Being and Becoming an Evidence-Based Practitioner: Occupational Therapists’ Journey Toward Expertise

Study Purpose

The aim of this study was to describe how expert evidence-based occupational therapists conceptualize and enact their expertise in stroke rehabilitation, a context that is ideal for studying EBP expertise; occupational therapists are key members of interprofessional teams and play a vital role in optimizing stroke rehabilitation outcomes (Mountain et al., 2020; Teasell et al., 2020). Moreover, a substantive body of evidence is available to guide occupational therapists’ clinical practice (https://strokengine.ca/en/; http://www.ebrsr.com).

Study Design

We used qualitative interpretive description (ID), a method that relies on an inductive analytic approach to create ways of understanding phenomena that yield applications and implications in practice. ID seeks to generate new knowledge that can then be applied in clinical practice to help orient clinical decision-making (Thorne et al., 1997). The authors of the ID method suggest that any researcher interested in phenomena that have clinical applications can and should “use methods that are grounded in our epistemological foundations, adhere to systematic reasoning of our discipline and yield legitimate knowledge for our practice” (Thorne et al., 1997, p. 172). Therefore, this approach is well suited for capturing and describing the experiences and perceptions of expert clinicians regarding EBP in stroke rehabilitation.

Participants

We recruited participants from a larger sample of occupational therapists working in stroke rehabilitation, who were identified through a process of peer nomination as described in Hallé et al.’s (2018) study. In that study, the authors aimed to identify the attributes of evidence-based occupational therapy stroke rehabilitation experts from the perspective of their peers. Forty-six occupational therapy clinicians and managers, who were members of the Canadian Association of Occupational Therapists and worked with a population of clients with neurological conditions across Canada, were asked to complete an online peer nomination questionnaire. This questionnaire asked respondents to nominate “outstanding” and “expert evidence-based” occupational therapists in stroke rehabilitation and explain their choices. A total of 216 nominations (123 for outstanding clinician and 93 for expert evidence-based clinician) were received, 111 of which were unique nominees.

Recruitment

Contact information was sought for the 111 uniquely nominated clinicians in Hallé et al.’s (2018) study. We searched Google for missing information, and the nominators were emailed and asked whether they had the nominees’ contact information. Of the 111 uniquely nominated clinicians, we had contact information for 93. An electronic invitation was sent to nominees with a retrievable email address, and a paper invitation was sent to those with a retrievable work address. Interested participants were asked to contact the research team via email.

Data Collection

The nominated expert evidence-based occupational therapists (n = 93) identified in the 2018 study were invited to participate in a semistructured interview consisting of questions that addressed topics such as how they developed their expertise in EBP, when and how they use the EBP process, how EBP supports their clinical decision-making process, how they use EBP in their day-to-day practice, how they adapt evidence-based knowledge to a given context, and how the available evidence influences their decision-making process. Participants were also asked to complete a sociodemographic questionnaire (e.g., year of graduation, entry-level qualifications, area of practice). Of the 93 nominated expert evidence-based occupational therapists in stroke rehabilitation who received an invitation to participate, 8 volunteered to take part in the study.

The institutional review board of the Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal granted ethical approval for this study. All participants provided informed consent before all interviews.

Data Analysis

Interviews were audio recorded and transcribed verbatim. We performed an inductive thematic content analysis informed by principles of the constant comparative method, which seeks to discern conceptual similarities, refine the discriminative power of categories, and discover patterns (Glaser, 1992; Strauss & Corbin, 1998). Techniques included memo writing, close reading and rereading, coding, data matrices, and diagrams to support data analysis. Reflective memos were used from the outset to outline our assumptions and the impact of these on data collection and analysis. An audit trail consisting of extensive note-taking during data collection and regular meetings in which team members engaged in a reflective exercise on data collection were used to optimize the trustworthiness of the data (Boyatzis, 1998; Creswell, 2012). Subsequent team discussions were held until a consensus regarding the accuracy of coding was reached. Given the relatively small sample size, we were cognizant of the fact that we needed to exercise reflexivity within our expert team of researchers and occupational therapists to ensure we could generate a rich description of the phenomenon with these interviews. There were no new insights gained from the data with the eight interviews.

Description of the Nominated Experts

Respondents’ demographic characteristics are summarized in Table 1. Their age ranged from 38 to 57 yr, and they had graduated from an occupational therapy program between 1978 and 2004.

Analysis of the interview data resulted in six overarching themes, each one with embedded subthemes: (1) relying on personal attributes to engage in practice improvement, (2) acting on factors that motivate and trigger EBP, (3) achieving better outcomes because of engagement in EBP, (4) using an adaptive decision-making process, (5) participating in professional activities that contribute to practice improvement, and (6) working in a practice area with a large body of evidence. Corresponding participant quotes for the themes and subthemes can be found in Table 2.

Who They Are

That expert evidence-based practitioners exemplify personal qualities such as altruism and humility is not at all surprising. Some of these attributes are like those of reflective practitioners; as Epstein et al. (2008) described, they include curiosity, adopting a nonjudgmental stance, acting with awareness (which they described as being akin to being on autopilot), openness to multiple possibilities, adopting more than one perspective, and having the ability to describe one’s inner experience. Indeed, studies of experts have shown that expertise is characterized in part by numerous interpersonal qualities that result in experts garnering trust and collegiality from peers (Alexander, 1997, 2003). These attributes, however, go beyond amicability. For example, our findings in this study highlight that experts are also passionate about their work; driven to surpass themselves as clinicians; and that, in general, they have a positive disposition.

Research has suggested that adaptive expert practice is characterized by what Schwartz et al. (2005) called “habits of inquiry,” such as flexibility; continuous learning; and seeking out challenges, which underpin the ability to innovate when required. It is important to note that these habits of inquiry are considered a skill set that can be taught and learned through specific types of experiences. What type of learning experiences might have helped support the development of these habits of inquiry in our participants, or whether these had always been present (i.e., intrinsic) and refined further in their practice, or developed over time, is unclear. If these experiences are developmental, it does beg one important question: Are some people more likely to become experts because, at the outset, they embody these qualities? If so, then would only a subset of people ever reach a level of expertise in EBP? Although these characteristics seem key to what it means to be an expert evidence-based practitioner, according to peers’ perspectives (Hallé et al., 2018), and as reported in the expertise literature (Ackerman, 2003; Alexander, 1997), they are seldom discussed in studies of EBP in this profession. Most studies of EBP in rehabilitation focus on attributes such as knowledge of, confidence in, skills in, and attitudes (including openness) toward EBP, but very few have explored the role that these interpersonal features may play in supporting the development and refinement of EBP expertise. Vachon et al. (2010), however, described how deliberateness, client-centeredness, and system-mindedness were developed by occupational therapists learning to use reflective practice in pursuit of becoming an evidence-based practitioner. This was related to the efforts they made to understand their clients’ complex problems using different perspectives and to the value they placed on helping their clients to the best of their ability. According to Epstein et al. (2008), people can develop such personal attributes by exercising the metacognitive functions necessary to engage in self-monitoring and reflective practice.

Why They Do What They Do

Expert evidence-based practitioners are deeply motivated to do good. We noted both intrinsic motivators, such as having a goal orientation toward learning and respecting high ethical standards (e.g., quality of care, altruism), and some external motivators, such as openness to various sources of evidence and feedback from students that contributes to their learning. Our data suggest that the drive for EBP is due to practitioners’ deeply held belief that they must provide the best possible care for their clients. EBP becomes the vehicle for achieving this goal. Moreover, it appears that EBP is used to uphold an ethical responsibility to do good not only as a health care professional, but also, more specifically, as a member of the occupational therapy community (CAOT, 2012).

Our experts described triggering moments that served as drivers for EBP; these were key instances when they experienced uncertainty or discomfort in how they were providing care, moments of dissonance between what needed to be done and what was being done. The recognition of a gap in knowledge or skills prompted them to engage the EBP process in a more formalized manner. This finding is consistent with the general expertise literature (Feltovich et al., 1997), which describes experts as seeking to acquire knowledge that they may be missing when faced with a complex problem derived from practice; this is both an inherent feature of many health care environments and consistent with the literature on adaptive expertise specifically, in that our experts were seeing the problem to be solved as an opportunity to do so something different and were willing to innovate (Feltovich et al., 1997).

Students were described as major sources of motivation. This is consistent with previous work (Rappolt, 2003; Thomas et al., 2017) showing that students’ close exposure to and knowledge of the latest scientific evidence encourages preceptors to stay up to date and to model best practices. Preceptorship may indeed be one important mechanism for supporting clinicians in refining their EBP competencies (Hallé et al., 2021; Rochette et al., 2020).

The expertise literature also provides robust insights into how experts engage in deliberate practice to solve problems and to innovate (Carbonell et al., 2014) because they are fundamentally motivated to enhance their performance and recognize that intentional efforts, accompanied by tailored feedback, are needed to do this. Although our data do not explicitly illuminate this notion of deliberate practice, they do suggest that experts are driven and highly motivated to provide the best possible care, which is why they adopt EBP; EBP is the process that allows them to, in their way, improve their performance.

What They Get Out of It

Our findings on the consequences and positive outcomes of EBP reveal features of EBP that have infrequently appeared in the rehabilitation literature. It is likely an uncontestable fact that most clinicians aspire to achieve positive client outcomes. However, in this study, and likely inextricably linked to the motivating factors discussed earlier, we noted a strong belief in the “products” of EBP. By using EBP, clinicians garner credibility and trust from clients; they become better at understanding and solving their clients’ complex problems through shared clinical decision-making and can better innovate in practice. This often results in positive feedback from clients and colleagues, which then further motivates them and appears to lead to what has been referred to as the virtuous circle (Brockopp et al., 2013; Levin et al., 2011).

Of importance is that the occupational therapy profession has wrestled with notions of credibility and legitimacy. Often viewed as being under the thumb of the biomedical model, the profession has been at the end of a frequently swinging pendulum (Weinstock-Zlotnick & Hinojosa, 2004). Although a discussion of the evolution of occupational therapy as a legitimate profession is beyond the scope of this article, embracing and advancing EBP as a means to legitimize this profession is a more recent conversation in the literature (Hallé et al., 2018; Thomas et al., 2017). We see three reasons for why EBP may have been slower to enter into the narratives of many occupational therapists as something that can be used to legitimize the profession: (1) the scientific evidence base in occupational therapy is far more recent than in other health professions, such as medicine or nursing; (2) EBP has only recently been introduced as a core professional competency in professional educational programs (CAOT, 2012; Thomas et al., 2021); and (3) occupational therapists have long advocated for various sources of knowledge (other than those derived from empirical studies) as having a unique role in clinical decision-making (Hammell, 2001; Law et al., 1995). Our data suggest that experts have bought into the notion that an EBP approach will legitimize what they do and help them build strong and trusting relationships with clients.

How Evidence-Based Practice Is Enacted and Facilitated

The data on the enactment of EBP reveal a portrait of actions regarding experts’ decision-making processes; their continuous engagement in activities that both inform EBP and further cultivate their expertise; and the factors in their workplace that support or inhibit EBP, which they endeavor to overcome. Experts are noticeably committed to staying up to date with the scientific evidence in their area of practice. Becoming an expert requires deliberate actions that span teaching, involvement in committee work, and research. It is not surprising that to maintain a level of expertise that requires well-consolidated complex knowledge and advanced practice skills (Carbonell et al., 2014), clinicians need to remain up to date. Other studies of EBP in the rehabilitation professions illustrate that, without some form of continuous learning and reflection on one’s practice, and support from the organization (Thomas et al., 2021; Thomas & Law, 2013), clinicians are challenged to successfully enact EBP (Krueger et al., 2020).

Despite the challenges associated with EBP (e.g., resource constraints, difficulties in translating the evidence in a way that is relevant to clinicians), our experts found ways to overcome these barriers. They engaged in research, participated in national committees on stroke best practices, and took courses. Although how they managed to overcome these barriers is unclear, we wonder whether the attributes they embody help mitigate these challenges, making them more likely to find creative solutions and persevere in the face of adversity (Barnett & Koslowski, 2002; Varpio et al., 2009).

In articulating their evidence-based decision-making processes, our experts revealed that decision-making is largely rooted in, and informed by, questioning, self-awareness, and reflection. They were acutely aware of their knowledge gaps and constantly questioned their actions. It is this constant questioning of their practice, which relies heavily on their extensive experience in stroke rehabilitation, that helped them make sense of complex client cases to which the evidence may not apply fully. These findings mirror the high degree of self-awareness and insight into one’s practice that has been discussed in the expertise literature (Carbonell et al., 2014).

Expert evidence-based practitioners are constantly looking to innovate, keep learning, and seek out challenges (Mylopoulos & Woods, 2009). They mobilize vast amounts of knowledge when dealing with new challenges, and they display self-regulation (i.e., they monitor their levels of knowledge and understanding of a problem, determine when these are not adequate for the problem they are attempting to solve, and take steps to address the gap; Wineburg, 1998). These may be the processes that guide decision-making in these complex contexts.

As suggested by scholars in the profession (Hallé et al., 2018; Thomas et al., 2017; Townsend & Polatajko, 2007; Wilcock, 2006), evidence does not operate in a vacuum. Our participants were clear that decision-making is a complex act that requires critical thinking to evaluate the relevance of the evidence. This is yet another feature of adaptive experts: They carefully balance the relevance and usefulness of different sources of knowledge and can discern what is best in a given situation. Woven through this process, and consistent with the profession’s core philosophical tenets of client-centered practice (Law et al., 1995; Sumsion & Law, 2006), is the vital role that clients play in their care. This study highlights that any act of decision-making in this profession, whether in the context of EBP or not, is inextricably tied to the client.

Where the Expertise Develops: The Saliency of Context

Our experts were likely working in organizations that have embraced EBP; when managers witness the benefits of EBP for client care they may be more inclined to support clinicians in activities that further develop their EBP competencies. Moreover, it appears that the stroke rehabilitation context is ripe with opportunities to develop expertise in EBP. There may be two reasons why this may be the case. First, the availability of robust and prepackaged evidence is known to facilitate clinicians’ application of EBP (Yamada et al., 2015). Unlike other areas of occupational therapy practice where there is little or conflicting evidence, stroke rehabilitation has a wealth of evidence to support clinicians in their assessment and treatment of stroke survivors. Websites such as Stroke Engine (https://www.strokengine.ca) and Evidence-Based Review of Stroke Rehabilitation (https://www.ebrsr.com), are premier sources of evidence that are accessible to practitioners, clients, and families. This rich evidence is used to enhance experts’ knowledge, helps them remain up to date, and cultivates their reflection on how and when this evidence can be used. The second reason pertains to the multiple interconnected and complex elements of the poststroke condition (Hostettler, 2021; Mayo et al., 2002; Rochette et al., 2007a, 2007b). Occupational therapists working with this population must use a biopsychosocial approach to address the global effects of stroke. Our experts indicated that the many intricate features of stroke and its impacts provide them with an opportunity to gain more advanced knowledge and monitor their knowledge to ensure they remain at the forefront of EBPs. It appears that context (because of the domain dependency of expertise, which is accumulated over time) plays a role in how one develops and further hones their expertise.

Our findings on the importance of the practice context in the development of adaptive expertise mirror those from the expertise literature; indeed, these rich contexts afford clinicians with an opportunity to acquire experience and repeated exposure to similar problems. However, that can also lead to developing only efficiency. Problem solving must be (at least sometimes) an opportunity to learn. As Hatano and Inagaki (1986) pointed out, “People have many pockets of routine expertise where they are highly efficient without a deep understanding of why” (p. 33). A context that demands that one develop that understanding to innovate solutions is core to the ongoing performance of adaptive expertise, that is, context that provides variability and space to take risks and values long-term learning over short-term performance.