Client-Centred Care & Ethical Dilemmas

Client-Centred Care & Ethical Dilemmas

Client-centred care (or patient-centred care or patient preference) is one of the core philosophies underpinning Occupational Therapy.  In any modern healthcare practice, it also forms part of the Evidence Based Practice (EBP) equation:

Research + Clinician Expertise + Patient Preference = EBP

How much weight each part of the formula should contribute to the overall treatment ‘answer’ is not clear cut, and when an extreme weighting from one or another element is proposed, it causes ethical dilemmas. Ethical dilemmas cannot be solved alone, but through collaboration with colleagues and professional body standards (such as the RCOT).

otter law

I find myself almost never listening to Radio 1 anymore instead tuning in to BBC 6, BBC 2 and even 4… is this a reflection of becoming more interesting or more boring? Or that I need talk radio to keep me awake on the more frequent long car journeys I seem to do now? Either way, in the BBC 4 programme ‘Inside the Ethics Committee’ one episode discusses a woman who wants her leg amputated in order to forego any further knee surgeries. Read more

Menu: Conducting a literature review

Menu: Conducting a literature review

Clicking on the category to the right ‘How to conduct a literature review’ does bring up all blog posts related to doing a lit review, but there were getting to be too many to keep track of the order.Otter menu

So this is just a menu of all the blog posts related to writing a literature review, and also EBP in general, so they are in some kind of order and all in one place.


What is Evidence Based Practice? Why does it matter in everyday life?

Barriers to Evidence Based Practice

Article review: “Evidence-based medicine: a movement in crisis?” by Greenhalgh et al (2014)

Conducting a literature review:

Conducting a literature review: Where do I look for evidence to use in my Evidence Based Practice?

Conducting a literature review: creating a good question

Conducting a literature review: How to accurately evaluate any evidence before basing your practice on it

Conducting a literature review: evaluating the quality of research methods used in an article “Comparison of a traditional and non-traditional residential care facility for persons living with dementia and the impact of the environment on occupational engagement” by Richards et al. (2015)

Protected: All aboot Statistics

Conducting a literature review: Quality reviewing a research article “Strategies used by older women with intellectual disability to create and maintain their social networks: An exploratory qualitative study” by Mackenzie & White (2015)



What does Evidence Based Practice mean to me now that I have studied it at MSc level?

What does Evidence Based Practice mean to me now that I have studied it at MSc level?

Since starting the research module on my course, I have gained an understanding of the need to be critical of the evidence itself!  And also how complicated the process of creating bias-free valid evidence is, and how many opportunities for bias there are in each study.

umm not sure otter

I have gained lots of skills around the methods for gathering and analysing data. I feel that I already had a fairly questioning thought process as default, but now I am able to articulate more clearly why something is biassed or can only be trusted so far.

I never thought I would have a blog or enjoy blogging as much as I do, so I am really grateful that I was forced to start as a result of my course.  Although it is nice to see other people reading the blog it is mainly an ‘online study notes’ tool that I use; it enables me to quickly search for topics, search for module content by date, and reminds me to cover all aspects of a topic, such as the need to create a blog entry for each OT model. It is proving to be a real motivating factor (organising my thoughts, finding an otter picture that represents the topic, seeing a pretty blog page at the end) and helps make what I have typed more memorable- as well easier to link ideas together. This is probably helped by needing to categorise and tag the blogs each time; by grouping ideas from different modules or timescales together it make it easier to see how they might all connect. I suppose I probably have more technical social media knowledge now as a result, although I don’t think I was terrible to begin.

Already both when reading articles and overall in life I find myself dialoguing with myself in my head about the possible devil’s advocate outcomes of an article or a situation. I guess this could be the start of reflection-in-action!


Article review: “Evidence-based medicine: a movement in crisis?” by Greenhalgh et al (2014)

Article review: “Evidence-based medicine: a movement in crisis?” by Greenhalgh et al (2014)

If you need reminding what Evidence Based Practice (EBP) is, check here.

Not sure what Trish was up to but this article is printed in really small font and I had to zoom to 170% in order to be able to read it.


Zoom activated, I could now tell the article discusses some limitations of EBP, and the authors argue that although EBP has many benefits it has created some unintended negatives as well, which they describe as:

Drug companies controlling the research agenda, meaning evidence base is biassed according to their vested interests. Examples include fiddling inclusion criteria to make it likely people who will create desired results will participate, and only publishing positive results.

Volume of evidence has become unmanageable. We’ve all done a CINAHL search and returned 1,062 results. You don’t see how you can narrow your search terms anymore and you certainly can’t read all the abstracts…

Benefits identified as statistically significant may actually provide negligible  difference to patients in real life situations. Especially when research is carried out poorly, eg small sample size or drug company fiddling as mentioned above, the efficacy of treatment is falsely inflated for what it would actually be on a real population.

Inflexible rules risk healthcare becoming management-driven (following technical instruction) rather than client-centred (using clinical expertise). Eg creating protocols or checklists from EBP and then only following these in patient care. Like the QOF, where GPs get money for achieving health targets- Greenhalgh suggests that patients are monitored and provided check-box medication if they meet the QOF criteria, without consultation about their individual circumstances (client-centred care). This is a point Cohen & Hersh (2004)  agree with. O’Halloran et al (2010) follow on by saying that the technical guidelines produced by EBP stifle creativity.

Evidence available for individual conditions and not for co-morbidity, making it difficult to find evidence for patients with multiple diagnoses.  An aging population plus better management of chronic disease means more people have multiple conditions, which research studies don’t cover, removing individualised patient care.


Greenhalgh et al (2014) suggest overcoming these negatives by providing individualised care taking the context and even professional creativity into account. Patient advocacy groups should dictate areas of research more than companies. Peer-reviewed publishers should up their standards for article inclusion, and information should be disseminated in more user-friendly ways/methods (like infographics/via YouTube).


Note: apparently comorbidity is more than one illness in a person, and multimorbidity is more than two illnesses in the same person.



Cohen AM and Hersh WR (2004) Criticisms of Evidence–Based Medicine. Evidence-based Cardiovascular Medicine 8(3): 197–198.
Greenhalgh T, Howick J, Maskrey N and for the Evidence Based Medicine Renaissance Group (2014) Evidence based medicine: a movement in crisis? BMJ 348(jun13 4): g3725–g3725. Available at: [Accessed on 03.05.2017]
O’Halloran P, Porter S and Blackwood B (2010) Evidence based practice and its critics: what is a nurse manager to do? Journal of Nursing Management 18(1): 90–95.
Conducting a literature review: Critical appraisal of a piece of non-research evidence (a website)

Conducting a literature review: Critical appraisal of a piece of non-research evidence (a website)

I have reviewed a piece of non-research evidence, in the form of a website

otter website

According to Sackett et al’s (1997) hierarchy of evidence, grey literature such as this is shouldn’t usually be the first source you turn to for evidence since there are other sources which are more reliable, for example because they have been peer-reviewed. However sometimes there may be an absence of quality sources or you are trying to gain an understanding of public opinion on a topic.

To help me assess the website I am going to use Aveyard et al’s (2001) ‘six questions to trigger critical thinking’, which are:

  1. Where does this information come from?
  2. What is being said?
  3. How did they write this?
  4. Who is telling me this?
  5. When was this written?
  6. Why has this been written?

Where does this information come from? I found this by searching for “guidelines stroke recovery eating” using the search engine DuckDuckGo to avoid any tracking cookies from Google biasing the results according to my previous search history. Read more

Conducting a literature review: How to accurately evaluate any evidence before basing your practice on it

Conducting a literature review: How to accurately evaluate any evidence before basing your practice on it

I can’t use any old piece of evidence which has an abstract and a few relevant keywords to base my clinical actions on.

wtf otter

It could be biased (such as being funded by someone with an interest in the study’s outcome), not statistically significant, methodically flawed or irrelevant to the precise patient problem I am investigating. I could be challenged by a well-informed ‘expert patient’ who has free and easy access to information themselves via the internet, so I need to make sure I can back my decisions up.

Instead I’ll need to identify the patient’s problem, find relevant studies, critically evaluate them, and then apply them to the problem taking into account the patient’s individual needs.

Research + Clinical Expertise + Patient Preference = EBP

The process of EBP has five steps, although Melnyk (2010) later added two additional ones shown in italics below. It should also be noted that sometimes ‘Health Service Restrictions’ are included in the above formula (DiCenso et al 1998), meaning that limitations due to resource cost/access are taken into account as part of pragmatic reasoning.

0. CULTIVATE SPIRIT OF INQUIRY   essential starting point

1. ASK   questions that are answerable!

2. ACQUIRE   search for the best evidence from the research available

3. APPRAISE   critically appraise/evaluate the evidence – is it relevant, valid, reliable, applicable to you clinical question?

4. APPLY   integrate the evidence with clinical expertise and patient’s preferences and values, and then implement it

5. ASSESS   evaluate and reflect on the outcomes of your decision

6. DISSEMINATE EBP RESULTS  share good practice and support other healthcare professionals Read more