Professional Documents
Culture Documents
Bennet 2000 The Process of EBP PDF
Bennet 2000 The Process of EBP PDF
Feature Article
As we move into the 21st century, there are increasing demands placed on occupational therapists to
ensure their practice is based on sound evidence. Evidence-based practice is an approach to clinical
decision making that has gained considerable interest and influence during the last decade. This
article describes and explains the process of evidence-based practice and its application to clinical
occupational therapy practice. Directions for resources that may assist therapists' self-directed
learning are also provided. As health care becomes more evidence-based, awareness of the principles,
skills, and resources for evidence-based practice is of relevance to all occupational therapists.
Bennett, S. & Bennett J.W. (2000). The process The demand for maximum quality of care,
of evidence-based practice in occupational combined with the need for prudent use of
therapy: Informing clinical decisions. Australian resources has increased pressure on health care
Occupational Therapy Journal, 47, 171-180. professionals to ensure that clinical practice is
It is published in the print edition of the Australian
based on sound evidence. Changes in
Occupational Therapy Journal and is available on treatments, an exponentially increasing volume
the Blackwell Synergy online delivery service, of research information, and increasing
accessible via the journal's website at: expectations from clients to provide the best
http://www.blackwell-synergy.com/doi/abs/ 10.1046/ care possible, place high demands on therapists
j.1440-1630.2000.00237.x
or www.blackwell-synergy.com
to maintain a service that is based on current
best evidence. This article outlines the process
Correspondence: of evidence-based practice as a means for
Sally Bennett informing the clinical decisions made by
Department of Occupational Therapy, School of occupational therapists.
Health and Rehabilitation Sciences, The University
of Queensland, Queensland 4072, Australia.
Email: sally.bennett@uq.edu.au The phrase 'evidence-based medicine'
originated in the 1980s as a way of describing
Accepted for publication August 2000
Used with permission: Australian Occupational Therapy Journal (2000), 47, 171-180
A literature search is undertaken to identify the therapists use to describe elements of practice
best research evidence available to answer the they are, by and large, still applicable to
question. As not all studies are well performed, occupational therapy practice.
a critical appraisal of the article for its validity
and clinical usefulness is important. Perhaps the Questions commonly emerge concerning the
most crucial aspect of the evidence-based effectiveness and choices of occupational
practice process is the use of evidence with the therapy treatments, how treatments are best
client. Clinical reasoning is used to determine implemented, and whether there are any
whether the evidence 'fits' with each feature of associated difficulties. Research evidence can
the client's context (person, occupation and also be used to answer 'prognostic' questions,
environment). Particular attention should be such as what the likely clinical course,
given to the preferences and values of the complications, or consequences of a disease,
client. Consideration must also be given to the injury or disability may be. Occupational
practice setting, clinical expertise, and therapists can use this sort of research evidence
resources available to the therapist. Clients, and to help clients understand, plan and cope with
where appropriate families or carers, are their situation.
actively engaged in the decision making
process to determine the action to be taken. Questions concerning diagnosis are also
Although not represented in the framework, relevant for occupational therapists although
evaluation of this process is undertaken to there are significant conceptual differences to
determine improvement in relevant outcomes traditional medical diagnosis. Rogers and Holm
and to identify factors that will make the (1991) refer to an occupational therapy
process more efficient (Sackett et al., 1997). diagnosis as a problem statement that describes
occupational status deficits amenable to
therapy. Rather than arriving at a label or
classification of a disease, as is often the case in
ASKING CLINICAL QUESTIONS medicine, occupational therapists identify
deficits in performance components,
Types of questions occupational performance or role performance.
Therapists use a range of assessment processes
There are many times that new information is to arrive at an occupational therapy diagnosis
required when seeing clients in order to resolve including history taking, physical examination
clinical problems and make treatment and standardized assessment tools. Many
decisions. These questions may relate to a questions concerning diagnosis can be
specific client or groups of clients. The types of answered by dialogue with the client,
questions that arise reflect the core clinical observation and clinical reasoning. However,
tasks of occupational therapy practice. there are other diagnostic questions that may be
Categories of clinical questions classified by answered by evidence from research that has
proponents of evidence-based medicine been performed with similar groups of patients
include, but are not limited to, questions or clients. Such questions include what the
concerning diagnosis, treatment/prevention, and most likely occupational diagnoses might be for
prognosis (Sackett et al., 1997). There is some clients presenting with a particular constellation
debate over the relevance of these categories to of problems, or which assessment measures
occupational therapy practice (Egan, Dubouloz, have the highest accuracy.
von Zweck, & Vallerand, 1998). While these
are not always the common labels occupational
Used with permission: Australian Occupational Therapy Journal (2000), 47, 171-180
Questions about what the most common When a specific client is being considered, the
occupational issues are likely to be for specific question can take into consideration the client's
client populations can be informed by context. Aspects of the person, such as the
descriptive research, and knowing what the client's values and preferences, knowledge
likely concerns or experiences clients may have about their environmental context and
can be answered by qualitative and descriptive occupational factors can further influence what
research ( Tickle-Degnen, 1999). Although the information is sought.
emphasis of this paper is on the use of
evidence-based practice in clinical care, Based on the clinical question formulated, a
therapists also participate in questions of a non- literature search strategy can then be
clinical nature, such as economic or policy formulated that includes search terms reflecting
issues. Examples of clinical questions relevant each component of the question. As it is
to occupational therapy are provided in Table 1. impractical to search the literature to find
Discussion about what 'categories' of clinical answers for every clinical question that arose, a
questions are most relevant and reflect the core logical approach would be to focus efforts on
clinical tasks of occupational therapy practice issues that arise frequently or that fit with the
may help to clarify the process further. client and therapy context.
Question formation
*Systematic reviews of these study types provide stronger evidence than single studies of the same type.
become outdated. Hence the focus of 'evidence' judgements on the validity and clinical
within the evidence-based practice framework relevance of the findings (Bury & Jerosch-
has most commonly been on clinically relevant Herold, 1998). Evidence-based practice focuses
research evidence, whether it is quantitative or on those papers that are clinically relevant, and
qualitative in nature (Sackett, Richardson, that use the best methods for each clinical
Rosenberg & Haynes, 2000). question (Bennett & Glasziou, 1997).
Research evidence is most frequently found in Importantly, the recent position statement of the
peer-reviewed journals as this is where results Canadian Association of Occupational
are first published and where enough detail on Therapists regarding evidence-based practice
methodology exists to make informed highlighted the need to integrate research
Used with permission: Australian Occupational Therapy Journal (2000), 47, 171-180
information with information from the client Considerable emphasis has been placed on
and from clinical experience (Canadian randomized controlled trials (RCT) as they can
Association of Occupational Therapists minimize the likelihood of bias in the
(CAOT), the Association of Canadian conclusions of studies addressing treatment
Occupational Therapy University Programs effectiveness. However, RCT are not
(ACOTUP), the Association of Canadian appropriate for answering all types of clinical
Occupational Therapy Regulatory questions, and other research methodologies
Organizations (ACOTRO) and the Presidents may need to be considered, depending on the
Advisory Committee ( PAC), 1999). question concerned ( Sackett et al., 1997). For
example, while RCT provide strong evidence
Hierarchies of evidence for the effectiveness of treatments, cohort
studies are more appropriate for 'prognostic'
The second issue is what constitutes 'best' questions.
evidence. Hierarchies of scientific evidence are
available, formulated with respect to the ability The commonly cited hierarchy of treatment
of various methodologies to reduce bias ( Ball, effectiveness, such as that used in the National
Sackett, Phillips, Haynes & Straus, 1999). The Health and Medical Research Council
type of clinical question being asked will (NHMRC) clinical practice guidelines, places
determine which research methodology can systematic reviews and RCT at the top of the
provide the best evidence, and hence what type hierarchy ( NHMRC, 1999). Any adherence to
of studies to search for ( Bennett & Glasziou, this hierarchy as a dictum for 'best evidence' by
1997). Research using the strongest and most external stake-holders can pose a problem for
appropriate study design for the question being the rehabilitation disciplines. Due to the highly
studied, will provide the best evidence. individualized nature of the treatments that are
Hierarchies of evidence are commonly often delivered by occupational therapists, and
presented for questions concerning treatment heterogeneity in the client groups examined,
alone; however, different hierarchies of RCT may not always be appropriate
evidence exist for other types of clinical (Ottenbacher,1990). Many questions
questions. Table 1 presents study designs in concerning the effectiveness of occupational
descending order of methodological rigour, for therapy treatments are more suited to quasi-
different types of clinical questions. This has experimental or single case experimental
been summarized from a number of sources ( designs (Johnston, Ottenbacher & Reichardt,
Ball et al., 1999; Bennett & Glasziou, 1997; 1995). Additionally, in many cases it is simply
Bury, 1998; Sackett et al., 1997). A more not feasible to carry out RCT ( Guyatt et al.,
complete collection of levels of evidence that 1986). However, there are biases in these other
considers different types of questions can be study designs that should be recognized, and
accessed from the following web address: that limit the certainty with which one can state
http://www.cebm.net/levels_of_evidence.asp that effects were due to the treatment ( Johnston
( Ball et al., 1999). et al., 1995). These biases need to be
considered and conveyed in clinical decision
Systematic reviews use rigorous methods to making. While such hierarchies can provide
locate, assess, and summarize the results of useful guidelines, continued discussion within
many individual studies ( Glanville & Lefebvre, the occupational therapy profession and with
2000). When available, appropriate and well external stake-holders regarding the
performed, systematic reviews can provide the applicability of the 'treatment' hierarchy to
best evidence (Oxman, Cook & Guyatt, 1994). occupational therapy is warranted. This issue
Used with permission: Australian Occupational Therapy Journal (2000), 47, 171-180
has been picked up by the NHMRC who have Effectiveness (DARE), the Cochrane Review
recognized that in many health disciplines, Methodology Database, and the Cochrane
RCT are often not appropriate, and that these Controlled Trials Register (CCTR)
disciplines 'should not be disadvantaged by the
rigid application of a hierarchy of evidence' (Australasian Cochrane Centre, 1999). In 2000,
(NHMRC, 1999; p. 14). CDSR contained 795 completed systematic
reviews, with 738 protocols. DARE is
Although there is a substantial focus on well- maintained by the National Health Service
performed quantitative research methodologies Centre for Reviews and Dissemination at the
as sources of strong evidence, qualitative University of York, UK, and contains hundreds
research is suitable for answering questions of abstracts, and references to over 1000
concerning how patients experience different systematic reviews not covered by the CDSR.
illnesses and treatments, or for gaining There are many reviews pertinent to
understanding about the workings of health occupational therapy practice contained on
services ( Gray, 1997). Qualitative research can these databases; however, they are not always
also play an important role in understanding identified by the term 'occupational therapy' as
how evidence for treatment effectiveness might many of the reviews are a result of
be applied to, or received by, particular patient multidisciplinary collaboration.
groups ( Taylor, 2000).
Journals such as Evidence-Based Medicine,
In summary, 'best' evidence comes from studies Evidence-Based Mental Health and Evidence-
with the strongest and most appropriate Based Nursing, contain structured abstracts that
methodologies for the specific clinical question give a clinical commentary and a 'bottom-line'
under consideration. conclusion about the clinical practices
reviewed. Although the majority of the reviews
How to search for evidence are directly related to medicine and nursing,
there are a number that also apply to
Sources of information are growing rapidly. occupational therapy practice. Notably, the
With millions of new health research articles Evidence-Based Nursing journal also contains
published each year, methods for focusing on brief abstracts of clinically relevant qualitative
the most relevant information are important. A research.
useful starting point is the use of specialist
databases or journals that only include articles If relevant information is not available in this
that meet a minimum entry standard. Examples type of source, traditional databases can be
of these databases, journals and web sites are searched (see Table 2). Many of these
listed in Table 2. databases are available through the internet, and
others are available at institutional libraries.
One of the most helpful resources is the
Cochrane Library, established as part of the When high quality research on the effectiveness
Cochrane Collaboration. The Cochrane of occupational therapy interventions is
Collaboration is an international effort that lacking, this does not preclude therapists from
aims to carry out high quality systematic taking an evidence-based approach. What is
reviews, and to locate existing systematic important is to seek and utilize the best
reviews and RCT. It contains the Cochrane available evidence (Sackett et al., 1997).
Database of Systematic Reviews (CDSR), the
Database of Abstracts of Reviews of
Used with permission: Australian Occupational Therapy Journal (2000), 47, 171-180
Bibliographic Databases
MEDLINE , PubMed, Embase, CINAHL,
CURRENT CONTENTS, SCIENCE CITATION
INDEX, ASSIA, CANCERLIT, HealthSTAR,
DISSERTATION ABSTRACTS, PROCEEDINGS.
Additionally, evaluating the effectiveness of the develop evidence-based practice skills. Equally
treatment or clinical practices implemented, in high on the agenda should be the development
terms of improvement in relevant outcomes, of succinct, clinically relevant summaries of
makes it possible to determine if the evidence- evidence to enable clinicians to rapidly access
based decision-making process has been pre-appraised evidence. Models for such
successful. Evaluation leads to asking more resources already exist in the medical and
questions and so the cycle continues (Bennett & nursing professions. This is likely to require a
Glasziou, 1997). continued international effort involving both
clinicians and academics.
ACTION TOWARDS EVIDENCE-BASED
PRACTICE CONCLUSION
Commonly cited barriers to the use of an The framework presented in this paper is
evidence-based practice approach by health offered as a means of helping clinicians move
professionals include limited time, information from 'paper to practice'. As indicated in the
overload, lack of skills in interpreting research framework, central to the evidence-based
results, or lack of research evidence (Rosenberg practice process are the client and the context
& Donald, 1995). Although this research was of therapy. These factors determine how
not carried out with occupational therapists, research evidence is used in making decisions.
these issues may well be similar. Some of the Clearly, the use of research evidence is only
ways in which occupational therapists can one part of the picture. Integration of research
overcome these barriers and promote an evidence, information from clients, and
evidence-based practice approach include the clinicians' experience are essential to sound
following: clinical decision making.
Acknowledgements
We gratefully acknowledge the comments and advice provided by Sylvia Rodger (the University of
Queensland) regarding the framework for evidence-based occupational therapy practice presented in
Figure 1, and the support of the University of Queensland Evidenced Based Occupational Therapy
Group.
References
• Naylor,C. D. (1995). Grey zones of clinical • Sackett,D. L., Rosenberg,W. M., Gray,J. A.,
practice: some limits to evidence-based Haynes,R. B., Richardson,W. S. (1996).
medicine. Lancet, 345, 840 842. Evidence based medicine: What it is and what
• Ottenbacher,K. (1990). Clinically relevant it isn't. British Medical Journal, 312, 71 72.
designs for rehabilitation research: The • Taylor,M. C. (2000).Evidence-based
idiographic model. American Journal of practice for occupational therapists. Oxford:
Physical and Medical Rehabilitation, 69, 286 Blackwell Science.
292. • Tickle-Degnen,L. (1998). Quantitative
• Oxman,A. D., Cook,D. J., Guyatt,G. H. research series. Communicating with clients
(1994). Users' guides to the medical literature. about treatment outcomes: The use of meta-
VI. How to use an overview. Evidence-Based analytic evidence in collaborative treatment
Medicine Working Group. JAMA, 272, 1367 planning. American Journal of Occupational
1371. Therapy, 52, 526 530.
• Rogers,J. C . & Holm,M. B. • Tickle-Degnen,L. (1999). Organizing,
(1991).Occupational therapy diagnostic evaluating and using evidence in occupational
reasoning: A component of clinical reasoning. therapy practice. American Journal of
American Journal of Occupational Therapy, Occupational Therapy, 53, 537 539.
45, 1045 1053.
• Rosenberg,W. & Donald,A. (1995).
Evidence-based medicine: an approach to Sally Bennett BOccThy(Hons); Sessional
clinical problem-solving. British Medical Lecturer and PhD Scholar, Department of
Journal, 310, 1122 1126. Occupational Therapy, School of Health and
• Sackett,D. L., Richardson,W. S., Rehabilitation Sciences, The University of
Rosenberg,W., Haynes,R. B. (1997).Evidence- Queensland.
based medicine: How to practice and teach John Bennett BMedSc, MBBS, BA(Hons),
EBM. Edinburgh: Churchill Livingstone. FRACGP; Adjunct Senior Lecturer,
• Sackett,D. L., Richardson,W. S., Department of Social and Preventive Medicine,
Rosenberg,W., Haynes,R. B. (2000).Evidence- University of Queensland.
based medicine: How to practice and teach
EBM (2nd edn). Edinburgh: Churchill
Livingstone.