OZ OT EBP 21C: Australian occupational therapy, evidence-based practice and the 21st century

Australian Occupational Therapy Journal

(2001)

48

, 102–117

Blackwell Science Asia

2 0 0 1 S y l v i a D o c k e r L e c t u r e

OZ OT EBP 21C: Australian occupational therapy, evidence-based practice and the 21st century

Anne

Cusick

College of Health and Social Sciences, University of Western Sydney, Penrith South, NSW, Australia

Occupational therapy in Australia is entering the 21st century as a dynamic and growing profession. The adoption of evidence-based practice is an important feature to ensure the profession’s continued success. There are also other issues evident in Australian occupational therapy today that need to be considered to ensure the profession’s continued growth. These are: the terminology that is and could be used in occupational therapy; the possibility of ‘collateral damage’ to occupational therapy concepts and processes if deterministic elements of evidence-based practice predominate; and the importance of making explicit our national position on occupational therapy core concepts and processes. Regarding the latter, the author proposes that this position is best described as ‘finding unity in diversity’. This position reflects the national heritage, character and social /health priorities facing Australian occupational therapy. The implications of these issues are explored.

K E Y W O R D S

future, ICIDH-2, occupation, professional issues, qualitative research.

INTRODUCTION

How are we to hold together? By being Australian; by cele-brating, exploring, criticising and reassessing our heritage,all the things that have defined and still define what it meansto be Australian and live in this place. (John Hirst, 2001)

The 18th Sylvia Docker Lecture today will explore thetheme of evidence in our practice. The lecture title is anabbreviation of concepts that are of interest to us at thebeginning of a new millennium. ‘OZ OT’ stands for‘Australian occupational therapy’; ‘EBP’ abbreviates theterm ‘evidence-based practice’; and ‘21C’ stands for the‘21st century’, which we have just entered. ‘OZ OT EBP21C’ was thus the short title I needed to fit in the

conference brochure and programme outline, to indicate thattoday we would be exploring aspects of evidence relatingto the Australian occupational therapy profession as weenter the new millennium. Today I want to explore ideasabout the right mix we need in evidence to get Australianoccupational therapy practice right for our clients andour future.

There are many therapists in our profession whounderstand what the term ‘EBP’ means. There are alsotherapists in our profession who may have occasionallyheard the term, but they do not know what it really means.So we shall start with definitions, practical applications andfrom there move on to other aspects of evidence relatingto Australian occupational therapy.

Anne Cusick

PhD; Associate Professor.Correspondence: Anne Cusick, Associate Professor, College of Health and Social Sciences, University of Western Sydney, Locked Bag 1797, PenrithSouth, NSW 1797, Australia. E-mail: [email protected]

Accepted for publication June 2001.

AOT281.fm Page 102 Wednesday, August 1, 2001 3:55 PM

2001 Sylvia Docker Lecture

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The meaning of ev idence

The general meaning of ‘evidence’ relates to informa-tion which helps establish facts, from a range of sources,information which helps people draw or support con-clusions, with this information having the attributes ofclarity, obviousness and conspicuousness (Moore, 1976).With this generally accepted meaning in mind, we cansee that ‘evidence’ would indeed be a useful element tohave in occupational therapy practice, because it wouldhelp us draw conclusions by using factual informationfrom a range of sources. In our usual terminology thatmeans making clinical decisions using carefully derivedinformation usually from research and the informationwe gain from our clients.

Ev idence-based pract ice

The term ‘evidence-based practice’ (EBP) takes thegeneral meaning of ‘evidence’ and applies it to the processesand outcomes of health services. It means using evidencewisely in decisions you will make about client care. Thereare a number of ways to define EBP, but today we willfocus on a very practical one. When we practice withevidence, it means we should ask ourselves the followingquestion: ‘Am I doing the right thing in the right way withthe right person at the right time in the right place for theright result — and am I the right person to be doing it?’(based on Gray, 1997). Your manager, client or servicepurchaser may also ask ‘is it at the right cost?’.

A pract ical appl icat ion

So that we all have a sense of what EBP may actually belike, here is a practical example of these questions inaction. We all know older people who may be at risk offalling and thus at risk of the health consequences of falls.In our example today we are all therapists working inaged care, and we have been asked to participate in aprogramme to prevent falls in older people. The ‘rightresult’ we want is less falls for older people.

Are we the r ight people?

Our first question is easy. What should we do as occupa-tional therapists to help prevent falls? What special servicecan we contribute to help ensure older people are less atrisk of falling? Is there something special that we can do,

or would the rest of the aged care team do just as wellwithout us? In other words are we the right people to bedoing the job?

Are we doing the r ight th ing?

To find out the range of services we could offer as occupa-tional therapists in this situation, we may contact ourcolleagues and read a few books. From this we find thatoccupational therapists, among other things, do home visitsto assess and then make changes in the home environmentto reduce home hazards. But as practitioners who base ourwork on evidence, how do we know home assessment andchange works? How do we know this is the right thing todo? We may then look in the literature, in journals and ona range of EBP sites on the Internet, and we find studiesthat say, ‘yes, this type of intervention does reduce fallrisk’. So now we feel more confident to proceed as theright people offering the right type of service.

Are we doing i t the r ight way?

But then we wonder does it matter how we actually do it?Will any approach to home inspection do? Or should weuse specially designed standardised assessments foroccupational therapists that will make sure we do athorough job, for example the

Westmead Home Safety

Assessment

(Clemson, 1997)? Is that a better way? Havingassessed the home and made recommendations for homehazard reduction, how should we then ensure theserecommendations are taken up? What is the right way toget those mats up, rails in, fluffy slippers off and lightson? We thus look further for literature that will give usinformation about the best way to do it.

Are we doing i t wi th the r ight c l ients?

Being occupational therapists (and evidence-based practi-tioners) we also know that clients have views, values andunique issues which are important to consider. Are theredifferent ways which suit different clients? Will one way ofmaking home safety change work with one client, butanother way is needed for a different client because ofthe type of people she lives with or the beliefs she holdsabout her home? Will some clients make changes withoutour intervention, while others are at high risk and needour help because they would not otherwise make changesto increase their safety? Here we can again be informed byresearch literature but we also need to rely fairly heavily onour own enquiries of the client and our own judgement.


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Are we doing i t at the r ight t ime?

We should also think about timing. Would our interven-tion be more successful if it was done at a different time?For example, do older people need to fall first, before theysee the need to make their homes safer? Or can theymake safety changes before they fall? Or even more sim-ple aspects of timing: is take-up of recommendations morelikely with older people in the morning or afternoon?

Is i t be ing done in the r ight p lace?

Do we really need to go out to people’s homes? Where isthe proof that individualised inspection, assessment andchange plans are worth the travel time, on-costs such ascars, the effort and personal safety risk to staff?

Is i t at the r ight cost?

What are the costs and benefits of the assessment andintervention? Do these weigh up as reasonable whencompared to alternatives, or when compared to the con-sequences of no intervention at all? Is it just as effective,for example, to use a low cost approach like handing outself-help pamphlets on ‘how to make your home safer’ andhaving a little chat with families in the aged care unit, asgoing on a home visit to inspect and make suggestions forchange which may or may not be taken up by that family?One intervention is relatively cheap, the other high cost;does the effectiveness of each match the cost? Is it rightfor what you get in health outcomes?

Ev idence-based pract i t ioners ask i f i t is r ight

These questions about whether or not things are ‘right’are the sort of questions evidence-based practitionerswould ask themselves every day. So for those occupationaltherapists new to EBP, just take a minute to think about aday in your life as a therapist, and how you might haveasked these questions of what you were doing, how youwere doing it, with whom, where, when and why. Thequestions and their answers may have changed what youdid that day, and how you did it. We can see that the ‘arethings right?’ questions are in fact ‘just right’ for focusingon the more general meaning of evidence I mentioned atthe beginning of this lecture. Even therapists new to EBPtoday would be able to make clinical decisions with con-fidence if they had the right answers to their ‘are thingsright?’ questions.

Ev idence = research (most ly)

One thing I need to make clear ‘right here’, is that the sortof evidence we are after is, mostly, that information whichis generated through research. Research is the best waywe have of finding out information which establishes facts.So when you hear the term EBP, you need to thinkresearch-based practice. This means that we each need tohave a working knowledge of research to be able to fullyparticipate in EBP activities (Domholdt, 2000). If you donot have this right now, then do not despair, you can stillbe part of this approach as there are ‘shortcuts’ available(Dawes, 1999). These shortcuts (like findings from systematicreviews, or clinical guidelines, or summaries on certaintopics), mean other people with good research expertisecan do some of the more difficult research-related tasks foryou, so you can still find out about good quality informa-tion for your practice decisions. The only challenge is thatsometimes there are no shortcuts available in some areasof our practice, but you can use what is there, while youhone up your research knowledge and skills for practiceareas which are short on shortcuts.

Now you have a pract ice quest ion, what do you do?

Today, and this particular lecture, is not the time or placeto take you through the practical steps which follow aquestion about therapy effectiveness. Suffice to say thatthere are standard procedures which can be easily learntby occupational therapists to know how to:1. Ask your practice question in a way that makes it easy

to look for answers;2. Look for information in the professional literature in

a systematic way;3. Do the Internet searching to locate your items of interest;4. Judge or appraise what you find so you know whether

it is any good or not and whether it applies to you andyour client; and

5. Apply the evidence to your situation, and the uniqueneeds, values and preferences of your client.These five steps are the nuts and bolts of EBP.

How can I learn what to do?

There are many easy to access books (e.g. Dawes

et al.

,1999; Taylor, 2000), articles (e.g. special editions on EBP



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in the Australian, Canadian, British Journals of Occupa-tional Therapy), resources (e.g. Snowball, 1999, reviewsthe range of types available) and web sites (e.g. TheCochrane Library, 2001; NHS Centre for Reviews andDissemination, 2001; Physiotherapy Evidence Database,2001). In addition, there are local workshops and courseswhich can teach you about EBP and how to become anactive evidence-based practitioner. The recent specialedition of the


(2000) on EBP presented many references, Internet sitesand some ideas about how to learn these tasks, and howto promote EBP in your workplace through a range ofstrategies which target more than the individual therapist(Cusick & McCluskey, 2000). The ‘Evidence-basedSymposium’ organised by the University of QueenslandEvidence-Based Occupational Therapy Group, held inBrisbane just prior to this conference, examined a range ofstrategies including the development of something like anAustralian-based occupational therapy evidence bank onthe Internet. OT AUSTRALIA will keep you up to datewith these developments. The elegance of EBP in

your

practice is that you are in control: it is you who uses theresearch evidence and your knowledge of the client andcontext to make your decision right.

Now we al l know: Ev idence-based pract ice reforms and transforms

At this point in the lecture, I can now assume that weall know what ‘evidence’ and ‘evidence-based practice’means. I can also now assume that we all have an idea ofwhat it might look like, at least for a therapist workingwith older people to prevent falls, and how it has thepotential to inform our daily practice by asking the rightquestions. I now want to move on to the way in whichevidence can not only

inform

but

transform

our practice. Iwant to question whether

we

are going to be doing theright things in the right way at the right time to get theright result for

our

profession.There are three issues I’d like to explore today which are

most likely to affect our ability to be dynamic, relevant, goodquality service providers in the 21st century. They are:1. Words to communicate;2. Collateral damage and EBP;3. The choice between diversity or consistency.

I’ll briefly explore each of these to formally place themon the professional agenda for this new century.

WORDS TO COMMUNICATE

The EBP process starts with a question. This questionneeds words, and if the words are not right, the questionwill not be right either. Twenty-one years ago, when I firstbecame an occupational therapist, there were not too manyspecialist terms to learn. ‘Biopsychosocial’ was probablythe longest, ‘purposeful activity’ was the most commonlyused, and ‘adaptation/rehabilitation/remediation’ werethe most complex concepts to grapple with.

Now, when I look around and see the number ofpractical and theoretical approaches to occupationaltherapy increasing, I feel a sense of wonder that I evermanaged to muddle through occupational therapy with sofew conceptual tools. I feel proud to know that we have anevolving professional language which aims to present theconcepts of our profession with greater refinement. Theseefforts towards precision enable us to better define what itis we are, what it is we do, and what it is we work with.Having words with greater precision should make formulat-ing the questions we need to ask for EBP easier. Having aprofessional language should also make articulating thenature of our practice easier so that we can better provideevidence of its effect. These are

benefits

of profession-specific language.

But in other ways, it carries risks. Fifteen years ago,Mocellin (1984) described one view about specialised termsin occupational therapy thus: ‘Unless … [we] are preparedto use terms and concepts which demystify rather thanobscure what occupational therapy is and does, … [we]will continually be relegated to the “rare species” section ofthe zoo that is the health field’ (p. 539). Clearly, Mocellinwas not a fan of terms about occupation which were justemerging in the early 1980s (Townsend, 1997). But all thesame, his message is still worth reflecting on, as the healthsector is a bit of a zoo. In this zoo it is words, the constructsthey represent and measures they infer, that are the meansby which different species distinguish each other, preenand position themselves for the scarce resources available.Having a language of our own, which cannot be readilyunderstood by other species in this zoo, could be a riskybusiness.

Let me use an example given by a leading Australianauthor, Pierre Ryckmans (1996), to illustrate possiblerisks. He described the old practice of authors of classicalChinese prose, who wrote their carefully crafted essaysusing dictionaries which would encode their message in


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precise but ‘obscure, allusive language’ (p. 37). Theseauthors clearly required years of training to be able to dothis well. Their readers, to understand the essays, would inturn ‘consult similar dictionaries in order to decode [themessage]’ (p. 37). Ryckmans says one of their con-temporaries, Lu Xun, had the radical idea ‘that it mightbe more sensible and economical for both writers andreaders to discard their special dictionaries, and, bypassingall esoteric allusions, to communicate directly in plainlanguage’ (pp. 37–38). How shocking!

In telling this story I am certainly not advocating anabandonment of occupational therapy’s search for preci-sion in words. We need to be able to get to the core of thephenomena we work with, and words with definitions arethe best way to do it. But I am saying we need to be alertto the risk that comes with it. The risk is the limiting ofwho we can talk to and who in turn is able and willing tolisten to us.

R isks of profession-specific language

An unchecked development of profession-specific termscould run the risk of replicating the practice of the oldChinese essayists; where we find it difficult to formulatepositions, questions or answers without recourse to ourown specialist dictionaries. Right now we have a numberof these ‘dictionaries’ in occupational therapy (both inseparate books, for example, Jacobs, 1997; and glossaries,for example, the glossary in Townsend, 1997). At the ratewe are going with the increased numbers of theoreticalapproaches with their own specialist terms, we may needmore glossaries and dictionaries. Is this a problem? Itcould be, if we want our words to communicate what wedo to others

outside

our professional group who do nothave our ‘occupational dictionaries’ or who do not consultthem. We need to choose and use our words carefully, asthe ultimate purpose of words is to communicate. We needto be cautious for three reasons: who we communicatewith outside; who we communicate with inside; and whywe communicate. I will explore each of these now.

Who we communicate with ‘outs ide’

We need to be cautious that in our zeal for describing thethings we work with, and the processes we use, we do notland up in a world where we can effectively communicateonly with ourselves. Ottenbacher (1996) found in an

analysis of citation patterns across different disciplinesthat occupational therapists, more than other professions,had a marked tendency to cite their own occupationaltherapy journal sources. Citing oneself has been identifiedby Ryckmans as a ‘fatuous habit … at risk of [makingauthors] appear lazy and pretentious’ (Ryckmans, 1996;p. 10). While there are important exceptions where self-citing is used appropriately (for example to demonstratean evolving programme of research or reflection; to draw onprevious findings; or to track changing views), I wonderif we as a

profession

should perhaps take this criticismof self-citing to heart when considering our own habits ofdiscipline citation.

The Ottenbacher finding (1996) thus raises the worry-ing prospect that we are already only communicating withourselves, and we appear to be substantially only readingourselves. There is also, however, a far more worrisomeprospect in another of his findings in the same study. Heidentified that in major journals in the rehabilitation field,citations of our work

by others

are frighteningly smallwhen compared to another profession, physiotherapy. Ittherefore begs the question of whether or not anyone out-side our profession is

reading us

. Could it be that words, inparticular ‘keywords’, which are the usual way outsidersaccess our information, are just not working to communicateour relevance to rehabilitation?

Who we communicate with ‘ ins ide’

If we are not cautious in the proliferation of specialityoccupational therapy terms, we may also find that we arecommunicating not only with ourselves, but also with onlythe few in the profession who understand the code: thosefew who have the ‘occupational dictionaries’ as well as theskill, time and interest to decode encrypted messages sent.I know there are a reasonable number of therapists hereat this conference who do not understand the currentmeaning of certain words used in our professional languagetoday. I know because some therapists have told me theydo not understand ‘occupational’ terms. They may havebeen educated prior to the explicit focus on ‘occupation’,they may work in specialist areas where the relevance of‘occupational terms’ is not readily understood, or theymay have been to professional development sessionswhere terms were not fully explained. There may also be anumber of therapists here today who may not even knowthat they do not know; I have certainly met colleagues



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such as this at other conferences. We therefore need tobe aware that our internal professional audience couldshrink too.

Why we communicate

We also need to remember why we use words in the firstplace. We use words to communicate. If we truly havesomething important to say to the world, then we need tobe able to say that directly. Oscar Wilde, well known forhis direct communication, once wrote: ‘nowadays, to beintelligible is to be found out!’ (Wilde, 1893/1996). Are weworried that we will be ‘found out’? That we either havenothing really unique to say or that we are not sure ofwhat it is we need to get across? I think we should makegreat efforts to be found out; to be discovered, rediscoveredand cited, by lots of people who need to know what wehave found out about occupation.

We need to be able to persuade ourselves and othersabout the importance of occupation in health (Wilcock,1998), the value of occupational therapy and its way ofcreating the self and changing the world (Wilcock, 1999).Unless we can persuade people outside our profession ofour worth, we will not have a viable future as a service. Ourmessage needs to be in terms which do not always requiretranslation to make sense to outsiders. We therefore eitherneed to transform the language of the world to one ofoccupation (not impossible, but very clear strategies to dothis are needed now); or we need to look at the languageof the world and see what terms suit us without too muchtampering.

Words from the World

One example of suitable words is the World HealthOrganization (WHO)

International Classification of Func-

tioning, Disability and Health

(ICIDH-2 Final draft; WorldHealth Organization, 2001) and the words which compriseit. This classification has been a major project of WHO.The revision has brought together social and medicalapproaches to disability, and in so doing presents a newglobal understanding of disability. It also presents keywords that have common disability definitions (Madden,2000; Madden & Hogan, 1997). Dialogue relating to dis-ability (which includes us as speakers) can therefore nowuse terms which are internationally understood, andindicators which present internationally relevant measures

relating to these terms, so evidence generated to answerquestions about disability is globally meaningful.

When I read the revised classification (ICIDH-2), Iwas struck by the commonality of purpose and scopebetween the WHO definitions and conceptual frame-work, and the scope and understandings of occupationaltherapy in relation to disability. It was almost as if theWHO had finally caught up with what we have known allalong. I will show you what I mean: while a remnant of theold approach to disability, illness and handicap was left inthe word ‘impairment’, remaining dimensions soundedvery familiar:• ‘activities’ related to functioning at the level of the

person;• ‘participation’ related to the person’s involvement in

all domains of life;• ‘contextual factors’ were any factors in the physical or

social environment which impacted on the person; and• ‘participation outcomes’ were experienced by indi-

viduals and related ‘not only to their impairments oractivity limitations, but also to interactions with thesociety and the physical environment in which theylive’ (Madden, 2000; p. 2).I thought that sounded familiar. If the WHO document,

due for a final version this year (2001), uses terms whichare sympathetic to much of the business of occupationaltherapy, I wondered how useful it might be if such termswere part of the essential dialect for those practitionerswho worked with people who have a disability.

Of course we should continue to use occupationaltherapy terms, but if we also used these universally acceptedwords more, and generated evidence with indicators thatreflected these global concepts (Australian Institute ofHealth & Welfare, 2000), not only could we communicateinternationally with people outside our profession, but wecould also talk to each other about our work in disabilityin terms which complement our professional language butat the same time reinforce the global importance of whatwe do. In addition, by doing this we could contributeevidence (with measures, relevant indicators) needed tomake practical sense of WHO words in the areas of activ-ity, participation, contextual factors and participation out-comes (Australian Institute of Health & Welfare, 2000).Our evidence relating to occupation could be immediatelyuseful to national and international disability initiatives.We could then provide some evidence to show: that weare the right people to be enabling occupation and thus


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facilitating WHO disability objectives; that we have theright interventions to do it; that we know the right wayto implement them; and that we know whether or notthey work, so we are the right investment for disabilityresources.

If we choose and use the right words in occupationaltherapy, we could open up a range of opportunities thatare right for us and our future. If we use terms and relatedmeasures that can present the same idea to many people,it means our audience can be much larger and the likeli-hood that someone will listen is increased, and the messagewe send to them and what we hear back can be very direct.No encryption. In a world where there are few resourcesfor many in need, our profession and the people out therewho need us have to send strong clear messages to those whomake decisions about the health services and resources.We need to get our words right, so we can be in theredoing the right things with the right people and showingthat what we do works with evidence that makes sense toeveryone.

COLLATERAL DAMAGE AND EVIDENCE-BASED PRACTICE

The first part of this lecture explained what EBP was, andthe important role evidence played in doing the right thingby our clients. I now want to explore this from the point ofview of the type of information we can use as evidenceand how this relates to the type of profession we maybecome.

I have already indicated that the move towards EBP isessential for our profession. We need to demonstrate thatwe are doing the right things to achieve health outcomesthat are right for our clients. As we have just seen, havingthe words to be able to ask the right questions is a criticalfirst step. Once having asked a question, we then need tofind the right sort of evidence to provide us with the rightanswer to help inform our practice.

R ight ways of knowing: Qual i tat ive and quant i tat ive

In occupational therapy, we need different types of informa-tion to answer different questions. Different traditions ofknowing, understanding and investigating reality have tobe part and parcel of the ‘working knowledge of research

design’ (Domholdt, 2000; p. 3) that we use in EBP. Weneed to be alert to the broad worlds of both qualitativeand quantitative research as these two approaches generatedifferent types of information.

Practitioner programmes for EBP therefore need toteach the value and technical requirements of good qualit-ative

and

quantitative research so that both approaches toknowledge are considered important and essential parts ofour evidence base. There are already resources availableto help guide educators and therapists in this (e.g. deLaine, 1997; Giacomini & Cook, 2000; Law

et al.

, 2001;Taylor, 2000), but the way qualitative and quantitativeinformation can be used in EBP also needs to be explained.

Quant i tat ive dominant : ‘ therapy’ type quest ions

Presently, there is a heavy emphasis on the quantitativeapproach to knowledge in EBP (Seers, 1999), and how thistype of evidence can be

used

to answer practice questions.This is not surprising, as many of the types of questions weask are so-called ‘therapy questions’ (Snowball, 1999).These ask about the effectiveness of an intervention andso need information in the form of outcome studies toanswer them. Studies with specific measured outcomes allowus to say whether or not one intervention is more effectivethan another or whether intervention is more effectivethan doing nothing at all. Outcome studies are importantevidence in occupational therapy for this reason.

Other types of quest ions

But, like other health professions, we also have other typesof questions in occupational therapy practice that needdifferent sorts of information to answer them. These canbe quality of life questions, cost-effectiveness questions,prevention questions, prognosis questions, questions ofharm versus risk, and questions of how we should gatherand interpret our practice findings (Snowball, 1999). Inaddition, as occupational therapists, we are interested inquestions related to people’s perceptions of their experi-ence in occupation, their ideas about identity, and howthey attribute meaning to their experience. These ques-tions require information beyond the scope of outcomestudies but are central to our focus on occupation. Some ofthese questions can only be answered with informationthat is derived through qualitative methods.



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Benign approach to qual i tat ive informat ion

In the EBP literature, there seems to me to be a benignapproach to qualitative information which indicates that:(a) it is there (e.g. Cochrane Qualitative Methods Net-work, 2001); (b) it can be evaluated for quality and this ishow you do it (e.g. Giacomini & Cook, 2000); and (c) itexplains that qualitative work is useful to explore things,to help inform definitions of interventions or selection ofmeasures to include in effectiveness reviews, and toinform people about issues so they can be more sensitivein practice (e.g. Giacomini & Cook, 2000; Khan, Popjay &Kleijnen, 2001). However, the literature does not reallygive a guide on the way in which qualitative informationcan be used as valued evidence to make importantpractice decisions.

Instead, qualitative research is presented more as asource of evidence, for those questions and issues whichare ‘difficult or impossible to quantify [where] values,cultural perceptions or other types of “soft” complexitymake generalisation between groups or populationsdifficult or inappropriate’ (Snowball, 1999; p. 18). Thisso-called ‘soft’ complexity, is of critical importance tooccupational therapy.

The emphasis on ‘therapy’ type questions and theresulting focus on outcome studies and thus quantitativework, carries a risk of collateral damage to occupationaltherapy. The possibility is that over time, the importanceof qualitative work in our knowledge base and in ourpractice decisions will be reduced, in spite of the increas-ing volume and quality of this sort of work. This riskarises partly from the sector in which most of us work,where:1. Therapy and cost-effectiveness questions are the most

commonly asked;2. Biomedical or medico-legal models continue to have a

dominant position; and,3. ‘Hard’ complexities are of most interest to decision-

makers in power as these permit generalizations topopulations and groups.

The r isk is real

Authors within the EBP literature recognize the differentvalue placed on qualitative research compared to quant-itative research and they too see it as a problem. Popay &

Williams (1998) identified barriers to the use of qualitativework in EBP and others have confirmed the real risk of alesser role for qualitative evidence. As Seers (1999) noted‘the largely medical quantitative perspective is dominantand there may be a tendency to regard only knowledgegenerated from this approach as worthwhile knowledge’(p. 113).

So the risk of a diminished place for qualitativeresearch is a real one for us and the prospects of collateraldamage are high. In occupational therapy, there is thepossibility over time that criteria used to judge the weight,strength, impact, quality and importance of evidence willveer towards the quantitative paradigm as more peopleuse, understand, interpret and apply quantitative work.We may find that evidence we use is increasingly

outcome

driven in sympathy with the sector we work in. We mayfind that the way we think about ourselves will be more interms of outcomes rather than processes. We may find thatoutcomes become the drivers of the development andselection of processes we choose. This may lead to changein what we do, what we think we should do, and why wedo it. It could well influence what we will become.

This is a problem, as qualitative research providesevidence about human experience and perception thatcannot be accessed any other way (Bogdan & Taylor,1975; Denzin & Lincoln, 1994). It can thus provide infor-mation about

occupation

that is essential for the informedconduct of occupational therapy. We desperately need thisat a time in our profession’s history when we are discover-ing, defining and refining the uniqueness of our serviceand our professional focus.

What are we to do?

I suggest that, rather than accepting a benign place forqualitative research as an additional resource to informus about ‘soft’ complexities, we bring it up to the front ofthe EBP debate so it becomes one of the hard-gunswhich drives the way we think of evidence and the ques-tions we ask. Some of our academics and practitionershave excellent links with a variety of EBP centres tofurther this task on a national and international scale. Amore scholarly debate about the nature of evidence andways of knowing, with recourse to our colleagues inphilosophy, would also create a more inclusive view ofevidence, and thus an equal place for qualitativelyderived information.


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Consequences

If we do not do this, the collateral damage which is pos-sible to our knowledge base, our evidence, and practicetradition is terrifying. We could lose respect for the veryways of knowing that can help us answer practice ques-tions about who we are, what we do, what we could do,and what we might become. We could start believing that‘hard’ questions cannot be answered by ‘soft’ complexities.We could start believing that it is quantitative researchthat provides evidence which is truly more useful to us. Wecould continue thinking that the question we should mostoften ask is: ‘is it effective?’ We could continue usingqualitative research as a benign source of information toincrease our ‘sensitivity’ or as a mine for questions thatcan then be answered with ‘real’ quantitative methods. Wecould finish up asking questions that can only be answeredwith quantitative methods, and in so doing we could loseour professional soul.

The immater ia l aspects of our business

Let me elaborate on the risk to our ‘professional soul’.Occupational therapy, with its primary concern of occupa-tion, has, whether we recall it or not, an obligation to con-sider, articulate, work with and enhance dimensions of aperson which are immaterial. If we are ‘real’ occupationaltherapists, we recognise that individuals have a spirituallife, that they have an emotional and intellectual life, values,morals and an essential nature that goes beyond observableaspects of performance. These dimensions are an essentialpart of occupation, and thus an essential part of occupa-tional therapy.

A number of our professional practice models claimthis. These dimensions cannot adequately be investigatedwith quantitative methods. If we do not act to maintainand enhance the place of qualitative knowledge in EBP,we may find that these dimensions of the person are mar-ginalised in our practice as we come to know less and lessabout them. As this happens, the sort of questions whichdimensions like this need will not be asked, and as timegoes by the importance of immaterial aspects of the personwill diminish. This would be a terrible loss as it is a defin-ing part of our practice.

We need to work now to keep the soul of our profes-sion, to maintain the intensity of focus on clients and theirworld, both material and immaterial. We therefore need to

bring qualitative research to the fore in EBP debates.If we do not do this we may find, to our great loss, thatin the process of fostering evidence-based practitioners,we suffer the unintended consequence of sideliningimportant dimensions of our practice, thus losing theinnovation and insight of our qualitative research, andunintentionally nurturing a deterministic practice, therebyfurthering the dominance of biomedical approaches tohuman health.

Evidence-based practice approaches have the poten-tial not only to inform and reform our practice, but also totransform it. We must ensure that the changes made to ourprofession with the introduction of EBP are changes thatare consistent with our focus on occupation and our interestin the daily reality of our client’s lives. This requires anexplicit and balanced approach to ways of knowing so thatwe can ask the right questions, investigate them in theright way and in so doing get the right answers.

THE CHOICE BETWEEN DIVERSITY AND CONSISTENCY

One piece of evidence that is of particular relevance to meas an occupational therapist is that I am Australian. I amproud to be a member of an international professionalcommunity. However, it is a fact that I practice and workin Australia. Consequently, as an Australian I am veryconcerned with the health of my Australian community,the strategies we use in Australia to help promote health,and in particular the future of the Australian occupationaltherapy profession. I am now going to address the topic ofhow we, as Australian occupational therapists, should makeexplicit the positions we hold on matters of professionalimportance.

From my is land home

As an Australian, I do what a lot of us do in daily life. Ilook to other countries and keep up to date with what ishappening overseas. In doing this, I feel in touch, informedand in the picture. I do not think I am particularly unusual;most people in Australia like to keep up with what ishappening elsewhere. It is a likely consequence ofbeing a citizen of a cosmopolitan island nation. I do thiswith occupational therapy professional and practicematters too.



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The Canadian achievement : enabl ing occupat ion

One thing that has caught my sustained professional atten-tion for a number of years is the incredible achievement ofthe Canadian Association of Occupational Therapists(CAOT) over the past 10 years in identifying the need for,supporting, and implementing the massive task of nationalprofessional change: the ‘Enabling Occupation’ project.The project developed and then provided a reflective andclient-centred approach to practice, which focused onoccupation, occupational performance, and enablement.It explicitly stated concepts, processes and outcomes forCanadian occupational therapy and ‘present[ed] valuesand beliefs, the Canadian Model of OccupationalPerformance (CMOP) and client centred-practice as coreconcepts of occupational therapy’ (Townsend, 1997; p. 4)in Canada. In other words, they developed a consistentnational position

.

Us too? A surpr is ing conclusion

Over the past few years, I have been doing the ‘Australianthing’, and thinking a great deal about what they did overthere in Canada. I have been thinking a great deal aboutwhether we should do something like this here inAustralia: whether we too, should have a national positionon core concepts and processes of occupational therapy.My interest in a consistent national position was alsobrought about by the findings of an exploratory study Iconducted with a colleague recently, where we asked localoccupational therapists their views about the present andthe future (Cusick & Yule, 2001). One of the issues thatemerged was the perception that occupational therapyneeded to be much more unified in the future than it isnow, and that the occupational therapy association shouldhave a strong leadership role in bringing that about. Therewere no ideas about how this unity might be achieved. Iwondered whether a national position on core conceptsand processes may be one way to further unity in theprofession to help meet these therapists’ hopes for thefuture. In the course of thinking about this, I have cometo a surprising conclusion, and I want to share this withyou today.

At first I wondered if it would be possible to have anational project of this size and scope to target occupa-tional therapy core concepts and processes. My belief was

yes, we have done other things that were just as big (theAccredited Occupational Therapy programme being one ofthem). But I also thought that unless there was a combina-tion of sticks and carrots which would help Australiantherapists comply with or ‘choose’ preferred national con-cepts and processes, I doubted anyone in Australia wouldtake any notice. I thought further on this view and came tothe conclusion that anything which professed to representa ‘national position’ outlining our core concepts and pro-cesses would be treated by therapists with the same feignedignorance that is the fate of most edicts in this country. Ithen started to reflect on what it was in our country,Australia, that would make such a great idea a likelypractical failure.

Not qui te us

I looked again at the evidence in the exploratory study Ireferred to earlier (Cusick & Yule, 2001). I saw that thesetherapists were very keen to have increased professionalunity which they perceived would address a number ofchallenges facing occupational therapy in the future, butthey also wanted to keep the

diversity

which they saw wasa strength in the profession now. This was enough to get methinking about diversity and unity as professional themesthat might be of relevance to ‘big picture issues’ such ashaving a consistent national position on core concepts andprocesses in Australia.

I concluded that the great idea of a consistent Australianposition would most likely be a practical failure as itwould go against attributes of our national character.However, while any description of national features isbound to be a ‘blunt axe’ (with all the flaws of generalisa-tion), I felt it was worth going further down this path.Come with me now.

Austral ian nat ional character

The Australian national character was described by IngaClendinnen (1999) as ‘egalitarianism and … obstinatelyindependent empiricism’ (p. 31). These attributes meanthat we generally think of each other as equal, in fact wedo not much like anyone who thinks they are better thanthe rest of us; we are not easily persuaded to do anythingwe do not already think we should do; we do not muchlike depending on authority, or something else, to say thatwhat we do, who we are, and what we want is valid; and


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we tend to regard the knowledge of experience, observa-tion or practical experiment as the right sort of knowledge.Being an Australian I found these fine qualities endearing,and a reasonable assessment of the character of manyAustralians I knew.

Nat ional character of our profession

Applied to Australian occupational therapy, these attributesgive us an indication of the national character of our pro-fession. These are: that every therapist has the expectationthat he or she is equally up to the task of considering arange of approaches to occupational therapy (whetherread in the literature, heard in the lecture room or atconferences); having observed or tried them out, everytherapist is then equally entitled to choose the one thatsuits his or her practice the best. To be told by an authority,particularly an institutionalised one like a professionalassociation, what core concepts and processes are thepreferred Australian way, would be foreign. It would be‘unAustralian’, as every therapist and every approachwould not be having a fair go in the matter. If anyone triedto do this, being laconic Australians, we would probablydo what we have always done with substantive matters ofconflict, and deal with such a situation by saying very littleabout it. In time our expectation would be that the wholething would, like a drought or flood, pass over the profes-sional landscape, leaving whatever is left, and we wouldpull together and get on with it like we always did.

Nat ional posi t ion on core concepts and processes?

The excursion down the path to thoughts about Austra-lian national character, and the relevance of this to ournational ‘professional character’ was illuminating. As anAustralian (and therefore, as an apparently obstinatelyindependent empiricist) it was clear I needed to thinkabout the practicality and worthiness of a national approachto core concepts and processes in the light of our nationalcharacter, as it is an important contextual factor whichwould influence the way in which a national position wasconsidered by Australian occupational therapists; personalworld views are very likely to influence professional deci-sions (Cusick, 2001). Hence my conclusion of the likelypractical failure of a great idea. I also concluded that therewas nothing fundamentally wrong with this Australian

approach or the consequence. Apart from the fact it mightbe a reflection of national character, the principle uponwhich it rested was good and proper: in this nation, theprinciple was an equal right to freedom of choice byordinary people over things that matter to them.

We have an approach: an Austral ian one

In this profession, the principle is thus the equal right tofreedom of choice in occupational therapy approach bytherapists. To uphold this principle, we need to have abelief in the common sense of ordinary practitioners tomake reasonable decisions about core concepts andprocesses they choose for use in their practice. I realisedwith a shock, after these reflections,

this

was our nationalposition. We had one already! I came to the belief that theunity of our professional position in core concepts andprocesses came not with consistency, but rather withthe recognition of our reality: acceptance of individualdiversity.

Let ’s make our approach expl ic i t

The Canadian approach of nationally advocated coreprinciples and processes is innovative, inspiring, scholarlyand flexible. It provides national consistency at a policylevel to guide the nation’s therapists, even if as individualssome choose not to ‘run with it’. But here in Australia, anationally advocated position on core concepts and pro-cesses would, I think, not be practically possible becauseof our national character and would not be desirablebecause of our national heritage, of which I speak later. Itherefore concluded, to my own surprise, that instead ofconsidering what the Canadians had done, we needed to

spend some energy on making explicit what we already

have

. Today I start this process with reflections, but I hopethese act as an invitation to follow through with evidence.

F inding uni ty in d ivers i ty

Our national position on core concepts and processes canbe titled ‘finding unity in diversity’. To state again, theunity of our professional position in relation to core con-cepts and processes comes not with efforts to promoteconsistency, but rather with the recognition and accept-ance of the diversity of practice approaches by individualoccupational therapists in this country. Yes, it can be a bit



113

hit and miss, as from time to time poorly formulatedapproaches get adopted; but in the course of experienceand with exposure to information, most therapists can anddo use their own judgement to come to a satisfactory posi-tion on concepts and processes of occupational therapy.It is not particularly systematic, but it is in keeping withour Australian character. It thus has a ‘goodness of fit’which is not a bad test of reasonableness.

‘Finding unity in diversity’ has five principles:1. That diversity of practice approach is a right;2. That individual therapists have a responsibility to be

informed about the range of practice approaches and afreedom to choose their practice approach with dueregard to the needs of their clients and communities;

3. That tolerance of diversity in practice approach isexpected;

4. That the unity of our Australian profession is derivedfrom a recognition of the values which underpindiversity and ‘civic’ processes designed to protect andpromote that diversity; and

5. That the strength of our profession is found in itsdiversity.These principles and the position are something we

should protect and promote.

Uni ty in d ivers i ty

The name I have given to this position sits well in broaderAustralian debate of who we are as a nation and asAustralians. ‘Unity within diversity’ has been identified asa national theme by eminent Australian, Donald Horne(2001) who publicly reflected on Australia in this year2001. 2001 commemorates 100 years since the Federationof our country from a coalition of rival independent statesto one national entity. He suggested that Australia is ‘heldtogether by a civic culture: tolerance, fairness, a commit-ment to parliamentary democracy, respect for due process,minority interests and diversity … these civic virtues’(Hirst, 2001).

As an Australian profession that adopts a position ofdiversity in core concepts and processes, we should dowhat Donald Horne suggests for the nation: ‘seek tomaintain harmony by exercising our civic virtues, accept[ing]diversity and strengthen[ing] forces for unity within thatdiversity’ (Horne, 2001). This is an important thing to doin our nation and in our formal Australian organisations,of which our professional association is one. This is

because diversity is a central theme in our national herit-age and it is not something that has come about easily.

It is important to remember that Federation in 1901was, to a large extent, brought about at that time byefforts to keep Australia a place where diversity wassuppressed, particularly in race and in culture. For many thatheritage is a painful one that is only now being considered.Since that time, we have as a nation made incredible,hard fought and hard won advances to build a societywhich is now one of the most diverse, cosmopolitan andpeaceful places on earth. The acceptance of diversity isthus a

national achievement

, which we as Australians mustprotect in all our institutions — including our profession.

I therefore suggest that formal institutions of theAustralian occupational therapy profession, such as OTAUSTRALIA, should not try a project to develop pre-ferred core concepts and processes with a view to encourag-ing adoption of consistent approaches. I want us toconsider instead what we already have, and ask the rightquestions to learn more about it, before we move intocourses of action which may lead us in different directions.

Our nat ional her i tage and future tasks

Our direction has to be towards an understanding of whoand what we are now and where we have come from toget here. This will provide us with information to thinkclearly about the future and what we hope to become. Ihave identified that diversity is a national achievement forAustralia. It is something as a nation we have slowly andactively worked towards since Federation; it has nothappened by accident or without conflict. For this reason,tolerance of diversity in practice approach will have asymbolic meaning in our Australian profession, which maynot figure in other occupational therapy associationsoverseas. Diversity has a symbolism here which representsnot only where we have come from, but also what sort ofsociety and profession we want to become.

It is therefore my view that a position which advocatesconsistency in therapy approach turns our back not onlyon our national heritage and character, but also on thetasks of national unity which lie ahead, and in which we asimportant members of the health sector should play asignificant role. These tasks include:• helping to address the diverse problems identified in

Australian government national health priority areas:cancer control, mental health, injury prevention and


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control, cardiovascular health, diabetes mellitus, andasthma (Australian Federal Government, 2001);

• working towards meaningful reconciliation withindigenous peoples particularly in areas of health(NSW Department of Health, 2000) and in the emerg-ing field of occupational justice (Townsend & Wilcock,2001);

• working with our land in sustainable ways that enhancethe belonging that each of us feel towards this place(Read, 2000);

• valuing and helping through occupation those in ourcountry who feel the disaffection and misery of poverty,isolation, and unemployment;

• helping to renew and reverse the degradation of smallrural towns, suburbs on the urban fringe and other com-munities through use of occupation as a means to com-munity inclusion, social participation and individualdignity;

• exposing the neglect of occupational needs and rightsof young people in our society; and

• assisting those adults whose skills and backgroundsmake them outsiders in the knowledge and serviceeconomies (Rosen, 1998), through a critical look at therequirements, values and meaning of certain types ofoccupations in our society.

Gett ing pract ical

How then can we practically support ‘diversity’ in practiceapproach, and in so doing the unity of our Australianprofession? We clearly need more research to inform ourdecisions on this. We need to know more about the diversitywe have, and the hopes of our profession for unity in thefuture. We need to know how diversity can best be sup-ported, if indeed it proves to be the right thing to do. Inthe interim, I have come up with a few tentative suggestionsabout how diversity as a national position might practic-ally become real.1. Development of a national OT AUSTRALIA posi-

tion statement on acceptance and promotion ofdiversity in practice approaches (these being publishedoccupational therapy approaches, developed by andfor occupational therapists);

2. Development of practical OT AUSTRALIA strategiesfor information and communication relating to practiceapproaches (for example, provision of web links toindependent sites which advocate certain approaches);

3. Targeted use of the ‘AccOT’ Accredited OccupationalTherapist Programme (OT AUSTRALIA, 2001) forcontinuing professional development;

4. Conduct of education programme accreditationreviews which ensure that a broad overview of prac-tice approaches is made, even within curricula whichuse a single approach as a curriculum framework;

5. Development of guidelines for OT AUSTRALIAprogramme and project group membership which requiredeclarations of practice approach preference; and

6. Increased consultation and debate in departments andbusiness about practice approaches that could andshould be used: no more imposition of models byproclamation of the manager or area senior.We need to be confident that the issue of a national

position on core concepts and processes is one worthpursuing. I have argued it is, and that this is the right timeto do it, as we move from a focus on accreditation to onethat will inevitably involve notions of EBP. I have suggestedthat we already have a clear national position on core con-cepts and processes which can guide us in the evidence-related activities we are about to embark on. I haveproposed that this position is one that is sympathetic to ournational qualities and priorities. It is

finding unity in diversity

.This provides a base from which the profession can moveinto the future

using

evidence to support our position,rather than seeing what happens as we go along. If it is theright position, it will guide us to make the right decisions,about the right way to provide the right type of support toour therapists so that they exercise their right to makechoices about the occupational therapy practice approachthat is right for each of them and their communities.

CONCLUSION

I started this lecture saying I was going to talk aboutaspects of evidence in Australian occupational therapypractice. I described EBP as it is now, and identified thatEBP in occupational therapy should start with the rightquestions. For these questions, I argued we need the

right

words

that communicate what it is we are interested in,and what it is we hope to be able to achieve. We also needto know what

type of knowledge

is required to answer eachquestion, how to best

use

different types of knowledge,and how knowledge types can influence the sort of ques-tions we ask. I suggested that to ask questions which are



115

meaningful and relevant to our profession and thecommunity in which we live, Australia, we need a positionon professional concepts and processes which reflect ournational heritage, national achievements and the challengeswhich face our society in the century ahead. I concludedthat we already have a national position on core conceptsand processes, and it is one that has been around for a longtime. This is

finding unity in diversity.

I outlined principleswhich underpin this position that are in keeping with ournational character and the heritage of our profession inthis country.

Occupational therapy in Australia is standing at athreshold of a new era. Evidence-based practice asks us toconsider current questions and look to the past — things thathave already been done — for the answers. This approachhelps us get things right. But we also need to keep an eyeon the future to get that right too. ‘We cannot simply driftinto a future worth having … the challenge is to activelydesign it’ (Slaughter, 2000). Today I have described EBP,and raised a number of issues that I hope will focus ourthoughts and actions on what is right for our professionand the people we serve now and in the future.

As we enter the new millennium, we can now answer1984 Sylvia Docker Lecturer Joanna Barker, who asked:‘Into the 21st Century: are we ready?’ (Barker, 1984; p. 98).I think we are, but we need to make explicit: evidence thatdemonstrates the value of what we do, principles thatindicate who we are, and ideas that influence what we willbecome. We will then be able to build upon the greatheritage of ‘occupational therapy and its place in Australia’shistory’ (Anderson & Bell, 1988), and move towards anunderstanding, based on evidence, of occupational therapyand its place in Australia’s future.

ACKNOWLEDGEMENTS

My sincere thanks to OT AUSTRALIA for the honour ofthis award, and to my colleagues Gwynnyth Llewellyn andRosalind Bye for their review of the emerging paper.

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Documents

OZ OT EBP 21C: Australian occupational therapy, evidence-based practice and the 21st century