The process of evidence-based clinical decision making in occupational therapy.

473 There is a need for occupational therapy to conceive of evidence-based practice in a way that reflects the contextualized nature of occupational engagement. In occupational therapy, we should resist following the lead of experts in evidence-based medicine, such as Sackett and his colleagues (Rosenberg & Donald, 1995; Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996; Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000), who advocate that clinical decision-making must be based on systematic appraisal of the best research evidence. Instead, we argue here that evidence-based clinical decision-making in occupational therapy should encompass the diverse variety of evidence brought to the clinical context by both the client and therapist. The following definitions of evidencebased practice are excellent examples of those espoused by medicine. Rosenberg and Donald (1995, p. 1122) define evidencebased practice as “the process of systematically finding, appraising, and using contemporaneous research findings for clinical decision.” Similarly, Sackett et al. (1996, p. 71) describe evidence-based practice as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” Both of these definitions reflect a core belief that evidence-based practice entails systematic appraisal of the best research evidence. More recently, Sackett et al. (2000, p. 1) refer to evidence-based medicine as “the integration of best research evidence with clinical expertise and patient values.” Although this definition acknowledges the expertise of the clinician and the values of the patient, it still clings to research as the only source of evidence. We propose that the values, beliefs, knowledge, and experiences of the clinician and client be recognized, in addition to research, as valuable sources of evidence in the clinical decisionmaking process. Although the core belief about evidence-based medicine is beginning to acknowledge the expertise of the clinician and the values of the patient, it does not adequately reflect the highly contextualized and dynamic nature of occupational therapy. The practice of occupational therapy is an individualized activity shaped by a unique client-therapist relationship; it is not a static outcome that can be achieved by following a rigid procedure. Furthermore, as noted by Tickle-Degnen and Bedell (2003), the use of a single, invariant hierarchy of research evidence serves to depreciate the information provided by research methods other than randomized clinical trials. There are many kinds of research, and each variety can provide important insights into the nature of occupational performance. Occupational therapy is highly contextualized, and evidence-based practice should reflect the different kinds of evidence that clients as well as therapists bring to the therapeutic process. When describing evidence-based practice in occupational therapy, it is important to emphasize that rehabilitation is a dynamic process. Unlike medical interventions, which can be described as standardized procedures, occupational therapy interventions are often more aptly described as dynamic processes. Indeed, the Occupational Therapy Practice Framework: Domain and Process (American Occupational Therapy Association [AOTA], 2002) clearly identifies occupational therapy as a dynamic process. To further delineate the distinction between medical practice and occupational therapy practice, consider the role of the patient or client. Medical procedures are frequently pharmacological or surgical in nature, with the patient playing a passive or receptive role. In contrast, the rehabilitation client plays a participatory role in the dynamic therapy process. Therefore, we argue that effective evidence-based practice in occupational therapy should acknowledge the diverse kinds of evidence brought to the clinical context by both the client and therapist.