Has occupational science taken away the occupational therapy evidence base? A debate.
Abstract: Health policy requires occupational therapy to demonstrate evidence-based clinical outcomes and efficiency in order to survive. This has significant implications for occupational therapy researchers and managers and suggests a re-evaluation of the profession's priorities for research. This opinion piece aims to stimulate debate regarding the impact of occupational science on occupational therapy and the need for research that evaluates the effectiveness of occupational therapy interventions. This is achieved by reflecting on a personal experience of evaluating research evidence for clinical guidelines and by exploring current and future challenges.

Key words:

Occupational therapy, occupational science, evidence-based practice.
Subject: Evidence-based medicine (Analysis)
Occupational therapy (Usage)
Practice guidelines (Medicine) (Usage)
Brain (Injuries)
Brain (Care and treatment)
Authors: Morley, Mary
Atwal, Anita
Spiliotopoulou, Georgia
Pub Date: 10/01/2011
Publication: Name: British Journal of Occupational Therapy Publisher: College of Occupational Therapists Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 College of Occupational Therapists Ltd. ISSN: 0308-0226
Issue: Date: Oct, 2011 Source Volume: 74 Source Issue: 10
Geographic: Geographic Scope: United Kingdom Geographic Code: 4EUUK United Kingdom
Accession Number: 271053265
Full Text: Introduction

Occupational science was developed as a means to generate knowledge about human occupation and broaden the practice of occupational therapy; for example, by also adopting a more preventive approach (Wilcock 2001). Although this knowledge underpins occupational therapy practice, there is a need to know how it is used within the field in order to make a holistic and significant contribution to existing practice. This opinion piece has been written to stimulate debate on this matter. The authors include two researchers (AA and GS), who share their journey to develop evidence-based guidelines for occupational therapy for people with brain injury The first author works as a director of occupational therapy within a National Health Service (NHS) organisation and reflects on this case study as an example of the current and future challenges to ensure that occupational therapy can be evidenced and funded.

These issues need to be considered against the backdrop of new health policy presented by the coalition government in the United Kingdom (UK). The NHS White Paper (Department of Health [DH] 2010a) set out the intention to drive a:

relentless focus on clinical outcomes. Success will be measured, not through bureaucratic process targets, but against results that really matter to patients such as improving cancer and stroke survival rates (p1).

The NHS will be held to account against clinically credible and evidence-based outcome measures. This builds on Darzi's health care reforms (DH 2008), initiated by the previous government.

A new NHS outcomes framework will develop national outcome goals, financial incentives and model contracts to be used by commissioners to drive up quality (DH 2010b). The framework will span three domains of quality, with the first being the effectiveness of treatment and care, to be measured by clinical outcomes and patient-reported outcomes. The framework will also consider safety issues and the broader patient experience. Quality standards, developed by the National Institute for Health and Clinical Excellence (NICE), will inform the commissioning of all NHS care and payment systems. Inspection will be against essential quality standards, and will have an impact on organisations' income because payment will be linked to quality indicators and clinical outcome. To support the development of quality standards, NICE will advise the National Institute for Health Research on research priorities. In addition, the Social Care Institute for Excellence has developed an online evidence-based website (http://www.scie-socialcareonline.org.uk) as an important tool for promoting evidence in social care.

The White Paper (DH 2010a) reinforces the UK government's commitment to the promotion of research as a core NHS role:

These policy drivers signal a move to funding for services that are increasingly evidence based, can demonstrate clinical outcome and efficiency, and are informed by applied clinical research. The vital importance of these issues calls for a re-evaluation of occupational science's focus and priorities for research. As Clark (2006) stated, the survival of occupational science is influenced by institutional, political and economic factors. The primacy of occupational science as the focus of theory and knowledge development has engaged academics for a decade or more. These arguments will not be fully re-rehearsed here. Rather, the two researchers present a personal experience to highlight recent challenges in providing an evidence base for one area of practice.

It is contended that if similar difficulties occur in other areas of practice, the lack of an evidence base could lead to funding being diverted from occupational therapy to other services. As an example, this trend has been identified in the United States (US), where funding has been diverted from mental health occupational therapy into other services. The proportion of mental health occupational therapists has dropped from approximately 30% to 7% of US occupational therapists (American Occupational Therapy Association, personal communication, 2010). The profession in the UK needs to focus its efforts and seize opportunities to meet the new outcomes-focused policy agenda.

Developing clinical guidelines: a case study

The two researchers reflected on their experiences in completing occupational therapy evidence-based guidelines for brain injury patients on behalf of the College of Occupational Therapists. Both have been fortunate to have spent time with Ann Wilcock debating the complexities and challenges of occupational science. In her role as visiting professor at Brunel University, Wilcock brought refreshing new ideas about the use of occupation by occupational therapists. During these discussions, her passion, her knowledge and her belief that occupational science would promote and facilitate occupation-based research was clear. However, using as an example one research question from a study aiming to produce evidence-based guidelines, the authors discuss why occupational science research could not be included in this instance within occupational therapy guidelines for brain injury patients.

The evidence

Clinical practice guidelines are systematic statements that enable occupational therapists and other health care professionals to proceed with the best decision making regarding the treatment and management of the patient. They improve the quality and appropriateness of care as well as its effectiveness and efficiency (Manchikanti 2008), and are a means to increase the likelihood of policy support (Tang et al 2003). Clinical guidelines are established through evidence-based practice.

Table 1 demonstrates one search from the Medline and CINAHL databases (both from January 1990 to June 2010), aiming to answer the question: 'What evidence is available to support the effectiveness of occupational therapy to improve quality of life for adults with acquired brain injury?' Table 2 shows the inclusion and exclusion criteria for the literature search.

From the seven full-text papers that were read, only one could be included in the review because it was the only one demonstrating the effectiveness of occupational therapy intervention. Although the other papers provided a useful insight into the meaning of occupation for people with acquired brain injury, they did not evaluate any occupation-based intervention or make direct reference to occupational therapy (Asikainen et al 1998, Steadman-Pare et al 2001, Man et al 2004, Cicerone and Azulay 2007, Eriksson et al 2009, Turner et al 2009). For example, the Scandinavian study by Eriksson et al (2009) explored couples' happiness and its relationship to functioning in everyday life after brain injury. Also, the Australian paper by Turner et al (2009) explored re-engagement in meaningful occupations, during the transition from hospital to home, for people with acquired brain injury and their family caregivers. The results of the above studies are of interest since they highlight the importance of occupation and the difficulties people have in regaining skills. However, they do not measure the outcome of any occupation-based intervention and they do not clarify whether there was any occupational therapy involvement in the process.

In contrast, the US paper by Huebner et al (2003) explored community participation and quality of life after adult traumatic brain injury. What is of interest in this study is that it managed to capture the occupational profile of the participants, as well as the occupational therapy focus. In this study, 87% of the participants were very satisfied with occupational therapy and 91.7% would recommend occupational therapy to a friend or family member. However, most respondents (exact number not stated) expressed a desire for more rehabilitation, including occupational therapy. Consequently, one can assert from this paper that there is evidence that brain injury patients would like further rehabilitation, with only six patients receiving outpatient therapy.

Future developments

There has been much debate in occupational therapy regarding the quality of occupational therapy journals (Brown and Williams 2011), and one of the factors associated with this might be the level of evidence resulting from the published research in these journals. Are researchers failing to evaluate occupational therapy practice or the effectiveness of occupation-based intervention either on people with disabilities or as part of a preventive approach? Are clinical trials for occupational therapy and rehabilitation interventions too expensive or too difficult to do in practice? What are the risks associated with this? It could also be suggested that it is the responsibility of researchers, reviewers and editors to ensure that research papers published in occupational therapy journals clarify the role of the occupational therapist in the therapeutic team, if such involvement exists.

The authors support Clark's (2006) view that occupational science needs to make a recognisable contribution to society, the international community and occupational therapy. Therefore, there is a need for occupational scientists to make their research transferable to occupational therapy practice, using qualitative, quantitative or mixed methods research. This is essential if occupational therapy, as an intervention, is to be included in national guidelines and outcomes frameworks. At a local level, commissioners of services will demand evidence that occupational therapy is effective in terms of both costs and outcomes. Consumers of occupational therapy services need this evidence too. Managers of services have a part to play in building infrastructure in terms of information systems (Morley and Aveling 2009), and in ensuring the use of standardised assessments to promote evidence-based practice within a research-oriented culture (Blount and Parkinson 2010). Most importantly, managers have a responsibility to make the case for clinical research to academic colleagues and to facilitate collaborative approaches to investigation.

In order to deliver the above, those setting the research agenda within the profession should ensure that all commissioned research is directly related to occupational therapy. There are scarce resources for this vital work. It is hoped that this opinion piece will be seen as an attempt to debate how occupational science research can enhance the growth and development of occupational therapy. It is our profession and, consequently, our responsibility to ensure that it survives and flourishes.

References

Asikainen I, Kaste M, Sarna S (1998) Predicting late outcome for patients with traumatic brain injury referred to a rehabilitation programme: a study of 508 Finnish patients 5 years or more after injury. Brain Injury, 12(2), 95-107.

Blount J, Parkinson S (2010) Assessment linked to professional models of practice strengthens our evidence base. Mental Health Occupational Therapy, 15(2), 37-40.

Brown T, Williams B (2011) Journal quality metrics: how does BJOT measure up? British Journal of Occupational Therapy, 74(4), 159.

Cicerone KD, Azulay J (2007) Perceived self-efficacy and life satisfaction after traumatic brain injury. Journal of Head Trauma Rehabilitation, 22(5), 257-66.

Clark F (2006) One person's thoughts on the future of occupational science. Journal of Occupational Science, 13(3), 167-79.

Department of Health (2008) High quality care for all: NHS next stage review final report. London: HMSO.

Department of Health (2010a) Equity and excellence: liberating the NHS. White paper. London: HMSO.

Department of Health (2010b) Liberating the NHS: transparency in outcomes: a framework for the NHS. Consultation paper. London: HMSO.

Eriksson G, KottorpA, Borg J,Tham K (2009) Relationship between occupational gaps in everyday life, depressive mood and life satisfaction after acquired brain injury. Journal of Rehabilitation Medicine, 1(3), 187-94.

Huebner RA, Johnson K, Bennett CM, Schneck C (2003) Community participation and quality of life outcomes after adult traumatic brain injury. American Journal of Occupational Therapy, 57(2), 177-85.

Man DW, Lee EW, Tong EC, Yip SC, Lui WF, Lam CS (2004) Health services needs and quality of life assessment of individuals with brain injuries: a pilot cross-sectional study. Brain Injury, 18(6), 577-91.

Manchikanti L (2008) Evidence-based medicine, systematic reviews, and guidelines in interventional pain management, part 1: introduction and general considerations. Pain Physician, 11(6), 161-86.

Morley M, Aveling P (2009) Meeting the challenge: OT and IT. British Journal of Occupational Therapy, 72(12), 559-61.

Steadman-Pare D, Colantonio A, Ratcliff G, Chase S, Vernich L (2001) Factors associated with perceived quality of life many years after traumatic brain injury. Journal of Head Trauma Rehabilitation, 16(4), 330-42.

Tang KC, Ehsani JP, McQueen DV (2003) Evidence based health promotion: recollections, reflection, and reconsiderations. Journal of Epidemiology and Community Health, 57(11), 841-43.

Turner B, Ownsworth T, Cornwell P, Fleming J (2009) Reengagement in meaningful occupations during the transition from hospital to home for people with acquired brain injury and their family caregivers. American Journal Occupational Therapy, 63(5), 609-20.

Wilcock AA (2001) Occupational science: the key to broadening horizons. British Journal of Occupational Therapy, 64(8), 412-17.

Mary Morley, (1) Anita Atwal (2) and Georgia Spiliotopoulou (3)

(1) Director of Therapies, South West London and St George's Mental Health NHS Trust, London.

(2) Senior Lecturer in Occupational Therapy, Director of the Centre for Professional Practice Research, School of Health Sciences and Social Care, Brunel University, West London.

(3) Lecturer in Occupational Therapy, School of Health Sciences and Social Care, Brunel University, West London.

Corresponding author:

Dr Mary Morley, Director of Therapies, South West London and St George's Mental Health NHS Trust, Springfield University Hospital, 61 Glenburnie Road, London SW17 7DJ. Email: mary.morley@swlstg-tr.nhs.uk

Reference: Morley M, Atwal A, Spiliotopoulou G (2011) Has occupational science taken away the occupational therapy evidence base? A debate. British Journal of Occupational Therapy, 74(10), 494-497.

DOI: 10.4276/030802211X13182481842065

Submitted: 7 August 2010.

Accepted: 15 April 2011.
Research is vital in providing the new knowledge needed to improve
   health outcomes and reduce inequalities ... It identifies new ways of
   preventing, diagnosing and treating disease. It is essential if we
   are to increase the quality and productivity of the NHS (p24).


Table 1. Literature search from Medline and CINAHL (January 1990 to
June 2010)

Database      Key words used         Abstracts meeting the criteria

Medline    Occupational therapy    Asikainen et al 1998,
           and brain injury and    Steadman-Pare et al 2001,
           quality of life         Huebneretal 2003, Man et al 2004,
                                   Cicerone and Azulay 2007, Eriksson
                                   et al 2009, Turner et al 2009

CINAHL     Occupational therapy    Huebner et al 2003, Cicerone and
           and brain injury and    Azulay 2007, Man etal 2004
           quality of life

Database              Full papers read               Paper meeting the
                                                     inclusion criteria

Medline    Asikainen et al 1998, Steadman-Pare       Huebner etal 2003
           etal 2001, Huebner etal 2003, Man
           et al 2004, Cicerone and Azulay 2007,
           Eriksson et al 2009, Turner et al 2009

CINAHL     Huebner et al 2003, Cicerone and          Huebneretal 2003
           Azulay 2007, Man etal 2004

Table 2. Inclusion and exclusion criteria for the literature search

Inclusion criteria    1. Published between January 1990 and June 2010
                      2. Qualitative or quantitative research
                         articles published in English
                      3. Making direct reference to occupational
                         therapy and quality of life
                      4. Evaluating occupational therapy or
                         occupation-based interventions
                      5. Sample including people with acquired brain
                         injury aged 18-65 years

Exclusion criteria    1. Literature reviews and systematic reviews
                      2. Articles that made no direct reference to
                         occupational therapy and quality of life
                      3. Sample including people with acquired brain
                         injury and people with a stroke
                      4. Sample aged less than 18 years or over 65
                         years
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