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Ensuring That Education, Certification, and Practice Are Evidence Based
Abstract
The occupational therapy profession has put forth a vision for evidence-based practice. Although many practitioners express a commitment to the provision of services informed by evidence, the reality that tradition still determines much of our education, certification, and practice cannot be ignored. In this article, we highlight the disconnect between the profession's aspirations and actual practices using neurophysiological models as an example. We describe actions to actualize the shift from traditional interventions to evidence-based approaches. We challenge readers to become agents of change and facilitate a culture shift to a profession informed by evidence. It is our hope that this article will provoke critical discourse among educators, practitioners, authors, and editors about why a reluctance to let go of unsubstantiated traditions and a hesitancy to embrace scientific evidence exist. A shift to providing evidence-based occupational therapy will enable us to meet the objectives of the Centennial Vision.
... Nonetheless, an undercurrent of value for INCREASING OCCUPATION-CENTERED PRACTICE IN SNFS 35 occupation and a desire to create an authentic therapy experience often push therapists either to seek meaning in their practice by framing component-based interventions with occupation in mind, or by hiding occupation-centered practice (Burwash, 2013;Hanson, 2009). On a collective professional level, literature reveals a call for continued research yielding evidence to support the use of occupation-centered practice, and to prepare students entering the profession with evidence based practice skills and relevant theory to face the scholarship-practice gap in medically oriented settings (Doucet & Watford, 2014;Fleming-Castaldy & Gillen, 2013;Hammell, 2009;Iwama, 2003;Roberts & Robinson, 2014;Rogers, Bai, Lavin, & Anderson, 2016;Price, Hooper, Krishnagiri, Taff, & Bilics, 2017). ...
... Despite the tendency of occupational therapy to conform to the expectations and definitions imposed by the medically oriented SNF setting, therapists maintain a unique set of skills within the setting to address client-centered needs. Research data tended to identify professional skills in keeping with the core values of the profession such as holism, occupation-based and focused methods, evidencebased practice, reflective practice, and use of relevant theory in practice (Aiken, Fourt, Cheng, & Polatajko, 2011;Fleming-Castaldy & Gillen, 2013; A fork in the road: An occupational hazard? (Eleanor Clarke Slagle Lecture), 2013; Mattingly, 2012;Rogers S. L., 2007). ...
... There is a documented need to bridge the gap from scholarship to clinical practice in the occupational therapy profession (Fisher, 2013;Fleming-Castaldy & Gillen, 2013;Kielhofner, 2005). ...
The purpose of this study was to use the Kawa Model to discover and analyze the performance of the occupational therapy profession to incorporate occupation-centered practice in the skilled nursing setting. The guiding questions of the Kawa Model were used to guide phenomenological research inquiry into literature sources to generate drawings of the historical and current aspects of occupation-centered practice in the SNF setting. Environmental restrictions and obstacles from multiple sources were identified to prevent the implementation of occupation-centered services, while professional skills and values were identified with potential to initiate change in current practice trends. Two possible strategies for changing current practice were proposed from analyzing the river drawings generated from the Kawa Model’s framing of the research question.
... Plus encore, à propos de la responsabilité relative à la compétence et au contenu enseigné, Fleming-Castaldy et Gillen (29) affirment que, au même titre que l'ergothérapeute clinicien doit maintenir ses compétences professionnelles et pratiquer des interventions basées sur la science, l'enseignant en ergothérapie doit demeurer réceptif aux changements et questionner régulièrement les notions qu'il enseigne. Faillir à cette responsabilité peut entraîner une diminution de la qualité des soins prodigués aux clients qui seront desservis par les ergothérapeutes de demain (29). ...
... Plus encore, à propos de la responsabilité relative à la compétence et au contenu enseigné, Fleming-Castaldy et Gillen (29) affirment que, au même titre que l'ergothérapeute clinicien doit maintenir ses compétences professionnelles et pratiquer des interventions basées sur la science, l'enseignant en ergothérapie doit demeurer réceptif aux changements et questionner régulièrement les notions qu'il enseigne. Faillir à cette responsabilité peut entraîner une diminution de la qualité des soins prodigués aux clients qui seront desservis par les ergothérapeutes de demain (29). Dans le même ordre d'idées, il est de la responsabilité éthique des ergothérapeutes-enseignants de s'assurer que le cursus universitaire soutienne véritablement le développement de la pratique centrée sur le client (30). ...
Si les enjeux éthiques de l’enseignement sont bien documentés dans les écrits, tel n’est pas le cas des enjeux éthiques que pose l’enseignement en ergothérapie. Aucune étude n’a été menée sur le sujet au Québec. Pour pallier cette lacune, une recherche a été réalisée. Cet article en présente les résultats. Puisque l’état des connaissances sur le sujet est limité, un devis qualitatif a été utilisé. Onze ergothérapeutes-enseignantes ont participé à un entretien individuel semi-dirigé pour discuter des enjeux éthiques que soulèvent leurs enseignements. Six unités de sens émergent des données : 1) l’équité entre les étudiants : un défi ; 2) la santé et le bien-être des étudiants et des enseignantes : un portrait troublant ; 3) des injustices au sein du corps enseignant : l’éléphant dans la pièce ; 4) l’identité professionnelle tiraillée par des conflits de rôles ; 5) la présence de conflits d’intérêts préoccupants et 6) l’équilibre occupationnel : un mythe plus qu’une réalité. Les résultats rejoignent en général ceux documentés dans les écrits. Cela dit, un élément peu documenté dans les écrits émerge, soit la présence d’une culture académique hiérarchisée où l’autorité épistémique est détenue par les professeurs-chercheurs au détriment des autres types d’enseignants et des milieux cliniques. Ainsi, bien que la profession ergothérapique valorise la justice occupationnelle, les départements universitaires sont dominés par une injustice épistémique qui, par ricochet, engendre une injustice occupationnelle, ce qui d’un point de vue ergothérapique est préoccupant. Aussi, le contexte universitaire est lié à une surcharge de travail peu propice à l’agir éthique et à la pratique réflexive.
... In the work by Sackett et al. (1996), EBP is defined as the "integration of best research evidence with clinical expertise and patient values" (p.72). Greater emphasis on EBP has been given among rehabilitation specialties with foci originating via various organizational documents and resources including American Occupational Therapy Association (AOTA) Code Ethics (AOTA, 2015), AOTA's Centennial Vision (AOTA, 2007), American Physical Therapy Association (APTA) Vision 2020 (Physical Therapy, 2003), APTA's Position Statement on Clinical Competence (Slavin, 2004), and the American Speech and Hearing Association Scope of Practice (2016)) and in key statements by Fleming-Castaldy and Gillen (2013) and Kumar, Grimmer-Somers, and Hughes (2010). These statements proclaim the importance for NRS to use EBP as foundational, professional, and ethical guides in order to provide the best possible service and intervention for patients. ...
... NRS have been charged to engage in EBP through a variety of mechanisms from professional associations, state licensing boards, ethical standards, and funding sources (AOTA, 2015(AOTA, , 2007Physical Therapy, 2003;Slavin, 2004;ASHA, 2016;Fleming-Castaldy & Gillen, 2013;Kumar, Grimmer-Somers & Hughes, 2010). Yet, a challenge is navigating high volumes of evidence, such as with CIMT, in order to determine dosage that may be useful and effective for given settings and/or populations. ...
Objective:
Play is the primary occupation of young children, and it creates the opportunity for children to develop novel cognitive, motor, and social skills by providing an environment with minimal expectations or structure. The goal of this study was to describe the frequency and duration of different types of play patterns of young children.
Methods:
Data came from a retrospective cohort of 16 parent/infant dyads and were collected through 1-hour recordings at 8, 12, and 16 months of age. A coding scheme was used to evaluate four categories of play patterns: play object choice, play purpose, play type, and play construction. Datavyu software was used to analyze the coding scheme.
Results:
Overall duration for the play patterns of play object choice and play purpose increased with age, whereas a gradual decrease was seen in average duration for play type. For the play construction pattern, an increase was seen in both average frequency and duration across all three age points.
Conclusion:
This study showed that observing unstructured play can give occupational therapists a better understanding of developmental milestones and provide an efficient method for addressing the potential need for therapy services. Research is needed to explore observations within a daycare environment, in the presence of other young children, and with infants and toddlers who were born prematurely. [Annals of International Occupational Therapy. 2020; 3(2):84–91.]
... In the work by Sackett et al. (1996), EBP is defined as the "integration of best research evidence with clinical expertise and patient values" (p.72). Greater emphasis on EBP has been given among rehabilitation specialties with foci originating via various organizational documents and resources including American Occupational Therapy Association (AOTA) Code Ethics (AOTA, 2015), AOTA's Centennial Vision (AOTA, 2007), American Physical Therapy Association (APTA) Vision 2020 (Physical Therapy, 2003), APTA's Position Statement on Clinical Competence (Slavin, 2004), and the American Speech and Hearing Association Scope of Practice (2016)) and in key statements by Fleming-Castaldy and Gillen (2013) and Kumar, Grimmer-Somers, and Hughes (2010). These statements proclaim the importance for NRS to use EBP as foundational, professional, and ethical guides in order to provide the best possible service and intervention for patients. ...
... NRS have been charged to engage in EBP through a variety of mechanisms from professional associations, state licensing boards, ethical standards, and funding sources (AOTA, 2015(AOTA, , 2007Physical Therapy, 2003;Slavin, 2004;ASHA, 2016;Fleming-Castaldy & Gillen, 2013;Kumar, Grimmer-Somers & Hughes, 2010). Yet, a challenge is navigating high volumes of evidence, such as with CIMT, in order to determine dosage that may be useful and effective for given settings and/or populations. ...
Background:
Neurological rehabilitation specialists must determine appropriate dosage, consisting of frequency, intensity, and duration of specified treatments.
Objective:
The objective of this study was to perform a content analysis of the current literature related to dosage (duration, frequency and intensity) for constraint-induced movement therapy (CIMT) in the adult population.
Methods:
A content analysis was conducted which yielded 62 scholarly articles.
Results:
The frequency of CIMT ranged from 1 to 7 days per week with the average frequency being 4.98 days. The duration of CIMT, ranged from 2 to 10 weeks with the average duration 3.14 weeks. All three components of dosage were reported collectively in outcomes studies conducted in inpatient settings and rehabilitation clinics.
Conclusions:
The findings provide a groundwork for evidence based practice for clinician in the application of CIMT dosage with consideration of settings and CIMT components.
... It also gives the profession credibility. EBP is linked to ethical responsibilities (Coster, 2005;Fleming-Castaldy & Gillen 2013;Holm, 2000) as reflected in the WFOT Code of Ethics which states that "Occupational therapists will . . . apply their acquired knowledge and skills in their professional work, based on the best available evidence" (World Federation of Occupational Therapists, 2016a). ...
... apply their acquired knowledge and skills in their professional work, based on the best available evidence" (World Federation of Occupational Therapists, 2016a). It is our responsibility as occupational therapists to ensure we develop and maintain competence and that our services are firmly rooted in science (Fleming-Castaldy & Gillen 2013). Training in the five-step model of EBP has been promoted as a support for life-long learning (de Groot et al., 2013;Eason, 2010) and a means to strengthen decision-making skills (McFadden & Thiemann, 2009). ...
... An AOTA workforce survey conducted in 2018, however, indicated that fewer than 8% of therapists in the workforce reported home health as their primary work setting (AOTA, 2019). The low number of occupational therapists and occupational therapy assistants in this growing field creates a vacuum destined to be filled by outside professions that attempt to use occupation as an intervention, as noted by Fleming-Castaldy and Gillen (2013). ...
As of January 1, 2022, licensed occupational therapists have the permanent ability to open home health cases for the first time since 1999. This ability creates opportunities for occupational therapists to casemanage in the home health setting and showcase the benefits of occupation-based interventions for their clients. Further, occupation-based interventions create opportunities to establish aging-in-place and other cost-saving strategies. Occupational therapists will need to inform their home health agencies about this new ability, emphasizing the benefits of a more substantial presence in home health episodes of care. They will also need to develop new skills in the admission process or hone previous ones to maximize this opportunity. This article aims to provoke thought and conversation regarding the new option for occupational therapy to admit home health clients and the profession's future in this setting.
... Accreditation procedures that guide certification for various professionals are discussed by several authors (Hudson & Ramsay, 2019;Sentance & Csizmadia, 2017;Lengnick-Hall & Aguinis, 2012;Carliner & Hamlin, 2014;Fleming-Castaldy & Gillen, 2013;Pusey et al., 2005;Adams et al., 2004;Matlock et al., 2001;Moline, 1986). Partnerships between universities and professional bodies will further the attainment of certification (Yapa 2000;Harvey et al., 1995). ...
Higher education globally is characterized by numerous universities producing millions of graduates with slightly differentiated professional degrees. Graduates later race for common professional certification as the normal requirement of the job market. The motivation for many private universities is to breakeven even, remain profitable and sustain their positions in the market place. Public universities with science orientations focus more on scientific competence, research, innovation, and professionalism. A new system of Chartered Professional Examinations for non-business degrees is proposed and discussed in this article. The objective is to promote professionalism, develop and test competence and create an equivalence of all similar degree programs awarded by universities. Universities reserve the right and autonomy to function and award degrees as independent institutions of higher learning. Harmonization of examinations improves university education and standardize degrees across universities. PhD programs and master’s degrees are exempt from these examinations since many PhDs are research focused, therefore the contribution of a PhD degree is evaluated by the value of its scientific output.
... z.B. Meyer, 2011;Darlow et al., 2012;Fleming-Castaldy & Gillen, 2013;Hinojosa, 2013;Harvey et al., 2013;Lidström & Hemmingsson, 2014;Hackett et al., 2014;Tupe, 2014;Marterella & Aldrich, 2015;Aravena, 2015;Brousseau & Engels, 2015;Hesselstrand et al., 2015;Wilson & Magalhães, 2016;Gantschnig et al., 2016;Murad et al., 2016;Niemeyer & Duddy, 2017;Saeed et al., 2018;Dawson, 2018;Pozzi et al., 2020;Warner et al., 2021) und weiterentwickelt (vgl. u.a. ...
For the collection and synthesis of research findings in order to answer
clinical questions about decision-making in daily health care, the
Research Pyramid and Pyramid-Reviews offer a foundation that values
and integrates external evidence from multiple research approaches.
This article presents an update following the latest revision of
the levels of evidence.
Für die Aufbereitung und Systematisierung wissenschaftlicher Forschungsergebnisse
und Beantwortung klinischer Fragestellungen im
Hinblick auf Entscheidungen in der alltäglichen Versorgungspraxis
bieten das Modell der Forschungspyramide und die Systematik eines
Pyramiden-Reviews die Grundlage zur Bewertung und Integration
externer Evidenz aus unterschiedlichen Forschungsansätzen. Dieser
Beitrag stellt die jüngste Revision der Evidenzklassen in einem Update
vor.
... The survey was created by the first author following a comprehensive review of the literature. Literature included the scholarly examination of OT education (AOTA, 2014;Schaber, 2014); challenges in transitioning from clinician to educator in allied health (Anderson, 2009;McDonald, 2010;Smith & Boyd, 2012) and OT (Crepeau et al., 1999;Crist, 1999;Mitcham et al., 2002;Nolinske, 1999); skills required for entry-level teaching at the college and university level (Clement, 2010;Cutting & Saks, 2012;Dennick, 2012) and skills specifically required for teaching OT (ACOTE, 2012;Commission on Education, 2009;Fleming-Castaldy & Gillen, 2013;Schaber, 2014 (Dillman et al., 2014;Gall et al., 2007;Gray, 2009). ...
There is a transitional process that occurs when an occupational therapy (OT) practitioner assumes the role of an educator. Various challenges have been reported, though few directly address occupational therapy assistant (OTA) education. This study aimed to identify challenges faced by OT practitioners when they transition from working in a clinical setting to working as OTA faculty members. A 29-item online survey was developed covering three key areas of new OTA faculty members’ responsibilities: a) Learning the Educator Role, b) Curriculum and Class Development, and c) Interacting with Students. The survey was distributed through the American Occupational Therapy Association Program Directors’ and Academic Fieldwork Coordinators’ listservs, the Education Special Interest Section listserv and direct email to faculty members. Two hundred twenty-three participants completed the survey. Eight items were rated by 60% of participants as “Moderately” or “Very” challenging. Six of these items were in the category of Curriculum and Class Development, and two items were in the category of Learning the Educator Role. Interacting with Students was a relative area of comfort and strength. No significant relationships were found between the level of challenge experienced by OT practitioners transitioning to OTA educators and the demographic factors that were examined. Content analysis of open-ended survey questions yielded additional themes in each of the three categories that offer deeper insights into specific challenges. Collectively, results highlight areas where support and professional development can enhance successful clinician to OTA educator transitions.
... Education of the next generation of clinicians has increasingly focused on theory-and evidence-based interventions (Fleming-Castaldy & Gillen, 2013). That theory-driven models to facilitate the development of students' clinical reasoning skill are integrated into academic programs is essential. ...
To advance evidence-based practice across rehabilitation professions, clinicians, and researchers could benefit from a structured way to clearly describe the treatment interventions used by their discipline. Development of the Rehabilitation Treatment Specification System is an interprofessional effort to use a theory-driven and systematic approach to define, specify, and quantify the complex nature of rehabilitation treatments. In this article, we introduce this novel approach and provide a case example that illustrates application to clinical practice. We invite occupational therapy practitioners to consider how clear specification of the content and process of their interventions could benefit practice, research, and education. Copyright
... Despite clinical evidence and a deep philosophical belief in the therapeutic power of occupation, evidence suggests that there is still limited use of occupation in clinical practice (American Occupational Therapy Association [AOTA], 2011;Jewell, Pickens, Hersch, & Jensen, 2016;Fleming-Castaldy & Gillen, 2013). A survey of occupational therapy students (n = 312) reported that 91% of student observations did not include use of occupation (van den Heever, 2014). ...
A challenge of intervention research is the lack of a means to identify and measure clinical practice from an occupation-centered approach. The objective of this study is to establish basic psychometric properties of the Occupation-Centered Intervention Assessment (OCIA). The study is approached by establishing content validity and utility through expert panel and two focus groups. Interrater reliability (IRR) was determined through standardized video analysis and Krippendorff's alpha. Results from the expert panel and focus groups indicated an overall agreement that the OCIA was able to capture the full range of elements of rehabilitation-focused interventions for older adults (occupational, contextual, and personal relevance) and a good fit with the occupational therapy intervention process model. IRR found adequate level of agreement (α = .76). The OCIA has demonstrated initial basic psychometrics for observation of rehabilitation-focused interventions with older adults.
... The contemporary occupation paradigm, which began in the late 1960's, provided a renewed interest in the use of occupation as a therapeutic modality in occupational therapy practice (Kielhofner, 2009). Although remnants of the mechanistic paradigm continue to exist in current practice, especially in occupational therapy settings that have a medical model focus such as skilled nursing facilities, a resurgence of the use and acknowledgement of the importance of occupation continues to grow in both research and occupational therapy educational programs (Fleming-Castaldy and Gillen, 2013;Wood et al., 2000). Occupational therapists are urged to shift away from the mechanistic paradigm toward occupation-centered practice and research (Doucet, 2013;Gillen, 2013) indicating that now is the time to bridge the gap from the philosophical and theoretical models centered on occupation into clinical practice. ...
Aims: The aims of this pilot study were to identify occupational therapy interventions provided to short-term rehabilitation clients at skilled nursing facilities and to determine if therapists engaged clients in interventions with an occupation-centered approach. Methods: This study utilized a prospective mixed methods design with in-depth observations of two occupational therapists and three clients. Field notes, schematic drawings, and the Occupation-Centered Intervention Assessment documented and captured 57 interventions. Results: Provision of interventions occurred primarily in the clinic (36/57), with exercise and rote practice as the most common intervention approach (26/57), and interventions that utilized occupation were rated higher on the OCIA indicating a more occupation-centered approach. Conclusions: More than half of the interventions did not involve the use or focus on occupation, indicating a gap between theoretical frameworks and interventions taught in professional school and what actually occurs in practice.
... The FMA was created from Brunnstrom's (1966) sevenstage classification system of UE recovery that had a small description of movement correlated to each stage. It is widely used despite the fact that no research has found that stroke survivors pass through the predictable Brunnstrom stages or supported the effectiveness of Brunnstrom's movement therapy on people living with disabilities secondary to a neurological event (Fleming-Castaldy & Gillen, 2013). Moreover, the FMA does not address performance in activities of daily living (ADLs) in a functional or meaningful manner but is still used to categorize a patient's general arm function (Sabari, Capasso, & Feld-Glazman, 2014). ...
Objective:
The Functional Upper Extremity Levels (FUEL) is a new classification tool to assess a person's upper-extremity functional and physical performance after sustaining a stroke. The aim of this preliminary study was to develop the tool and determine its content validity and interrater reliability.
Method:
Forty-four licensed occupational therapists ranging in years of experience from 6 mo to 16 yr participated in this study. A two-phase study was conducted: (1) constructing the FUEL and determining its content validity and (2) ascertaining its interrater reliability.
Results:
We found that the FUEL had initial content validity and substantial interrater reliability (Fleiss κ = .754).
Conclusion:
The FUEL can be a useful clinical and research tool in occupational therapy for the assessment and classification of upper-extremity function for people after stroke. Further studies with larger samples and comparison studies with other similar tools are required to support the tool's reliability and validity.
... Sg2.com predicts that by the end of this decade, " …few truly independent players will remain " (2010, p. 7). If ever there was a time for rehabilitation provision of care to be streamlined, efficient, costeffective , and based on best practices, it is now (Valdes, 2010; Fleming-Castaldy & Gillen, 2013; Lin, Murphy & Robinson, 2010). Kroll (2012) suggests the following: ...
Numerous authors have documented the challenges of promoting evidence-based practice (EBP) among occupational therapists around the world. A business-based cultural change model is presented as a framework to direct occupational therapy practice culture toward EBP.
Introduction: Occupational therapy research to support clinical decision-making must be responsive to local needs, illustrate our unique value to clients, communities and providers, and demonstrate efficacy for quality assurance and reimbursement. This article examines the publication trends in the South African Journal of Occupational Therapy (SAJOT) with the intention of contributing to dialogues about evidence-based practice. Methods: A mapping review was undertaken of articles published in the SAJOT from January 2009 to December 2021. All articles excepting commentaries, book reviews and editorials were included. Articles were categorised by year of publication, title, author, research approach, study design, practice area, research affiliation, and nature of authorship.Quantitative research articles were classified according to the Australian National Health and Medical Research Council (NHMRC) levels of evidence. Results: Of the 265 articles published in the 13-year period, slightly more took a quantitative approach (52.1%) comparedwith qualitative approaches (42.4%). Most quantitative studies were Level 111-2 studies (31.3%). Children and Youth was the practice area with the highest number of articles (34.8%) and the strongest evidence base. Conclusion: As occupational therapy continues to wrestle with EBP, further dialogue about a national occupational therapy research strategy to identify and harness enablers and explore and mitigate the barriers identified in this review, is recommended. Implications for practice • This research serves as a bridge between theoretical findings and practical applications, by providing data from research that can be put into action through the development of research agendas by institutions. • By understanding what research has been done, professionals can make informed decisions that are backed by evidence-based findings. This not only enhances the quality of their work but also improves overall efficiency and effectiveness. • The study helps practitioners identify areas where improvements or interventions are needed. They shed light on potential challenges and offer possible solutions that can be implemented to address specific issues or concerns within their respective fields. • This data provides a platform for collaboration between researchers and practitioners across institutions in terms of common research agendas.
Importance:
Research is needed to validate an easy-to-use, functional, evidence-based neurological upper extremity (UE) assessment that requires minimal training.
Objective:
To establish convergent validity for the Functional Upper Extremity Levels (FUEL), a function-based upper limb measure, with the Upper Extremity Fugl-Meyer Assessment (UE-FMA), the gold standard assessment of upper limb recovery poststroke.
Design:
Retrospective chart review of 292 clients with admission and discharge data for the UE-FMA and the FUEL. Correlation statistics were analyzed to determine a relationship between these assessments.
Setting:
Inpatient stroke rehabilitation unit.
Participants:
Clients with a stroke diagnosis admitted to the stroke inpatient rehabilitation unit at a rehabilitation hospital between January 2017 and June 2019.
Outcomes and measures:
FUEL (a classification system) and UE-FMA (an impairment-based motor recovery assessment of the upper limb recovery poststroke).
Results:
Pearson correlation coefficient yielded a significant positive correlation between the UE-FMA and the FUEL for both initial (r = .929) and discharge (r = .943) scores.
Conclusions and relevance:
Convergent validity of the FUEL is established using the UE-FMA as a comparison. The FUEL can be applied in neurological rehabilitation to provide a clinical picture of a client's UE function. This research supports the value of the FUEL's application in clinical poststroke care. What This Article Adds: The FUEL is a valid tool to assess the UE in an acute neurological population.
Cet article consiste en la 2e partie des résultats d’une étude que notre équipe a menée sur les enjeux éthiques de l’enseignement en ergothérapie et leurs pistes de solutions. Tandis que le premier article de 2020 a mis en lumière ces enjeux, le présent article porte sur les moyens de les résoudre. L’ergothérapeute qui enseigne à des étudiants en ergothérapie est tôt ou tard confronté à des enjeux éthiques. Or, ces enjeux sont peu documentés dans les écrits, de même que les pistes de solutions que les ergothérapeutes qui enseignent utilisent ou envisagent. Cette étude qualitative a permis à onze ergothérapeutes-enseignantes des quatre universités francophones du Québec qui préparent la relève ergothérapique de partager leurs bons coups. Dix unités de sens relatives à ces pistes de solutions émergent des résultats, lesquelles ont été regroupées suivant les trois domaines de l’éthique (micro, méso et macro) de Glaser. Les quatre pistes de solutions micro-environnementales sont : a) développer ses compétences éthiques; b) se soutenir entre pairs; c) développer ses compétences en lien avec sa tâche; et d) prendre soin de soi. Les quatre pistes de solutions méso-environnementales sont : a) créer des espaces de parole; b) offrir de la formation en éthique; c) faire de l’advocacy méso; et d) changer la culture académique. Les deux pistes de solutions macro-environnementales sont : a) faire de l’advocacy macro et b) travailler en partenariat avec les milieux cliniques. Bien que des pistes de solutions documentées dans les écrits n’aient pas été discutées par les participantes, celles que ces dernières discutent rejoignent les pistes de solutions abordées dans les écrits. Il ressort des résultats que l’éthique occupe une place limitée dans la préparation et la formation continue des enseignants en ergothérapie et que le contexte organisationnel, c’est-à-dire la culture du monde académique en général et de la recherche en particulier, est susceptible d’occasionner des enjeux éthiques préoccupants.
The Research Pyramid is a model that values and integrates external evidence from multiple research approaches. It provides a basis to collect and synthesize research findings for answering questions that emerge in occupational therapy practice and for subsequent decision making, based on research evidence.
In this article, the following theoretical principles that underline the model are presented: the understanding of evidence, of clinical reasoning and the therapeutic process, and of occupational therapy as a complex intervention.
Die Forschungspyramide ist ein Modell zur Bewertung und Zusammenführung von externer Evidenz aus unterschiedlichen Forschungsansätzen. Sie bietet eine Grundlage zur Aufbereitung und Systematisierung von Forschungsergebnissen, um, basierend auf wissenschaftlicher Evidenz, ergotherapeutische Fragestellungen zu beantworten und ergotherapeutische Entscheidungen in der alltäglichen Praxis zu treffen. Dieser Beitrag arbeitet die folgenden theoretischen Grundlagen des Modells auf: das Verständnis von Evidenz, von therapeutischer Entscheidungsfindung und vom therapeutischen Prozess sowie das Verständnis von Ergotherapie als komplexer Intervention.
Für die Aufbereitung und Systematisierung wissenschaftlicher Forschungsergebnisse und die Beantwortung
klinischer Fragestellungen im Hinblick auf Entscheidungen in der alltäglichen Versorgungspraxis
bietet die Forschungspyramide ein Modell zur Bewertung und Integration externer Evidenz
aus unterschiedlichen Forschungsansätzen. Dieser Beitrag bietet ein Update zu den neueren Entwicklungen
und dem aktuellen Stand des Modells sowie den Grundlagen eines Pyramidenreviews.
To collect and synthesize research findings in order to answer clinical questions about decision-making in daily health care, the Research Pyramid offers a model that values and integrates external evidence from multiple research approaches. Recent developments and the current state of the model are presented, in addition to the basics of a pyramid evidence review.
Stroke is the leading cause of disability in the United States and a top diagnosis for occupational therapy (OT) services among neurological conditions. Academic programs teach OT students neurological frames of reference (FORs) to provide a foundation for future practice. To meet accreditation standards, entry-level curricula must reflect current practice and evidence-based interventions. A survey of OT practitioners working in upper extremity stroke rehabilitation was conducted to investigate current clinical practice in a variety of treatment settings. Survey questions probed the use of motor rehabilitation techniques exclusive to one of six neurological FORs: Brunnstrom, Constraint-induced Movement Therapy, Neurodevelopmental Treatment, Proprioceptive Neuromuscular Facilitation, Rood, and Task-Oriented. Responses from 167 OT professionals indicated interventions representing all six FORs are currently being utilized in stroke rehabilitation. Techniques from the Task-Oriented and Neurodevelopmental Treatment approaches were used most frequently; however, the Rood–based techniques were used much less than interventions from the other FORs. No single neurological approach was found to dominate practice regardless of the number of years of experience in stroke rehabilitation or years since graduation from an entry-level program. A majority of participants appear to employ techniques from multiple approaches frequently, suggesting contemporary OT practice in upper extremity stroke rehabilitation is eclectic in nature.
To realize the American Occupational Therapy Association's Centennial Vision, occupational therapy practitioners must embrace practices that are not only evidence based but also systematic, theoretically grounded, and driven by data related to outcomes. This article presents a framework, the Data-Driven Decision Making (DDDM) process, to guide clinicians' occupational therapy practice using systematic clinical reasoning with a focus on data. Examples are provided of DDDM in pediatrics and adult rehabilitation to guide practitioners in using data-driven practices to create evidence for occupational therapy.
Copyright © 2015 by the American Occupational Therapy Association, Inc.
Although rapid progress has been made in generating evidence to support occupational therapy interventions for clients who survive a stroke, the areas receiving research attention show a lack of balance that researchers should correct in order to better guide practice.
Aims: To examine the professional reasoning process of occupational therapists using multi-sensory environments (MSEs) to treat clients with dementia. Methods: This was a qualitative study design which used interviews to uncover the multi-faceted professional reasoning process used by occupational therapists when implementing MSE interventions for individuals with dementia. Results: Qualitative data analysis yielded three themes regarding the professional reasoning process of occupational therapists that use MSEs to treat clients with dementia. Clinicians use MSEs because the intervention emphasizes client-centered care; facilitates neural changes; and promotes emotional connections. Conclusions: Current evidence does not support the professional reasoning process which occupational therapists use when integrating the MSE into the occupational therapy plan of care. Further qualitative research is indicated to explore why occupational therapists continue to use interventions that are not evidence-based and to examine the process in which clinicians abandon current practice methods when research evidence does not support their use.
Objective:
Mirror therapy (MT) is a potential intervention to improve function after stroke. How to apply this intervention in practice is not clear. This case report illustrates the feasibility and effectiveness of a self-administered home-based MT program.
Method:
A home-based MT program was practiced over 5 wk. The participant was encouraged to use MT for 30 min 5×/wk. Therapist contact occurred 1×/wk to monitor performance. An independent evaluator administered three outcome measures pre- and postintervention: Upper Extremity Sensory and Pain sections of the Fugl-Meyer Assessment; Jebsen-Taylor Test of Hand Function, and the Manual Ability Measure-20.
Results:
The participant engaged in a mean of 39.23 (±7.44) min of MT per day and used a variety of the recommended activities. Change scores indicated improvement on all of the included outcome measures.
Conclusion:
This case report suggests that a predominantly self-administered home-based MT program is feasible and effective at improving function after stroke.
The health care environment of the past quarter century went through numerous evolutionary processes that affected how occupational therapy services were provided. The last iterations of these processes included requests for the evidence that supported what we were doing. This year's Eleanor Clarke Slagle Lecture (a) examines the strength of the evidence associated with occupational therapy interventions-what we do and how we do it-(b) raises dilemmas we face with our ethical principles when some of our practices are based an limited evidence, and (c) proposes a framework of continued competency to advance the evidence base of occupational therapy practice in the new millennium.
In the campaign to implement evidence-based practice, the current single-hierarchy model of levels of evidence fails to incorporate at parity all types of research evidence that are valuable in the practice of occupational therapy. A new model, originally developed by Borgetto et al. (2007) and modified and expanded, is presented. By separating the evidence-level criteria of internal and external validity, by incorporating explicitly the evidence provided by qualitative studies, and by retaining the critical notion of rigor, a pyramidal evidence model emerges. This model, the Research Pyramid, aligns itself with the revised model of evidence-based medicine and, more important, with the basic modes of clinical reasoning in occupational therapy. It constitutes a beginning attempt to order evidence-based practice in accordance with the epistemology of the profession. It may better guide occupational therapy research and meta-synthesis and their incorporation into practice decisions.
Background:
Powerful professions have the capacity to obtain leadership positions, advocate successfully in the policy arena, and secure the resources necessary to achieve their professional goals. Within the occupational therapy profession, cultivating power and confidence among our practitioners is essential to realize our full capacity for meeting society's occupational needs.
Purpose and key issues:
Drawing from a historical analysis of the medical and nursing professions, this paper discusses the implications of power and disempowerment among health professions for their practitioners, clients, and public image. Theoretical perspectives on power from social psychology, politics, organizational management, and post-structuralism are introduced and their relevance to the profession of occupational therapy is examined.
Implications:
The paper concludes with recommendations for occupational therapy practitioners to analyze their individual sources of power and evaluate opportunities to develop confidence and secure power for their professional work--in venues both in and outside the workplace.
The primary aim of the present study was to investigate, based on data from our study in 2000, whether the Bobath approach enhanced quality of movement better than the Motor Relearning Programme (MRP) during rehabilitation of stroke patients.
A randomized controlled stratified trial of acute stroke patients. The patients were treated according to Motor Relearning Programme and Bobath approach and assessed with Motor Assessment Scale, Sødring Motor Evaluation Scale, Nottingham Health Profile and the Barthel Index. A triangulation of the test scores was made in reference to the Movement Quality Model and biomechanical, physiological, psycho-socio-cultural, and existential themes.
The items arm (p = 0.02-0.04) sitting (p = 0.04) and hand (p = 0.01-0.03) were significantly better in the Motor Relearning Programme group than in the Bobath group, in both Sødring Motor Evaluation Scale and Motor Assessment Scale. Leg function, balance, transfer, walking and stair climbing did not differ between the groups. The Movement Quality Model and the movement qualities biomechanical, physiological and psycho-socio-cultural showed higher scoring in the Motor Relearning Programme group, indicating better quality of movement in all items. Regression models established the relationship with significant models of motor performance and self reported physical mobility (adjusted R(2) 0.30-0.68, p < 0.0001), energy (adjusted R(2) 0.13-0.14, p = 0.03-0.04, emotion (adjusted R(2) 0.30-0.38, p < 0.0001) and social interaction (arm function, adjusted R(2) 0.25, p = 0.0001).
These analyses confirm that task oriented exercises of the Motor Relearning Programme type are preferable regarding quality of movement in the acute rehabilitation of patients with stroke.
Occupational therapy practitioners may encounter challenges when they try to incorporate evidence into practice. To embrace evidence-based practice (EBP), clinicians must have readily available, relevant, and concisely summarized evidence. Although researchers have described the importance and process of EBP, less has been written about how to efficiently integrate evidence into practice. Clinicians may benefit from examples of reasoning, strategies, and resources to successfully integrate evidence. This article reviews the steps of EBP and offers recommendations to overcome common barriers. For EBP to become integrated into practice, greater communication and collaboration among all stakeholders must occur. EBP and knowledge translation require multiple processes and coordinated efforts. Therefore, everyone from practitioners to employers has a role in increasing EBP and transferring knowledge for practice. To encourage discussion and actions, the article provides implications and recommendations for practitioners, researchers, educators, organizations, and policymakers.
This study was aimed at understanding the current physical and occupational therapy practices in stroke rehabilitation in the Midwest. The insights gained from this pilot study will be used in a future study aimed at understanding stroke rehabilitation practices across the nation. Researchers and clinicians in the field of stroke rehabilitation were interviewed, and past studies in the literature were analyzed. Through these activities, we developed a 37-item questionnaire that was sent to occupational and physical therapists practicing in Kansas and Missouri who focus on the care of people who have had a stroke (n = 320). A total of 107 respondents returned a com pleted questionnaire, which gives a response rate of about 36%. The majority of respondents had more than 12 years of experience treating patients with stroke. Consensus of 70% or more was found for 80% of the items. The preferred approaches for the rehabilitation of people who have had a stroke are the Bobath and Brunnstrom methods, which are being used by 93% and 85% of the physical and occupational therapists, respectively. Even though some variability existed in certain parts of the survey, in general clinicians agreed on different treatment approaches in issues dealing with muscle tone, weakness, and limited range of motion in stroke rehabilitation. Some newer treatment approaches that have been proven to be effective are practiced only by a minority of clinicians. The uncertainty among clinicians in some sections of the survey reveals that more evidence on clinical approaches is needed to ensure efficacious treatments.
This article reviews the models and theories of motor behavior that are the foundation for the traditional approaches to central nervous system (CNS) dysfunction and presents a new theoretical model and approach that are beginning to influence practice. Reflex, hierarchical, and systems models of motor control and developmental and motor learning theories are discussed. The relationships of these models and theories to past, present, and future treatment approaches to CNS dysfunction are explored. The assumptions and limitations of the muscle reeducation, neurodevelopmental, and motor relearning approaches are discussed. A contemporary task-oriented approach based on the systems model is proposed and contrasted with traditional neurodevelopmental approaches.
Objective: To determine the effectiveness of the Bobath concept at reducing upper limb impairments, activity limitations and participation restrictions after stroke.
Methods: Electronic databases were searched to identify relevant trials published between 1966 and 2003. Two reviewers independently assessed articles for the following inclusion criteria: population of adults with upper limb disability after stroke; stated use of the Bobath concept aimed at improving upper limb disability in isolation from other approaches; outcomes reflecting changes in upper limb impairment, activity limitation or participation restriction.
Results: Of the 688 articles initially identified, eight met the inclusion criteria. Five were randomized controlled trials, one used a single-group crossover design and two were single-case design studies. Five studies measured impairments including shoulder pain, tone, muscle strength and motor control. The Bobath concept was found to reduce shoulder pain better than cryotherapy, and to reduce tone compared to no intervention and compared to proprioceptive neuromuscular facilitation (PNF). However, no difference was detected for changes in tone between the Bobath concept and a functional approach. Differences did not reach significance for measures of muscle strength and motor control. Six studies measured activity limitations, none of these found the Bobath concept was superior to other therapy approaches. Two studies measured changes in participation restriction and both found equivocal results.
Conclusions: Comparisons of the Bobath concept with other approaches do not demonstrate superiority of one approach over the other at improving upper limb impairment, activity or participation. However, study limitations relating to methodological quality, the outcome measures used and contextual factors investigated limit the ability to draw conclusions. Future research should use sensitive upper limb measures, trained Bobath therapists and homogeneous samples to identify the influence of patient factors on the response to therapy approaches.
Neurodevelopmental treatment (NDT) is a rehabilitation approach increasingly used in the care of stroke patients, although no evidence has been provided for its efficacy.
To investigate the effects of NDT on the functional status and quality of life (QoL) of patients with stroke during one year after stroke onset.
324 consecutive patients with stroke from 12 Dutch hospitals were included in a prospective, non-randomised, parallel group study. In the experimental group (n = 223), nurses and physiotherapists from six neurological wards used the NDT approach, while conventional treatment was used in six control wards (n = 101). Functional status was assessed by the Barthel index. Primary outcome was "poor outcome", defined as Barthel index <12 or death after one year. QoL was assessed with the 30 item version of the sickness impact profile (SA-SIP30) and the visual analogue scale.
At 12 months, 59 patients (27%) in the NDT group and 24 (24%) in the non-NDT group had poor outcome (corresponding adjusted odds ratio = 1.7 (95% confidence interval, 0.8 to 3.5)). At discharge the adjusted odds ratio was 0.8 (0.4 to 1.5) and after six months it was 1.6 (0.8 to 3.2). Adjusted mean differences in the two QoL measures showed no significant differences between the study groups at six or 12 months after stroke onset.
The NDT approach was not found effective in the care of stroke patients in the hospital setting. Health care professionals need to reconsider the use of this approach.
Aprofession’s official documents reflect the philosophical and practice beliefs of its members. Such documents determine how members of the profession make decisions that influence the viability and evolution of the profession. Typically, documents that originate in the Commission on Practice are reviewed on a 5-year timetable and revised as necessary (American Occupational Therapy Association [AOTA], 2004a). The purpose of this article is to discuss the implications of the American Occupational Therapy Association’s adoption of the Occupational Therapy Practice Framework: Domain and Process (AOTA, 2002b) and the potential effects it has had on the profession. This article discusses the Framework’s strengths and limitations and its implications for practice and education. It is hoped that an analysis of these issues will contribute to the discussion of the revision of the document and prompt an earlier review and modification. Analysis began with an exploration of the component parts of the Framework. This was followed by an identification and systematic examination of the concepts, assumptions, and statements written in the document. The concepts, assumptions, and declarative statements in the document are foundational to the Framework’s use and influence how occupational therapists organize their thoughts and actions. Our goal was to evaluate the document to raise concerns regarding how the Framework’s use may affect practice and education. Analysis and recommendations for future revisions of the Framework were based on methods of logical reasoning. Sources for our analysis were Mosey (1996), Nickerson (1986), Rosen (2000), Sorensen (1993), and Stroll
SUMMARY Occupational therapy has experienced a tremendous growth both of theory and research. However, there is little evidence that this renaissance of knowledge has been paralleled by changes in practice. Instead, academics tend to express concern that practice lags behind scholarship while clinicians bemoan the irrelevance of theory and research to their everyday work. This paper discusses the scholarship of practice. This approach is based on the assumption that those who ultimately will use the knowledge must be partners in its generation. Thus, it emphasizes cooperative efforts in which practitioners and scholars work together as partners to advance both knowledge and practice.
Effective fieldwork provides students with learning experiences in preparation for entry-level practice as occupational therapists (OT) or occupational therapy assistants (OTA). In 2003, the National Board for Certification in Occupational Therapy, Inc.® (NBCOT) conducted a practice analysis of entry-level certified occupational therapy practitioners (OTR & COTA) to validate a test blueprint for the national certification examinations. This study reports a novel, elective survey reflecting the total percentage of entry-level practitioners, who reported use of 88 different interventions. The purpose of this paper is to translate the practice analysis intervention data gathered in the optional survey to plan and implement effective fieldwork that prepares fieldwork students for entry-level practice. The results of this study will provide understanding of intervention use among entry-level practitioners (OTR = 479; COTA = 168) as a function of practice context. An initial correlation of a random sample of 100 OTRs and COTAs found group equivalency, meaning that the OTR information could be used for the major analyses and generalized to include COTA. Fourteen interventions were found commonly across all practice settings for OTR. These fourteen were factored into three areas or themes (preparatory and activities of daily living; motor skills, posture and coordination; and mental functions) with significant frequency of intervention utilization. Further analysis indicated a high variability of the top thirty interventions for each setting with regard to utilization of interventions above and below the 50 percentile. This snapshot of practice regarding entry-level intervention utilization in occupational therapy across seven major practice settings is described and application to fieldwork processes elaborated. The information provides a description of practice in each setting that can be used by academic fieldwork coordinators for student placement decisions. Fieldwork educators can use this information as a guide for planning comprehensive fieldwork-learning activities, as well as supervising students. Fieldwork students can use this intervention utilization information to assess their readiness for entry-level practice in each setting.
The process of evidence-based practice is essentially the same for occupational therapy as for other health disciplines. However, some differences in its application arise from the differing practice domains and theoretical models used. A framework for the use of evidence-based practice in occupational therapy is presented in Fig. 1, drawing on concepts presented by Bennett and Glasziou (1997), Law et al. (1996) , and Sackett, Richardson, Rosenberg & Haynes, (1997). This framework presents evidence-based practice as a process that follows a cycle stemming from clinical decisions that need to be made in all stages of the occupational therapy treatment process. Clinical questions are identified that reflect the information needed to make clinical decisions, and which take into account the specific client or group of clients being treated, as well as the context in which treatment occurs. A literature search is undertaken to identify the best research evidence available to answer the question. As not all studies are well performed, a critical appraisal of the article for its validity and clinical usefulness is important. Perhaps the most crucial aspect of the evidence-based practice process is the use of evidence with the client. Clinical reasoning is used to determine whether the evidence ‘fits’ with each feature of the client’s context (person, occupation and environment). Particular attention should be given to the preferences and values of the client. Consideration must also be given to the practice setting, clinical expertise, and resources available to the therapist. Clients, and where appropriate families or carers, are actively engaged in the decision making process to determine the action to be taken. Although not represented in the framework, evaluation of this process is undertaken to determine improvement in relevant outcomes and to identify factors that will make the process more efficient ( Sackett et al., 1997 ).
We investigated the specific type of occupational therapy intervention used by occupational therapists during inpatient stroke rehabilitation in one midwestern U.S. hospital to determine the frequency of prefunctional versus functional activity use.
A retrospective chart analysis was conducted of clients who received inpatient stroke rehabilitation between January 2003 and June 2004. Type of intervention, intervention strategies, and adaptive equipment use were recorded for each session provided.
The majority of sessions (65.77%, n = 1,022) consisted of activities that were prefunctional in nature compared with 48.26% (n = 750) that focused on activities of daily living. Musculoskeletal intervention strategies were used in more than half (52.25%) of the sessions.
More sessions were spent on prefunctional than on functional activities, and musculoskeletal intervention strategies were most common. Future research studies are warranted to determine the most effective intervention for this client population.
Human motor behavior continues to evolve and, therefore, may never be fully understood. Still, occupational therapy treatment approaches that are based on neurophysiological principles are fairly well accepted, and there is much potential for the development of treatments that will facilitate recovery of function. Occupational therapy must face and confront its roles in relation to the field of motor control; a health care profession involved with performance and motor control issues cannot afford to ignore the rapid advances in neuroscience information and the parallel developments in the field of motor control. Rood (1980) stated that many people want a "womb with a view," so that they remain protected and yet passively observe the outside world. However, if occupational therapy is to remain current with new developments in the field of motor control, it cannot afford to be passive.
This paper discusses the place of occupational therapy technology in practice and the growth of scientific technology. It is suggested that practice is an important source for the development of technological theory. A historical review of the treatment of hand dysfunction in cerebral palsy is presented as an illustration of the development of a specific occupational therapy technology.
Occupational therapists have used many media and methods over the years to achieve the therapeutic potential of occupational therapy. Yet the reasons for selecting a specific medium or method frequently have been lost or changed without consideration of the result to the therapeutic situation. When neither therapist nor patient understands fully the rationale for a medium or method, the therapeutic potential of that medium or method may be compromised. The author suggests there are eight factors that influence the selection and discarding of media and methods in the practice of occupational therapy. The effects of the eight factors can be summarized in 14 assumptions. Three examples--arts and crafts, sanding blocks, and work-related programs--are used to illustrate the factors and assumptions. It is suggested that improved analysis of occupations based on values and interests could reduce the separation of meaning and purpose in the selection and discarding of media and methods used in occupational therapy practice.