Book reviews

Critical review

Occupational therapists’ attitudes, knowledge, and implementation of evidence-based practice: a systematic review of published research Dominic Upton,1 Danielle Stephens,2 Briony Williams,3 and Laura Scurlock-Evans 4 Key words: Evidence-based practice, occupational therapy, knowledge, research utilization.

1 Professor

of Psychology, Faculty of Health, University of Canberra, Canberra, Australia. 2 PhD student, Institute of Health and Society, University of Worcester, Worcester. 3 Head of Academic Unit, Health and Applied Social Sciences, University of Worcester, Worcester. 4 Psychology Assistant, Psychological Sciences, University of Worcester, Worcester. Corresponding author: Laura Scurlock-Evans, Psychology Assistant, Psychological Sciences, University of Worcester, Henwick Grove, Worcester, WR2 6AJ. Email: [email protected] Twitter: @LScurlockEvans Reference: Upton D, Stephens D, Williams B, Scurlock-Evans L (2014) Occupational therapists’ attitudes, knowledge, and implementation of evidence-based practice: a systematic review of published research. British Journal of Occupational Therapy, 77(1), 24–38.

DOI: 10.4276/030802214X13887685335544 © The College of Occupational Therapists Ltd. Submitted: 2 May 2012. Accepted: 30 August 2013.

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Introduction: Evidence-based practice is the procedure whereby clinicians incorporate best research evidence, clinical expertise, and patient values to provide best patient care. Recently, there has been a significant push towards occupational therapists’ adoption of evidence-based practice. This systematic review aimed to determine occupational therapists’ attitudes, knowledge, and utilization of evidence-based practice. Method: A search of literature published between 2000–12 was conducted in relation to occupational therapists’ practice. Academic Search Complete, Cumulative Index of Nursing and Allied Health Literature Plus, PsycARTICLES, Ingenta, Medline, Science Direct, and Journal Storage were systematically searched using MeSH and free-text keywords. Google Scholar and reference lists were also searched. Findings: Thirty-two papers were selected for review: 23 were quantitative, 8 were qualitative, and 1 used a mixed methods design. Studies demonstrated that occupational therapists hold positive attitudes towards evidence-based practice. However, these attitudes do not translate into practice, with research indicating a lack of evidence-based practice utilization. Occupational therapists perceive a number of barriers to evidence-based practice, including lack of time, lack of availability and accessibility of research, and having limited research skills. Conclusion: It is essential that educational and training initiatives provide therapists with the tools and support they need to engage fully with research evidence and its application within clinical care.

Introduction Evidence-based practice (EBP) is the procedure whereby clinicians incorporate best research evidence, clinical expertise, and patient values, resulting in the presentation of the most appropriate and efficient services to their patients (Strauss et al 2010). EBP is conceived as a 5-step process involving: 1) the development of a clinical question; 2) assimilation of the best available evidence in order to answer the question; 3) systematic and critical appraisal of this evidence; 4) applying this evidence to a clinical problem; and 5) evaluation and revision of the previous steps in the process and identifying any areas of change for future applications (Strauss et al 2010). EBP provides a framework in which practitioners can consider clinical problem solving, allowing them to keep informed with current and best practice within their area (Upton and Upton 2006a). Due to the significant demand for healthcare, which seems to be surpassing supply, EBP has recently been considered as a highly favourable approach which promises both quality and efficiency in patient care (Oliver and McDaid 2002, Taylor 2007). Support for the adoption and implementation of EBP is apparent across health professions and internationally (Stergiou-Kita 2010). Additionally, EBP has been associated with improvement in patient outcomes and care, whilst also reducing associated healthcare costs (Melnyk et al 2010). Moreover, researchers have argued that the interventions used by therapists need to be

British Journal of Occupational Therapy January 2014 77(1)

Dominic Upton, Danielle Stephens, Briony Williams, and Laura Scurlock-Evans

both clinically and cost effective in order for occupational therapy to survive in the current healthcare climate (Taylor 2007). Thus, there has been a significant push towards occupational therapists’ adoption of EBP within their daily clinical care (Brown et al 2009). Occupational therapy is a profession that reiterates the importance of EBP implementation for both ensuring high quality care (College of Occupational Therapists [COT] 2003, Crist 2010) and advancing the field (American Occupational Therapy Association [AOTA] 2007). The process of EBP implementation within occupational therapy is, essentially, based on the same principles of EBP for other healthcare disciplines (Bennett and Bennett 2000). However, despite the importance attributed to these principles, a gap between practice and research within occupational therapy is frequently reported (Hu et al 2012, Salls et al 2009). Although this problem is not unique to the field of occupational therapy (it has been observed with numerous other professional groups, such as nurses [Melnyk et al 2004]), it is of concern. Research has indicated that occupational therapists may rely overly on personal clinical experience (Bennett et al 2003) and peer opinion (Döpp et al 2012). Furthermore, occupational therapists may neglect to develop and pursue information-seeking behaviours, such as learning to locate, access, evaluate, and utilize best available evidence, that are considered vital for appropriate EBP implementation (Gilman 2011). However, it is important to realize that occupational therapists are faced with multiple challenges within their daily practice, including limited organizational and structural systems, which may contribute to their lack of EBP utilization (Caldwell et al 2008). At a time of increasing accountability in the healthcare professions (Prior et al 2010), it is essential that occupational therapy, as a profession, encourages the uptake of effective and relevant research to enhance the quality and consistency of clinical decision making. This requires that efficient initial EBP training and continuing educational opportunities for developing and expanding EBP skills are available to therapists throughout their careers (Bennett and Bennett 2000). However, a thorough understanding of the factors affecting EBP implementation is first required to ensure such training and support effectively meets the needs of the profession.

Aim of the review The aim of this review was to synthesize research examining occupational therapists’ attitudes, utilization, knowledge, and understanding of EBP. The findings of the review are then considered in terms of how EBP implementation can be increased and enhanced within clinical practice.

Method Design Owing to the heterogeneity of study designs and outcome measures, and inclusion of qualitative research, a meta-analysis

was rendered unfeasible. Therefore, the present systematic review adopted a narrative analysis approach (using words and texts to summarize and explain findings of research synthesis), following the guidelines and reporting standards identified by PRISMA (Moher et al 2009) and Green et al (2006). This review framework was adopted due to the flexibility it provides for synthesis of both quantitative and qualitative study results.

Search strategy A search of the literature was conducted in relation to occupational therapists’ current practice during the period 2000–12. Free-text key words and MeSH (or equivalent) terms were used in combination (using Boolean operators) to systematically search the following databases: Academic Search Complete, Cumulative Index of Nursing and Allied Health Literature (CINAHL) Plus, American Psychological Association databases (e.g. Psych Articles), Ingenta, Medline, Science Direct, and Journal Storage (JSTOR). Specific keywords and phrases used included: ‘evidence-based practice’, ‘occupational therapy’, ‘clinical practice’, ‘guidelines’, ‘barriers’, ‘attitudes’, ‘knowledge’, ‘understanding’, ‘effectiveness’, ‘implementation’, and ‘evidence’. Examples of specific MeSH (and equivalent) terms used included: ‘“Evidence-Based Practice”[Mesh]’, ‘MH “Evidence-Based Practice+”’ and ‘MH “Occupational Therapy Practice, Evidence-Based”’. Google Scholar was searched using the free-text keywords identified above, and reference lists of retrieved articles were also searched for any additional articles meeting the criteria. An example search strategy of one of the databases is available from the corresponding author upon request.

Quality appraisal Studies included in the review were quality appraised using tools based on the guidelines developed by the McMaster University Occupational Therapy Evidence-Based Practice Research Group (Law et al 1998, Letts et al 2007) and adapted by Alexandratos et al (2012). These tools were further modified to allow each article to be rated as strong, average, or poor, based upon the percentage of assessment criteria fulfilled (0–33%, 34–66% or 67%+). Articles were appraised by two independent raters and disagreements resolved by consensus. Quality rating was not used as an inclusion criterion but was used to help to inform the confidence with which study results could be interpreted in the review synthesis.

Search outcome The studies were each reviewed initially in relation to the following inclusion criteria: ■ English language publications between 2000 and 2012 (to ensure both breadth of coverage and currency of information) ■ Published within a peer-reviewed journal ■ Provided sufficiently detailed, extractable results for qualified occupational therapists if more than one professional group’s results were reported


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Occupational therapists’ attitudes, knowledge, and implementation of evidence-based practice: a systematic review of published research

A focus was given to either one or all of the following: — Occupational therapists and perceived attitudes towards EBP — Occupational therapists and perceived knowledge or understanding of EBP — Occupational therapists and EBP implementation (including barriers)

■

provided a summary of key findings for quantitative reports (Table 1), qualitative reports (Table 2), and mixed methods reports (Table 3). Of the reviewed articles, 14 were assigned a good quality rating, 16 articles were assigned an average rating, and 2 were assigned a poor rating.

Attitudes and values toward EBP

Records identified through database searching (n = 12970)

Included

Additional records identified through other sources (n = 20)

Records after removal of duplicates publications (n = 10652)

Records screened using title and abstract (n = 10652)

Records excluded (n = 10568)

Full text articles assessed for eligibility (n = 86)

Full text articles excluded based on inclusion criteria (n = 54)

Eligibility

Screening

Identification

Fig. 1. PRISMA flowchart of the study retrieval and selection process (Moher et al 2009).

Quantitative studies included (n = 23)

Qualitative studies included (n = 8)

Mixed methods studies included (n = 1)

In addition to the above, for quantitative studies an outcome measure was used to measure at least one of: attitudes towards EBP, knowledge of EBP, or implementation of EBP, and studies were reviewed in relation to these criteria. Qualitative studies were reviewed in relation to whether the study explored any or all of: perceived knowledge, understanding, attitudes, or implementation of EBP and whether the study gave clear and accurate definitions of the research question and methodology adopted. In total, 32 studies met the above inclusion criteria, of which 23 were quantitative, 8 were qualitative, and 1 used a mixed methods design. The PRISMA flowchart provides a breakdown of the assessment and exclusion of the above articles (Fig. 1).

Findings All 32 articles were summarized under the following headings: reference, sample, design, purpose, and results (Green et al 2006). In addition, a quality rating was assigned to each article. Study results were extracted from the abstract and full article by one author and reviewed by a second author (to ensure consistency and rigour), based upon the themes of EBP attitudes, knowledge, and implementation. Study results

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All studies demonstrated positive attitudes towards EBP to some degree, and some suggested therapists valued EBP as a means of enhancing the credibility of both the field and themselves as professionals (Fänge and Ivanoff 2009, Karlsson and Törnquist 2007, Swedlove and Etcheverry 2012). However, the research indicated a substantial proportion of therapists viewed EBP more negatively: for example, some practitioners perceived EBP as too complicated, and the transition of research into practice as requiring too much effort (Döpp et al 2012). Furthermore, whilst many therapists valued EBP and research utilization (RU) in principle (Bennett et al 2003, Brown et al 2009, Curtin and Jaramazovi 2001, Humphris et al 2000, Heiwe et al 2011, Hu et al 2012, Lyons et al 2010, Lyons et al 2011), some felt ensuring knowledge was up-to-date, rather than RU per se, was the priority (Karlsson and Törquist 2007), and others considered active research to be unnecessary (Lyons et al 2011). This suggests there is a potential issue concerning research generation, which may have an impact on the amount of practitioner-led contributions to research. Research examining EBP attitudes across numerous disciplines discovered that occupational therapists held positive attitudes (which were at a similar level to professionals from other disciplines), but reported greater levels of shared EBP learning with colleagues (Caldwell et al 2007). However, they were also less likely to report changes within their clinical practice due to research evidence (Caldwell et al 2007), indicating a disparity between attitudes and behaviour. A range of factors may influence, or relate to, therapists’ attitudes towards EBP. For example, Brown et al (2010) identified higher occupational educational attainment as a strong predictor of positive attitudes towards EBP, although Cameron et al (2005) found the opposite to be the case. However, slight differences in the demographics of the two studies’ samples may explain these contradictions. Nevertheless, Sweetland and Craik (2001) found that participants identified postgraduate courses as playing an influential role in intervention choice. Döpp et al (2012) discovered that occupational therapists practicing within an academic hospital held significantly more positive perceptions of EBP than occupational therapists in other clinical settings. Furthermore, Bennett et al (2003) found that occupational therapists practicing within rural areas were also found to hold more negative attitudes towards EBP, claiming that it was too demanding. However, this pattern failed to be replicated in other research (Hu et al 2012). The differences between the two studies may reflect advances within technological infrastructure in rural areas. Additionally, therapists who had graduated more recently or had received prior EBP training appeared to hold more


Table 1. Study characteristics and findings of quantitative reports Reference Sample Design Purpose Explore factors that inhibit Cross-sectional Convenience Humphris and facilitate the use of postal survey sample of 78 et al 2000 research evidence by (questionnaire occupational occupational therapists. developed by therapists from the authors). the UK (response rate = 78%).

Results Many occupational therapists held positive attitudes towards the use of research in practice. Top three barriers to EBP implementation were: workload pressures, time limitations, and insufficient staff resources. Top three facilitators were: protected time, frequent educational sessions, and specific additional staff to enable research evidence implementation.

Quality rating Poor

Pollock et al 2000

Stroke rehabilitation professionals: physiotherapists (n = 27), occupational therapists (n = 26), nurses (n = 22), speech and language therapists (n = 6), others (n = 5).

Focus group resulting in the development of a postal questionnaire.

Identify the barriers to EBP in stroke rehabilitation; examine differences of perceived barriers between the disciplines.

Key barrier in ability found to be lack of training in appraisal and interpretation of research results; occupational therapists expressed significantly less confidence in their ability. Key barriers towards EBP were found to be a lack of confidence in the validity of research and difficulties in applying findings to clinical practice. Majority of respondents held positive attitudes towards EBP (92%). Occupational therapists perceived more, or bigger, barriers than nurses.

Average

Sweetland and Craik 2001

Random sample of 125 members of the National Association of Neurological Occupational Therapists working with adult stroke patients.

Postal survey developed by the authors.

Identify the extent to which EBP was used by therapists working with adult stroke patients.

Other therapists were identified as a key influential factor in intervention choice, alongside attendance at postgraduate courses. Custom, practice, and expert opinion were identified as the most frequently applied forms of evidence. Recently qualified professionals were more likely to report using higher levels of evidence in their practice. Other important factors influencing practice included: relevance of research, time, knowledge, and support.

Average

Dysart and Tomlin 2002

Random sample of 209 (response rate = 58%) American occupational therapist members of the American Occupational Therapy Association.

Postal survey designed by the authors.

Explore how American occupational therapists access and use clinically relevant research findings.

Occupational therapists occasionally accessed research information; 57% implemented 1–5 new, research-based treatment plans a year. A greater number of participants with 15 or more years of clinical experience did not feel that research conclusions usually translated into treatment plans compared to participants with less experience (p < 0.01). 59% of respondents had time provided for training, but 45% felt there was no time to access research information. Barriers included: lack of time, education costs, lack of research skills, and placing less value on research evidence than clinical experience.

Average

Bennett et al 2003

Random sample of 649 (response rate = 44%) occupational therapists currently members of Occupational Therapy Australia Limited (OTA, formerly OT Australia).

Postal survey; modified version of McColl et al (1998) questionnaire; evidence-based medicine.

Determine practitioners’ attitudes and perceptions of EBP and their training needs; perceived confidence in practitioners’ EBP skills; what EBP resources are relied upon and what barriers practitioners perceive towards EBP utilization.

Highly positive attitudes towards EBP (95.7%) and 56.0% reported using research in clinical decision making; however, practitioners rely on clinical experience in clinical decision making (96.3%); practitioners infrequently utilize EBP resources and lack confidence in their EBP related skills; lack of time and available evidence perceived to be significant barriers.

Strong

McCluskey 2003

Purposive sample of 67 Australian (New South Wales) occupational therapists.

Questionnaire survey; modification of Upton and Lewis (1998) survey concerning EBP and healthcare professionals.

Determine therapists’ EBP knowledge and skill; participation in continuing EBP education; practitioners’ perceived barriers towards EBP utilization.

Practitioners who had graduated in the previous 5 years displayed more confidence in their EBP skills but lack confidence in critical appraisal of evidence. Perceived barriers included lack of time and large workloads.

Average


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Table 1 (continued) Reference Sample Gosling and Random sample Westbrook from 65 hospitals: physiotherapists 2004 (n = 228), social workers (n = 146), occupational therapists (n = 118), pharmacists (n = 84), dietitians (n = 78), speech pathologists (n = 77), clinical psychologists (n = 59).

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Design A survey consisting of a 25-item questionnaire comprising close-ended questions.

Purpose Aimed to determine practitioners’ awareness of an online evidence system; utilization of the evidence; perception of the evidence system on clinical practice; and perceived barriers preventing utilization.

Results A large proportion of respondents who had heard of the online evidence resource utilized it (75%). Factors that affected utilization of the evidence resource included accessibility, perceived support, and computer skills. Lack of training in utilization of the online evidence system was perceived to be a significant barrier.

Quality rating Strong

Cameron et al 2005

Random sample of occupational therapists practicing in the United States (USA) and Puerto Rico (n = 131).

Postal survey questionnaire based on design by Humphris et al (2000).

Examine USA occupational therapists’ utilization of EBP; determine whether EBP utilization differs based on demographics.

Large proportion of therapists held positive attitudes towards EBP (98%). Very few therapists utilize EBP within their clinical practice (p < 0.01). Therapists with higher educational attainment held increasing views of the importance of EBP utilisation.

Strong

McKenna et al 2005

Two random samples of Australian occupational therapists: national sample from members of the Australian occupational therapy association (Occupational Therapy Australia) (n = 124), and State sample from Queensland and New South Wales (n = 89).

Postal survey.

Explore therapists’ uptake of OTseeker (an online EBP resource) and to explore whether it has had an impact on their clinical practice.

Most participants had heard of OTseeker (86%), whereas only over half of these had accessed the resource (56.3%). Main barriers were found to be lack of time. Only 13.6% of practitioners indicated that the resource had impacted their clinical practice, although two-thirds reported improved knowledge due to accessing the information on OTseeker.

Strong

Upton and Upton 2006b

Stratified sample of 1,000 UK allied health professionals (response rate = 66.6%), 188 being occupational therapists (response rate = 72.9%).

Postal survey.

Explore allied health professionals’ practice and knowledge of EBP.

Occupational therapists reported greater knowledge of EBP than podiatrists, radiographers, and orthoptists, but similar knowledge levels to physiotherapists, dieticians, speech and language therapists, and psychologists. However, the majority of occupational therapists (41.7%) self-reported their knowledge as low. Occupational therapists (and podiatrists) rated their awareness of information sources lower than most other groups, and (alongside pathology assistants and pharmacists) preferred to use evidence provided by colleagues. Barriers to EBP were similar between all health professionals, two key barriers identified were lack of time and money.

Strong

Caldwell et al 2007

Random sample of recent graduates from 3 London-based universities: occupational therapists (n = 29), nurses (n = 1), physiotherapists (n = 10), and social workers (n = 26).

Anonymous postal questionnaire.

Explore relevance of initial training in relation to EBP; explore practitioners’ confidence in engaging with EBP.

Practitioners held positive attitudes towards EBP and research evidence; however, implementation of EBP by practitioners is infrequent with limited utilization of research resources.

Strong



Table 1 (continued) Sample Reference Karlsson and 425 Swedish occupational Törnquist therapists 2007 (response rate = 74.4%) took part in a baseline questionnaire and 442 (response rate = 70.4%) took part in a follow-up survey.

Design Follow-up postal questionnaire design.

Purpose Identify Swedish occupational therapists’ perceptions and attitudes of researchrelated activities, and engagement and planned future engagement with research.

Results Small differences were identified between the two surveys. Research was identified as important to the development of the professional role and status. Reading research literature to update knowledge identified as a priority, but applying findings to practice less so.

Quality rating Strong

Welch and Dawson 2007

24 senior occupational therapists currently practicing within the NHS.

‘In-house’ selfadministered survey.

Explore therapists’ perceptions of EBP; identify demand for selected components concerning EBP; and ascertain preferred learning strategies.

Therapists recognize a gap in their knowledge and subsequent skills in utilizing published research. Staff need to improve skills pertaining to the appraisal and utilization of evidence within practice.

Average

Brown et al 2009

Convenience sample; paediatric occupational therapists from Australia, United Kingdom and Taiwan (n = 696, response rate = 56.6%).

A postal survey; Edmonton Research Orientation Survey (EROS) (Pain et al 1996); Research Knowledge, Attitudes and Practices of Research Survey (KAP Survey) (Van Mullem et al 1999); Barriers to Research Utilization Scale (BARRIERS) (Funk et al 1991).

Investigate and compare the perceived knowledge, attitudes, practices, barriers, and orientation to EBP.

Occupational therapists were positive toward EBP but lacked confidence in their research knowledge and practices. Differences between countries’ professionals were identified on ratings of knowledge, practices, and attitudes. Although organizational factors were identified as key barriers to research utilization overall, UK and Taiwanese occupational therapists recorded organization as the top barrier to EBP, whereas Australian occupational therapists recorded communication as the greatest barrier.

Average

Salls et al 2009

Purposive sample of occupational therapists practicing in Pennsylvania (n = 930).

Unpublished postal survey: adapted from surveys by Jette et al (2003) and Dysart and Tomlin (2002).

Examine occupational therapists’ attitudes, knowledge, and utilization of EBP.

Majority of respondents hold positive views of EBP (96%); just over half of respondents reported having learned about EBP during their education; very few therapists are using EBP within their clinical practice (12%); lack of time was primary barrier.

Strong

Brown et al 2010

Convenience Sample; occupational therapists from Taiwan (n = 413), Australia (n = 137), and the United Kingdom (n = 144).

A postal survey; EROS (Pain et al 1996); KAP Survey (Van Mullem et al 1999); BARRIERS (Funk et al 1991).

Investigate the factors predicting paediatric occupational therapists’ attitudes towards EBP and research utilization.

Level of academic occupational therapy qualification was the most significant predictor of research utilization. Predictive factors towards EBP included level of academic occupational therapy qualification and attitudes towards establishing current best practice.

Strong

Lyons et al 2010

Convenience sample of 145 UK paediatric occupational therapists (response rate = 30%).


Examine perceived knowledge, attitudes, utilization, and barriers towards EBP and research utilization.

Participants held positive views toward research, were willing to access new information and implement findings into practice, but lacked confidence in their research knowledge and practices. Key barriers to utilization included: workplace/organizational factors, accessibility, and quality of research.

Average


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Table 1 (continued) Sample Reference Recent graduates Gilman from the Pacific 2011 University’s school of occupational therapy (n = 28).

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Design Anonymous online survey; adapted questionnaire developed by Powell and CaseSmith (1991).

Purpose Provide an understanding of recent Pacific University graduates’ information-seeking behaviours; contribute to the planning of the university’s EBP curriculum.

Results Barriers towards EBP included; limited search skills, difficulty in accessing literature, and lack of available evidence.

Quality rating Average

Heiwe et al 2011

Swedish University Hospital; dieticians (n = 41), occupational therapists (n = 57), physiotherapists (n = 129).

A cross-sectional survey; translated questionnaire developed by Jette et al (2003).

Explore dietitians’, occupational therapists’ and physiotherapists’ attitudes, beliefs, knowledge, and utilization of EBP.

All practitioners held overall positive attitudes towards EBP and its importance within clinical decision making; the majority of practitioners indicated having the skills and knowledge needed in interpreting and understanding research evidence; lack of time was perceived to be greatest barrier for all practitioners.

Strong

Lyons et al 2011

Convenience sample of Australian paediatric occupational therapists (n = 138).


Examine perceived knowledge, attitudes, utilization, and barriers towards EBP and research utilization.

Therapists held overall positive attitudes towards EBP and research utilization but indicated lack of knowledge and ability in performing research activities and engaging in conducting research. Therapists indicated moderate research utilization. Article presentation and accessibility of research were found to be greatest barriers to research utilization implementation.

Strong

Döpp et al 2012

Random sample of Dutch occupational therapists (n = 100).

Postal and online survey questionnaire.

Examine how Dutch occupational therapists perceive EBP, what sources they rely on in decision making, and what barriers they perceive when implementing EBP.

Dutch therapists generally hold positive attitudes towards EBP; however, over half perceive it to require too much effort (53%). Therapists working in academic hospitals held significantly more positive attitudes (p < 0.01). Therapists relied on colleagues (79%) more often than research evidence in clinical decision making. Most significant barrier was in evaluating the quality of research with 56.2% of therapists perceiving research articles to be written in an inaccessible style.

Strong

Hu et al 2012

Convenience sample of 64 occupational therapists (response rate = 87.7%) in the UK.

Descriptive survey.

Explore the perception, involvement and participation of EBP of occupational therapists in rural areas.

No significant differences identified between rural and urban occupational therapists. Most occupational therapists held positive attitudes toward EBP, but owing to obstacles to implementation low numbers had involvement in EBP related activities.

Average

Lizarondo et al 2012

Maximum variation sample of Australian occupational therapists (n = 36), speech therapists (n = 10), physiotherapists (n = 19), social workers (n = 15), and dietitians (n = 12).

Pilot pre-post study design, using the EBPQ (Upton and Upton 2006b) and Adapted Fresno test (McCluskey and Bishop 2009).

Explore the impact of an iCAHE journal club on practitioners’ knowledge, attitudes, and use of EBP.

Occupational therapists demonstrated a statistically significant increase in EBP knowledge, but not attitude or self-reported use. Occupational therapists reported lowest levels of EBP objective knowledge prior to the intervention, but no significant differences were observed on self-reported knowledge, attitudes, and use. Journal clubs may not be effective methods of enhancing EBP on their own, but could be integrated with other strategies.


Good


Table 2. Study characteristics and findings of qualitative reports Reference Sample Design Purpose Convenience McQueen Pre-post study To explore the impact of a sample of 7 UK et al 2006 analysed journal club on EBP NHS occupational qualitatively behaviours and attitudes. therapists. using content analysis.

Results Participants’ responses following participation in the journal club indicated greater awareness of EBP.

Quality rating Poor

Reagon et al 2008

Purposive sampling of occupational therapists working in the NHS and Social Services departments (n = 21). Members of staff observed (n = 90).

Case study design; focus groups, in-depth interviews, and observation.

Aims to uncover the meanings occupational therapists attribute to EBP.

Four emerging themes including: perceptions of EBP, functions of EBP, client-centred occupational therapy, and EBP. Tensions were discovered between concepts of EBP and traditional client-centredness.

Average

Copley and Allen 2009

Australian occupational therapists within a university-based paediatric clinic (n = 9).

Action Research design; focus groups.

To explore occupational therapists’ perception of EBP and its utilization; to identify strategies and resources that can increase EBP utilization.

Therapists strongly support and accept the broad definition of EBP within their clinical practice. Therapists identified: that they used both research-based and practice-based evidence to inform their clinical practice; the occupational research base as being limited; a key limitation being the way research-evidence is generated (randomized controlled trials, etc.), which may not be applicable to everyday clinical contexts.

Average

Fänge and Ivanoff 2009

Whole population sample of Swedish local health authority occupational therapists (n = 15, response rate = 83%).

Three focus group interviews (five different occupational therapists in each).

Identify and analyse the experiences of Swedish occupational therapists of participation in and implementation of research.

One core category (feeling professionally competent) emerged from analysis, comprising three subcategories: perceiving congruence between research and practice, having the necessary skills, and making a contribution. Engaging with research was seen to bring both professional and personal gains.

Average

Vachon et al 2010

Purposive sample of 8 Canadian occupational therapists who had attended a 4-day EBP workshop.

Collaborative research methodology over a period of 15 months, analysed using grounded theory.

Explore the clinical decisions making processes used and describe the empowerment process they developed to become evidence-based practitioners.

Six different modes of decision making (which affected evidence utilization) were identified: defensive, repressed, cautious, autonomous, intuitive, and autonomous thoughtful. Reflective learning facilitated evidence utilization through a staged empowerment process: deliberateness, client-centredness, and system mindedness.

Strong

Kristensen et al 2011

Purposive sample of 25 Danish occupational therapists, working in three clinical (stroke rehabilitation) settings. Participants were only selected if they had more than 2 years’ clinical experience.

Phenomenological hermeneutical research approach including: participant observation, focus group discussions, and individual interviews over 20 months. Analysed following Ricoeur’s (1976) approach.

Investigate facilitation of evidence-based practice in stroke rehabilitation (specifically in relation to five evidence-based clinical guidelines), over a period of 20 months.

Learning processes became part of developing professional identities and resulted in greater confidence. ‘Facilitators’ (individuals in charge of the learning process) were identified as important to the change process. Being able to see the purpose of integrating research evidence into practice was important to participants. Working in isolation was a barrier to implementing standardized practice. Participation in the research process was identified as important, and having a critical attitude to clinical guidelines was seen as necessary when adapting them to specific contexts. More experienced therapists appeared to be able to work more flexibly through the process.

Average


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Table 2 (continued) Reference Sample Bayley et al Convenience sample of 2012 Canadian occupational therapists (n = 23), nurses (n = 17), physical therapists (n = 23) and hospital managers/directors (n = 16). Swedlove and Etcheverry 2012

Convenience sample of 10 Canadian occupational therapists from a large healthcare facility.

Design Focus groups held within 2–4 weeks of completion of a 6-month implementation project. Focus groups involved 3–6 professionals working in the same field.

Purpose To describe barriers to implementation of evidence-based recommendations in stroke rehabilitation.

Results Occupational therapists most frequently identified lack of time, team functioning and communication, patient/provider safety, and prioritizing treatments as barriers to implementation of evidence-based recommendations.

Quality rating Average

Qualitative, exploratory research involving interviews.

Exploring perceptions of the value of research and factors influencing these perceptions.

Participants valued research for informing practice, underpinning the profession, providing credibility, and economic justification for decisions. Perceptions were influenced by experiences with research, resources, and practice culture.

Average

Results Occupational therapists held positive attitudes toward EBP, but identified lack of time, high staff turnover, and staff shortages as important barriers to implementation. Facilitators of EBP included: support from colleagues, personal motivation, and access to resources.

Quality rating Quantitative: average. Qualitative: average. Overall: average.

Table 3. Study characteristics and findings of mixed methods reports Reference Sample Design Purpose Purposive sample Mixed methods: Explore the views and Curtin and perceptions of interviews Jaramazovi of UK senior occupational therapists followed by occupational 2001 working in England therapists (n = 27). questionnaires. regarding EBP. Convenience sample of 653 occupational therapists (response rate = 76.5%).

positive attitudes towards the use of EBP when compared with more experienced therapists (Bennett et al 2003, Dysart and Tomlin 2002, McCluskey 2003, Sweetland and Craik 2001), and the number of jobs held since qualification was associated with a decrease in active research. However, Kristensen et al (2011) found that more experienced Danish occupational therapists were able to work more flexibly through the process of EBP.

Research-based practice and traditional methods Therapists may value different forms of evidence to those typically placed at the top of the evidence pyramid (for example, systematic reviews of randomized control trials); a number of studies identified colleagues (Döpp et al 2012, Dysart and Tomlin 2000, Sweetland and Craik 2001) and personal clinical experience (Bennett et al 2003, Copley and Allen 2009, Sweetland and Craik 2001) as important in decision making. Copley and Allen (2009) identified two differentiated sources of evidence by which therapists make clinical decisions: evidence-based practice, and professional, practicebased knowledge. Although participants agreed upon the importance of EBP and its significance within clinical care,

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they found the restrictions of research in relation to sample and interventions made findings inapplicable to practice. Consequently, therapists suggested a need to also take into account their own clinical experience and evaluations of case-by-case outcomes. Similarly, Reagon et al (2008) found that occupational therapists, despite regarding EBP with some ambivalence, associated EBP with some positive outcomes in terms of demonstrating effectiveness of interventions, informing knowledge gaps, and providing a cost-effective provision of care. However, the therapists indicated the importance of client-centeredness within care and the tension often apparent between this and EBP. Hence, as the previous study illustrated, the therapists believed EBP to be inadequate on its own in relation to individual client care, suggesting the need to incorporate multiple sources of evidence. Therapists raised concerns regarding the relevance and applicability of research evidence to clinical practice problems (Copley and Allen 2009, Döpp et al 2012, Fänge and Ivanoff 2009, Gilman 2011, Pollock et al 2000, Reagon et al 2008, Sweetland and Craik 2001), with some questioning the appropriateness of applying sterile ‘scientific evidence’ (Reagon et al 2008) to ‘authentic practice’ (Copley and Allen 2009). Hence, it would seem that there continues to be a


significant gap between the research base and its relevance to interventions used on a daily basis and the clients treated within actual clinical settings. However, participants in Reagon et al’s (2008) study did agree that EBP is important within clinical practice, although in conjunction with clinical reasoning. Perceiving congruence between research and practice (Fänge and Ivanoff 2009) and being able to see the purpose of integrating research evidence into practice (Kristensen et al 2011) have also been identified as important to practitioners, highlighting the need for clinically applicable research findings.

Education and knowledge surrounding EBP A large proportion of the research indicated some limits to practitioners’ EBP knowledge and skills. For instance, Döpp et al (2012) discovered that Dutch occupational therapists perceived their critical research appraisal skills to be lacking significantly, expressed difficulty with understanding statistical analyses, and felt articles were written in an inaccessible style. Similar findings were identified by Dysart and Tomlin (2002), Lyons et al (2010), and Pollock et al (2000). Comparing the practices of different health professionals, Upton and Upton (2006b) discovered that occupational therapists reported equivalent knowledge of EBP to physiotherapists, dieticians, speech and language therapists, and psychologists, and greater knowledge than podiatrists, radiographers, and orthoptists. However, the majority of occupational therapists (41%) still rated their knowledge as low; furthermore, they rated their awareness of information sources as lower than most other allied health professionals, and preferred evidence provided by colleagues. Lacking confidence in research and knowledge processes was a common theme in the literature (for example, Bennett et al 2003, Brown et al 2009, Lyons et al 2010). McCluskey (2003) found that therapists rated their ability as low in relation to generating clinical questions, critical appraisal skills, and conducting literature searches, but that they reported being confident in evaluating their own clinical practice, and their ability to change their practice based on new evidence. Similarly, Caldwell et al (2007) discovered that just under two-thirds of their therapists reported being confident about their skills and knowledge. However, Heiwe et al (2011) and Salls et al (2009) found that over 70% of their samples reported confidence in critically appraising research and literature searching skills. Furthermore, Bennett et al (2003) discovered that their respondents reported being most confident in literature searching skills, although they were less confident in determining clinical significance, study design, validity and using specific electronic databases. These results may be confounded by level of academic preparation, as the relatively high level of both Heiwe et al (2011) and Salls et al’s (2009) samples reported receiving formal EBP-associated training and Bennett et al (2003) discovered that therapists holding higher qualifications were found to be more confident in their EBP skills. In addition, Salls et al (2009)

identified that therapists who had been practicing for less than 5 years were more likely to report receiving EBP education during their academic preparation than those who had been practicing longer, potentially explaining differences in attitudes toward EBP observed between recent graduates and more experienced professionals. Studies revealed that therapists desired to improve their knowledge and skills surrounding EBP (Brown et al 2010, Salls et al 2009) and in the use of an online evidence retrieval system (Gosling et al 2004) in order improve their implementation of EBP within their everyday clinical practice. McCluskey (2003) also considered continued EBP education, and discovered that a small proportion of respondents had attended EBP workshops, suggesting a desire to engage in continuing professional development. Learning about EBP and associated skills has been associated with a number of benefits, including developing professional identities and fostering confidence (Kristensen et al 2011). Furthermore, reflective learning was found to facilitate RU through a staged empowerment process (Vachon et al 2010). Two studies explored the impact of participation in a journal club on EBP behaviours and attitudes; although while McQueen et al (2006) found participants demonstrated greater awareness of EBP post-journal club, Lizarondo et al (2012) found that while occupational therapists’ knowledge increased, they had not changed their attitudes or practice following participation. The researchers suggested that journal clubs may need to be integrated with other intervention strategies in order to be effective in enhancing EBP uptake. Despite the benefits and interest in EBP, the time constraints associated with the occupational therapy role mean that many practitioners are unable to attend EBP training sessions (McCluskey 2003). Welch and Dawson (2007) noted these time constraints in their study and discovered that, with regard to continual learning, therapists preferred practice-based interactive strategies delivered through ‘in-house’ forums, suggesting that such strategies would bridge the knowledge gap while negating the time constraints associated with therapists’ workload. Finally, issues surrounding a lack of perceived knowledge and research skills also seem to be apparent when considering therapists’ engagement with conducting research (Lyons et al 2011), suggesting a possible reason for the lack of practitioner involvement in research.

Implementation of EBP The studies revealed consistent results in relation to a lack of utilization of EBP within occupational therapists’ clinical practice. For example, Salls et al (2009) discovered that a meagre 12% of surveyed occupational therapists reported frequent utilization of EBP. Lyons et al (2011) discovered that although therapists reported some implementation of research, there was significant room for improvement in terms of degree of implementation within everyday clinical practice.


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Worryingly, one of the most recent studies, conducted by Döpp et al (2012), indicated that despite positive attitudes towards EBP, therapists continually relied on colleagues as a source of clinical decision making, replicating the earlier findings of Sweetland and Craik (2012). Of further concern was the finding that 82.8% of therapists relied upon information from non-occupational therapists on a weekly basis. The authors indicated that journal articles and databases were the least frequently used sources of information. Heiwe et al (2011) explored EBP implementation by dieticians, physiotherapists, and occupational therapists and found a significant difference in RU between them: specifically, occupational therapists read and critically appraised significantly fewer articles. Similarly, Gosling et al (2004) considered the utilization of an online EBP resource and noted that although 86% of occupational therapists were aware of an online evidence resource, only 79% of these individuals actually used it. The authors also indicated that compared to physiotherapists, occupational therapists used the resource less often, although this may have been confounded by differences in level of access to computers in patient-care areas. However, research by Lizarondo et al (2012) revealed no significant differences in the level of EBP use between occupational therapists, physiotherapists, dieticians, social workers, or speech pathologists prior to a journal club intervention. Research also indicated differences in EBP utilization in relation to level of academic attainment. For instance, Cameron et al (2005) discovered that the higher the therapist’s degree, the lower the EBP utilization. Surprisingly, the findings illustrated that occupational therapists with an undergraduate degree tended to rely on the research process more than those with Master’s level qualifications, despite the latter’s focus on research methodology. Additionally, it was found that as the therapists’ years of clinical experience increased, the extent to which they implemented research decreased; this was a finding often found in relation to EBP utilization (McCluskey 2003).

Perceived limits and barriers to EBP implementation There was a general consensus across the studies regarding the dominant EBP barriers perceived by therapists. A significant barrier related to the accessibility of research evidence in terms of accessing databases and the presentation of research articles (Bennett et al 2003, Dysart and Tomlin 2002, Heiwe et al 2011, Lyons et al 2010, Lyons 2011, Kristensen et al 2011, Salls et al 2009, Sweetland and Craik 2001). Such communication barriers have been evident across allied health professions (Metcalfe et al 2001); however, it may be that occupational therapists perceive the barriers to be of greater detriment towards EBP implementation (Lyons et al 2011). Lack of time was also considered a significant barrier (Bayley et al 2012, Bennett et al 2003, Caldwell et al 2007, Copley and Allen 2009, Dysart and Tomlin 2002, Heiwe at al 2011, Humphris et al 2000, Reagon et al 2008, Salls et al 2009, Sweetland

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and Craik 2001, Upton and Upton 2006b), even in relation to the utilization of an online EBP resource designed to overcome this obstacle (McKenna et al 2005). In addition, numerous studies reported that occupational therapists perceived the evidence base to be limited (Bennett et al 2003, Lyons et al 2011, McCluskey 2003), resulting in a lack of support in the implementation of appropriate interventions. Furthermore, Pollock et al (2000) indicated that therapists had great difficulty in transferring the research evidence into their clinical practice.

Table 4. Barriers to implementation of EBP and RU across quantitative and qualitative studies Key barriers to EBP Studies identified Workload pressures Curtin and Jaramazovi (2001), Humphris et al (2000), McCluskey (2003). Time pressures

Bayley et al (2012), Bennett et al (2003), Dysart and Tomlin (2002), Heiwe et al (2011), Humphris et al (2000), Kristensen et al (2011), Lyons et al (2011), McCluskey (2003), McKenna et al (2005), Salls et al (2009), Sweetland and Craik (2001), Upton and Upton (2006b).

Insufficient staff/ resources/finances

Curtin and Jaramazovi (2001), Dysart and Tomlin (2002), Humphris et al (2000), Upton and Upton (2006b).

Lack of training/ knowledge

Pollock et al (2000), Gosling and Westbrook (2004), Lyons et al (2011), Sweetland and Craik (2001).

Lack of skills

Döpp et al (2012), Dysart and Tomlin (2002), Fänge and Ivanoff (2009), Gilman (2011), Gosling and Westbrook (2004), Lyons et al (2011), Pollock et al (2000), Welch and Dawson (2007).

Lack of support, organizational barriers

Brown et al (2009), Cameron et al (2005), Curtin and Jaramazovi (2001), Gosling and Westbrook (2004), Kristensen et al (2011), Pollock et al (2000), Salls et al 2009, Lyons et al (2010), Sweetland and Craik (2001).

Relevance, applicability, availability, quality of research evidence

Bennett et al (2003), Copley and Allen (2009), Döpp et al (2012), Dysart and Tomlin (2002), Fänge and Ivanoff (2009), Gosling and Westbrook (2004), Gilman (2011), Lyons et al (2010), Lyons et al (2011), McCluskey 2003, Pollock et al (2000), Sweetland and Craik (2001).

Communication and team functioning

Bayley et al (2012), Brown et al (2009).

Requiring too much effort or personal motivation

Curtin and Jaramazovi (2001), Döpp et al (2012).

Conflict with clientcentred practice

Reagon et al (2008).

Patient/provider safety and prioritizing treatments

Bayley et al (2012).


A number of studies illustrated a perceived lack of demand and support for EBP from their reimbursement agencies or administrators (Cameron et al 2005, Salls et al 2009), with Gosling et al (2004) finding that occupational therapists reported low levels of support in implementing an online EBP resource. Also, Pollock et al (2000) found that despite 92% of their respondents perceiving EBP as highly important within their practice, only 58% agreed that their department held EBP as a priority. Finally, both Bayley et al (2012) and Brown et al (2009) discovered that the greatest perceived barriers toward EBP implementation were associated with organizational factors. These findings are problematic when considered in the light of research suggesting that perceived support from management and work colleagues are associated with increased capability in, and utilization of, EBP (Döpp et al 2012, Sweetland and Craik 2001).

Discussion Limitations of the review Narrative literature reviews are at risk of confirmation bias (Baumeister and Leary 1997). However, the adoption of a systematic review methodology (that is, systematic search strategy, quality appraisal, and data extraction procedures) and use of independent raters helped to mitigate this issue. The review included only papers that had been published in peer-reviewed journals: although this ensured that all research had been through the rigour of the peer-review process, it introduced the potential for publication bias. Furthermore, only articles written in English were included in the review, which may have led to the exclusion of other relevant research.

Strengths and limitations of the research reviewed Quality assessment of the studies revealed that the majority were rated as either average or good, indicating that many studies fulfilled at least 34% of quality criteria according to McMaster University’s guidelines. This suggests that research is of a reasonable quality, but there is substantial room for improvement. A range of issues were identified as contributing to the ‘average’ or ‘poor’ classifications, including issues in relation to the sampling methods employed in quantitative research. Specifically, a substantial proportion of studies recruited relatively small samples. Research surrounding practitioners’ EBP utilization often reported significant time constraints on the part of clinical practitioners (Metcalfe et al 2001), which may explain difficulties in recruitment. Furthermore, many studies used convenience /opportunistic sampling; this potentially limited the representativeness and generalizability of research findings. All of the quantitative studies collected data via selfadministered postal or online survey questionnaires. Although these methods may be the most feasible means of collecting data from occupational therapists (given their time constraints),

it has been argued that the use of self-report measures within research can be highly problematic (Gawronski 2009). For instance, self-report measures have the tendency to be limited in relation to introspection and are at risk of self-presentation bias and social desirability effects (Fisher 1993, Gawronski 2009). None of the quantitative studies included a measure of socially desirable responding in order to mitigate this. Additionally, although some studies adopted current or modified published questionnaires, others relied upon the development of their own ‘in-house’ surveys (Welch and Dawson 2007). Most of these surveys underwent piloting in order to ensure construct validity, but many were lacking rigorous statistical measures in determining their reliability in measuring what they intended. Thus, the studies’ methodological quality is undermined. The qualitative studies reviewed adopted a range of data collection methods, including focus groups, interviews, and observation. Although many articles specified the approach adopted (for example, participatory action research), this was not always clear. Furthermore, although qualitative research methodology is believed to reduce the risk of selfpresentation bias (Gawronski 2009), issues surrounding research bias need to be considered in order to determine the neutrality of research findings. Although some studies described decision trails, methods of triangulation, and potential sources of researcher bias, this aspect was not always specified clearly, making it difficult to ascertain the level of rigour in some studies. Based upon discussion of these issues, generalizations and conclusions from this review’s synthesis should be tentative. However, despite this, a number of important implications that may help to inform future practice and research do arise from the review’s findings.

Implications for practice, policy and research The research synthesis indicates that attitudes and practice may be linked, but the relationship is not causal. Therefore, interventions should not focus heavily on this aspect in order to enhance uptake of EBP. However, discrepancies between attitudes toward and practice of EBP may be evidence of socially desirable responding; future research should, therefore, aim to include a measure of social desirability to untangle this relationship. Occupational therapists’ motivation to implement EBP was both directly and indirectly identified as an important factor in EBP implementation by the research reviewed and may represent a link between EBP attitudes and behaviour. Further research is required to explore methods of enhancing individual and organizational motivation to implement EBP. In particular, identifying ways of making EBP personally relevant to practitioners (that is, how it benefits them and their clients directly) may help therapists to understand why it is a beneficial framework to adopt. Despite positive attitudes toward research, very few clinicians were actively involved in research; for many, this may be the result of workload and time pressures. Greater collaborative working by practitioners with local higher education


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(HE) institutions may be a means to both develop skills and ensure research is grounded in clinically relevant terms. Working in isolation and lack of support were identified as important barriers to EBP. There is, therefore, a need to identify cost effective and time efficient interventions and support networks (which could have longevity). Journal clubs and the use of social media may provide mechanisms to produce research communities that allow research, best practice, and skills to be shared and disseminated, but these must be embedded within an organizational culture that promotes EBP and integrates it with other training initiatives. Developing dedicated staff roles, such as knowledge brokers, to help facilitate dissemination of up-to-date research findings may promote EBP whilst addressing the time-demands placed on many occupational therapists. Although there are resource-demands that must be considered, mentoring may be another means of utilizing the skills within a workforce (for instance, technology skills of recent graduates and flexibility of experienced therapists), in a cost-effective manner. Mentoring further highlights the need for assessment of training needs prior to any EBP intervention; some research reviewed indicated that the needs of experienced staff might differ from those of newly-qualified practitioners. Being aware of where the strengths and needs of professionals lie will also help to ensure that these individuals are being used to their greatest advantage. Ultimately, this may provide the opportunity for professional enhancement for both the mentee and mentor in terms of career development. Many participants identified the inaccessibility of research as a barrier to implementing EBP: promoting open access resources, whilst being mindful of the cost implications of this, may be an important goal in occupational therapy in future research. Furthermore, appropriate use of professional alongside peer-reviewed publications may disseminate research to a wider audience. A preference for acquiring evidence from colleagues also suggests that knowledge brokers may, for example, be an efficient means of disseminating research. Finally, the research reviewed indicated that many occupational therapists rely on personal clinical experience, which was viewed negatively by some authors. However, personal experience is not in itself incompatible with the original conceptualisation of EBP (Taylor and Savin-Baden 2001). Further research is therefore required to understand what occupational therapists mean and understand by the term and how this could be used to increase the utility of the EBP approach within the field.

Conclusion The results from all of the studies indicated that occupational therapists tend to hold positive views towards EBP, its importance in clinical decision making and in providing the most appropriate care for their patients. Despite this, occupational therapists implement EBP infrequently within

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their day-to-day practice. This lack of RU was perceived to be due to significant barriers within the therapists’ organizational structures, their current work load and subsequent time constraints. Furthermore, many therapists’ perceived themselves to have a lack of knowledge with regards to critically appraising research evidence, whilst perceiving articles too inaccessible and difficult to translate into practice. Qualitative research demonstrated a perceived tension between EBP and traditional client-centred approaches. Therefore, although many therapists realized the importance and value of EBP, a substantial proportion of participants voiced concerns, or negative perceptions, of EBP. This highlights the need for good quality education for future occupational therapists, access to continual professional development programmes, and organizational support for qualified practitioners. Combined, this may help the principles of EBP to be implemented effectively within therapists’ daily practice in a way which benefits both clients and the profession as a whole.

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Key findings Despite occupational therapists holding generally positive attitudes toward EBP, a substantial proportion view EBP negatively. Occupational therapists have raised concerns about the relevance and applicability of research evidence to clinical problems. Factors identified as barriers to EBP implementation and RU include: workload and time pressures, lack of training/knowledge/skills/personal motivation, tension between EBP and traditional approaches, and organisational barriers.

What the study has added This review of both quantitative and qualitative research has identified a number of areas which could form the basis of interventions to encourage the uptake, quality, and consistency of EBP implementation. Such areas include: making EBP personally relevant to practitioners, developing social networks to support practitioners with EBP, mentoring, and encouraging practitioner involvement in research through collaborative working with HE institutions.

Conflict of interest: None declared. Funding: This review received no specific grant support from any funding agency in the public, commercial, or not-for-profit sectors. Research ethics: Ethics approval was not required for this review. References Alexandratos K, Barnet F, Thomas Y (2012) The impact of exercise on the mental health and quality of life of people with severe mental illness: a critical review. British Journal of Occupational Therapy, 75(2), 48–60. American Occupational Therapy Association (2007) AOTA Centennial vision and executive summary. American Journal of Occupational Therapy, 61(6), 613–614. Baumeister R, Leary M (1997) Writing narrative literature reviews. Review of General Psychology, 1(3), 311–320. Bayley M, Hurdowar A, Richards C, Korner-Bitensky N, Wood-Daphinee S, Eng J … Graham I (2012) Barriers to implementation of stroke rehabilitation evidence: findings from a multi-site pilot project. Disability & Rehabilitation, 34(19), 1633–1638.


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Metcalfe C, Lewin R, Wisher S, Perry S, Bannigan K, Moffett J (2001) Barriers to implementing the evidence base in four NHS therapies: dietitians, occupational therapists, physiotherapists, speech and language therapists. Physiotherapy, 87(8), 433–441. Moher D, Liberati A, Tetzlaff J, Altman GD, The PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Medicine, 6(7), e1000097. doi:10.1371/journal.pmed.1000097. Oliver A, McDaid D (2002) Evidence-based health care: benefits and barriers. Social Policy and Society, 1(3), 183–190. Pollock SA, Legg L, Langhorne P, Sellars C (2000) Barriers to achieving evidencebased stroke rehabilitation. Clinical Rehabilitation, 14(6), 611–617. Prior P, Wilkinson J, Neville S (2010) Practice Nurse use of evidence in clinical practice: a descriptive survey. Nursing Praxis in New Zealand, 26(2), 14–25. Reagon C, Bellin W, Boniface G (2008) Reconfiguring evidence-based practice for occupational therapists. International Journal of Therapy and Rehabilitation, 15(10), 428–436. Salls J, Dolhi C, Silverman L, Hansen M (2009) The use of evidence-based practice by occupational therapists. Occupational Therapy in Health Care, 23(2), 134–145. Stergiou-Kita M (2010) Implementing clinical practice guidelines in occupational therapy practice: recommendations form the research evidence. Australian Occupational Therapy Journal, 57(2), 76–87.

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Book review Rheumatology practice in occupational therapy: promoting lifestyle management. Lynne Goodacre and Margaret McArthur, eds. Wiley-Blackwell, 2013. £29.99. 240pp. ISBN: 978-0470655-160 This academic text book has much for every practicing rheumatology clinician to learn and use. It is divided into 13 chapters on all aspects of occupational therapy. Topics include Living with a Rheumatic Disease; Personal and Theoretical Perspectives; the Occupational Therapy Perspective; Work; Joint Protection; Pain; Independence; Splinting, and Maintaining a Sense of Self.

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Each chapter has a detailed resources section. One or two chapters are very theoretical, but most are practical and full of research evidence and, if used, will change your practice to be more evidence based. One chapter provides the resources that we need to develop local policy for occupational therapy in the Rheumatology Service, linking it to the latest government policy and research of longterm conditions. It provides guidance as to the evidence that we need to prove that occupational therapy has a role to play in a changing National Health Service.


My criticism of the book is that some suggested interventions do not fit well with the limited resources available to clinicians with a busy case load. This book has already changed my clinical practice with patients. I can also see it providing the basis for some excellent training courses, including Rheumatology Occupational Therapy Assessment. Overall, it is easy to read and is a great book to ensure you are using the latest evidence-based approaches. Christina Macleod, Occupational Therapist, Hampshire Hospitals NHS Foundation Trust.