80: What is "Evidence-Based Practice" in Nature-Based Therapy?
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Welcome to Therapy in the Great Outdoors, the podcast where we explore the business and practice of nature based pediatric therapy of all kinds. If you're an outdoor loving pediatric practitioner in the fields of occupational, physical, or speech therapy, social work, or mental health, this podcast will help you start and grow a successful nature based practice or program.
I am the ever honest, always a hundred percent real. You'll hear it all on this podcast. Dr. Laura Park Figueroa. I'm a pediatric OT with over 20 years of experience and I run a thriving nature based practice with profitable locations in two different states and multi six figures in revenue. I also host the free online community at therapyinthegreatoutdoors.
com to help you pursue your nature based therapy dreams too. Are you ready to take action on those dreams? Let's jump [00:01:00] in.
Hello, everyone. Welcome back to therapy in the great outdoors this week, we are going to talk about evidence-based practice. This is a buzzword in. Any kind of pediatric therapy, really, we all want to practice in a way that is based on the best available evidence. And we're going to talk a little bit today about what it is because I, the reason I'm recording this episode is because I came across some notes from when I was doing my PhD coursework before I did my research.
And. This. Outline that I had written of what I thought evidence-based practice was. I thought could be helpful for all of us as nature-based pediatric therapists to think through. And I hope it will really encourage you that it's not just about research. Research is a part of it, but it's not just about research.
So we're going to talk about that and I hope it will really encourage you in your work outdoors with children.
I believe evidence-based [00:02:00] practice is three different things. There are three components to it. The first is research analysis and application. The second is clinical reasoning and the third is reflective practice. So. The first one here is research analysis and application. And I think this is what most people think. Evidence-based practices when we think evidence-based practice, we think. What's the most recent research and how can we apply it to the work we're doing with kids outdoors?
So, if you're not familiar, there are different levels of evidence.
So if you have just gotten out of grad school, you probably know this, but if you've been practicing for a long time, it's really easy to forget this. The first level at the very, very top. Sometimes it's displayed in a chart form or in like a triangle form. But the very, very top, the most. Rigorous of all research is called level one and it's basically systematic [00:03:00] reviews or meta analyses of all randomized controlled trials on a topic. Now. When I say that you might realize that many of the things that we do in nature-based pediatric therapy work are not really able to be tested. With a randomized controlled trial.
Okay. There are valuable things to look at and research that cannot be tested with a randomized controlled trial. So when you proceed down through all the levels, I'm not going to go into detail on all the levels. So level one is that tippy top of the pyramid or the. Gold standard is that systematic review of randomized controlled trials.
And then you move down all the way to level seven. Which is expert opinion, reports of narrative or literature reviews that people have done. Things that are a little less rigorous and less. Kind of [00:04:00] operationalized, I guess I would say. And you have all these levels in between, you know, of different, different types of studies, right? So we have a lot of evidence. For. Supporting nature-based pediatric therapy work with children, but most of it is not randomized controlled trial evidence, but that doesn't mean that it's not evidence-based. Not all things can be. Studied with that randomized controlled trial.
Like I said, Qualitative research is research. And a lot of the evidence that we have for nature-based pediatric therapy is qualitative research. So I think. We need to, as pediatric therapist, we need to expand our.
Acceptance, I guess of. All different kinds of research rather than having this like. Utmost respect for the [00:05:00] randomized control trial as the one and only way that we can prove that something is valuable. Now I know I am probably preaching to the choir on this topic to many of you, because I know that I know nature-based therapy pretty well from the work I've done.
And what I mean by that is that you value. The research that. Is done in a qualitative way, not just a quantitative way with data and measurement tools and numbers. So both are necessary, but I do think we should see qualitative research as the rigorous research that it can be. I know this because I just finished a qualitative study and you guys, I am not a. Qualitative person.
I really am a black and white person. I chose to do a research study. That was a qualitative study where I developed a theory, which was probably.
The thing farthest, from what I thought I would end up doing when I started my PhD program, I originally wanted to [00:06:00] do like a comparison study of. Indoor versus outdoor therapy. And I realized when I was doing my coursework, that there isn't really, what was needed in the profession was kind of looking at what even is going on. In nature based pediatric OT in particular, I had to limit my study to OT because my degree was in OT. So that involved doing a qualitative study where I developed a theory that explained what is going on in the pediatric nature-based occupational therapy process.
So that's qualitative research is research. The other thing I wanted to say along this line of research analysis and application being part of evidence-based practice. Is that understanding of theory is necessary for analyzing research.
So theory. Just makes it would've been good if I said this before I talked about what I did for my research, but theory explains or guesses, or makes predictions about [00:07:00] what will happen in specific situations. So when you're looking at research, you want to consider the theoretical perspective of the researchers.
What assumptions are they making? Because. All research, all research is biased in some way. All of it. There's, there's very rarely, very rarely, maybe not ever absolute truth and research. There's always some other way to explain things, especially in qualitative research. There's some other way to explain things.
So for my study in particular, like what I was just talking about, If someone else did this study, they might come up with. A similar, but very different model than what I developed from the analysis that I did of the research. And that's, that's part of the beauty of living in this complex space of the nature-based pediatric therapy world.
Is that. Life is messy. I talk about this in the article that will be published. Like life is messy. Everything is in life is complex, [00:08:00] and there are always these, these factors that are underlying, that we don't see as humans. We are not all knowing as humans only God is. And so. We really, we really can't know the whole truth to anything. And so I think looking at research, that's part of the reason, this is kind of my segue into talking about the other elements of. Evidence-based practice because research is not the be all end all is what I'm saying here. So, really quick, I do want to say. I try to save you time to help you. Take current research and apply it to your nature-based therapy work by doing those review episodes where I'll take an article and talk about kind of the takeaways that you can apply to your practice.
There's many of those in the 72 episodes before this, there are many research episodes. So if you are just now starting to listen to the Tigo podcast and you want to get some quick. Tips about research that may apply to your work. You can just [00:09:00] search for research on the podcast website. Therapy in the great outdoors.com and click podcast.
That'll take you there and you can find the episodes or just scroll in your podcast player to you can search for research too. But any episode that I did, where I review a research article, then I give a few takeaways that apply to you and your work with children. So. The other thing. That you can do is Look for studies to apply to your work that are actual research versus just the expert opinion to give you A little bit more validity to the research.
So peer reviewed literature goes through a very rigorous, like I've mentioned very rigorous cycle of other people, looking at the research to determine if it is worth publishing versus a professional practice magazine, like OT practice or something. I don't know what they would be in other professions, but OT practice is like a magazine that our professional organization puts out and it's. It's like there's editors there, but it's not a [00:10:00] research article.
They might report on a program or run an article about outright. I've published an OT practice and it's like, we wrote an article about outdoor play, you know, so it's, it's not, it's not as rigorous of a process. So just know that. You can analyze the literature that you're reading to determine the validity of it and the importance of it to apply to your work. Okay.
All right. So wrapping up that first part evidence-based practice involves research analysis and application, but it also involves. Clinical reasoning. And after clinical reasoning, we will talk about reflective practice. So clinical reasoning. There is the most, one of the most beautifully written articles I have ever read.
It is like poetry. It is very heady and it takes. You have to read it and like, not try to race through it because it's just so beautifully written. It's called what is clinical reasoning by Cheryl Mattingly? And it was in the American journal of occupational [00:11:00] therapy in 1991. So it is. It is old you guys.
She, I think is still on staff. I think she's at USC now, but. So I'm gonna. talk with you about my takeaways from this article to help inform your thinking about clinical reasoning. So clinical reasoning is. more than. Just being able to explain the reason behind what you're doing in a therapy session. So Cheryl wrote, that in comparison to like a novice therapist, an expert therapist can quote think while doing barely noticing the thinking process that is guiding the doing. That's page 9 79 from her article. She calls this embodied, knowing I love it.
It's like, it's like a way of saying that when you develop expertise in something, your clinical reasoning is like in your bones, it's just part of who you are. And you probably experienced this in your profession, right? Like when you get around other OTs [00:12:00] or other PTs or their speech therapist or other mental health counselors, like. You have a shared understanding with them and embodied knowing of what your profession entails.
That that is it can't be. Replicated, it's kind of across professions. I mean, so really there's this embodied, knowing that you have, when you have clinical reasoning as an expert,
So Cheryl suggests that clinical reasoning is more than the application of theory. Theory is a starting place because we talked about like, you need theory to understand the, the. The standpoint of research, you need to understand where the research is coming from. Like what their perspective is. Cheryl also says that clinical reasoning is more than applied science or practical knowledge.
And she suggests that this comes from this biomedical model, right. Of like. This is the problem. Fix the problem. There's a solution. It's like a puzzle. You just [00:13:00] fix the puzzle, and then you have the solution to the problem. And I think this is a common understanding of clinical reasoning is that we just think that clinical reasoning is like, there is a quote, right answer. But again, going back to life, being messy and things being complex, practice is complex.
I don't care what profession you are in. It always requires. A constant re-analysis of things, a constant recalculating in the middle of a treatment session. That's what Cheryl called it. She said. She said it's a quirky, interactive process. Quote unquote, I love that. That's page 9 85 in her article. So. Clinical reasoning really is. An interpretive judgment.
This is also from, I don't think this was a direct quote, cause I didn't put it in direct quotes, but it's, taken, the ideas are taken from her article. It's an interpretive judgment as to the best course of action in this specific moment, directed toward helping clients make meaning. [00:14:00] It's a meaning-making process. It's engaging the client in a process of making meaning.
She also calls it. Listen to these words, you guys, you can just hear how great this article is. Improvisational tinkering. Like, it's just, gosh, it's so good. You all should read it. I mean, really it is guess it's over 30 years old, but it is still so valid. And, just resonated so much with me that. Clinical reasoning is not this.
Find a problem and fix it solution it's a matter of. Embracing the complexity of every given situation and helping our clients make meaning of that experience that they're having in that specific situation or helping our families make meaning. So embracing that it is going to be messy and it is going to feel hard.
And again, that I spoke about this last week on the episode about imposter syndrome. But if you are a novice therapist, this is what you're aiming for is to be able to do this clinical reasoning. [00:15:00] But what you need. In the process, what all of us need, even if you're an expert, even if you're not a novice. The takeaway here is that we need one another.
We need one another in order to do good clinical reasoning and to understand the complexity of what we have going on with any given client or family and our nature based work. So one way that you can do this is to be bold and take a risk. I talked about this last week too, on the imposter syndrome episode, I didn't realize how these would go together, but they do. Is. Take a risk to share your ideas in community with others to share failures that you've had to share the really tricky cases that you've had. That is what I have tried to create for you.
I've tried to create a safe space for that inside of the Tigo community in our free discussion forum. I will be honest with y'all. It isn't quite there yet. So, if you are listening to this, it isn't quite. It isn't quite to [00:16:00] where I feel like.
Lots of people are sharing their ideas and sharing their experiences and sharing, especially their failures.
I know this is hard for people to do. I know this is difficult to do when you have a hard case, right? But I want to encourage you to do that. So if you are listening to this. And you need to develop this clinical reasoning. We all need this. Even again, even if you're an expert. Then, please, please. Here this invitation for me to utilize that Tigo community free discussion space. To externally process the cases that you are dealing with, the ideas that you have about nature-based therapy or the struggles that you're having as a nature-based pediatric therapist because that is where we will all start to develop that embodied knowing when we know what to do in our bones as experts. And that takes a lot of time through that quirky, interactive process that Cheryl Mattingly described in that article [00:17:00] from so long ago, but that is still so relevant today. I have actually thought about doing a little journal club and reading this article together because it's just, it's so beautifully written and it is valid, I believe for any profession, not just for OT.
I don't even know if I said that she was an OT, but. She is, and it is a beautiful article. I'll link it in the show notes for you guys, if I'm allowed to, I'm not sure if it's open access, but it might be. Okay. So sharing ideas in community with one another is what allows us to develop this type of clinical reasoning. So we have research analysis and application clinical reasoning.
And then finally, the last thing is reflective practice. And to my knowledge, this is my definition of what evidence-based practices I added reflective practice. I don't think that this is in an article anywhere like, oh, evidence-based practices. Research analysis and clinical reasoning and reflective practice.
But. This is my, these are my [00:18:00] ideas here. So reflective practice is an idea that came from Donald Schoen. He wrote a book called the reflective practitioner. How professionals think in action. And I read that during my PhD coursework. And the way that I apply this in practice, the way that I teach reflective practice to students, to my employees, to people in my programs. Is to use a series of three questions or a little three word alliteration, which I'll tell you here.
So the three questions are what went well, what went wrong? What will I do differently next time? And if you think about the. Answers to those questions. What went well? Are the positives. What went wrong are the problems. And what will I do differently next time?
Is the proactive solutions. So positives problems, proactive solutions, or you can think about it in terms of those [00:19:00] questions.
What went well, what went wrong? What will I do differently next time? And I just had a meeting and I'm helping to train some fieldwork students that are working with my practice this summer. And I just had my first meeting with them yesterday. And. One of the things I said to them is that if you take the time. Two minutes after. Each therapy session.
If you take the time to actually just write down physically write down. Your answers to those three questions or maybe some thoughts on the positives problems and proactive solutions. I share both because maybe. It helps you to remember it one way or the other. We're all different. If you take time after a session to write down those things, you are going to develop better clinical reasoning. And better critical thinking than if you don't stop and do that reflection.
So a few moments of reflection to reflect on those questions after each session or after a day of camp or after a nature-based session outdoors with kids, like we'll give [00:20:00] you. A really good foundation. And help your brain start to think in terms of identifying what the salient information is in a given situation that was hard. As well as help you think creatively to come up with different ideas and be ready for the next treatment session, because you've thought proactively about what you are going to do differently the next time. So I hope that is helpful to you.
So finally again, my definition of evidence-based practice is that we combine research analysis and application clinical reasoning and meaning making in complex practice situations. And finally, Reflecting on your practice. You cannot do this alone. Y'all I say this all the time. I don't do this alone.
I have a huge community of people around me. I love you all. That includes some of you who are listening. And you need to be in community with others to learn and grow as a nature-based pediatric therapist. So I would invite you into the therapy and the great outdoors [00:21:00] community. We are here. For one another.
And I read every single post there. I can't reply to all of them, but I read every single post. And I'm just so grateful for all of you and the work that you're doing in the world, the meaning-making that you are doing with all the families that you serve. So. That's it, there are some references here for you have references that I have mentioned in this episode, I will put them in the show notes, the Mattingly article, as well as Donald Schon's book.
And. A link to the evidence-based practice, like levels of evidence table that I found online that I thought was really good. And you can get those in the show notes therapyandthegreatoutdoors.com/podcast. And then just click this episode and you will find them there. All right, I'll talk to you guys next time.
Bye.
Wait a second. Don't go yet. Do you want 120 ways that you can take your pediatric therapy work outdoors into nature? I wrote the free, big, huge [00:22:00] list of nature based therapy activities just for you. The Big Huge List will give you quick ideas for nature based sessions. In the Big Huge List, there are activities for gross motor, fine motor, visual perceptual, executive function, balance, group collaboration, and team building, social, emotional, and self regulation skills, as well as speech and language, and a whole section just for swing activities.
So go on and get your free Big Huge List so you can get started taking kids outdoors or have some new ideas if you've been doing this a while. You can download your free copy at therapyinthegreatoutdoors. com slash list. So until next time, get outside, connect, reflect, and enjoy therapy in the great outdoors.
