biopsychosocial implications. Washington, DC, US: American Psychological Association. 173-179. http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2007-11978-011&site=ehost-live||N/A||Excluded:
|Knott, L. (2008) Chronic
fatigue syndrome. GP, 30.
|Littrell, N. M. (2012) Misconceptions concerning chronic fatigue syndrome (CFS) among medical practitioners without CFS specialization. 73. US: ProQuest Information & Learning. http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2012-99160-234&site=ehost-live||N/A||Excluded :
This project has enhanced my understanding of the importance of EBG to support clinicians and patients clinical decisions. The process has allowed me to practice my systematic data-searching, comprehensive appraisal skills and clinical reasoning skills to provide a rationale for the included articles. I have reflected on how the guideline we produced required best available evidence for us to be confident that the recommendation we made would have a beneficial outcome. However, it is often difficult to make recommendations due to the lack of research (Oxman, 2004). I believe that my assigned Belbin roles of co-ordinator and resource investigator reflected my contribution in the team to a certain extent as I utilised my strengths in organisation, taking leadership when under pressure and being creative during the formation of the guideline. The team work required during the guideline development has improved my interaction skills and social support for peers, tested my critical thinking skills and enhanced my perception of team-based learning as effective and motivating. In the future I will have more confidence to take lead in group based projects.
The development and implementation of clinical guidelines are effective advances for defining and improving the quality of care as they can provide professionals with reliable advice and enable them to justify their practice (Stergiou-Kita, 2010). This guideline has been produced for Occupational Therapists who work with patients with chronic fatigue syndrome in order to support them with planning and implementing evidence based interventions. The guideline is applicable to patients in the community/outpatient setting with moderate-severe CFS and the recommended interventions should be facilitated by a qualified Occupational Therapist.
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SCHOOL OF HEALTH STUDIES
Student Assignment – Self-Assessment
MARKING CRITERIA – LEVEL 6
- You are required to complete this form & submit it with your assignment.
- This form provides an opportunity for you to reflect upon the work you are submitting for assessment.
- This is an important key skill that will contribute to your development as a reflective & evaluative practitioner.
- Completion of the form will assist lecturers in providing feedback, which is appropriate to your individual needs.
- This form will not be viewed until the script has been marked.
- The final mark awarded is not negotiable.
|Intake: 2017||1st Submission
– Evidence Based Guideline Development
|Academic Style||Comments: (i.e. What did you do well, not so well etc.)
I have used the module handbook and the health studies guidance to present my research report
I have proof read my work to ensure that my spelling and grammar is correct
I have used professional language throughout my work and have gained feedback from my mentor on how to improve my sentencing
|Learning Outcomes & Application||Comments:
I have used the assessment criteria to structure my work and ensured that i have covered all the areas required and have reflected on areas which I felt was a beneficial experience
I ensured that I included relevant content by reviewing our past lessons and reading my past reflections of group sessions.
I have reviewed the minutes to ensure that I have included all parts of the project
I have followed the Harvard referencing guide provided by the UoB
|Relevant Analysis & Argument||Comments:
I have discussed how my team systematically choose our articles and how we used the CASP tool to analyse them
I have provided a through methodology with a break down to demonstrate how we carried out our search
I have showed my analysis in my reflection on how the experience has developed my skills
|Relevant Investigation & standard of referencing||Comments:
I have used a wide range of resourced and used the Harvard guideline to reference
I used a varied of literature to back up my learning
|What changes have you made to your paper now you have reviewed the marking criteria?
I went back and ensured that my sentencing was easily readable and used more up to date sources to back up my work
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