Evidence based practice and

its integration into practice

By Laxmi Sutar , MOT 1st year
Guide: Ms. Shubangi , Associate Professor
• Evidence-based practice is composed of three equal core components:

(1) the current best evidence,

(2) the treatment environment, and
(3) each client's values and circumstances which, in combination with a
clinician’s expertise, aid in clinical decision making.
Organizing Evidence around Central Clinical
Tasks
• Evidence-based clinical reasoning involves the use of all forms of evidence
in the pursuit of optimal client outcomes. It is the integration of scientific
reasoning with reasoning that has been matured by clinical experience,
validated practice theory, and client-centered values and ethics .
• One of the first clinical tasks that the practitioner faces in working with a
client is getting to know the client.
• One aspect of getting to know a client is obtaining background knowledge
about the client's disorder. Background knowledge provides the basic
information on the clinical nature of a disease .
• The task of getting to know a client also involves gathering evidence
that is descriptive of the experiences and needs of clients with the
disorder in general .
• Research designs that would be relevant to this aspect of getting to
know the client are descriptive research, such as qualitative studies
and case series, and exploratory research, such as cross- sectional
studies and cohort studies.
• Diagnosis, assessing the presence and degree of disorders and their
effect on a client’s current status with respect to occupational needs
and status, is an important part of getting to know a client .
• High quality evidence on diagnostic tools ensures that services are
relevant and beneficial, specifically for that person.
• Research designs that would be relevant to this task are exploratory
research, such as cross-sectional studies and case-control studies .
• Choosing an effective treatment approach and procedure for
addressing the client's specific needs and goals.
• The task of choosing an effective intervention for a client involves
gathering evidence that evaluates the effectiveness or efficacy of a
type of intervention in comparison to alternative interventions or no
intervention at all.
• The most relevant research designs are experimental research, such as
randomized clinical trials (RCTs), quasi-experimental studies, and
exploratory research such as cohort studies .
• A third central clinical task is that of estimating the probable outcomes
for the patient based on variables such as the client age, history,
comorbidities, symptoms, and response to treatment, often referred to as
prognosis.
• This task assists the occupational therapist and patient to engage in
long-range treatment planning as well as discharge planning, including
additional therapies, home programs, education and training, and
accessing re- sources.
• The most relevant research designs are exploratory research, such as
cohort studies and case-control studies, or descriptive research, such as
case series .
The Steps of Evidence- Based Practice
1. Writing an answerable clinical question
2. Gathering current published evidence that might answer the question
3. Appraising the gathered evidence to determine what is the “best”
evidence for answering the question
4. Using the evidence to guide practice for individual clients by
collaboratively communicating the results to patients
Step 1: Writing an Answerable Clinical Question
• The question must be written by using key words and terminology that
tap into a general body of research literature that may hold an answer
to the question and that locates evidence that is relevant to performing
a particular clinical task with a specific client.
• There are two types of questions: background questions and
foreground questions
• Background questions identify descriptive research that is used to
better understand the nature of the problem.
• There are two elements to a background question: a question's root
(e.g., who, what, when, where) combined with a verb and a disorder,
problem, or some aspect of patient care .
• Foreground questions are about current knowledge related to best
practice treatment of a specific patient.
• They focus on recent interventions, diagnostic tests, potential patient
outcomes, and theories about causation
• There are three to four elements to an answerable foreground
intervention research question
1. The patient, population, or problem (P). The element identifies
features of the client population of interest, such as the client’s clinical
condition or diagnosis, gender, ethnicity, age group, and socio-
economic status.
2. The intervention of interest (I). This can be a specific technique or a
general type of treatment.
3. The comparison treatment (C). The best intervention studies are
experimental and examine the effectiveness of one treatment in
comparison to some other treatment.
4. The desired outcomes (O). These should be concrete results that are
directly applicable to occupational performance.
• The foreground question is often referred to as a PICO question (the
acronym of the first letters of each element).
• The PICO type question has to be modified when looking for diagnostic or
prognostic evidence.
• For diagnostic/assessment questions, the intervention will become a
diagnostic tool, whereas the outcome will be the ability of the tool to
accurately identify the degree of the problem, distinguish a diagnosis, or
the psychometrics of the tool.
• Prognosis, too, requires modifications in the standard PICO question with
the intervention becoming predictor variables that are expected to alter
outcomes, and the outcomes tending to focus on long-term participation,
health and wellness, and quality of life.
Step 2: Gathering Current Published Evidence
• Once a clinical question has been written, the practitioner draws on the
elements of the question to search for and gather evidence to answer
the question.
• Each element of an answerable clinical question contains one or more
key terms for searching the literature. It is important to generate a list
of synonyms for each key term in each element of the question before
beginning the search.
• Pubmed
• Medline
• Step 3: Appraising the Evidence
• The term best evidence is often used in relationship to evidence-based
practice.
• Evidence that is clinically useful and valuable
(1) is relevant to the clinical task,
(2) is trustworthy,
(3) has generalizability, and
(4) has clinically important results
Appraising the Relevance of a Research Study
• The relevance of a research study is determined by the degree to which it
answers the clinical question and how well its methods fit within the
constraints and resources of the practitioner's context of practice
• The most relevant research study is one that
• (1) investigates a variable that is the occupational variable of interest or
one highly related to that variable,
• (2) includes research participants who are members of your client’s
population, and
• (3) offers clinical methods that are suitable to your context of practice.
Appraising the Trustworthiness of a Research Study
• The trustworthiness of a research study is assessed primarily as a degree
of fit between the researcher's research question, or purpose, and the
methods of the study.
• A trustworthy study is one for which the conclusions are defensible with
respect to the methods of the study, and there are few, if any, alternative
plausible explanations—scientific explanations for the findings beyond
the conclusions drawn from the study and its
researchers .Trustworthiness is enhanced when the researcher carefully
and rigorously maintains standards of discovery, description, and
explanation.
• The most trustworthy research study is one that
• (1) uses a study design that will achieve the stated purpose and
• (2) provides various methods to enhance trustworthiness within the
study design with respect to standards of science.
• The first area to assess to determine the trustworthiness of a study is to
ensure that the best design was used to answer the research question.
• The second area to assess to determine the trustwor- thiness of a study
is the use of methods to reduce bias and enhance validity.
Interpreting the Results of a Study: Generalizability and Clinical
Importance
• First, the results must be generalizable from the sample to the
population; and second, they must be clinically important
• A hallmark of the quantitative paradigm of research and the scientific
method is the aim of understanding general, population-centered truths
rather than individual outcomes
• Inferential statistics allow us to determine how confident we should be
that sample results can be applied or generalized to the client
population.
• Statistical significance focuses on the ability to generalize the results
from the sample to the population, regardless of how effective those
results are.
• Statistical significance is strongly tied to sample size because it
examines the probability that the results rep- resent a true effect.
• An effect size describes the magnitude of the difference between two
treatment effects or the magnitude of the relationship between two
variables using some form of a standardized score.
• Another way to determine clinical effectiveness is the minimal
clinically important difference (MCID).
• The MCID is the smallest change in an outcome that will lead to some
perceived clinically beneficial improvement.
• Systematic reviews are frequently cited as the best “best evidence”
because they synthesize the results from multiple studies
• A meta-analysis, a form of systematic review that includes statistical
techniques to combine the results of multiple studies into a single
effect size, provides one of the best overall reviews of evidence.
• The best evidence is the best that can be found and not best in the
sense of meeting all of the standards. The possible answer this best
evidence delivers may be one about which you can feel a high,
moderate, or low degree of confidence.
Step 4: Using the Evidence to Guide Practice
• evidence- based practice emerges from the core values and ethics of
occupational therapy
• Evidence-based practice occurs in a respectful, truthful, and
collaborative relationship with the client and with those acting on the
client’s behalf.
• Clients are viewed as active contributors to the planning and
intervention pro- cess of therapy rather than as passive recipients of
infor- mation or services
• The main goal of communicating about evidence is to inform the process
of decision making .
• Communication that achieves these types of decisions
• (1) has content that accurately represents the research evidence, including
its strengths and weaknesses related to relevance and trustworthiness;
• (2) involves language that is mutually understand- able to all
participants; and
• (3) encourages an open and mutual discussion of information and ideas
rather than a closed-ended or unidirectional delivery of information from
one individual to another.
• One implication of autonomous reasoning and action is that clients can
choose to participate or not participate in occupational therapy
assessments and interventions.
Summary
• Evidence-based practice has become an integral part of occupational
therapy practice.
• In combination with the treatment environment and client values and
circumstances, evidence forms a strong base from which to achieve
best practice clinical decision making.
• To best inform the process of decision making, evidence can be
clustered into three types of clinical tasks: getting to know the client,
or diagnosis; choosing an effective treatment, or intervention; and
estimating probable outcomes, or prognosis.
• Occupational therapists must develop the skills to identify answerable
clinical questions, find and critically appraise research to identify the
best evidence for each of the clinical tasks, use their clinical expertise
to integrate this best evidence with their clients’ values and needs, and
implement it within their treatment environment.
• Critically appraising the evidence involves identifying the relevance,
trustworthiness, generalizability, and clinical importance of research.
• Once best evidence is determined, occupational therapists must be
able to communicate the evidence to clients to ensure collaborative
and informed treatment decisions.
• Without skills in evidence-based practice, an occupational therapist
will not be competitive in today’s health care system.
• Evidence- based practice takes time and energy; the skills needed are
acquired through active learning and practice.
• Throughout your career as an occupational therapist, you will refine
and improve your skills and ensure that you use the best evidence to
provide the best treatment for all of your clients.
• Article
• Title: Student perspectives on factors that influence the
implementation of evidence-based practice in occupational therapy
• June 2021
• Authors: Danielle Hitch et.al
Danielle Hitch,Kelli Nicola-Richmond, Kieva Richards, Rachel
Stefaniak
• Abstract
• Aim: Evidence-based practice (EBP) is perceived as an integral component of contemporary allied health
practice. While allied health clinicians (such as occupational therapists) have generally positive attitudes
towards EBP, research suggests that they find its implementation consistently challenging. The
professional literature increasingly suggests that more effective EBP learning takes place when social
constructivist approaches to learning are adopted.
• The authors of this study sought to use the pre-existing knowledge and perceptions of occupational
therapy students to inform a curriculum review of an EBP unit. Therefore, the aim of this content analysis
study was to investigate how occupational therapy students perceive and critically analyse factors that
influence the implementation of EBP, specifically strengths, weaknesses, opportunities and threats
(SWOT).
• Methods: The study sampled students in the third year of a 4-year, Bachelor level Australian Occupational
Therapy Program. The students were undertaking the first of two EBP units, and data were collected from
the first assignment they submitted for these units. The assignment required the students to complete a
SWOT analysis of EBP in occupational therapy, and response to a statement around whether it should be
mandatory. Data were collected over 2 consecutive years from a total of 64 occupational therapy students.
All data collected were subjected to content analysis, with themes identified by at least 25% of students in
each cohort retained for analysis and formation into overall themes.

• Results: Participating occupational therapy students identified five strengths, four weaknesses,
six threats but only one opportunity for EBP. Three key themes were identified within the data:
first, the role and purpose of EBP; second, the resources it requires and third, factors that
influence its success. The students perceived the main purpose of EBP as supporting positive
practice change, and highlighted its roles in building clinician capacity and professional
credibility. They also characterized EBP as a separate and specialist practice that requires
specific training and resourcing to achieve, and questioned its feasibility as an integrated part of
daily practice. Along with previously identified challenges around time and resourcing, the
students also highlighted negative attitudes and beliefs from senior colleagues as an important
negative influence on the success of EBP.
• Conclusion: The current study consolidates a growing body of international literature about the
value of social constructive approaches to EBP in undergraduate education. Vertical
constructive alignment that embeds EBP through undergraduate education, rather than the
provision of 'EBP'-specific units, should now be considered best practice. However, this
embedded approach requires the explicit and repeated communication of the presence of EBP in
all learning opportunities, to enable students to recognize opportunities to deploy their existing
knowledge and skills.
References
• Willard and Spacksman’s Occupational Therapy ,13 th edition
• Willard and Spacksman’s Occupational Therapy, 12 th Edition