Only the Best

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October 2004

By Mary Isaacson, EdD, OTR/L, ATP

Best practices are a professional's decisions and actions based on knowledge and evidence that reflect the most current and innovative ideas available."¹

Today's best practice often evolves into tomorrow's standard practice. This is how knowledge advances in a profession. Consumers look to the professional for the knowledge and skills needed to provide the best services possible.

Identifying best practices provides justification for conducting assistive technology and mobility evaluations in a certain manner. To funding agencies, it provides a rationale for the reasons why evaluations can sometimes be time-consuming and costly. Health care administrators can use such information in quality assurance programs. Last, and possibly most important, this information can be utilized to assist in identifying services that are of highest quality.

In the ever-changing field of seating and mobility, it may be difficult to stay abreast of new technology and procedures unless one chooses to specialize in the area. Credentialing is available to identify those therapists who specialize in assistive technology; however, the credential is not required. Currently, standards of best practices that would aid the therapist in establishing expertise in seating and mobility evaluations are very limited.

Profession	Years in Profession
PT	33.5
OTR	24
PT	23
OTR	23
PT	21
PT	19
PT	19
PT	18
OTR	18
PT	17
OTR	14
PT	14
PT	13
OTR	10
PT	10
Table 1. Expert panel experience in years.

THE BEST PRACTICES STUDY
The purpose of this study was to describe the perceptions of occupational and physical therapists that specialize in seating and mobility evaluations about the current best practices in the field. The focus was placed on determining best practices in the views of the leaders in the field. This was accomplished by using the Delphi technique to gather data from authorities on seating and mobility regarding their perceptions of best practices in their area of expertise. Potential experts were chosen based on previous work and determination on expert practice. A total of 15 experts comprised the sample for this study (see Table 1). Each met the following criteria: (a) have 7 or more years of clinical practice, (b) be involved in direct patient care at least 50% of the time, and (c) have completed formal or informal advanced work in the specialty area of assistive technology.² Two rounds of questions were sent to the therapists.

Round one consisted of open-ended questions that looked at the (a) seating and mobility evaluation process, (b) skills and knowledge needed for a thorough seating and mobility evaluation, (c) methods used to gain these skills and knowledge, (d) barriers that may exist that hinder the process, (e) changes in the field, (f) learning process, and (g) professional ethics. Several patterns and concepts emerged out of round one: experience, knowledge, and sensitivity to the consumer's needs. Consistently emerging from all of the responses was the need for experience. A second round of research was sent to the participants for confirmation and clarification of the information received in round one. In round two, 14 of the original 15 participants responded. The patterns and concepts that had emerged in round one were confirmed and expanded upon by the participants in the second round.

Figure 1. Best seating and mobility practices in wheelchair form.

Best practices in the area of seating and mobility may best be depicted by the metaphor of the wheel on a wheelchair (see Figure 1). In this metaphor, the hub represents the concept of best practices. The spokes on the wheel represent all the concepts that were identified by the research participants as necessities for the implementation of best practices in the area of seating and mobility. These best practice spokes include the following: (a) experience, (b) hands-on techniques, (c) skills, (d) technology, (e) resources, (f) self-directed learning, (g) follow-up, and (h) consumer relationships. If a spoke is missing or broken, the wheel does not run smoothly. The brake represents the barriers to effective practice. On a wheelchair, just as a brake can slow or stop the wheel, so barriers can be a hindrance on the road to best practice. Each of these components is further elaborated and described below.

HANDS-ON EXPERIENCE
According to experts surveyed, real-life clinical experiences are key elements in the implementation of best practices in the area of seating and mobility. Experience is identified as a primary tool for solving difficult seating and positioning problems. Lack of experience is identified as a primary cause of poor results produced by a seating and mobility evaluation. Those who know a great deal about what they are doing or experiencing are defined as experts, and those who have only basic knowledge are termed novices. One of the most fundamental differences between experts and novices is that experts bring more knowledge or experience to solving the problem and, therefore, are more efficient. In addition, experts are able to solve problems faster and in a more economical way, have stronger self-monitoring skills, and are able to view and solve problems at a deeper level than are novices.³

Analysis of responses received identified experience in several specific areas. Experience with various populations and a variety of diagnoses, experience with the different types of equipment available and the way in which they can be modified or created, experience with the consumers and knowing what questions to ask, experience with the mat assessment, experience with different positions, and experience looking at things both biomechanically and functionally are all identified.

Although many of the skills needed to perform seating and mobility evaluations can be obtained from textbooks, they are not truly learned until they are put into practice. For example, the completion of a mat examination involves getting the "feel" of something. The experienced clinician knows when something feels right. They are able to apply this feel through their hands-on techniques.

SKILLS AND TECHNOLOGY
A number of skills are necessary for the thorough implementation of a seating and mobility evaluation. Specifically, the skills include (a) the ability to perform a thorough mat assessment, (b) the ability to simulate the desired position through utilization of a seating simulator or trial equipment, (c) the ability to utilize and interpret a pressure mapping system, (d) the ability to apply biomechanical anatomical knowledge appropriately to the situation, including a thorough movement assessment, (e) the ability to complete a thorough environmental assessment, and (f) the ability to perform a complete and thorough interview.

Some of these components are contingent upon the specific practice situation. For example, the use and expense of pressure mapping are dependent on the consumer's needs and the specific situation. If no problems with pressure sores have been noted previously, pressure mapping may not be warranted. An environmental assessment may not always be needed if an individual lives in an environment such as a nursing home that is wheelchair accessible.

It is important for therapists wishing to participate in seating and mobility evaluations to have knowledge of the current technology, along with the ability to retain and use basic skills. Basic skills identified include mat examinations, simulations, and the ability to carry out product trials. Survey responses emphasized the need for technology skills, including computer-aided design or computer-aided manufacturing (CAD/CAM) skills, the ability to document on the computer and utilize the Internet, and the ability to utilize computerized equipment for seating and mobility, such as the use of pressure mapping.

The specific technology as it relates to the wheelchairs and seating systems is also constantly changing. Therapists need to stay up-to-date with this knowledge in order to provide current and objective information to facilitate consumers' knowledge and decision-making based on their personal needs.

RESOURCES AND LEARNING
Knowing one's resources and knowing how to attain and utilize these resources are another key to the implementation of best practices. A key component to this concept is knowing how to plan, evaluate, and select resources. Some of the resources identified include networking with other professionals, networking with manufacturer representatives and durable medical equipment suppliers, and networking with other therapists.

The field of seating and mobility is dynamic. Much of the information and technology quickly evolves and changes. Therapists who desire to utilize best practices must be active in their individual search for additional knowledge and skills. Although 100% of the participants identified experience as the method with which they have gained the majority of their skills and knowledge, they recognize that these skills and knowledge have not been gained through experience alone. They cited continuing education courses, peer mentoring, trial-and-error, reading, and utilization of trade shows as methods by which they furthered their personal learning and professional knowledge.

One important aspect of best practices is follow-up. Once an evaluation is completed, a plan developed, and the plan implemented, the professional evaluates whether the recommendations and the plan worked. Follow-up is identified as the best method for this confirmation. Follow-up is identified and defined as both formal and informal in nature. Formal follow-up may consist of a formal questionnaire. Informal follow-up may be completed when the consumer returns for adjustments or modifications to the seating system. Both forms of evaluation of outcomes are extremely useful.

Consumers know their needs, goals, and desires. Therapists utilizing a best practices model recognize and embrace this fact. As summarized by one participant, "They know more about themselves and their needs than I will ever learn through any evaluation process." No matter how skilled and knowledgeable the therapist may be, the consumer will be the one living with the results of the evaluation. The consumers bring to the process their own personal experiences, skills, and knowledge of their needs. Without the consumer who needs and utilizes the seating and mobility system, the necessity for thorough seating and mobility evaluations is nonexistent. Similarly, without a seating and mobility evaluation expertly implemented through the use of best practices, the consumers will not benefit from technology that can maximize their functioning as a result of improved positioning and comfort. Therefore, it may be conceptualized that best practices involve a partnership between the consumer, the rehabilitation specialist, and the other members of the evaluation team.

It is recognized that barriers can and do exist that may interfere with a thorough seating and mobility evaluation. However, this model of best practices also recognizes that a constant effort should be made to overcome these barriers. The barriers identified include time restraints, limited funding, unavailability of equipment for trials, and limited access for the completion of an environmental assessment. Creativity and the ability to think outside of the box are skills that the experienced therapist uses to overcome these barriers.

SUMMARY
In the area of seating and mobility evaluations, best practices can best be depicted and illustrated by a wheel similar to one found on a wheelchair. In the center or axle of the wheel is the concept of best practices. Spreading out from this center are the spokes that stabilize and support the wheel. The wheel requires that all of the spokes be in good working order for it to function properly. These spokes of best practices include experience, hands-on techniques, skills, technology, resources, self-directed learning, and the consumer. All the spokes must be strong and in place in order for the wheel to run well. Not only does a wheel have spokes, it also has a brake. This brake has the potential to slow or even stop the wheel. However, if the brake is not applied, it has no effect on the wheel. When the wheel is functioning properly, it can be put into motion.

Mary Isaacson, EdD, OTR/L, ATP, is a professor with the College of Allied Health, Department of Rehabilitation Sciences, The University of Oklahoma Health Sciences Center, and an owner of Adaptabilities Inc, Tulsa, Okla.

REFERENCES

Dunn W. Best Practice in Occupational Therapy. Thorofare, NJ: Slack Inc; 2000:1-6.
Jensen GM, Gwyer J, Shepard KF, Hack LM. Expert practice in physical therapy. PT Journal. 2000;80:28-43.
Ferry N, Ross-Gordon J. An inquiry into Schon's epistemology of practice: exploring links between experience and reflective practice. Adult Ed Quart. 1998;48:98-112.

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