EVIDENCE-BASED PRACTICE FORUM

Linda Tickle-Degnen, Associate Editor

The Role of Professional Expertise in Evidence-Based

Occupational Therapy
Susan Rappolt

vidence-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?

Susan Rappolt, PhD, OT Reg (Ont), is Associate Professor,

Department of Occupational Therapy, University of Toronto,
500 University Avenue, Toronto, Ontario, Canada M5G
1V7; s.rappolt@utoronto.ca

The American Journal of Occupational Therapy

(Ottenbacher, Tickle-Degnen, & Hasselkus, 2002, pp. 247249). 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 clinicians
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 ones 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 quantifi-

able 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, OHalloran, & 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, Shel589

don, & Thompson, 2002) and physiotherapy (Turner & Whitfield, 1997). Since
individual practitioners efforts to address
any of these barriers detract from their
direct clinical accountabilities, these barriers must be addressed at the level of the professional organization.
The neglect of qualitative research as evidence. The third, and somewhat more con-

troversial concern about evidence-based

practice is the failure to develop systematic
methods to apply the results of qualitative
research in clinical decision making. Based
on clinical-epidemiologically derived
research evidence for medical practices, the
commonly accepted notion of research evidence is essentially synonymous with quantitative research, with randomized controlled trials (RCTs) and systematic review
of RCTs as the gold standard. Questions
that are amenable to quantitative research
methodologies are generally composed of
discrete and controllable variables, unlike
the factors underpinning the problems of
occupational performance. Qualitative
methods, on the other hand, can be used to
access and analyse complex and abstract
phenomena and relationships (Hurley,
1999), and to systematically address the
kinds of questions that are not easily
addressed by experimental methods (Green
& Britten, 1998). Occupational therapists
therefore argue that qualitative research is
crucial for informing the collaborative process of enablement (Egan et al., 1998;
Hammell, 2001a, 2001b; Savin-Baden &
Tayor, 2001). So far, there is little to guide
practitioners on how to systematically apply
the results of qualitative research in clinical
practice. To address this gap, a program
within the Cochrane Collaboration, the
Cochrane Qualitative Methods &
Campbell Process Implementation Group,
is attempting to demonstrate the value of
including evidence from qualitative
research and process evaluations into systematic reviews (2002). However, attempting to fit research about social meanings
into the quantitative paradigm may be
futile (Giacomini, 2001), and efforts may
be better directed toward determining
which research methods best address which
types of questions. Upshurs (2001) twodimensional theoretical model of quantitative and qualitative research provides a
590

framework from which to address this

objective. The vertical axis of the model
permits the demarcation of studies that
range in their purpose from measurement
to examining meaning. The horizontal axis
describes the nature of problems, from
those that are focused on particular to general cases. Bennett and Bennett begin the
process of ascribing research methodologies
to types of clinical questions in their table
of hierarchies of evidence (2000, p. 174).
Pursuit of a complete taxonomy of research
methods in relation to types of clinical
questions is needed, but beyond the scope
of the current paper.
The role of professional expertise in evidence based practice. As noted above, the

movement toward evidence-based practice

in health care is a response to opinion-based
professional practices with the objective of
increasing the quality and improving the
outcomes of professional services. The rise
to prominence of client and research evidence in the evidence-based practice
paradigm implies a relative decrease in the
importance of professional expertise. In its
defense, the Joint Position Statement on
Evidence-Based Occupational Therapy,
developed by the Canadian Association of
Occupational Therapists (CAOT), the
Association of Canadian Occupational
Therapy University Programs, the
Association of Canadian Occupational
Therapy Regulatory Organizations, and the
Presidents Advisory Committee (1999),
suggests that professional expertise is on
equal footing with client and research evidence. A linear relationship between client
evidence (Cl.E), research evidence (RE),
and the professionals expertise (PE) is
inferred in the Joint Position Statement:
Cl.E + RE + PE = EBP
Graphically, the relationship between the
three types of evidence and clinical decision
making described within the Joint Position
Statement of Evidence-Based Occupational
Therapy (CAOT et al., 1999) is portrayed
in Figure 1.
In the remainder of the paper I will
examine this theoretical assumption by
analysing the relationships between client
and research evidence and professional
expertise across the process of client-centered evidence-based occupational therapy
practice. Figure 2 draws upon elements of

Professional
Expertise

Clinical
Decision
Making
Client
Evidence

Research
Evidence

Figure 1. Accepted Model of Clinical

Decision Making in Occupational Therapy.

the Occupational Performance Process

Model (Fearing, Law, & Clarke 1997), and
the steps for evidence-based practice delineated by Tickle-Degnen (1999a, 1999b,
2000a, 2000b, 2000c) to graphically
demonstrate the roles of client and research
evidence and professional expertise in the
process.
In Figure 2, the client, the process of
client-centered evidence-based occupational therapy, and the outcomes of the clients
engagement in that process are situated in
particular social, economic, and organizational contexts.
Stage 1: Gathering and appraising client
evidence. Ideally, when clients enter the

therapy process they work collaboratively

with the therapist to assimilate relevant
client evidence and define occupational
performance issues and goals. While a full
partnership between the client and therapist at this stage is optimal, the therapeutic
process is rarely abandoned when the client
is unable to fully contribute. The facility
with which client evidence is evoked, assimilated, and synthesized into occupational
performance goals and issues is highly contingent on the therapists assessment and
interview skills and theoretical knowledge
of occupation.
Stage 2: Framing the question and
accessing and appraising relevant research
evidence. There appears to be a strong con-

sensus on the strategies to accomplish these

three steps for evidence-based practice
(Sackett et al., 2000; Tickle-Degnen,
1999a, 1999b, 2000a). The occupational
therapist must first translate occupational
performance issues into researchable quesSeptember/October 2003, Volume 57, Number 5

Stage 1
Stage 2
Client
Research
Evidence
Evidence
1. Gather and 1. Identify
appraise
research
client
question
evidence
2. Identify
2. Gather
occuparelevant
tional perevidence
formance
issues
3. Appraise
quality of
evidence

Collaborative Professional
Role
Role
Professional
Research
& Client
Expertise

Stage 3
Stage 4
Integration of
Decision
Evidence
Making
1. Establish
1. Discuss
applicabiliCEc and RE
ty of REa to
with client
C1.Eb
2. Determine 2. Develop
appropriplans for
ateness to
enablesetting
ment col3. Determine
laboratively
method,
amount,
timing
4. Identify
evaluation
criteria
5. Anticipate
outcomes
Professional Collaborative
Role
Role
Clinical
Professional
Expertise
& Client

Stage 5
Enablement
& Evaluation
1. Further
assessments as
needed
2. Undertake
processes
for enablement
3. Evaluate
outcomes

Client Outcomes

Client

SPECIFIC CONTEXT OF PRACTICE

Evidence-Based Occupational Therapy Process

Collaborative
Role
Professional
& Client

RE = Research evidence
C1.E = Client evidence
c CE = Clinical expertise
a

Figure 2. Professional Expertise in the Evidence-Based Occupational Therapy Process.

tions, then systematically gather current

research evidence that could address the
question, and finally evaluate the quality of
the research evidence according to appropriate criteria. Although it has been argued
that the client should be included in the
retrieval, review, and evaluation of the
research literature (CAOT et al., 1999;
Hammell, 2001a), realistically, the requirements of these activities are beyond the
capacities of many occupational therapy
clients at the point of their engagement in
the therapy process. Stage 2, therefore, is
primarily a function of the therapists
research knowledge and skills. Occupational therapists acknowledge that their lack
of expertise in research retrieval and analysis is a significant barrier to their integration
of research evidence into practice (Dysart &
Tomlin, 2002; Humphris et al., 2000;
Rappolt & Tassone, 2002; Sweetland &
Craik, 2001).
Stage 3: Integration of evidence. Determining the applicability of the results of
RCTs and systematic reviews to individual
patients requires the analysis of the relevance of the research findings for the average participant in the RCT or member of
The American Journal of Occupational Therapy

the population to a particular client.

Quantitative methodologies have been
developed to facilitate the interpretation of
quantitative research results with respect to
the clinical needs and context of the individual client. Although clinical decision
analysis is regarded as altogether too cumbersome, the steps provided by Sackett et al.
(2000) and Tickle-Degnen (1998a, 1998b)
are more user-friendly. The application of
these quantitative methods for the integration of client and research evidence, however, require dedicated time and research
expertise, including a level of statistical
sophistication to establish the relevance of
research evidence to the individual client.
Even when these steps can facilitate the
integration of research and client evidence,
this stage of the evidence-based practice process is still, in part, dependent on the judgments (Law, 2002) or professional expertise
of the therapist. As argued by Giacomini,
Generalizing either [quantitative or qualitative] research requires a rather unscientific inductive leap, invoking ideas beyond
those provided by the research itself (2001,
p. 3). To date, there has been very little
empirical research to examine the strategies

and sequence of activities that are involved

in therapists integration of research and
client evidence. One exception is a recent
qualitative study in which Craik and
Rappolt (in press) examine therapists strategies for integrating research and client evidence, resulting in the theorization of the
sequence of reflection, case application, and
peer consultation for research utilization.
Stage 4: Clinical decision making. Like
the gathering and appraising of client evidence, clinical decision making is a collaborative process that begins with the communication of relevant research evidence and
its integration with client evidence (TickleDegnen, 1998a). Similarly, the quality of
both the discussion of client and research
evidence, and the shared plans developed
for the enablement of the client, are circumscribed by the clinical expertise of the
therapist.
Stage 5: Enablement and evaluation. The
merging of enablement and evaluation is
intended to show their reflexive relationship
in this necessarily collaborative therapeutic
process. There are three parallel outcomes
resulting from the enablement process. The
first outcome is the effect of therapy on the
clients occupational performance in his or
her social context. The second outcome is
the production of new client evidence that
may generate new occupational performance issues and subsequent goals and
researchable questions. The third outcome,
as suggested by Lee and Miller (2003), is
the therapists accumulation of client evidence as clinical experience, which has the
potential to affect future decision making.
The roles of professional expertise and
client and research evidence in evidencebased occupational therapy: The preceding
examination of the process of evidencebased occupational therapy demonstrates
that the role of professional expertise
includes the functions of establishing client
evidence and occupational performance
issues, their translation into researchable
questions, and the retrieval and appraisal of
relevant research evidence. It is argued that
success in Stage 2, developing questions and
retrieving and appraising research evidence,
is largely dependent on the research skills of
the therapist. It is also argued that Stage 3,
the analysis of research evidence with
respect to client evidence, depends on the
591

therapists clinical expertise, and that these

two stages are the exclusive responsibilities
of the therapist. Subsequent clinical decision making and enablement and evaluation are collaborative processes that are
facilitated by the therapist. This analysis of
the role of professional expertise in relation
to client and research evidence suggests a
different relationship than the one implied
in the Joint Position Statement on
Evidence-Based Occupational Therapy
(CAOT et al., 1999), and is represented by
the following equation:
PE (Cl.E + RE) = EBP
Graphic representation of this model for
the process of clinical decision making is
provided in Figure 3. The model is consistent with both the definition of evidencebased medicine (Sackett et al., 2000), and
evidence-based occupational therapy
(CAOT et al., 1999), but provides a more
accurate portrayal of the role of professional expertise in the determination and application of client and research evidence in
clinical decision making. This model also
adheres to the sociological definition of professional expertise as the application of
abstract and technical knowledge to individual cases (Freidson, 1970).
It is unlikely that the proposed models
for bringing professional expertise back into
prominence across the evidence-based practice process and within clinical decision
making will have any direct effect on the
shortage of research evidence or the neglect
of qualitative research evidence. However,
greater recognition of the importance of

Professional
Expertise

Client
Evidence

Clinical
Decision
Making

Research
Evidence

Figure 3. Model of Professional Expertise in

Clinical Decision Making.
592

professional expertise across the evidencebased practice process may persuade managers and funders to address organizational
barriers to evidence-based practice. By more
fully appreciating the centrality of professional expertise to evidence-based practices,
therapists may be inspired to become more
reflective about their clinical practices, educators may wish to reconceptualize their
curricula, and payers may reexamine their
funding mechanisms. This paper invites
both rigorous discussion and empirical
analysis of the proposed models.

Acknowledgments
I thank Nick Stitt and Janet Craik for their
thoughtful reviews of earlier drafts of this
paper and Sara McEwen for her assistance
with the figures.

References
Bennett, S., & Bennett, J. W. (2000). The process of evidence-based practice in occupational therapy: Informing clinical decisions. Australian Occupational Therapy
Journal, 47, 171180.
CAOT et al.: Canadian Association of Occupational Therapists, Association of Canadian
Occupational Therapy University Programs, Association of Canadian Occupational Therapy Regulatory Organizations,
and Presidents Advisory Council. (1999).
Joint position statement on evidence-based
occupational therapy. Canadian Journal of
Occupational Therapy, 66, 267277.
Craik, J., & Rappolt, S. (in press). Theory of
research utilization enhancement. Canadian Journal of Occupational Therapy. (2003
Special edition on evidence-based practice.)
Curtin, M., & Jaramazovic, E. (2001).
Occupational therapists views and perceptions of evidence-based practice. British
Journal of Occupational Therapy, 64(5),
214222.
Dysart, A. M., & Tomlin, G. S. (2002). Factors
related to evidence-based practice among
U.S. occupational therapy clinicians.
American Journal of Occupational Therapy,
56, 275284.
Egan, M., Dubouloz, C.-J., von Zweck, C., &
Vallerand, J. (1998). The client-centered
evidence-based practice of occupational
therapy. Canadian Journal of Occupational
Therapy, 65(3), 136143.

Fearing, V. G., Law, M., & Clark, M. (1997).

An occupational performance process
model: Fostering client and therapist
alliances. Canadian Journal of Occupational
Therapy, 64, 715.
Freidson, E. (1970). Profession of medicine: A
study in the sociology of applied knowledge.
Chicago: University of Chicago Press.
Giacomini, M. K. (2001). The rocky road:
Qualitative research as evidence. ACP
Journal Club, 134, A11-A12. Retrieved
January 28, 2003, from http://www.acpjc.
org/Content/134/ISSUE/ACPJC-2001134-1-A11.htm
Green, J., & Britten, N. (1998). Qualitative
research and evidence based medicine.
British Medical Journal, 316(7139),
12301232.
Hammell, K. W. (2001a). Using qualitative
research to inform the client-centered evidence-based practice of occupational therapy. British Journal of Occupational Therapy,
64(5), 228234.
Hammell, K. W. (2001b). Informing client-centred practice through qualitative inquiry:
Evaluating the quality of qualitative
research. British Journal of Occupational
Therapy, 64(5), 174184.
Hayes, R. L. (2000). Evidence-based occupational therapy needs strategically-targeted
quality research now. Australian Occupational Therapy Journal, 47, 186190.
Humphris, D., Littlejohns, P., Victor, C.,
OHalloran, P., & Peacock, J. (2000).
Implementing evidence-based practice:
Factors that influence the use of research
evidence by occupational therapists. British
Journal of Occupational Therapy, 63(11),
516522.
Hurley, R. E. (1999). Qualitative research and
the profound grasp of the obvious. Health
Services Research, 35(5) Suppl. Part 2,
11191136.
Law, M. (2002). Building evidence in practice.
In M. Law (Ed.). Evidence-based rehabilitation: A guide to practice. Thorofare, NJ:
Slack.
Lee, C. J., & Miller, L. T. (2003). The process of
evidence-based clinical decision making in
occupational therapy. American Journal of
Occupational Therapy, 57, 473477.
McCaughan, D., Thompson, C., Cullum,
N., Sheldon, T. A., & Thompson, D.
R. (2002). Acute care nurses perceptions
of barriers to using research information
in clinical decision-making. Journal
of Advanced Nursing Practice, 39(1),
4660.
Ottenbacher, K. J., Tickle-Degnen, L., &
September/October 2003, Volume 57, Number 5

Hasselkus, B. R. (2002). Therapists awake:

The challenge of evidence-based occupational therapy. American Journal of
Occupational Therapy, 56, 247249.
Rappolt, S., Mitra, A., & Murphy, E. (2002).
Professional accountability in restructured
contexts of occupational therapy practice.
Canadian Journal of Occupational Therapy,
69, 293302.
Rappolt, S., & Tassone, M. (2002). How rehabilitation therapists gather, evaluate and
implement new knowledge. Journal of
Continuing Education in Health Professions,
22(3), 170180.
Sackett, D. L., Straus, S. E., Richardson, W. S.,
Rosenberg, W., & Haynes, R. B. (2000).
Evidence-based medicine: How to practice
and teach EBM. New York: Churchill
Livingstone.
Savin-Baden, M., & Taylor, C. (2001).
Conference report: Qualitative evidencebased practice. American Journal of Occupational Therapy, 55, 230232.
Sweetland, J., & Craik, C. (2001). The use of
evidence-based practice by occupational

therapists who treat adult stroke patients.

British Journal of Occupational Therapy,
64(5), 256260.
The Cochrane Collaboration. (2002). Cochrane
Qualitative Methods Group & Campbell
Process Implementation Methods Group.
Retrieved January 24, 2003, from http://
mysite.freeserve.com/Cochrane_Qual_Me
thod/activity1.htm
Tickle-Degnen, L. (1998a). Using research evidence in planning treatment for the individual client. Canadian Journal of Occupational Therapy, 65(3), 152159.
Tickle-Degnen, L. (1998b). Communicating
with clients about treatment outcomes:
The use of meta-analytic evidence in collaborative treatment planning. American
Journal of Occupational Therapy, 52,
526539.
Tickle-Degnen, L. (1999a). Organizing, evaluating and using evidence in occupational
therapy practice. American Journal of
Occupational Therapy, 53, 537539.
Tickle-Degnen, L. (1999b). Gathering current
research evidence to enhance clinical rea-

soning. American Journal of Occupational

Therapy, 54, 102105.
Tickle-Degnen, L. (2000a). What is the best
evidence to use in practice? American
Journal of Occupational Therapy, 54,
218221.
Tickle-Degnen, L. (2000b). Communicating
with clients, family members and colleagues about research evidence. American
Journal of Occupational Therapy, 54, 341
343.
Tickle-Degnen, L. (2000c). Monitoring and
documenting evidence during assessment
and intervention. American Journal of
Occupational Therapy, 54, 434436.
Turner P., & Whitfield T. W. A. (1997).
Physiotherapists use of evidence based
practice: A cross-national study.
Physiotherapy Research International, 2,
1729.
Upshur, R. E. G. (2001). The status of qualitative research as evidence. In J. M. Morse &
J. M. Swanson & A. J. Kuzel (Eds.), The
nature of qualitative evidence (pp. 527).
Thousand Oaks, CA: Sage.

N E W A N D N O W AVA I L A B L E AT A O TA

Evidence-Based Rehabilitation
A Guide to Practice
Mary Law, PhD, OT(C), Editor
This book is formatted into four sections: Introduction to Evidence-Based
Practice, Finding the Evidence, Assessing the Evidence, and Using the
Evidence.
Each chapter is equipped with learning objectives, take-home messages
relating the key learning points, summaries or conclusions, learning and
exploration activities, and references. Some chapters include Web links and
additional resources. 14 appendices highlighting forms, examples, key
indicators, and timelines are also included.
Order #1356-J
$38.95 AOTA members
$53.50 nonmembers

Call toll free: 877-404-AOTA

Shop online: www.aota.org
BK-203

The American Journal of Occupational Therapy

593