9

Research and Evidence-Based Practice

Katrina Bannigan

INTRODUCTION

This chapter focuses on why research (see Glossary) is important to occupational therapists and why it is essential to the delivery of high-quality services. However, research alone is not sufficient to improve the quality of services (Grimshaw and Thomson 1998). Practitioners also need the skills to integrate research findings into practice. This chapter describes these skills.

Ultimately, the purpose of research is to advance knowledge (Wilson and Butterworth 2000). In the context of health and social care, research can be used to gain new knowledge about the most effective interventions to use in practice. ‘Research tells us what we should be doing. [Whereas] Clinical audit tells us whether we are doing what we should be doing and how well we are doing it’ (Health Quality Improvement Partnership 2009). Clinical audit is an important quality enhancement process but it is not research and will not be discussed further in this chapter (see Ch. 7 for more on clinical audit). For a detailed analysis of the differences between audit, service evaluation and research, see the work of the NRES Ethics Consultation E-Group (2007). Although research and evidence-based practice are generic skills, used by all practitioners in health and social care settings, this chapter focuses on the issues related to research and evidence-based practice in the field of mental health practice specifically.

The contested nature of evidence-based practice is discussed, because it has been a contentious topic within occupational therapy. The developments in, and challenges for, research and evidence-based practice in occupational therapy and mental health, are therefore considered in relation to this debate. An important development since the last edition of this book is the emphasis on service user and carer involvement in research, so this is also explored in this chapter.

WHY IS RESEARCH IMPORTANT?

Occupational therapists strive to do what is best for their service users but how do practitioners know the best, or most effective, intervention to use? Occupational therapists use different information sources, including anecdotal evidence and research findings to shape their thinking. For example, an occupational therapist may believe that using activities in group settings is an effective way of improving interpersonal skills because they have observed this in their practice, or they may have heard from other leading occupational therapists that group work helps to improve interpersonal skills (e.g. Breines 1995). However, if they were asked for evidence to support their assertion that the use of activities in group work was effective and they used anecdotal information to do so, their assertion would be challenged. The following arguments might be made, for example:

■ The occupational therapist was only seeing what they wanted to see

These challenges are legitimate because it is acknowledged that human beings are influenced by their assumptions, which biases the way they see the world (Patton 2002). One cannot be certain that an observation is accurate and not merely a reflection of personal bias (Patton 2002). This means that while clinical experience can be valuable in shaping practice, it has its limitations in decision-making about clinical effectiveness:

Furthermore, it makes no difference whether the observer is a renowned occupational therapist or a professional colleague; they are likely to carry around the same bias towards seeing the positive relationship between occupation and health. In order to mitigate bias and directly access the service user perspective, practitioners might employ patient satisfaction surveys. However, there are several reasons why these methods are also potentially problematic:

■ Respondents often comment on staff (such as individuals’ politeness and courtesy), rather than on services

■ Such surveys ‘require value judgements from patients about their care based on partial knowledge of their condition and maybe even less about how services are run’ (Modernization Agency 2003, p. 1).

It is because of these types of reliability and validity problems that the results of patient satisfaction surveys often lack credibility.

Questions of Effectiveness

Questions of effectiveness are concerned with researching cause and effect; such as asking whether activity-based group work (cause) led to an increase in interpersonal skills (effect). Randomized controlled trials have developed over time to enable researchers to answer questions about cause and effect and these are now generally used in health and social care settings to evaluate the effectiveness of interventions. Examples of randomized controlled trials conducted in occupational therapy and mental health, include Graff et al. (2006, 2007); Edgelow and Krupa (2011); Lambert et al. (2009).

There are three key features of a randomized controlled trial: a control group, random allocation and blinding. These techniques have been developed to ensure that, if the study has been well-conducted, its results reflect the effectiveness of the intervention and not another confounding factor, the bias of the observer or selection bias, or the play of chance.

The randomized controlled trial is not the only research method that has developed and evolved over time. Methods of ensuing rigour in qualitative research (understood as trustworthiness) have undergone a similar evolution. Qualitative research seeks to develop in-depth understanding of phenomena such as lived experience (phenomenology), or a person’s story or narrative about their own recovery journey, for example. Techniques have been developed in qualitative research, to maximize credibility, transferability, dependability and confirmability, to ensure that the findings of a qualitative study reflect the data collected and not the researcher’s bias (Polit and Hungler 1995).

Reflecting on the example of occupational therapists’ belief in the efficacy of activity-based group work, an overview of published research can be illuminating. A systematic review of activity-based groupwork aimed at helping people with severe and enduring mental health problems in community settings, improve their functional ability and/or reduce their mental health symptoms identified 136 papers (Bullock and Bannigan 2011). Of these, only three papers were relevant and met the inclusion criteria (see Bullock and Bannigan 2011 for more details on the method). Unfortunately, heterogeneity and flaws in quality in the three studies meant it was not possible to make specific inferences for practice from the studies. This means that, at the time this systematic review was published, occupational therapists only had anecdotal information to support their practice in relation to activity-based group work. Although it may have been supported by considerable theory (e.g. Cole 2005), there was no rigorous research to support the assertions that underpin this practice. This is important because activity-based group work is widely used by occupational therapists in mental health settings. The difference between evidence and information, in the context of evidence-based practice, is summarized in Table 9-1.

THE DIFFERENCE BETWEEN RESEARCH AND EVERYDAY LIFE

The discussion in this chapter so far highlights the difference between knowledge generated by research and that derived from everyday life (Abbott and Sapsford 1992). In everyday life, we are free to observe and draw conclusions at will but we know that we often ‘see what we want to see’. Research is more systematic than everyday life, drawing on a body of technical expertise or research methodology to ensure conclusions flow logically and cogently from the data and are open to public scrutiny. In this sense, research enables health and social care professionals to be accountable (Kumar 2011). Having a clear audit trail enables a transparency in decision-making that is not present in the use of customary assumption, intuition or tacit knowledge.

As well as having a sound methodological basis and being systematic in its approach, research also requires a certain attitude; a vigilance regarding gaps in arguments and/or weaknesses in the procedures used. Researchers and consumers of research always need to look for possible alternative explanations for the results or findings of a study; asking, for example, if there are any errors in the method. Researchers need to ask themselves ‘Are there any other competing explanations for what they have observed?’ When reading research occupational therapists need to ask, ‘Is there anything else that could explain what the researchers found?’ A questioning approach not only requires imagination, therefore, but a willingness to be open to other possibilities explaining the results or findings of a study. This means occupational therapists need to think carefully about the research findings they read and be open to the possibility that research may not demonstrate positive outcomes from occupational therapy.

In short, research methods allow us to collect data to generate new knowledge using methods and procedures which ensure the information is valid or trustworthy, and not biased by the researcher. This provides occupational therapists with a way of learning from their experiences which allows them to not be misled by their intuition or biased observations. This was partly the impetus for evidence-based practice. Practitioners in health and social care could no longer rely solely on their intuition or anecdote as sources of knowledge (Doust and Del Mar 2004). They had to start using rigorous, well-conducted research to underpin their clinical reasoning. Much of the new knowledge occupational therapists need in order to work competently post-qualification is gained through research. This is why occupational therapists need to be ‘research aware’ (see also Ch. 7, where continuing professional development is discussed in more detail in relation to professional accountability).

THEORY AND RESEARCH

Research questions are usually deemed to be important if they have cost implications, and/or involve high numbers of service users, and/or are concerned with increased morbidity and risk of mortality. In some instances, the priorities of service users are used to shape the questions that researchers are funded to research (see Keating et al. 2006; Wright et al. 2007; and http://www.twocanassociates.co.uk/routemap/setting- research-priorities.php). Although practice shapes research questions, the design and approach to data collection is rooted in theory (except in the case of grounded theory, which is used to generate theory).

Theory is needed to operationalize a research study. It is used to define the concepts within the study, understand how they relate to each other, and to understand how best to address the research question. Box 9-1 shows how such operationalization fits into the research process. An example of how operationalization allows for the exploration of underpinning theory is provided in the systematic review of activity-based group work described earlier. In this review, Bullock and Bannigan (2011, p. 257) state:

In this statement, the researchers are clearly explaining how the concept ‘activity’ is understood within their study and how they understand activity is used within group work. Both definitions are supported by references to the literature, drawing on the work of well-known theorists whose work is widely accepted within the profession. Bullock and Bannigan (2011) do not suggest that the definitions are contentious or that there are a number of different ways of defining the terms, which suggests these are fairly standard definitions.

Another example of how theory informs research is Creek’s (2003a) exposition on occupational therapy as a complex intervention. The Medical Research Council (2000) described a number of steps involved in evaluating a complex intervention. The first step is ‘to explore relevant theory to ensure the best choice of intervention’ (Medical Research Council 2000, p. 3) and the second is to ‘identify the components of the intervention and the underlying mechanisms by which they will influence outcomes’ (p. 3). Creek’s (2003a) definition of occupational therapy as a complex intervention provides researchers with a coherently structured description of the components of occupational therapy and how they relate to each other, so that researchers can evaluate the intervention consistently in different studies.

SERVICE USER AND CARER INVOLVEMENT IN RESEARCH

The inclusion of service user commentaries in the fourth edition of this book is indicative of the growth of the service user movement generally and the mental health service user movement in particular. The service user commentary on the research chapter in the previous edition (Ilott 2008) highlighted the following issues:

■ The use of language associated with research and evidence-based practice tends to exclude service users

The Practicalities of Involving Service Users and Carers in Research

There is an expectation that service users and carers will be involved in all kinds of research, including mental health research. The mental health research network in the UK has, as one of its priorities, to give people with experience of mental health problems and their families the opportunity to get involved in studies (Mental Health Research Network 2010).

This is not a purely altruistic gesture because involving service users and carers in research, if done well, improves the quality of research (RCN 2007) (see Box 9-2). The qualification ‘if done well’ is important here because there is a danger of tokenism; whereby the appearance of service user inclusion is created but without an authentic service user voice being heard. Avoiding tokenism requires researchers not only to think, but also to behave, differently. This may include, for example:

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Approaches to Practice Working on the Margins: Occupational Therapy and Social Inclusion Community Practice Life Skills Professional Accountability Play

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