Canadian Association of Occupational Therapists

Joint Position Statement on Evidence-based Occupational Therapy (1999 reviewed for currency 2009)

By the Canadian Association of Occupational Therapists (CAOT), the Association of Canadian Occupational Therapy University Programs (ACOTUP), the Association of Canadian Occupational Therapy Regulatory Organizations (ACOTRO), and the Presidents' Advisory Committee (PAC)

This joint position statement reviews the background, information, responsibilities and challenges required for evidence-based occupational therapy. It is hoped that this will be of use to those who require knowledge of how evidence is used by occupational therapists. Those interested may be occupational therapy students, practitioners, educators, researchers and regulators, as well as clients, administrators, payers and other health, social service or education workers.

Background

Occupational therapists continually make decisions to determine how to proceed with their clients (Mattingly & Fleming, 1994). Decisions are formed using information from the client, occupational therapists' experiences with previous clients, research findings and expert opinion from a variety of sources (Belenky, Clinchy, Goldberger & Tarule, 1986; Clark, Scott & Krupa, 1993; Dubouloz, Egan, von Zweck & Vallerand, 1999; Kirby & McKenna, 1989). Guidelines for critically evaluating information from diverse sources may be found in a number of disciplines (e.g. philosophy, history, medicine and law). Occupational therapists are urged to adhere to evidence-based practice since consumers, payers and practitioners want services based on the best available evidence regarding their effectiveness. Occupational therapists believe that evidence-based practice is a major element of what is now described as best practice.

Occupational therapists have tended to take evidence-based medicine as a starting point for evidence-based occupational therapy (Law & Baum, 1998). In evidence-based medicine, epidemiologic criteria are used to critically evaluate research evidence related to specific medical treatments. (Rosenberg & Donald, 1995). Treatment decisions are based on this critical evaluation as well as professional judgment using the previous experience and knowledge of the client.
(Sackett, Rosenberg, Muir Gray, Haynes & Richardson, 1996). Strict adherence to the procedures of evidence-based medicine may limit the occupational therapist who strives to enable occupation using a client-centred, occupation-focused approach.

Information required for evidence-based occupational therapy Congruent with enabling occupation, the production, retrieval, review, and evaluation of information is viewed as a joint responsibility of the client and therapist working in a collaborative relationship (Canadian Association of Occupational Therapists, 1997). Moreover, the focus is on information regarding occupational performance issues relating to the quality of life of individuals; or the empowerment of groups to achieve realization of their occupational performance potential through lessening the effects of barriers to achievement in areas such as employment, housing, leisure or self-care.

The client provides expert knowledge crucial for determining meaningful occupational priorities. The client's perspective on medical, developmental and social barriers to occupational performance is included as important information for understanding and taking action on issues. Also important are the client's subjective evaluation of present capacities, knowledge of personal and environmental resources and limitations, desired outcomes, acceptability of specific plans and criteria for success.

The occupational therapist provides knowledge of client, environment and occupational factors relevant to enabling occupation. Ideally, this evidence is derived from a critical review of the research literature, expert consensus and professional experience. The occupational therapist uses this information to assist the client to name and prioritize occupational performance issues. The client is encouraged to discover new ways of viewing occupational performance problems, implement accurate methods to assess present capacities, and consider suggestions for use of personal and environmental resources. The client then, with the therapist, formulates targeted outcomes, and commits to specific intervention plans and methods of evaluating desired outcomes (Egan, Dubouloz, von Zweck & Vallerand, 1998; Fearing, Law & Clark, 1997).

Responsibilities

Evidence-based occupational therapy demands that both the client's knowledge and the occupational therapist's knowledge be used in decision making. The individual, group, agency or organizational client must be given every opportunity to articulate and share knowledge. The occupational therapist must use all reasonable means to continually expand his or her professional knowledge base through review and critical evaluation of related research, professional literature and continuing education. The client must have regular opportunities to contribute whatever knowledge can be brought to the decisions required. Occupational therapy clients have the right to know why specific methods are used. Occupational therapists are responsible to ensure that evidence used in decision making is made explicit to clients.

Outside the client-occupational therapist interaction, occupational therapy education programmes are responsible for preparing future therapists for evidence-based occupational therapy practice. Regulatory organizations are responsible for protecting the public from incompetent practitioners. Competent practice includes reasonable efforts to base decisions on a critical review of the evidence, whether it be from the scientific literature, expert consensus or professional experience. Professional associations are responsible for facilitating evidence-based continuing education programmes and assisting occupational therapists to practice evidence-based occupational therapy through such actions as the promotion of research, publication of evidence, and the sponsorship of easy-to-read reviews of evidence in common practice areas.

Challenges

Challenges and opportunities abound in developing evidence-based practice. Occupational therapists and clients must work together to identify what they mean by best practice in enabling occupation. Funding arrangements and policy must be structured to support the time and resources required for evidence based occupational therapy. Occupational therapists, clients, administrators, regulators, the public at large and the professional and academic community must assume an active role in advocating change. The net result is that clients and payers are the benefactors of occupational therapy services which are based on the best available evidence.

Glossary

Best practice: a term used in business, health and education referring to procedures which are believed to result in the most efficient provision of a product or service. Occupational therapists believe that evidence-based practice is a major element of what is now described as best practice.

Occupational therapy clients:  individuals or groups who receive occupational therapy services. They may include persons with occupational problems arising from medical conditions, transitional difficulties or environmental barriers, families and caregivers of such persons, or organizations wishing to promote the health of their members.

Enabling occupation: the process of facilitating, guiding, coaching, educating, prompting, listening, reflecting, encouraging, or otherwise collaborating with people so that they may choose, organize, and perform those tasks and activities of everyday life which they find useful and meaningful in their environment (CAOT, 1997).

Evidence-based medicine: medical intervention which is based on the results of the most scientifically sound research applicable to the problem at hand, considered in light of patient characteristics and clinical judgment.

Evidence-based occupational therapy: client-centred enablement of occupation based on client information and a critical review of relevant research, expert consensus and past experience.

Payers: agencies who provide reimbursement for occupational therapy services.

References

Canadian Association of Occupational Therapists. (1997). Enabling occupation: An occupational therapy perspective. Ottawa, ON: CAOT Publications ACE.

Dubouloz, C.J., Egan, M., von Zweck, C., & Vallerand, J. (1999). Occupational therapists' perceptions of evidence-based practice. American Journal of Occupational Therapy, 53, 445-453.

Egan, M., Dubouloz, C.J., von Zweck, C., & Vallerand, J. (1998). The client-centred evidence-based practice of occupational therapy. Canadian Journal of Occupational Therapy, 65, 136-143.

Fearing, V.G., Law, M., & Clark, J. (1997). An Occupational Performance Process Model: Fostering client and therapist alliances. Canadian Journal of Occupational Therapy, 64, 7-15.

Law, M., & Baum, C. (1998). Evidence-based occupational therapy. Canadian Journal of Occupational Therapy, 65, 131-135.

Mattingly, C., & Fleming, M.H. (1994). Clinical reasoning: Forms of inquiry in a therapeutic practice. Philadelphia: F.A. Davis.

Rosenberg, W., & Donald, A. (1995). Evidence based medicine: An approach to clinical problem solving. British Medical Journal, 310, 1122-1126.

Sackett, D.L., Rosenberg, W.M.C., Muir Gray, J.A., Haynes, R.B., & Richardson, W.S. (1996). Evidence-based medicine: What it is and what it isn't. British Medical Journal, 312, 71-72.

Appendix

The Evidence-based Joint Position Statement has been prepared with the input of the Canadian Association of Occupational Therapists (CAOT), the Association of Canadian Occupational Therapy University Programs (ACOTUP), the Association of Canadian Occupational Therapy Regulatory Organizations (ACOTRO), and the Presidents' Advisory Committee (PAC). The latter three organisations are made up of the representatives of the occupational therapy academic programmes, the provincial regulatory organisations, and the provincial professional associations, respectively. The participation of these groups represents a desire to reach a broad common understanding on this topic; it does not imply the explicit endorsement of each constituent of these consortiums.

Position statements are statements on political, ethical and social issues that impact on client welfare or the role and practice of occupational therapy, or that affect the Association. They are frequently time-limited and persons wishing to use them more that two years after publication should confirm their current status by contacting the CAOT Director of Professional Practice by e-mail: practice@caot.ca

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