Annals of International Occupational Therapy

Original Research Supplemental Data

Building Consensus for Evidence-Based Practice Competencies for Occupational Therapists in the United States

Christine T. Myers, PhD, OTR/L; Samantha DeMaria; Jamie L. Pomeranz, PhD, CRC, CLCP

Abstract

Objective:

The field of occupational therapy needs a systematic approach to integrating evidence-based practice with client care. The goal of this study was to reach consensus on an initial set of evidence-based practice competencies for occupational therapists.

Methods:

A comprehensive review of the literature on evidence-based practice and evidence-based practice competencies led to a list of competency statements. According to the modified Delphi method, an expert panel evaluated the statements and rated their importance over two rounds of review.

Results:

A total of 77 competencies were identified from the literature. Participants (n = 17) reached consensus on 28 competencies in round 1 and 27 competencies in round 2. The final set of 56 competencies included seven domains.

Conclusion:

Future research should study the usability and feasibility of competencies as a tool for occupational therapists and employers as well as their applicability for other countries. After validation, these evidence-based practice competencies may assist occupational therapy practitioners and employers with professional development and training. [Annals of International Occupational Therapy. 2020; 3(1):14–20.]

Abstract

Objective:

The field of occupational therapy needs a systematic approach to integrating evidence-based practice with client care. The goal of this study was to reach consensus on an initial set of evidence-based practice competencies for occupational therapists.

Methods:

A comprehensive review of the literature on evidence-based practice and evidence-based practice competencies led to a list of competency statements. According to the modified Delphi method, an expert panel evaluated the statements and rated their importance over two rounds of review.

Results:

A total of 77 competencies were identified from the literature. Participants (n = 17) reached consensus on 28 competencies in round 1 and 27 competencies in round 2. The final set of 56 competencies included seven domains.

Conclusion:

Future research should study the usability and feasibility of competencies as a tool for occupational therapists and employers as well as their applicability for other countries. After validation, these evidence-based practice competencies may assist occupational therapy practitioners and employers with professional development and training. [Annals of International Occupational Therapy. 2020; 3(1):14–20.]

Evidence-based practice integrates research, client values, and practitioner expertise to provide optimal client care. Practitioners who use both internal evidence (i.e., client preferences, data from evaluations and interventions) and external evidence (i.e., evidence from research) to determine the best course of action will create the opportunity for the most positive outcomes for their client (Melnyk, Gallagher-Ford, Long, & Fineout-Overholt, 2014). However, the reported use of evidence-based practice by occupational therapists is low, with many practitioners reporting that they do not have the knowledge and skills needed to use evidence for making clinical decisions (Brown, Tseng, Casey, McDonald, & Lyons, 2010; Upton, Stephens, Williams, & Scurlock-Evans, 2014).

Occupational therapy training in the United States begins in a practitioner's entry-level educational program. Although students may have the opportunity to learn about evidence-based practice in the classroom, they cannot apply the information clinically until they enter supervised fieldwork. Findings from previous research on the use of evidence-based practice in occupational therapy suggest that its use is dependent on both practitioner and workplace factors (Cardin & Hudson, 2018; Wressle & Samuelsson, 2015). Several studies suggest that health professionals make limited use of databases and the Internet to access evidence or clinical guidelines (Bernhardsson, Johansson, Nilsen, Öberg, & Larsson, 2014; Duffy et al., 2015; Hoffman, Ireland, Hall-Mills, & Flynn, 2013; Keeley, Walker, Hankemeier, Martin, & Cappaert, 2016; Myers, 2019). Most health professionals report limited use of research articles and describe the most commonly reported sources of evidence as colleagues, conferences, and workshops (Cardin & Hudson, 2018; Keeley et al., 2016). Employer training and support are necessary to help practitioners to engage in evidence-based practice in the practice setting (Myers & Lotz, 2017).

Limited engagement in evidence-based practice may decrease the quality of occupational therapy services, resulting in reductions in reimbursement and an eventual decrease in the perceived need for occupational therapy in a value-based health care model (Leland, Crum, Phipps, Roberts, & Gage, 2015). Glasziou et al. (2017) described limited use of evidence-based interventions by clinicians as the “failure to deliver a health service that is highly likely to improve the quality or quantity of life, which is affordable, and that the patient would have wanted” (p. 169). The discrepancy between what is considered best practice and what clinicians actually do ultimately may result in more expensive, less effective treatment.

To address this discrepancy, practitioners and employers must take a systematic approach to integrating evidence-based practice into client care. A first step in this approach is determining an individual practitioner's understanding, use, and advancement of evidence-based practice in the workplace. The use of professional competencies is one way to identify integration of evidence-based practices within different settings. Professional competencies are broadly defined as the knowledge, skills, and attitudes necessary for successful performance in the workplace (Ash & Phillips, 2000).

Professional competencies are in place for intraprofessional collaboration, emerging practice, and vocational rehabilitation in occupational therapy (Buys, 2015; Diamant, Pitonyak, Corsilles-Sy, & James, 2018; Holmes & Scaffa, 2009). Although the American Occupational Therapy Association provides standards for continuing competence, the standards are general guidelines, not specific competencies for practice (American Occupational Therapy Association, 2015). Likewise, standards exist for entry-level occupational therapy programs in the United States, yet only a few relate specifically to evidence-based practice and they are not written as specific competencies (Accreditation Council for Occupational Therapy Education, 2018). The goal of this study was to reach consensus on an initial set of evidence-based practice competencies for occupational therapists. Clearly delineated competency statements will provide a foundation for assessing work-place needs for practitioner training and implementation within a variety of settings and practice areas.

Methods

The study was divided into two phases. In phase 1, the authors completed a comprehensive review of the literature on evidence-based practice and evidence-based practice competencies for health care professionals. The literature was reviewed for articles with competencies related to evidence-based practice in health professions. Two databases were searched, the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and PubMed, using the following terms: evidence-based practice, competenc*, occupational therapy, nursing, physical therapy, health, and medic*. The first two authors screened titles and reviewed abstracts to determine eligibility. They then extracted competencies from the eligible literature. Most articles listed the competencies. For articles that discussed the competencies in a narrative format, the following process was used to extract statements: (a) the second author reviewed the article and highlighted competency-related content; (b) the second author copied the highlighted content into a list of competencies; and (c) the first author reviewed the list, and if both authors agreed on the competency statement, it was included on the list sent out for review. Included competencies were categorized into groups from the five-step evidence-based practice framework: (a) asking questions, (b) acquiring the evidence, (c) appraising the evidence, (d) applying the evidence, and (e) analyzing and assessing the intervention or practice change (Dawes et al., 2005; Laibhen-Parkes, 2014; Tilson et al., 2011). The authors discussed each statement until they reached consensus. The authors then reviewed the occupational therapy literature on evidence-based practice to determine similarities between the categorized competencies from other professions and evidence-based practice recommendations for occupational therapy, determining that the competencies and recommendations were concordant. The authors then reviewed the statements for clarity and redundancy. Statements were modified for wording if needed or removed if the authors considered them redundant.

In phase 2, a two-round modified online Delphi method was implemented to reach consensus on an initial set of competencies (Figure 1). The Delphi method solicits and combines the opinions of a group of experts to achieve consensus on a specific topic (Hasson, Keeney, & McKenna, 2000; McMillan, King, & Tully, 2016). The Delphi method has been used in occupational therapy to gain consensus on a variety of competency-related topics, including preparation for community development and mental health practice and competencies for emerging practice (Holmes & Scaffa, 2009; Leclair, Ashcroft, Canning, & Lisowski, 2016; Scanlan et al., 2015). The study investigators used recommendations for conducting and reporting Delphi studies as a guide throughout this study (Jünger, Payne, Brine, Radbruch, & Brearley, 2017). The institutional review board at the University of Florida approved the study. Confidentiality of all participants was maintained throughout the Delphi process. Surveys were provided and data collected with Qualtrics online software.

Flow chart showing the stages of the modified Delphi process. OT = occupational therapy.

Figure 1.

Flow chart showing the stages of the modified Delphi process. OT = occupational therapy.

A purposive sampling approach was used to identify a panel of experts to take part in phase 2. The participants were occupational therapy practitioners, educators, and researchers who met the following criteria: a registered occupational therapist residing in the United States who was practicing clinically, working in higher education, or engaging in research, with previous participation in advanced training or education in evidence-based practice for occupational therapy. Recruitment occurred in two ways: (a) the National Board for Certification in Occupational Therapy sent a recruitment e-mail with study information to a random sample of 300 certified occupational therapists in their database, and (b) the first author engaged in purposive sampling by identifying prospective participants who met the inclusion criteria through reviews of online biographies and curriculum vitae and sending qualifying individuals a recruitment e-mail. Prospective participants who responded to the recruitment e-mail were sent a link to the online informed consent form and a survey screening tool. The tool included items to obtain more information about geographic location, practice area, employment setting, highest degree earned, certifications and credentials, years of occupational therapy practice, and training or education in evidence-based practice. Although there is no generally accepted minimum number of participants for a Delphi study, a modest range of 10 to 18 experts has been suggested (Okoli & Pawlowski, 2004). In this study, 17 experts participated.

The Delphi method was modified with the use of online surveys. Use of the modified Delphi method allowed for participation of a group of experts who were not limited by geographic location and increased the efficiency of the distribution and redistribution of the surveys across rounds (Yousef, 2007). The survey was piloted with an occupational therapist who had training in evidence-based practice and provided editorial suggestions. Because of the comprehensive literature review and collection of evidence-based practice competencies across several health care professions, an initial round for determining competencies was deemed unnecessary. The decision to use two rounds of online surveys to collect data on the competency statements was made before the start of the study. Participants were sent a reminder e-mail 2 weeks after the initial invitation was sent to encourage them to participate in each of the rounds. All participants were given a total of 4 weeks to complete each round of the survey.

Participants were sent an invitation e-mail for the first round of review with a personalized link to the survey to allow for authentication and tracking of participants across the two rounds. The survey included instructions and the competency statements. Participants were instructed to indicate the relative importance of the competencies for occupational therapists at all skill levels using a 5-point Likert scale (1 = not at all important, 2 = slightly important, 3 = moderately important, 4 = very important, 5 = extremely important). Text boxes were provided at the end of each statement to allow for comments, revisions, and suggestions for new competencies.

The authors analyzed the data with IBM SPSS Statistics, version 25. The interquartile range (IQR) measure of dispersion and median scores were used to determine consensus. The IQR is a measure of variability between the 25th percentile (first quartile) and the 75th percentile (third quartile). Median and IQR were chosen for analysis to decrease the effect of outliers (von der Gracht, 2012). The standard for an item to meet consensus for inclusion as an evidence-based competency for occupational therapists was set a priori to rating of an item as very important (rating = 4) or extremely important (rating = 5) by 75% or more of respondents. Criteria for levels of agreement were adapted from Jünger, Payne, Brearley, Ploenes, and Radbruch (2012) and categorized as (a) high agreement (i.e., median ≥ 4, percentage of agreement ≥ 75%, IQR ≤ 1); (b) moderate agreement (i.e., median = 4, percentage of agreement ≥ 75%, IQR = 2); and (c) low agreement (i.e., median < 4, percentage of agreement < 75%, IQR ≥ 2). After calculation of consensus data from round 1, the results for rating of importance were sent to participants with a second online survey that included only the competency statements that had not reached consensus. Participants were provided with their responses from round 1 in addition to consensus data (i.e., IQR, median). They were asked to review their previous responses and the consensus data and re-evaluate the competency statements from round 1. Data were analyzed with the same approach as in round 1 to determine consensus. The results of round 2 led to a final set of evidence-based practice competencies that included all competency statements that reached consensus.

Results

A comprehensive review of the literature on evidence-based practice and evidence-based practice competencies for health care professionals identified 10 publications from multiple health professions, including nursing, medicine, physical therapy, and chiropractic (Table A, available in the online version of the article). All extracted competency statements were considered relevant to occupational therapy. The number of statements from individual publications ranged from 4 to 32. In addition, 64 statements that were redundant across publications were reviewed and collapsed into 24 statements, with minor wording modifications, resulting in 78 competency statements for review.

Evidence-based Practice Competency Literature Used for Item DevelopmentEvidence-based Practice Competency Literature Used for Item Development

Table A:

Evidence-based Practice Competency Literature Used for Item Development

In phase 2, a total of 20 occupational therapists met the screening criteria and agreed to participate in the study. The round 1 survey was sent in February 2018, and responses were obtained from 17 of 20 occupational therapists. All responses were obtained within a 3-week period. Expert panelists represented the mid-Atlantic and Northeastern regions (n = 4), the Western region (n = 2), the Midwestern region (n = 6), and the Southern region (n = 5) of the United States. Of the respondents, 15 identified academia and 2 identified a hospital as their primary workplace. Years of practice as an occupational therapist ranged from 7 to 43 years (M = 25.1). The expert panel included a diverse group of individuals based on their highest qualifications, which included doctor of philosophy (n = 8), doctor of education (n = 2), clinical doctorate degree in occupational therapy (n = 4), master's degree (n = 2), and bachelor's degree (n = 1). Additionally, eight panelists held advanced certifications. Respondents obtained expertise in evidence-based practice through training in graduate school (n = 11), advanced continuing education (n = 4), or professional development in teaching courses on evidence-based practice (n = 2).

Round 1 resulted in consensus on 29 of 78 competency statements. However, one competency statement was inadvertently repeated in the questionnaire, so the final number of competency statements was 77, with 28 reaching consensus. Statements that reached consensus met the criteria for high agreement (n = 27) and moderate agreement (n = 1). At the conclusion of round 1, the authors reviewed the suggested competencies and recommended revisions to determine whether changes to the competency statements were warranted before round 2. Three new competencies were suggested, and four participants made comments, most of which focused on rewording. The authors reviewed the comments, and because the comments and suggestions did not substantially change the meaning of the competency statements and were from a limited number of participants, the authors maintained the competency statements as presented for round 2.

Competencies that had not reached consensus in round 1 and the three new competencies (n = 52) were sent to participants in round 2, with measures of dispersion provided. Of the 17 participants from round 1, 16 completed round 2. Consensus was reached on 27 competencies that met the criteria for high agreement (n = 22) and moderate agreement (n = 5). The remaining competencies did not achieve consensus (n = 22) and were categorized as low agreement. The final 56 competencies were grouped into seven domains modified from the five-step framework that was used to categorize the original list of competency statements. Six competencies that were originally in the “asking questions” category were moved to the “understands evidence-based practice” domain because the authors considered these items to be foundational to asking structured clinical questions. To provide a more detailed description of the competencies in the category “analyzing and assessing the intervention or practice change,” the authors divided the competencies into two domains: “assesses practice outcomes” and “advances use of evidence-based practices.” The domains “demonstrates evidence-based practice knowledge and skills,” “acquires evidence,” “applies evidence,” and “advances use of evidence-based practice” were organized to present some competencies as general, with specific competencies listed below them. Table B (available in the online version of the article) shows the domains, competencies, and consensus ratings.

Evidence-based Practice Competency Domains, Competencies, and Consensus RatingsEvidence-based Practice Competency Domains, Competencies, and Consensus RatingsEvidence-based Practice Competency Domains, Competencies, and Consensus RatingsEvidence-based Practice Competency Domains, Competencies, and Consensus Ratings

Table B:

Evidence-based Practice Competency Domains, Competencies, and Consensus Ratings

Discussion

This study used a modified Delphi process to obtain consensus on a preliminary set of evidence-based practice competencies for occupational therapists. The competencies represent several areas of engagement in evidence-based practice, including tasks needed to gain and demonstrate knowledge about evidence-based practice; actions related to the acquisition, appraisal, and application of evidence; and activities to assess the outcomes of evidence-based practice. The greatest number of competencies that met the criteria for consensus were found within two domains: “demonstrates evidence-based practice knowledge and skills” and “applies evidence.” The necessary knowledge and skills included the ability to formulate an answerable question and the basic skills to identify and evaluate relevant literature and understand basic research terms. It is not surprising that the expert panel achieved consensus on these competency statements because they are foundational to other evidence-based practice competencies that involve acquiring and appraising evidence.

Competencies for applying evidence included integration of internal and external evidence sources as well as the synthesis of clinical expertise with internal and external evidence. The literature on evidence-based practice often emphasizes external evidence from research and clinical guidelines. The inclusion of internal evidence and clinical expertise in this competency set underscores their importance in evidence-based practice. An example of using internal evidence in evidence-based practice is data-driven decision making, a framework for clinical reasoning through the occupational therapy process in which client data are used to guide the creation and measurement of outcomes (Schaaf, 2015).

The competency set from this study has potential for use as self-assessment for occupational therapists, although 56 competencies is a large number. A smaller set of competencies could be developed into an evaluative tool with the use of a Likert scale to rate practitioner competence for each statement. Further review by a diverse group of practitioners and educators could shorten the list to include only essential competencies. Despite attempts by the researchers to remove redundant items, some of the domains with large numbers of items included statements with only minor differences. For example, the domain “acquires evidence” included several items related to literature searches, which potentially could be collapsed into fewer competencies. After further development, employers may use the competencies to determine strategies and activities for continued development of occupational therapists into evidence-based practitioners. For instance, applying evidence may require hiring an occupational therapist who assists with translating knowledge from research studies to the health care setting (i.e., knowledge broker) (Hitch, Rowan, & Nicola-Richmond, 2014).

A list of evidence-based practice competencies for health professionals to use in designing teaching and learning programs consists of 68 competencies across six domains (Albarqouni et al., 2018). The statements from this interdisciplinary list were not included in this study because it was published after the completion of data collection. An informal comparison of these interdisciplinary competencies and the occupational therapy competencies presented here found many similarities, with more specificity noted in the interdisciplinary competencies. Additionally, the occupational therapy competencies included the domain “advances use of evidence-based practices,” which included competencies that address self-evaluation of the use of evidence in practice, communication of evidence to stakeholders besides patients, and integration of evidence in organizational planning. Although the inter-disciplinary list does not address this domain, these competencies may be important for improving the use of evidence-based practice in health care because they support the inclusion of evidence-based practice in the organizational culture rather than just efforts by individual practitioners (Melnyk et al., 2014).

Although the initial set of competencies was developed based on articles published in the United States and internationally, a limitation of this study was that the panel consisted only of occupational therapists working in the United States, which may restrict the generalizability of findings to other countries. Many reviewers were academics and educators, reducing the diversity of the panel. Additionally, Jünger et al. (2017) recommended external validation of Delphi results by an external board at the end of the study and before publication, which was not done for this study, but could be a next step in the development of competencies.

This study produced a preliminary set of competencies, and additional research is warranted before they are widely adopted. Usability studies could establish the degree to which occupational therapists and employers understand the competency statements and find them useful for decision making. Further, a feasibility study would provide information about how occupational therapists perceive the time and effort involved in identifying their level of competence in evidence-based practice and whether organizations consider this time beneficial. Future research should also include validation of the competencies among occupational therapy assistants in the United States because they are involved in gathering evidence and using evidence-based practices with clients. Although the focus of this study was on competencies for practicing occupational therapists, future work could investigate the usefulness of the competencies for occupational therapy education.

Conclusion

The reported use of evidence-based practice among occupational therapists is low. To the authors' knowledge, this is the first study to obtain consensus on a set of evidence-based practice competencies for occupational therapists. The expert panel members reached consensus on competencies that cover the entire evidence-based practice process, suggesting that occupational therapists require a wide range of knowledge and skills to demonstrate competence. The development of a set of evidence-based practice competencies may assist occupational therapists to recognize the need for professional development, and employers may use the competencies to develop training. Identification of levels of competence for the knowledge and skills needed for evidence-based practice may lead to improvements in evidence-based practice and assist with improving the quality and value of occupational therapy services.

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Evidence-based Practice Competency Literature Used for Item Development

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Evidence-based Practice Competency Domains, Competencies, and Consensus Ratings

Item% rating 4 or 5 (n=17)MedianInterquartile RangeCategory
Domain 1: Understands Evidence-based Practice
Understands the evidence-based practice process6,1094.540High
Explains how to integrate evidence-based practice into practice1083.451High
Articulates how to follow the evidence-based practice process6,1077.841High
Discusses the intent of evidence-based practice1083.441High
Describes the four skills of evidence-based practice (ask, access, appraise, apply)381.341High
Explains different levels of evidence and quality of evidence37542Moderate

Domain 2: Demonstrates Evidence-based Practice Knowledge and Skills
Tracks best evidence487.641High
Demonstrates understanding of scholarship by asking questions in day-to-day practice377.841High
Identifies patient-specific outcomes related to particular clinical problems177.841High
Translates uncertainty into an answerable question283.341High
  Formulates a structured answerable question (e.g. PICO)577.841High
Identifies databases for literature searching383.341High
Evaluates the literature393.841High
Understands applicability of studies to practice9,1094.451High
Understands meanings of common research terms9,1093.840High
  Understands the following terms from quantitative study designs: a. Sample and power, b. Statistical concepts, c. Clinical vs. Statistical significance, d. Validity and reliability, c. Responsiveness and reproducibility, f. Treats/biases9,107542Moderate
  Understands the following terms from qualitative study designs: a. Trustworthiness, b. Credibility, c. Transferability, d. Dependability, e. Confirmability9,1081.340High

Domain 3: Acquires Evidence
Performs a literature search3,487.640High
  Designs and conducts efficient search to answer questions when conducting literature searches975.141High
  Searches for and retrieves best evidence7,893.841High
  Chooses appropriate sources when conducting literature searches981.340High
  Searches medical databases to retrieve useful and up-to-date health care information and evidence5,681.341High
Seeks evidence-based practice resources377.841High
  Locates sources of evidence from a reputable database relating to the PICO question187.641High
  Demonstrates use of a systematic approach for searching for evidence in a reputable database183.341High
Understands strength/weakness of sources when conducting literature searches983.340High
Assesses relevance of evidence to clinical question (e.g. PICO question)983.441High

Domain 4: Appraises Evidence
Understands strengths and limitations of studies9,1077.741High
Critically appraises the strength of evidence1081.341High
Critically appraises literature by determining if study is internally valid, and if valid, assesses the clinical importance of the findings/study2,7,977.842Moderate
Critically appraises published research and determines practice applicability7,883.341High
Critically analyzes the research literature in respect to generalizability to the overall target population181.341High
Critically judges evidence appropriate to clinical management of patient conditions and issues1083.341High

Domain 5: Applies Evidence
Plans and applies evidence-based findings from literature search to practice6,983.351High
  Integrates the evidence (internal and external) from literature search with clinical expertise and patient preferences to make the best clinical decision and evidence-based changes5,7,888.951High
  Incorporates evidence-based practice while integrating patient values and preferences: sensitivity to issues, expectations, quality of life, setting/environment1,1083.351High
  Integrates internal evidence (client data) into intervention for optimal outcomes177.741High
  Implements practice changes based on evidence, clinical expertise, and patient preference7,893.851High
Synthesizes evidence while integrating patient concerns, clinical experience, and judgement into clinical decisions1094.451High
  Uses evidence to select valid/ reliable assessments(statement suggested by participant)93.84.51High
Assesses relevance of evidence to individual patient and policy987.641High
Explains summary statistics in manner appropriate to patient's level of understanding981.341High
Advocates for the patient based on evidence-based literature983.351High

Domain 6: Assesses Practice Outcomes
Keeps record of questions to be answered related to practice outcomes981.341High
Evaluates effectiveness and efficiency of evidence-based practices281.341High
Evaluates and measures the outcomes of evidence-based practice change7,881.341High

Domain 7: Advances Use of Evidence-based Practices
Practice is informed and up-to-date988.951High
Engages in self-evaluation of his or her process of accessing, appraising, and incorporating new evidence into practice677.741High
Reflects on and questions clinical practice to improve healthcare7,983.351High
Disseminates best practice supported by evidence to improve quality of care77542Moderate
  Able to synthesize, summarize results of research, and effectively communicate them to others (i.e. faculty, peers, staff)177.741High
  Communicates best evidence to individuals, groups, colleagues, and policy makers887.641High
Integrates evidence (internal and external) to plan evidence-based practice changes within an organization87542Moderate
  Builds evidence-based practice into an organization improvement plan975.142Moderate
  Advocates to corporate administration to allocate time and resources needed to integrate evidence-based practice into daily practice routines(statement suggested by participant)81.341High
Authors

Dr. Myers is Clinical Associate Professor and Program Director, Master of Occupational Therapy and Doctor of Occupational Therapy Programs, Department of Occupational Therapy, University of Florida, Gainesville, Florida. Ms. DeMaria is a student, Master of Occupational Therapy Program, Department of Occupational Therapy, University of Florida, Gainesville, Florida. Dr. Pomeranz is Clinical Associate Professor, Department of Occupational Therapy, University of Florida, Gainesville, Florida.

The authors have no relevant financial relationships to disclose.

This study was supported by the National Board for Certification in Occupational Therapy, Inc.

The authors thank the occupational therapists who participated in this study.

Address correspondence to Christine T. Myers, PhD, OTR/L, Clinical Associate Professor and Program Director, Master of Occupational Therapy and Doctor of Occupational Therapy Programs, Department of Occupational Therapy, University of Florida, PO Box 100164, Gainesville, FL 32608; e-mail: ctmyers@phhp.ufl.edu.

Received: February 04, 2019
Accepted: July 16, 2019
Posted Online: September 23, 2019

10.3928/24761222-20190910-02

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