The role of professional expertise in evidence-based occupational therapy.

589 Evidence-based practice has been a dominant theme in professional literature for over a decade. “Evidence” has been considered synonymous with research evidence, and there are no reasonable arguments against the value of systematically infusing research evidence into clinical practices. The compelling logic of integrating the best available research evidence into professional practices has driven clinical decision making beyond the range of the opinions of individual practitioners and their local colleagues. The professional literature has focused on methods to acquire the skills to access and evaluate research evidence, with the development of user-friendly guides for framing questions, gathering research evidence, and appraising its quality and applicability. More recently, a greater emphasis has been placed on the need to integrate client evidence with research evidence. In occupational therapy, the identification of occupational performance issues and goals as well as the determination of clients’ values and preferences, are essential for developing meaningful therapeutic partnerships and valued client outcomes. Egan, Dubouloz, von Zweck, and Vallerand (1998) itemize the types of client and research evidence relevant to each stage in the process of enabling occupational performance. Why, then, do we continue to struggle with the questions “What is the best evidence for occupational therapy?” and “How do we interpret that evidence?” (Ottenbacher, Tickle-Degnen, & Hasselkus, 2002, pp. 247–249). This submission to the Evidence-Based Practice Forum critically examines the premises and methods involved in evidence-based occupational therapy to reveal four main limitations. The shortage of creditable research evidence and the organizational barriers to research utilization are two limitations to evidence-based practice that are common across the health professions. The neglect of qualitative research as evidence is perhaps most pertinent to client-centered practices such as occupational therapy. The fourth limitation, and the particular focus of this paper, is the lack of comprehensive models describing how to integrate client and research evidence with professional expertise. Never enough research evidence. The most fundamental premise of evidencebased practice is the belief that a clinician’s application of research evidence to clinical practices will greatly improve therapeutic outcomes. As logical as this theory would seem, there is, as yet, very little research evidence to demonstrate that the construct of evidence-based practice actually works (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000)! Given widespread faith in the process, however, we can look beyond this concern to see that implicit in the promotion of evidence-based practice is the notion that high-quality research evidence is available to address each clinical question. Lay observers (for example, managers or funders of professional services) may interpret the failure to base one’s practice on the results of a randomized controlled trial as clinical incompetence or lack of diligence. The reality is, however, that even in the much larger, and relatively more quantifiable and controllable field of medical research, there is a shortage of coherent, consistent scientific evidence (Sackett et al., 2000, p. 7). How much more difficult is it, then, to produce research evidence on the effectiveness of occupational therapy practices, when occupational therapy focuses on the complexities of individuals in their occupational contexts rather than on their cells or biological subsystems? The scarcity of research on the effectiveness of occupational therapy practices (Hayes, 2000) increases the burden on the therapist; first, by requiring the therapist to search for research evidence that is only somewhat relevant, and then, through laboriously extrapolating the findings of such studies to their individual occupational therapy clients. Contextual barriers to evidence-based practice. Recent research on occupational therapists’ capacities to integrate research evidence into their practice suggests that their difficulties are partially attributable to constraints in their practice environments. Economic and organizational factors, such as insufficient time to acquire and evaluate client and research evidence, the shortages of necessary equipment to carry out searches, assessments, or interventions, and constraints on the number of funded occupational therapy visits, place external parameters on therapists’ abilities to translate research evidence into their practices (Curtin & Jaramazovic, 2001; Dysart & Tomlin, 2002; Humphris, Littlejohns, Victor, O’Halloran, & Peacock; 2000; Rappolt, Mitra, & Murphy, 2002; Rappolt & Tassone, 2002; Sweetland & Craik, 2001). The results of these studies are similar to the findings of studies of nursing (McCaughan, Thompson, Cullum, ShelSusan Rappolt