This thesis documents the conceptualisation, development and implementation of a programme of work designed to facilitate the integration of research evidence into the decision-making of occupational therapists. The programme was born out of recognition of the critical need to support evidence-based practice (EBP) in occupational therapy, a process that is now the norm in health care practice. This thesis aimed to: 1) review the process of EBP as it applies to occupational therapy, 2) determine occupational therapists' perceptions of EBP. and more specifically. to identify barriers occupational therapists face when integrating research in practice, 3) describe the development and evaluation of a valuable resource to support EBP in occupational therapy, and 4) explore the potential for this resource to inform the profession regarding the quantity and quality of research, and research gaps and priorities. Following an introduction, five articles that have been published or are in press are presented, in addition to a further three manuscripts currently under review for publication.
An initial survey of the perceptions of 649 Australian occupational therapists about EBP showed that while 96% agreed that EBP was important to occupational therapy, insufficient time, evidence, skills and access to research evidence were identified as major barriers to its implementation. Participants relied on clinical experience (96%). continuing education (82%) and colleagues (80%) ahead of research (56%) to inform clinical decision-making. highlighting the need for targeted resources, educational initiatives and systems to support EBP in occupational therapy.
In response to the needs identified in the survey and trends occurring internationally in cognate disciplines, OTseeker (Occupational Therapy Systematic Evaluation of Evidence) was developed. OTseeker is an Internet database (www.otseeker.com). providing free access to over 3000 abstracts of systematic reviews and critical appraisals of randomised controlled trials (RCTs) relevant to occupational therapy. It was designed to increase access to research about the effectiveness of interventions relevant to occupational therapy and to support occupational therapy research.
Two independent raters critically appraised each RCT in OTseeker for internal validity and inclusion of clinically useful statistical information using the PEDro scale. The inter-rater reliability of the PEDro scale was evaluated in two studies: 1) five raters scored 100 RCTs using the original PEDro scale guidelines and 2) two raters scored 40 different RCTs using revised guidelines. The results found 'good to excellent' inter-rater reliability in the first study (Kappas ≥ 0.53: ICCs ≥ 0.71). After revising the rating guidelines, the reliability levels were equivalent or higher (Kappas ≥ 0.53: ICCs ≥ 0.89), except for the item, ·groups similar at baseline’ which still had moderate reliability (Kappa = 0.53). This indicates the PEDro scale is a reliable instrument for rating the quality of RCTs and that detailed rating guidelines may help improve inter-rater reliability. Recommendations were made to improve the quality of reporting of RCTs.
In addition to improving access to research evidence for occupational therapy, analysis of the content of OTseeker has the potential to inform the profession about the status of intervention research, and research gaps and priorities. Of 2234 RCTs and 593 systematic reviews in OTseeker in December 2004 most were published in rehabilitation and general medical journals. Methodological features of RCTs that were infrequently reported, despite their relative simplicity to include, were allocation concealment, intention-to-treat analysis and assessor blinding. Recommendations to improve the quality of reporting were made. This survey also identified core areas of practice for which limited numbers of RCTs and systematic reviews exist, highlighting areas where greater research effort may be needed.
To inform the research priority discussions within the profession, a random sample of search terms submitted to OTseeker (n = 4,500) were coded according to diagnostic and intervention categories, and compared with the amount of research contained in OTseeker. The most frequently sought intervention topics included modes of service delivery, sensory interventions, and physical modalities. The most frequently sought diagnostic topics were neurology and neuromuscular disorders and mental health. While many frequently sought topics had a correspondingly high volume of research in OTseeker, areas such as fine motor skill acquisition and autistic spectrum disorder, had very little content. This study emphasised the need for a strategic and prioritised approach to occupational therapy research.
The use and impact of OTseeker was evaluated using Australian and international samples. Responses to a mailed questionnaire of 213 randomly sampled Australian occupational therapists and occupational therapy facilities showed that while most (85.9%) had heard of OTseeker, only 56.6% had accessed the database. with a lack of time being the main reason for not using it. Of the 103 participants who had accessed OTseeker 63.1% agreed that it had increased their knowledge and 13.6% had changed their practice as a result of information obtained from OTseeker. Findings from an international online survey of OTseeker confirmed that information located through OTseeker contributes to a modest change in practice. Responses from 498 participants who had used the database more than once, showed 19% agreed that the information had contributed to a change in their practice. Those who had not changed practice agreed that use of OTseeker had improved their knowledge generally (38%), confirmed their practice (15%), or that there was not enough research relevant to their topic of interest (19%). Importantly, 62% believed it improved their ability to locate research about the effectiveness of occupational therapy interventions, demonstrating that one of the major aims of the database is being achieved.
OTseeker is now a widely used resource with approximately 200,000 visits to the website since March 2003, across more than 50 countries. In summary, the studies in this thesis confirm the important contribution of OTseeker to the occupational therapy profession, demonstrating its potential to support both clinical decision-making and the professional research agenda However, while the provision of information in a way that is accessible and credible, may contribute to the quality of decision-making, it is only one of many factors required for implementing evidence-based practice.
Recommendations are provided about future directions for EBP in occupational therapy. These encompass strategies for improving the quality, reporting and dissemination of occupational therapy research and for providing targeted initiatives for consumers, educators and clinicians. It is certain that the challenge of integrating research in health care decision-making will continue with employers and professional associations playing a pivotal role in facilitating this process.