Evidence Based OT Practice, Part III: How to Become an Evidence-Based OT Practitioner

Evidence Based Practice Series (1)

Current literature indicates that many healthcare practitioners – including OT practitioners – are failing to identify or utilize high-quality, up-to-date sources of evidence and are instead relying on personal experience, popular media, and outdated treatment protocols to provide intervention.

 

I have observed firsthand the difficulty of integrating evidence into practice during my OT education and employment experiences. During one of my fieldwork placements, a veteran fieldwork educator with 15+ years of experience gave the same home exercise program (HEP) to every client she saw, despite their diverse diagnoses and abilities. Although one could argue that upper body strengthening may be generally helpful for any person who is recovering from illness or injury, I began to wonder whether or not giving the same handout and Theraband to every client was actually benefiting them. In short, what was the evidence supporting this practice?

 

The fieldwork educator certainly wasn’t harming any of the clients by giving them a generic home exercise program. But not causing harm isn’t a particularly good reason to use a treatment or intervention. By that logic, you could provide any treatment whatsoever as long as you aren’t hurting your patients! It seemed to me like this supervisor had simply included “home exercise program” as part of her routine, rather than carefully considering each person’s condition, learning style, or level of health literacy and incorporating this information into her plans of care.

 

I don’t fault my fieldwork educator for her actions; since joining the workforce I’ve experienced firsthand how challenging it can be to ensure that the interventions I provide are evidence-based. It’s exhausting to spend all day treating patients, answering emails, talking with interdisciplinary team members, documenting, and going to meetings – some days it feels like Googling an unfamiliar diagnosis is the most than I have the time or energy to do. Despite this, I push myself every week to read an article, pick a coworker’s brain, talk with a mentor, or find another way to continue incorporating evidence into my everyday practice. And I’ve found that while it’s not always easy, it is always worth it to find evidence to support the interventions I provide and grow my knowledge base and clinical skills.

 

Why Is It So Hard to be an Evidence-based OT?

There are a plethora of reasons why many occupational therapists struggle to consistently utilize evidence within their daily practice, such as:

  • Utilization of EBP leading to a disruption in established routines or workplace dynamics
  • Lack of research applicability to occupational therapy issues
  • Weak skills for “accessing and implementing evidence” (see the resources at the end of this post to help sharpen your own skills)
  • “High clinical workloads”
  • “Lack of time”

 

In addition to overcoming these challenges, researchers also found that increasing therapists’ use of evidence-based practice required in-depth involvement and support from clinicians, managers, and policy-makers that is not always easy to come by in the workplace.

 

The list below summarizes several additional barriers I have personally identified for many OT practitioners who struggle to utilize an evidence-based approach to practice:

  • Overreliance on anecdotal and personal experience as the most valuable forms of evidence
  • Limited ability to discern high-quality vs. low-quality evidence for OT interventions
  • Inability or unwillingness to identify appropriate research and other information to improve quality of interventions
  • Flawed belief that “there is no evidence” for most OT interventions, so any intervention is “fair game” for treatment

 

Clearly, evidence-based practice can present a challenge at the individual and organizational levels that can be difficult to overcome. However, if you are committed to becoming a more evidence-based practitioner, the tips below should help you get started and stay the path!

 

9 Tips for Incorporating Evidence into OT Practice

  1. Improve the quality of the evidence you are already using. Establish an “evidence baseline” for yourself to identify knowledge areas in which you are confident in your evidence base and those where you could use more recent or high-quality information. Make a short list of 4-5 assessments or interventions you use most often with clients. Then, use the OT-focused research pyramid, database searches, professional networks, and other sources to determine whether your evidence for each item on the list is high quality…or highly questionable.

    After conducting this exercise, you will have a good idea of which interventions are worth using and which ones might warrant a closer look. Based on the results of your self-assessment, you can choose to stop using certain interventions, gather stronger evidence for others, and expand the evidence base for those that are already high-quality.

  2. Apply the CRAAP test. This resource from California State University-Chico has a funny name and a serious purpose. The CRAAP test is quick and provides clear-cut guidelines for the evaluation of evidence that requires the user to answer a series of questions about the source to identify potential red flags. Example red flags include out-of-date studies or links, author biases or conflicts of interest, and lack of supporting evidence from multiple reputable sources. Using the CRAAP test before you use an evidence source (article, website, etc.) can give you a good indication of whether or not the material is legitimate or low-quality.
  3. Make EBP a habit. Make it part of your daily or weekly routine to look for articles and other information to support your interventions and recommendations. For example, after completing an evaluation or treatment, form a simple clinical question (“Do home exercise programs have an impact on functional outcomes?”). Then conduct a search using Google Scholar, AJOT, OT Practice, or other databases for relevant articles and information. Alternately, take time during one lunch break per week to research at least one intervention you would like to try with clients the following week. If you are a commuter, use your time on the bus, subway, or car ride to bookmark articles to read later. Before long, it will be habitual for you to hunt for evidence whenever you encounter a new clinical challenge!
  4. Develop a personal resource list or evidence library. You can improve your evidence base and professional credibility by maintaining a list of high-quality sources of evidence that clients, colleagues, and others can consult to understand the work you do as an occupational therapist. I took some time earlier this year to research and develop a binder of quick, evidence-based assessments to use in the acute care setting and it has become an invaluable resource for myself and my coworkers as we work towards incorporating more evidence into our hospital-based services. Start a Word document, Google Doc, or binder to house the resources you collect and share the information with your team members. Additionally, consider putting a little money aside each month or asking management for funds to purchase new tools or materials for your personal resource library. In time, you will have a variety of high-quality, up-to-date articles and sources to draw from in your daily practice.
  5. Start small and set SMART goals. If EBP has not been a regular part of your practice, don’t expect to change overnight! Start slowly and incorporate evidence into your practice over time with the use of SMART goals. As a starting point, estimate the number of treatments you provide per week or per month, and make it a goal to include evidence for five or ten percent of all your interventions in that period. As you build your evidence “library” and get more comfortable appraising and applying evidence, you will eventually be able to incorporate high-quality evidence into more and more of your treatments.
    • Example Short Term Goal: Lauren will read one research article per week to increase use of evidence-based OT interventions for post-stroke patients.
    • Example Long Term Goal: Lauren will participate in high-quality stroke intervention CE event within 6 months to strengthen clinical evidence base and improve client outcomes.

NOTE: I didn’t use this strategy at first, and during my previous job, I got extremely burned out trying – and struggling – to find evidence for the interventions my colleagues and I used with students as school-based therapists. Soon I got frustrated and gave up trying to find information for anything but the most challenging cases. If I’d known then what I know now, I would have realized that finding evidence for OT interventions can be difficult, and it’s unrealistic at this point in our profession’s history to expect to find irrefutable evidence for every intervention I provide. By starting small, you can avoid having a similarly negative experience with incorporating evidence into your practice.

  1. Advocate for access to EBP resources in your workplace. It can be difficult to be evidence-based in a workplace where this is not an existing benefit or cultural norm. If you don’t have access to high-quality journals, standardized assessments, or professional memberships and resources at work, ask your employer to make these resources available to you. Start by researching your department’s budget, patient population, and priorities and identify several resources that would improve your ability to meet your organization’s goals. Then, meet with coworkers and managers to discuss the multiple benefits of EBP for employees, patients, and the organization and how the resources you are requesting will help each of these stakeholders. Gaining access to evidence at work can also help educate leaders and colleagues on its importance and ultimately improve patient and organizational outcomes.
  2. Join a professional association or local library. If you aren’t working at a university or a university-affiliated facility, it can be very difficult to access high-quality sources of evidence to support your practice. Thus, joining AOTA, your state association, or the library of a local university can give you access to a plethora of resources (in the form of articles, systematic reviews, professional forums, and conferences) for a moderate price – with infinite potential for return on your investment with better information, better treatment, and better outcomes.
  3. Incorporate EBP into your professional network. The experience, knowledge, and resources available from coworkers, mentors, and others can be invaluable in improving your utilization of evidence in practice. Create a formal or informal journal club with your coworkers, collaborate with colleagues to create an EBP resource binder, connect with a professional mentor with expertise in your practice setting, or join an online network like AOTA’s CommunOT to get information and resources from OT practitioners around the world.
  4. Ask Wh- questions. Considering the Who, What, When, Where, and Why of your treatments can shed light on whether or not you are incorporating evidence into your practice successfully. Ask yourself several questions from each category to shed light on whether you should reconsider the use of a particular intervention or identify additional sources of information to support your treatments.

    If your answers to the questions below include responses like “Because that’s what I’ve always done,” “During an OT school class or CE course I took 10 years ago,” or “Because I saw it on Pinterest,” that’s generally not a good sign. And if you can’t answer a clinical question with at least one recent research study, critically appraised paper, systematic review, professional document, or other high-quality source of information, it’s time to find some new evidence (and possibly a new intervention)!

 

Who ·         Who recommended this intervention?

·         Who was this intervention designed for? Are the results applicable to my client or population?

·         Who developed this intervention? What are his/her relevant qualifications/credentials?

·         Who is a knowledgeable person I can ask about this intervention?

What ·         What is the underlying premise of this intervention? Is it applicable/appropriate for my client?

·         What areas of occupational performance am I impacting with this intervention? Do the client’s outcomes indicate that it is effective?

·         What level is the evidence for this intervention on the research pyramid?

·         What evidence or information could I provide for a caregiver who wanted to know more about the effectiveness of this intervention? Would I feel confident sharing it with them?

 

When ·         When did I last review the evidence for this intervention?

·         When was the evidence supporting/refuting this intervention published?

·         When was my last CE course on this topic?

 

Where ·         Where did I learn about this intervention? Was it a reliable source?

·         Where can I go to find evidence for this intervention?

Why ·         Why am I using or recommending this product/treatment/protocol/equipment?

·         Why should I trust the publishers of this evidence? What are their credentials?

·         Why does this intervention require the skills of an occupational therapist?

 

 

 

Conclusion

It can be a difficult transition from using “your gut” or “clinical experience” as your primary sources of evidence to including other forms – especially when accessing other forms of evidence requires more time and effort.

 

Although this post includes several strategies related to improving access to and use of research-based sources of evidence, it is important to acknowledge that evidence also comes in the form of client reports, behaviors, and preferences; therapist/caregiver/provider observations and reports; and therapist experience. And while these sources can be valuable evidence for (or against) specific interventions, if most of your current evidence is from “lower-level” sources like these, you should identify additional “high level” evidence sources (clinical trials, critically-appraised topics, professional documents, or systematic reviews) to supplement them or implement treatments with a stronger evidence base. OT evaluation and intervention services are holistic in nature, and truly occupation-centered and evidence-based practice requires that multiple sources be considered when developing and implementing a treatment plan.

 

Ultimately by using the tips above to hone your research skills, change your practice habits or workplace culture, and incorporating stronger evidence into your everyday practice, you will improve not just your clinical skills, but your clients’ outcomes.

 

 

ADDITIONAL RESOURCES

East Carolina University Libraries: If you feel that your skills for appraising and applying research could use a refresher, this resource from the East Carolina University Libraries provides a helpful overview of how to apply evidence-based practice as a healthcare practitioners. Click the tabs from left to right to learn about the foundations of evidence-based practice and establish skills for accessing, interpreting, and applying evidence. Of note, each source should be evaluated individually to determine its quality and applicability/generalizability to your research question. Case studies, qualitative research (phenomenological, ethnographic, narrative, etc.), and other forms of evidence found at the “bottom” of the hierarchy can provide strong evidence, and systematic reviews may result in a lack of compelling evidence for a particular treatment.

OTSeeker: The EBP resources from from OTSeeker provide a very clear introduction into the value of EBP and the process for successfully integrating evidence into your OT practice. Additionally it has helpful tip sheets and pages on finding free full articles, searching for evidence, and implementing evidence in practice.

 

AOTA: AOTA has a wide variety of EBP resources. Those I find most useful are the Practice Guidelines, OT Practice articles and references, and Critically Appraised Topics.

 

 

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