EVIDENCE

BASED
PRACTICE
INTRODUCTION
• Educators, scholars, and practitioners increasingly discuss and encourage the use of
theoretically grounded and supported OT interventions and the development of solid evidence
of successful outcomes of interventions.

• Systematic OT practice (SOTP) is needed in all professional domains (individual, group,

community, agency, and government) if OT is to remain a viable and valued field that will
continue to flourish in the competitive environment of managed care and fiscal scarcity.

• Systematic OT practice involves the integration of research-based techniques into all elements
of OT practice.
 MODELS OF EBP
• Many models of EBP have been presented in the literature.

• Each approach identifies different sources as credible evidence in three categories:

1. Client generated: By client generated we mean that information put forth by the client is
considered as part of the evidence base for professional interaction.
2. Professionally generated: It refers to provider education and experience as a valued
source of knowledge for use.
3. Scientifically grounded: Scientific evidence is that developed by rigorous methods of
inquiry.
THE SOTP MODEL
• Systematic OT practice is defined as the integration of critical, analytic, scientific thinking, and
action processes throughout all phases and domains of OT practice.

• First, we distinguish thought and action from each other. In systematic inquiry, it is essential for
the thinking sequence and its rationale to be presented clearly.

• Thinking processes: Involves the selection of a theoretical framework in which the OT

practitioner plans the steps necessary to assess problems, evaluate intervention, specify
desired outcomes, and plan a strategy to determine and systematically demonstrate the degree
to which client centered outcomes were met for an individual receiving OT services.
• Action processes: Are the specific behaviours involved in implementing thinking processes. Action
processes are behavioural step.

• In systematic OT practice, these steps are founded on logical inquiry such that any claim is
supported with empirically derived information from a variety of sources

• Although SOTP is not research in itself, it is the organized application of research to the
conceptualization, enactment, and investigation of the process and outcome of intervention.

• “Evidence based practice(EBP) is like a toolbox of methods available to the occupational

therapy practitioner to aid clinical reasoning. The toolbox consists primarily of methods
designed to integrate current and best evidence from research studies into the clinical
reasoning process”- Tickle-Degnan
• In SOTP, we define evidence as
information that is used to support a
claim.
WHAT IS
• This expansive definition allows for
the identification and acceptance of a
EVIDENCE ?
broad scope of evidence as the basis
for decision making in practice as
long as the evidence is identified and
used within the systematic thinking
and action processes
• Within the profession, OT practitioners can use the information obtained from SOTP not only
to improve the processes and outcomes of their practices but also to engage in informed
thinking when choosing among possible interventions and to contribute to the overall
knowledge base of our profession.

• SOTP systematically guides practitioners in determining which interventions are effective to

produce desired outcomes, which interventions need to be improved, and what kinds of new
knowledge need development.

• Additionally, having credible evidence to demonstrate that the interventions OT practitioners

use produce desirable outcomes provides concrete feedback to the consumer.

• By systematically evaluating interventions, OT practitioners can provide evidence for advancing

clinical practices in the profession.
• Pressures and demands on health practitioners from external sources render SOTP even more
practical for three reasons:
1. First, the location of service delivery and the time allowed for service delivery are in flux.
Long-term hospital stays and treatments in acute care settings have been replaced by
community-based treatment, and the length of time for delivery of treatment is shortening
as third-party payers demand more efficient and cost-effective healthcare. SOTP guides the
practitioner in balancing the multiple factors involved in practicing within a quality-focused
fiscal driven healthcare environment.
2. Second, by systematically examining the processes and outcomes of current practice, OT
practitioners can provide an evidentiary basis for clinical thinking and action, which then can
be presented to consumers, other professionals, insurers, and policy makers.
3. Third, systematic inquiry transcends professional boundaries through shared language and
theory. for example, the systematic foundation of the International Classification of
Functioning, Disability and Health28 is consistent with the Occupational Therapy Practice
Framework (OTPF) and provides a common forum and language for cross-disciplinary
communication.
SOTP is grounded in logic and the systematic thinking that undergirds
all research thinking processes. Inductive and deductive reasoning
methods form the basis for these thinking
processes. Moreover, the two major research design traditions,
naturalistic and experimental-type inquiry, are based on these logic
structures. Therefore, OT practitioners must understand them and use
them to guide thinking and action and to support claims regarding the
process and outcomes of OT intervention.
THEORETICAL
Inductive reasoning is a thinking process whereby one begins with
seemingly unrelated data and links these data together by discovering
AND LOGICAL
relationships and principles within the data set. In inductive systematic
approaches, the data may take many forms. Inductive reasoning leads us
FOUNDATION
to select naturalistic strategies, those in which theory is derived from
gathered evidence rather than tested by scientific experimentation.
OF SOTP
Among the methods used in naturalistic design are interview,
observation, and textual analysis. Data are collected and themes that
emerge from repeated examination of the data are named, defined, and
placed in a theoretical context.
• Deductive reasoning begins with a theory and reduces the theory to its parts, which are then
verified or discounted through examination. Deductive reasoning provides the foundation for
experimental-type research, in which theories or parts are stated in measurable terms and
standardized measurement forms the basis of all inquiry. Strategies used in deductive traditions
include sampling, measurement, and statistical analysis. Because the rules of logic guide thinking,
one can easily follow thinking processes and identify the basis on which guesses, claims,
decisions, and pronouncements are made and verified
 Complementarity with Contemporary Practice
Models

Steps in SOTP
1. Identification and clarification of the problem to be addressed by the
intervention

2. Understanding of need—what is needed to resolve all or part of the

problem?

3. Setting goals and objectives to address the need

4. Reflexive intervention to achieve the goals and objectives

5. Outcome assessment
RELATIONSHIP BETWEEN OT PROCESS AND SOTP
 1. STATEMENT OF THE PROBLEM
Although we often see problems as entities existing outside ourselves, problems are contextually
embedded in personal and cultural values. A problem is a value judgment about what is undesirable or in
need of modification. Therefore, a problem statement is defined as a specific claim of what is not desired
or of what should be changed.Although it seems simple to specify a problem, we often see problems
stated in terms of a preferred solution; this error limits our options in analyzing problem components
and solutions. Moreover, in systematic OT practice, problem statements must be derived from credible,
systematically generated knowledge, including scholarly literature and inquiry, client report and data, and
other sources.

If proceeding from the initial problem statement in the referral, the therapist may have missed the
essence of the client’s problem and thus may have selected inappropriate interventions and outcomes.
The second edition of the OTPF, the OTPF-2, guides us to define problems for OT by using a client-
centered approach. Thus, in SOTP, it is critical to include the client and other diverse sources of
knowledge beyond practitioner guessing in formulating the problem statement.
.
• There are many ways to identify problems. Problem mapping is a method in which one expands
a problem statement beyond its initial conceptualization by asking two questions repeatedly:1
“What caused the problem?” and “What are the consequences of the problem?” Similar to
other professionals, OTs do not address all aspects of the problem statement. Problem mapping
helps us operationalize the OTPF in that it provides a thinking process to locate impairment
and individual function within seven broad contexts: cultural, physical, social, personal, spiritual,
temporal, and virtual. As we see in the example that follows , the problem areas for OT
intervention are defined by the scope of our professional activity
 Example
Apply the problem mapping method to the statement, “Jane has impaired short-term memory
resulting from traumatic brain injury sustained in an automobile accident caused by a drunk driver.”
To conduct problem mapping, we first need to conceptualize the problem as a river. Articulating
the original statement of the problem is analogous to stepping into the river and picking up one
rock. As we look upstream, we see causes of the problem, and as we look downstream, we see the
problem’s consequences. Keep in mind that the evidence that is used to identify causes and
consequences must be generated from credible, identifiable sources, including client, professional,
and scientific sources.
2.ASCERTAINING NEEDS
• After problem mapping, the next step is ascertaining need. In this step, one must clarify exactly
what one needs to resolve the part of the problem that has been targeted for change.
• As discussed earlier, a problem is a value statement about what is not desired. While a need
statement is a systematic, evidence-based claim linked to all or part of a problem that specifies
what conditions and actions are necessary to resolve the part of the problem to be addressed.
• . A need statement should specify who is the target of the problem, what changes are desired,
what degree of change is desired, and how one will recognize that the change has occurred.
• Thus, the identification of need involves collecting and analyzing diverse sets of information
such as assessment data and the information from the client interview, thus forming an
occupational profile to ascertain what is necessary to resolve a problem.
• The need statement must be based on systematically derived data already contained in
credible resources such as the relevant practice and research literature or documentation,
professional education, knowledge, and experience, or revealed by the client in a needs
assessment inquiry.
Example…
• As already mentioned, the problem as stated (impaired short-term memory) is not a problem
that an OT practitioner can resolve.Yet it is common for referrals for OT intervention to
identify problems such as this one. A problem map or similar problem analysis is not just a
reasonable thinking tool, but it is also essential if we are to define the nature of our
interventions more clearly and thereby document the unique contributions and outcomes of
OT both within and outside of our field.
• As we mapped the problem, we found that OT did indeed have a critical role to play in Jane’s
treatment. Her ability to engage in meaningful occupational performance is impaired in that she
is unable to manage her time and arrive at work on time as a result of her impaired short-term
memory.
• Given the problem statement, the therapist chooses to conduct a research-based needs
assessment to determine what is necessary to resolve the targeted part of the problem, to set
goals and objectives to guide the selection of an intervention, and to determine what
processes and outcome should be expected.
• Using a systematic approach to data collection, the OT practitioner uses naturalistic
techniques, including an interview and systematic observation of Jane, to ascertain Jane’s
desires and skills
Example…
• The OT practitioner administers a standardized cognitive assessment and an occupational
performance assessment. ( integrating qualitative and quantitative inquiry strategies to
document a complete understanding of need and to provide the empirical basis for clinical
decisions, as well as expected outcomes) to access Jane.

• COPM is used to identify client-perceived problems in daily functioning in the areas of self-
care, productivity, and leisure. By means of a semi structured interview format, the COPM may
be used to assess the performance skills and patterns the client identifies as interfering with
the client’s ability to function in a particular area. The data from the COPM are credible,
outcome based, and accepted as evidence in the research.(performance assessment)

• The Wisconsin Card Sorting Test (WCST) reveals that she is able to solve problems and that
she demonstrates abstract reasoning . The WCST is a standardized cognitive assessment of
executive function that was developed to assess problem solving, abstract reasoning, and the
ability to shift cognitive strategies.
RESULT…
• The Systematic assessment reveals that Jane identifies returning to her job as a saleswoman in
a boutique as her most important goal. Additionally, the results of the COPM interview reveal
that Jane is not satisfied with her ability to manage her time or her ability to be punctual and
that she perceives these two issues as the greatest barriers to achieving her desired goal of
returning to work. She recognizes that her difficulties with short-term memory will affect her
ability to do other work-related tasks, but she reports being most concerned about time
management and promptness.
Result …
• The results of standardized testing also suggest that Jane is able to learn new behaviors with
specific, well-structured practice in the environment in which she will function
• Based on this empirically generated information, the therapist and Jane have a sound and
credible basis for deciding that the intervention will be directed to the need to find and teach
Jane compensatory strategies for time management and promptness.
• Further, Jane indicated in her occupational profile that she is married and that her husband
would be supportive in helping her get to work. Based on this information generated from
naturalistic inquiry, the therapist and Jane decide to include Jane’s husband in the intervention
and to work first in Jane’s home environment and then transfer her treatment to the work
environment.
• NOTE: The desired outcomes are implicit in the need statement, which provides a basis for
formulating measurable outcomes of intervention.
3.GOALS AND OBJECTIVES
• The next step in the process of systematic OT practice is translating the needs into goals and objectives.
In SOTP, goals and objectives emerge from the need statement and are essential not only for structuring
intervention, but also for specifying how the process and outcome of intervention will be examined and
supported.
• Goals are statements developed by clients and relevant others identifying the client’s outcome of the
service—what would the client like to be able to do or be.
• Objectives are statements about both how to reach a goal and how to determine if all or part of the
goal has been reached. The two basic type of objectives are:
1. Process objectives are those interventions or services that will be provided or structured by the OT
practitioner. Defines concrete steps to attain goal.
2. Outcome objectives define the criteria that must occur or exist to determine that all or part of the
goal has been reached; outcome objectives further specify how these criteria will be demonstrated.
• To develop goal and objective statements in this model, the therapist examines the need carefully,
including the evidence to support the need statement.
• Note: One critical element of goal setting in SOTP is specificity.
• Example..
• Goal: Jane Will Improve Her Promptness to Be Able to Get to Work on Time (Performance) and to Her
Satisfaction .
• Outcome: The process (P) and outcome (O) objectives we will use to attain this goal include the following:
• 1. Jane will be presented with assistive technology supports and services and catalogs of assistive devices from
which she can select those she thinks will be most useful for her to achieve the goal. (P)
• 2. Given a choice of a variety of assistive devices (e.g., alarm watches, paging devices, and clocks), Jane will
choose one or more devices to use as an external cue provider for promptness. (P)
• 3. Jane will select one daily activity at home for which she needs an external promptness cue. (P)
• 4. With assistance from the OT practitioner, Jane and her husband will configure the device to cue Jane to
attend to this daily event. (P)
• 5. Jane’s husband will monitor her promptness and provide feedback to Jane and the therapist regarding the
effectiveness of the assistive device in meeting the goal. (P)
• 6. Once Jane has demonstrated that she can promptly attend to her schedule at home, she will begin to use
the promptness cue to arrive at work. (O)
• 7. Once Jane has demonstrated that she can arrive at work on time, the therapist will work with Jane at the
work site so that she can use the device to attend promptly to her work schedule to her and her employer’s
satisfaction. (P)
• 8. Using the most effective strategy and devices, Jane will improve her promptness and satisfaction with work
performance.
4.REFLEXIVE INTERVENTION
• By reflexive intervention, we refer to the thinking and action strategies during the intervention
phase of OT practice
• In reflexive intervention, the OT systematically monitors the client, the collaboration,
professional practice, setting-based resources, and therapeutic use of self and other internal
and external influences that impact practice process and outcome.
• The OT makes decisions based on feedback from the actual intervention itself, as well as from
an examination of the therapeutic use of self and other influences on the intervention process
• Process assessment, the systematic monitoring of process objectives ( P) occurs throughout
the reflexive intervention phase in order to provide the evidence on which, to describe
intervention and the context in which the intervention occurs, as well as to yield the evidence
on which decisions are made regarding the need for intervention or programmatic change.
NOTE: Knowing what outcomes occurred without knowing what was done to cause them limits
our knowledge base and our ability to communicate the benefits of OT practice to those outside
of the profession
• In process assessment, the COPM can be used to document changes in occupational
performance and illustrate the benefits of OT to Jane and other diverse audiences.
• Documentation is an excellent way to show Jane and others that Jane has improved through
OT. Similar strategies could be used to examine and document time management and other
areas that Jane and the OT are addressing.
• NOTE: It is useful to refer to the OTPF to guide reflexive intervention
 5.OUTCOME ASSESMENT
• Outcome assessment is a set of thinking and action processes conducted to ascertain and
document what occurs as a result of being voluntarily or involuntarily exposed to a purposive
intervention process and to assess the worth of an intervention.
• The outcome objective(O), is assessed by using both quantitative and naturalistic techniques
and by applying systematic inquiry to examine whether objectives have been attained.
• Example..
• To carry out an outcome assessment of Jane’s intervention, a pre-post test design is selected
using the COPM and the other documentation .
• Although Jane’s performance will be measured multiple times, only the change from beginning
to end will be used for outcome assessment
• Multimethod strategies is recommended for outcome assessment . Following shows how
some of the objective will be assessed.
Example…
Goals, Objectives, Evidence, and Success Criteria .
Goal No. 1: Jane Will Improve Her Promptness to Be Able to Get to Work on Time
(Performance) and to Her Satisfaction.
• 1. (P) Jane will be supplied with catalogues and assistive devices from which to select those that she
thinks will be most useful for her to achieve the goal. Criterion for success: completion of activity
Evidence: notes of each session documenting progress toward goal.
• 2. (P) Given a variety of assistive devices (e.g., alarm watches, paging devices, and clocks), Jane will
choose a device to use as an external cue provider for promptness. Criterion for success:
selection of device Evidence: notes of each session documenting progress toward goal
• 3. (P) Jane will select one activity at home for which she needs an external promptness cue.
Criterion for success: selection of activity Evidence: notes of each session documenting progress
toward goal
• 4. (P) With assistance from the OT, Jane and her husband will configure the device to cue Jane to
attend to this daily event. Criterion for success: demonstration that Jane and her husband have
completed the objective Evidence: progress notes indicating mastery of task
• 5. (O) Jane will demonstrate that she can promptly attend to her schedule at home. Criterion for
success: daily record of Jane’s promptness at home Evidence: husband’s written time charts
SUMMARY
• SOTP, a practice approach in which systematic thinking and action are not only valued but are
essential tools in OT practice.
• The model begins with a clear problem statement that guides all of the remaining steps.
• Naturalistic and experimental research traditions are applied to clinical decision making to
guide the subsequent steps of identifying and documenting need, positing goals and objectives,
reflexive intervention, and outcome assessment.
• Systematic thinking and action provide the specificity and credible evidence supporting the
extent, to which the intervention resolved the part of the problem that was identified as falling
within the OT domain.
THANK YOU…