9 Potential Barriers and Solutions to Using EBP as a Fieldwork Student or New Grad

Erika Dobson, MOT, OTR/L, CBIS

Evidence-based practice (EBP) is the use of critically appraised research results and evidence-supported interventions to guide clinical decision making. EBP is supported by the use of outcomes measures to monitor progress toward client-centered functional goals. As a student or a new entry-level clinician, you may encounter difficulties implementing EBP, but don’t be discouraged—there are solutions to these common challenges!

Challenge 1: I would like to have a mentor for EBP, but EBP is not used in my fieldwork site or workplace.

If a lack of mentorship at your fieldwork site or workplace is limiting your use of EBP, look beyond your practice setting for a mentor. There are a number of places to find support and mentorship, including AOTA’s CommunOT, current and former classmates and professors, or social media and networking groups.  

After you have mentorship and start to develop your own strategies for EBP, try to lead by example. Some ways to demonstrate the benefit of EBP and make it accessible to colleagues include starting a journal club; measuring your own outcomes and presenting them as case examples; highlighting EBP as a means of providing best practice care; demonstrating the benefits of EBP in relation to reimbursement; or conducting an in-service on how to find, read, and apply evidence. 

Challenge 2: I can’t find any evidence related to my setting, population, or research question.

If accessing evidence is an issue, there are a number of great (and free!) scholarly search engines and databases including Google Scholar and PubMed, as well as AOTA member research resources, such as the Critically Appraised Topics and the American Journal of Occupational Therapy. Try asking your fieldwork coordinator or employer about EBP resources at your site, the availability of facility-specific continuing education courses, or funds that are available for outside education. Chasity Traxler, MOT, OTR/L, said, “my company currently lacks access to some of the large medical databases that I would typically utilize to thoroughly search for evidence that could be incorporated into my practice. However, every quarter [my company] performs an evidence-based search for all disciplines, and disseminates the top 5 articles to all clinicians in order to encourage EBP.” Traxler also noted that she draws on evidence-based materials from continuing education courses. If you’re a student, you can access research databases through your school library; these libraries often offer access to alumni as well. There are many ways to gain access to substantial evidence and research; sometimes you just have to ask around! 

If searching for evidence seems daunting, try adjusting your search strategy by using both a top down and bottom up approach. For example, if your client is an adult with osteoarthritis (research population) who wants to garden (occupation), identify which factors are limiting participation (range of motion [ROM], pain, strength, flexibility). A bottom up search might appear as (osteoarthritis + ROM + treatment), whereas a top-down search might be (gardening + osteoarthritis). Don’t be afraid to search for evidence that is not OT specific; there is a lot of useful research done in other professions (e.g., physical therapy, speech-language pathology, nursing) that includes interventions within the scope of OT practice and can be used to inform OT interventions.  

Challenge 3: I don’t know how to judge the quality of research articles.

When initially reviewing an article, pay attention to the study design (randomized control trial, single group, etc.), the sample size (small studies are often underpowered), and the risk of bias (the quality of the study). Scientific evidence should also use reliable and valid outcome measures, and report on all gathered data and the type of statistical analysis. The AOTA Journal Club Toolkit is a great resource for making sure you have chosen a quality article and provides a Quick Reference on statistics to help you interpret the data. 

Challenge 4: I feel overwhelmed and don’t know where to start.

Getting started is often the hardest part, but starting small can help. Choose outcome measures to use before and after implementing evidence-based interventions with your client to track progress. Begin with one client, develop a clinical question, and look for studies focusing on interventions related to the clinical question. Based on your client’s needs and interests, choose and implement an evidence-supported intervention, considering the factors that will need to be in place to adapt that intervention to your client and the setting. Finally, evaluate the outcomes. 

Challenge 5: The High Quality Evidence I’m Finding Isn’t an Exact Match for my Client’s Needs

If difficulty with finding exact research protocols is holding you back from using EBP, don’t worry! Research should be used as a guide to treatment, and using evidence in practice does not always look exactly like following a research protocol. For most of us, it involves integrating researched theories and treatment approaches into client-centered treatment. A simple way to do this is to focus on the underlying effective factors of the researched treatment, all the while recognizing that specific treatments are shown to be effective in specific doses, following specific protocols. 

For example, constraint induced movement therapy focuses on forcing the use of the affected extremity after a stroke to maximize neuroplastic changes and increase function. According to the available evidence, it is effective when provided in specific dosages (e.g., X times per day, over X weeks). Attempting constraint induced movement therapy without following a protocol or outside the effective dosage recommendations is not evidenced based. However, if your client is recovering from a mild stroke and has been discharged to home, they may only receive OT services a few times a week. In this case, encouraging them to use the affected extremity for as many functional tasks as they can throughout the day is evidence-informed, according to the principles of neuroplasticity.

Challenge 6: I don’t have time outside of treatment to do research.

Time is invaluable, especially when juggling the demands of being a student or a new practitioner. If you want to use EBP but are having trouble finding the time to do so, consider speaking to your fieldwork coordinator or manager to see if there are any site-specific insights or ideas to solve this issue. Another strategy to consider is spending 20 minutes per day researching interventions. Your colleagues may be facing similar time challenges, so consider asking if they want to team up to tackle research questions. Finally, using scholarly search engines by filtering for year published (the more recent the better), language, journal type, and cost are great ways to save some time and energy.

Challenge 7: I don’t have any resources at my site.

If your fieldwork site or workplace does not offer access to databases that provide access to research articles, there are other options to help you access peer reviewed research to help make your practice evidence based. Search for open access articles by filtering your scholarly search engine or database, and search for no-cost outcomes measures from sites like StrokeEngine and Shirley Ryan AbilityLab Rehabilitation Measures Database. If you find a strong study with an intervention that resulted in improvement related to your clinical question, and the assessment used in the study has a cost associated with it, discuss assessment options with other practitioners and managers to see if there are options for purchasing the assessment. If there is an assessment that is highly recommended and appropriate for your setting, consider speaking with your manager about its benefits to clients and the organization. Remember, you can use client factors/performance skills outcomes measures that are not OT specific (e.g., Beck Depression Inventory-II (1996), as long as you tie the use of these measures back to occupation and function.

Challenge 8: I don’t think my clients will buy into evidence-based treatment, especially if it doesn’t look like traditional therapy. 

Buy in is vital to any successful client–practitioner relationship. When developing a treatment plan and possible evidence-based approaches, ask yourself: If an intervention is not evidence based (i.e., shown to be effective), is it worth doing? Initiate a conversation with the client about possible interventions that are evidence based; why these interventions would maximize their time commitment and possible outcome; and options for implementation based on their preferences, abilities, and needs. For example, if a deconditioned patient tells you they hate exercise, don’t provide a home exercise program! A more appropriate EBP and client-centered approach would be to provide aerobic conditioning in a purposeful way, through interventions focused on a desired leisure activity, community mobility, or instrumental activity of daily living (IADLs), which would also increase function. 

Challenge 9: I’m in (or went to) OT school, so I don’t see why I need to find research about how to practice.

What is the point of implementing evidence-based practice, when you learn how to practice OT in school? The most important reason is quality of care for your clients. Interventions should be personalized and unique to each client, and if you cannot explain the rationale for the intervention you choose, you should strongly question its use. Is it worth doing if you don’t know why you’re doing it? In addition to providing quality care to our patients, evidence-based practice also allows us to stay up to date with best practice, and demonstrate the impact of OT in a clear, objective way to administrators, payers, and other professionals. Doing so will in turn advance the profession, by justifying OT treatment with a wider variety of populations and solidify our role on the rehabilitation treatment team in new and emerging settings. Additionally, you can share your strategies and knowledge of implementing EBP through local, state, and national presentations and lectures to demonstrate the unique value of OT. 

Reference

Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation.

Erika Dobson, MOT, OTR/L, CBIS, graduated from Thomas Jefferson University (2017), and is an occupational therapist working in acute care at a large, urban, academic medical center, specializing in medically complex patient populations. Her professional interests include functional cognition, outcomes measurement and assessment, data collection and analysis, and OT's role in emerging practice areas.