Evidence-Based Practice by Psychologists Treating Secondary Psychological Injuries Within State Insurance Regulatory Authority Governed Frameworks

Abstract

While psychopathology arising from musculoskeletal injury (i.e., secondary psychological injury) is predictive of poor recovery by injured people claiming compensation, the application of evidence-based practice (EBP) treatment guidelines is associated with improved outcomes. In 2010, the State Insurance Regulatory Authority (SIRA) in New South Wales (NSW), Australia- a body that governs the regulatory functions of Workers Compensation (WC) and motor vehicle Compulsory Third Party (CTP) insurance schemes-implemented EBP treatment guidelines. These guidelines are contained in the document titled: Clinical framework for the delivery of health services (Transport Commission & WorkSafe Victoria, 2012). At the time of conducting this research, the SIRA EBP treatment guidelines had been in effect for over five years; however, their effect on psychologists' practice and injured persons' outcomes was unknown. Therefore, the aims of the thesis were to: 1) to examine the effect of the introduction of the EBP treatment guidelines on claims cost and injured person outcomes within the SIRA insurance schemes and assess the use of EBP by psychologists treating musculoskeletal injuries with secondary psychological injury in this context, 2) to identify barriers to psychologists' use of EBP from the perspective of psychologists and 3) from the perspective of key stakeholders and 4) to elicit and test the feasibility of recommendations made by expert psychologists to improve psychologists' practice. <br/> Study 1 investigated whether the implementation of EBP treatment guidelines had reduced claims costs, improved injured person outcomes and resulted in psychologists using EBP. From a time range sample of n = 238 administrative records of people with a musculoskeletal injury and secondary psychological injury, the results revealed that the implementation of EBP had acted as a buffer against broader negative trends in claims cost and return to work timeframes (i.e., compared to the population of injured people n = 26,254 who had suffered a musculoskeletal injury and not consulted a psychologist during the same time period). The second phase of the study included a qualitative case-level analysis of n = 12 WC files and n = 9 CTP showed that within both WC and CTP positive injured person outcomes occurred when psychologists' adherence with EBP guidelines was high. However, the findings also showed that psychologists' application of EBP treatment guidelines was suboptimal. <br/> Study 2 explored the barriers in psychologists' adherence with the SIRA EBP guidelines. Psychologists (n = 20) practicing within rural, regional and metropolitan in NSW participated in focus groups. The results revealed three key issues functioned as barriers: 1) a lack of trust in the validity of the recommended EBP guidelines, 2) a lack of knowledge of the psychologist's role in this context and insufficient skills to fully apply the guidelines, protocols and procedures and 3) a poor fit between EBP guidelines, client presentations and circumstances and the SIRA compensation schemes. The findings showed that both individual practitioner variables and contextual barriers influenced adherence to EBP. <br/> Study 3 explored the contextual barriers that were identified in Study 2 as affecting practice. These included perceived barriers created by general practitioners (GPs), insurers and injured patients' actions. A sample of n = 27 participants was involved. The results showed that GPs were reticent to access psychological services due to a poor fit between their practice and treatment guidelines. Insurers lacked trust in the validity of 'secondary psychological injury' claims and this was exacerbated by psychologists' non-adherence to insurers' protocols and deficits in insurers' knowledge. Injured peoples' willingness to engage with treatment was impaired by a poor fit between the treatment guidelines and their experience of insurers' and psychologists' practices. <br/> Study 4 elicited recommendations to overcome the barriers in psychologists' adherence to EBP guidelines that were identified in Study 2 and examined the feasibility of their implementation. The recommendations proposed by field experts (n = 8) included: 1) mandatory training and continuing professional development in the area of practice, 2) using independent consultants for expert advice, 3) completion of outcome measures prior to the first session, 4) completion of a treatment plan in-session with the injured person and 5) completion of outcome measures in the eighth and final session. These recommendations were considered feasible by most of the participating psychologists (n =150). <br/> Taken together, the findings of this project highlight the important role of psychologists in the treatment of musculoskeletal injuries with secondary psychological injury and reinforced the need to integrate the best available research evidence with clinician's expertise and patient expectations and values to deliver beneficial outcomes to people. In addition, the findings illustrate that while psychologists have skills in the treatment of mental disorders they may not be competent in EBP approaches for managing and addressing pain and functional disability arising from secondary psychological injury within the compensation frameworks. The findings also highlight that to increase the application of EBP guidelines, a broad-based commitment from all stakeholders within the SIRA compensation schemes is required. This includes education programs that support all stakeholders to understand that the management of secondary psychological injuries requires a functional restoration perspective within a biopsychosocial paradigm. Lastly, empirical data from the research can be used to encourage stakeholders to change their practices and for policymakers, administrators and professional associations to provide support to facilitate psychologists' adherence with EBP in ordinary clinical settings.