The Prepared Mind

Susan L. Garber

doi:10.5014/ajot.2016.706001

Abstract

Every day, in clinics and hospitals around the world, occupational therapists care for patients with serious problems requiring viable solutions. Each patient is unique, and his or her problem does not necessarily correspond to existing practice models. Practitioners must adapt standard approaches to provide effective outcomes, yet problems exist for which few or no beneficial approaches have been identified. Such clinical issues require solutions to be generated de novo from the practitioner’s body of knowledge and past experience. Yet, no single new intervention can be used without prior validation of its efficacy. Only a therapist with a prepared mind can accept such challenges, recognize what is known and not yet known, design studies to acquire that needed knowledge, and translate it into successful clinical treatment strategies. The occupational therapist with a prepared mind is one willing to seize unexpected opportunities and construct new paradigms of practice. Innovation through scientific inquiry requires a prepared mind.

Susan L. Garber, MA, OTR, FAOTA, FACRM

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Receiving the Eleanor Clarke Slagle Lectureship Award is a great honor and a cause for reflection about my career and its trajectory. Mine has been a far from traditional journey in the practice of occupational therapy; it may provide lessons for occupational therapists at any phase of their careers. A central theme in my career has been one identified by Louis Pasteur, that of the “prepared mind” (Gelson, 1965).

A few weeks after I received this prestigious award, I came across a quote from this brilliant 19th-century French scientist: “Chance favors the prepared mind” (Pasteur, cited in Gelson, 1965), and it resonated with me immediately. When presented with complex problems, Pasteur recognized them as opportunities for new solutions. Hence, his many diverse accomplishments were derived from his readiness to seize opportunities as they arose.

This is the description of a prepared mind. Every day, in clinics all over the world, occupational therapists can ask the questions that will direct them to effective solutions to their patients’ unique challenges.

Part I. Preparing the Mind

The value of a college education is not the learning of many facts but the training of the mind to think.

—Albert Einstein, paraphrased, cited in Frank (1947, p. 185)

Early Occupational Therapy Curricula

Albert Einstein observed that the value of a college education is not the learning of many facts but the training of the mind to think. When I entered college in the early 1960s, the traditional route for the entry-level occupational therapy student consisted of 2 years of a liberal arts curriculum followed by 2 years in an occupational therapy program. A 3-month clinical “affiliation” was required in psychiatry and rehabilitation along with one 3-month affiliation in a clinical area of one’s choice. Then, we were awarded a bachelor’s degree. Some university occupational therapy programs offered a certificate program for students with a bachelor’s degree in another field.

The curriculum for a junior entry-level occupational therapy student at Columbia University consisted of courses in occupational therapy history, theory, and philosophy; life and social sciences; applications in psychiatry; and myriad craft courses, some of which were repeated at the advanced level during senior year. The senior-year’s curriculum introduced courses in the medical specialties, applications in treatment, four advanced craft courses, and a physical disabilities clerkship. In advanced weaving, we were required to thread our own loom and produce a product. I still have the pink dresser scarf I made for my mother. It was during the senior year that “activity analysis” was emphasized in every craft course.

The curriculum did not include formal courses in research design or implementation, nor were there discussions about finding research opportunities in the clinic. We were not prepared to question the status quo. However, my academic mentors at Columbia University, Professors Franciscus and Schnebley, Mrs. Fidler, and Miss Brunnstrom, among others, emphasized that patient outcomes should be evaluated continuously and that clinical decisions frequently emerge from beyond our textbooks (Fidler, 1966, 1981).

In the 1960s, many hospital-based occupational therapy departments had limited funding and support. Hence, staff therapists, students (of which I was one), and patients used crafts for therapy as well as to fabricate items that could be sold in the hospitals’ gift shops. The proceeds of the sales were used to buy more supplies to make more items to sell. Does anyone remember the “monkey” doll? The clown doll? Woven pot holders?

Occupational therapy services were not always reimbursed and sometimes were billed as physical therapy. This also was the time in which occupational therapy was trying to become more “scientific” and to define the profession in a way that would make it more acceptable and respected, especially to facilities’ administrators and payers of services. In many facilities, the use of crafts as therapy was declining. We were attempting to move away from the identity as “basket weavers” and into an identity as health care professionals. Therapeutic exercise was becoming more popular as evidenced by elevating sanding boards, bicycle saws, and treadle sanders used in some clinics without an occupational outcome.

Evolution of Clinical Practice

Clinical practice for newly certified therapists was defined by the traditions of the facility in which they practiced and the patient populations treated. Assessments and time-honored interventions were introduced for improving strength, range of motion, gross and fine motor coordination, and activities of daily living (ADLs). Because the availability of commercial assistive devices was limited, therapists designed and fabricated many assistive devices and splints de novo. We sought the assistance of certified orthotists, if they were available. In some cases, we sought help from maintenance engineers at our facility who had tools and experience to help us design and fabricate devices or equipment to improve function; hence, occupational therapists have a long tradition of working in the design and fabrication of customized assistive devices for patients with a variety of physical impairments.

Across the years, numerous devices were developed for ADLs, communication, wheelchair mobility, and environmental control. Articles in the American Journal of Occupational Therapy frequently presented unique device design and use (e.g., Dickens, 1952). Rarely, however, were the long-term use of and satisfaction with these devices measured and reported. Failure to do this meant that local advances were infrequently incorporated into treatment programs nationally. Critical evaluation of innovative programs and devices became a major focus of my future activities as an occupational therapist.

Professional growth, development, and advancement came with longevity at the facility as well as with increased responsibility such as promotions, student training, and hospital committee participation. With rare exception, clinical research did not occur directly within occupational therapy departments, nor were occupational therapists often invited to participate in research projects at their facilities. We had few opportunities to measure and then express dissatisfaction with long-established, conventional interventions. At that time, therapists did not assert themselves by questioning traditional but minimally successful treatments, nor was research often performed on alternative therapies in clinics.

Some therapists may have recognized that there were alternatives to traditional approaches but had few resources to create and then try out new ideas. Certainly, little translation of such ideas occurred. Why was that the case? Part of the explanation lay in the lack of training in formulating a research question, lack of precedent in performing research, and a reluctance to question supervisors and managers. In short, we were unprepared for these opportunities.

My first position as a staff occupational therapist was at Philadelphia’s Moss Rehabilitation Hospital. The primary patient population consisted of people who had had a stroke. Conventional approaches were implemented for improving function. Some crafts were used but not extensively. Cognitive rehabilitation was in its infancy. Often, wheelchair mobility was the purview of physical therapists, although we fabricated wheelchair cushions, usually a block of foam rubber on a plywood board.

The evolution of assistive technology and advances in computer technology changed the landscape of health care and rehabilitation, resulting in the emergence of new practice environments for occupational therapists. School systems, home health agencies, long-term-care facilities, and private practices sought our services. Specialty private practice clinics opened, initially in hand rehabilitation and pediatrics. Occupational therapy within school systems became extremely important as children with developmental, physical, and psychological impairments were mainstreamed into regular classes.

Occupational therapists began to expand their repertoires of occupations for patients with impairments not previously addressed. Interventions to improve driving; mobility; vision; and feeding, eating, and swallowing skills arose within the context of specialty certification. Occupational therapists were working in acute care, intensive care units, and neonatal settings, as well as home modification and work site accommodation. Nontraditional areas of practice included cancer rehabilitation, sexuality, autism, and wheelchair mobility and seating. One of the first recognized accredited adapted driving courses was developed at Texas A&M University and implemented into clinical practice at the Institute for Rehabilitation and Research in Houston (Garber & Lathem, 1995).

Occupational Therapy and Wheelchair Mobility

By the mid-1970s, wheelchair mobility and the selection of wheelchairs and seating became the responsibility of many occupational therapists. The technology in these devices literally exploded with new designs, lighter materials, and new uses for the wheelchair. Motorized wheelchairs, sports chairs, and scooters came on the market with numerous adaptations. Many of these devices were manufactured with limited clinical or scientific evaluation, thus opening another new opportunity for occupational therapists to question the utility, practicality, and advantages of the new technology. In time, wheelchair mobility became a specialty area for occupational therapists.

In view of expanding technology in many areas of medicine and rehabilitation, the U. S. Department of Health, Education, and Welfare recognized the need for comprehensive programs in which clinicians and engineers would collaborate to solve some of the most significant problems affecting people with a wide range of disabilities. A special section of the Rehabilitation Act of 1973 (Pub. L. 93–112) mandated that 25% of research funding under the act go to the establishment of Rehabilitation Engineering Centers (RECs; Reswick, 2002). Each REC was a consortium of institutions, and each identified a core area.

Two of the early RECs were devoted to wheelchair mobility and seating, and each sought an occupational therapist to provide essential clinical expertise. The Tennessee REC addressed wheelchair seating and mobility for children (Hobson, 2002); the Texas REC would conduct research on pressure ulcers in people with spinal cord injury.

The Texas REC was located at the Texas Institute for Rehabilitation and Research (as it was then called; TIRR), where the occupational therapists were responsible for providing wheelchairs and cushions. This REC would introduce a new perspective to preventing and treating one of the most devastating secondary complications among people with spinal cord injury. Soon, occupational therapists would have new tools on which to base their decisions. It takes a prepared mind to accept such tools (DiSante, 1978; Taylor, Trefler, & Nwaobi, 1984).

Part II. Rehabilitation Engineering Centers and Wheelchair Mobility

The People Who Get On in This World Are the People Who Get Up and Look for the Circumstances They Want and, If They Can't Find Them, Make Them.

—George Bernard Shaw (1898, p. 193)

Effect of Pressure on Tissue

My career was put on hold when I took time to have my children and moved halfway across the country. In 1974, newly arrived in Houston, and with two little boys now in school, I set out to return to my profession as a practicing clinician. Because local professional organizations are usually very supportive of their members as well as of new arrivals, I attended the annual meeting of the Texas Occupational Therapy Association. A chance meeting with Mary Joyce Newsom, then director of occupational therapy at the TIRR, changed the direction of my professional life. She indicated that a consortium of Houston institutions had received a new federal grant, and the principal investigators—engineers and physicians—sought an occupational therapist to be part of their team. The core area of this new endeavor was “the effect of pressure on tissue,” described as the prevention and treatment of pressure ulcers in people with spinal cord injury.

The Texas REC had been established in 1972. Three institutions formed the consortium: the TIRR (later known as The Institute for Rehabilitation and Research), Baylor College of Medicine, and Texas A&M University. The primary aim of this REC was to identify strategies to prevent pressure ulcers in people with spinal cord injury. Thus, the formal collaboration among engineers and occupational therapists provided a new, unprecedented, and exciting avenue for advancing occupational therapy. It was an extraordinary opportunity to participate in novel and nontraditional areas of health care and rehabilitation, one in which an occupational therapist could make a significant contribution (Gordon & Kozole, 1984). New technology was being developed, and it needed to be systematically and rigorously evaluated through clinical investigations in areas never previously pursued by occupational therapists.

In 1975, with limited experience in spinal cord injury, even less with “bed sores,” and none in clinical research, I was appointed to participate as a member of the REC. From this chance encounter between an opportunity and a prepared mind emerged my career.

It is extremely important to note that although I was hired specifically to participate in the research of the REC and was paid by the grant, Ms. Newsom insisted that I also hold a position within the occupational therapy department at TIRR, where I remained for 19 years. Ms. Newsom was extremely forward thinking in the belief that research should be conducted in occupational therapy clinics and that having occupational therapy researchers in the clinic would enhance practice. Truly, she was a pioneer in this philosophy and an important contributor to the growing professionalism of occupational therapy (Newsom, Canzoneri, Pelosof, & Fuhrer, 1973; Newsom, Keenan, Maddry, & Aguilar, 1969).

State of the Knowledge

PubMed, from the U.S. National Library of Medicine, became my constant companion. It contains 25 million citations for biomedical literature from Medline, life science journals, and online books. PubMed is an essential tool for characterizing the state of knowledge in any given medical field. Every medical professional should become familiar with PubMed, the premiere search engine of medicine.

I had to learn as much as possible about pressure ulcers—etiology, physiology, and treatments from topical dressings to surgery. The publications provided new questions to ask and new applications of relevant emerging technology. In fact, every patient provided an opportunity to ask new questions. As an occupational therapist, I was extremely well positioned to ask those questions that would lead to improved outcomes.

The physiology of the effects of pressure on tissue was being studied long before the creation of the RECs. From Kosiak’s 1959 classic study on time at pressure to studies on blood flow and tissue mechanics, pressure ulcer researchers have recognized that tissue breakdown is multifactorial. Causes other than pressure have included shear; metabolism, age, and body build; neurological factors such as diminished or absent sensation; medical comorbidities; and psychological and social issues.

Many of the studies examined only one or two variables and left others uncontrolled or assumed them to be constant. As a result, it was difficult to compare studies from one laboratory to another. Numerous studies have focused primarily on quantifying interface pressure, which was considered the main culprit in the etiology of tissue breakdown. Many of these studies were conducted with animal models that were unsuited to test psychosocial and behavioral factors associated with pressure ulcer occurrence (Kosiak, 1959, 1961; Kosiak, Kubicek, Olson, Danz, & Kottke, 1958).

Collaborating With Engineers

Initially, REC projects focused on wheelchair seating and minimizing interface pressure. A few commercially manufactured wheelchair cushions were available, and new ones were being developed. NASA had developed what became known as “memory” or “viscoelastic” foam: temper foam, the mainstay for wheelchair cushions in many clinics. Additionally, therapists were fabricating cushions using available high-resiliency foams of different densities and contours. Air-filled bladders and various gel-like materials in new geometric designs were appearing on the market.

My very first REC project was to test a prototype of an interface pressure monitoring system, which I called the “PEP,” or pressure evaluation pad, designed to quantify the pressure-reducing properties of cushions. Thomas Krouskop, the engineer and principal investigator on the REC, had actually designed and constructed this device in his garage to be tested and validated in the “real world” of the clinic with spinal cord–injured patients (Garber, Krouskop, & Carter, 1978).

The large, seat-size sensing pad design was unique; it contained a flexible printed circuit of pneumatically controlled contact switches connected by wires to a data output module. Each of the lights on the readout display was wired to a corresponding transducer in the pad and represented a localized point of tissue loading. An air pump controlled pressure at which the contact switch closed. Ischial tuberosities and other bony prominences were located by palpation, and corresponding lights on the display box were noted on a data collection sheet. The pad was inflated with a hand pump until all of the lights went out, and then, as the air in the pad was released, a pattern of pressure, specifically over the ischial tuberosities and coccyx areas, was observed. A Polaroid camera was used to photograph the patterns of pressures on the various cushions.

Unfortunately, the wires were so fine that, with the pad’s inflation and then the patient’s sitting pressure, they would snap, rendering the light grid dark. The message to me was that without some creativity on my part, this job was going to be extremely short lived, as I was calling the engineers every day to repair the system. Under clinical conditions, this system’s design was too cumbersome and the sensing pad design too delicate to be clinically useful. It did not provide reproducible results and, therefore, would not be predictive of pressure ulcer risk, two basic scientific principles of measurement. I needed to find a tactful way of telling the engineers that the pressure evaluation device was not a functional clinical tool.

My strategy was to invite the engineers to observe me with patients in the clinic to demonstrate the difficulties encountered. We then worked together to modify this device to make it a more effective and durable evaluation tool. We introduced a different design with sturdier materials to overcome the problems occurring in the clinic. The redesigned pressure mapping system, now called the Texas Interface Pressure Evaluator (TIPE), became a clinical evaluation tool widely used by occupational therapists at TIRR to assess the pressure-reducing properties of wheelchair cushions.

Projects of the Texas Rehabilitation Engineering Center

The intent was to provide the one cushion that reduced and redistributed sitting pressure most effectively for that specific patient. However, we learned firsthand that there was no universal cushion; rather, each patient required an individualized assessment (Garber, 1985; Garber & Dyerly, 1991).

Thus, the role of the occupational therapist was essential in developing a feasible evaluation device. The selection of an effective pressure redistribution cushion would improve sitting tolerance and occupational performance and reduce the risk of pressure ulcers (Garber, Rintala, Rossi, Hart, & Fuhrer, 1996). Commercially manufactured pressure-mapping devices followed, and an industry was born. We took the TIPE on the road to other facilities and introduced it to patients other than those with spinal cord injury, such as people with spina bifida and residents in nursing homes. It also was used to assess interface pressure of people confined to bed on a variety of hospital mattresses, overlays, and specialty beds (Krouskop, Williams, Krebs, Herszkowicz, & Garber, 1985).

Owing to the limited predictability of pressure per se for preventing future ulcer occurrences, we needed to look beyond merely the pressures measured by the TIPE because the wheelchair cushion, no matter how sophisticated the evaluation tool used to select it, was only part of the answer to preventing pressure ulcers. Other factors were posture, occupations performed from the wheelchair, ability to perform weight shifts, general health and comorbidities, and social support. An occupational therapist’s observation skills were invaluable in expanding these ideas (Fuhrer, Garber, Rintala, Clearman, & Hart, 1993; Garber, Rintala, Hart, & Fuhrer, 2000).

Recognizing factors other than pressure resulted in several clinically relevant projects that, in combination, addressed the central problem of pressure ulcer prevention and development. For example, periodically shifting one’s weight allows blood and oxygen to return to the tissue. However, patients often did not remember when it was time to shift their weight. The “reminder of excessive pressure” was a device that intermittently produced a mild superficial electrical shock, usually to the upper arm where sensation was intact, to remind the patient to perform a weight shift. Weight-shift techniques were based, in part, on the patient’s upper-extremity range of motion and strength. Thus, for patients who shifted their weight side to side, we used the TIPE to determine how far they would have to lean to the side to reduce pressure on the opposite side. We then taught the patients the most effective way to incorporate weight shifts into their daily routine, and the reminder of excessive pressure helped them develop a time sequence for the weight shifts.

Sitting time and tissue tolerance became another area of concern. Often, we did not know our patients’ true sitting time and, hence, how long they could sit without developing a pressure ulcer. We developed and tested a “sit time monitor” to document consistently and accurately how much time patients actually sat in their chairs (Halstead, Damon, Zatlin, Hanover, & Bohlen, 1982). This device resulted in studies of tissue viability and time sequences for weight shifts, turning in bed, and performing daily occupations.

For spinal cord–injured patients who were returning to their prior jobs or starting new ones, we needed to evaluate work environments to adjust sitting times and maximize function. To evaluate the maximum functional reach in a vocational setting, we tested an evaluation tool called the “range of motion sensor” to determine the extent of reach needed to achieve effective weight distribution when a person was performing sedentary occupations. Pressure redistribution was best achieved when the person performed a cross-body reach. Workstations were modified so that people with spinal cord injury could perform their work tasks in safe and functional environments (Swarts, Krouskop, & Smith, 1988).

We customized cushions for the wheelchair by first evaluating and then carving up different types of foam. In one study, we wedged the underside of a block of temper foam and found that pressure was reduced significantly for some patients. This investigation became the focus of my master’s thesis at Texas Woman’s University (Garber & Krouskop, 1984). We also recognized that posture, balance, and stability were important considerations for people in wheelchairs. The evolution of back and side supports became significant adaptations to wheelchairs for our patients. We also worked with manufacturers to design pressure-reducing seating for surfaces other than the wheelchair, such as the Roho^® saddle. The clinical occupational therapists at TIRR participated in data gathering and interpretation and, in some instances, writing up the results. Expansion of research translation in the clinic was the true legacy of the REC.

The development and testing of the technology produced by the REC was the beginning of the clinical science of pressure ulcer prevention. As the lead clinician and patient advocate on the REC team, I literally brought the engineers into the clinic to observe the utilization of the technology and resulting outcomes. Initially, these technological devices were designed for testing within clinical settings and were not directly transferrable for use by people in their homes. However, the reminder of excessive pressure evolved into watches that beeped or chimed when a person was supposed to shift weight; the maximal reach sensing apparatus enabled us to design functional, safe workstations for people returning to sedentary employment. Every effort was made to assess accurately interface pressure and provide a cushion that would maximally reduce the risk of ulcers.

We were successful most of the time. However, occasionally we discovered that although pressure itself had been reduced on a particular cushion, that cushion was not meeting the needs of people who had returned to their home, community, or employment. For example, in one patient, we used the TIPE to evaluate several cushions and selected the Roho, a rubber air-filled cushion with a manual valve. A week later, the patient returned complaining that the cushion had developed a leak. We replaced the cushion immediately and sent him on his way. This was repeated several times over several weeks before we finally learned that he had returned to work as a welder. Every time he used the welding torch, sparks caused a small hole in the rubber cushion. We did additional testing and found an alternative to the Roho to be used during work hours. Observing and understanding a patient’s occupational performance needs are at the very core of every occupational therapist’s professional mandate.

Developing Research Questions and Care Models

Observation of our patients and the evolving technology gave way to many new questions:

What specific patient characteristics needed to be addressed so that healthy skin was maintained?
How did one’s body build and posture effect pressure distribution (Garber & Krouskop, 1982)?
For the patient in the side-lying position in bed, what position of the legs would reduce trochanteric pressure (Garber, Campion, & Krouskop, 1982)?
What was the effect of cushion covers on pressure redistribution?
What lifestyle factors influenced adherence to recommendations for prevention?
What were the risks of recurrence once the person with a spinal cord injury returned to his or her home and community (Rodriguez & Garber, 1994)?

Many times, manufacturers of wheelchair cushions and seating systems requested “testing” of their products. These requests consisted of putting their product under patients, observing how they “liked it,” and reporting back to the company. This method was neither a credible nor a valid means of objectively evaluating a pressure-reducing device, or any device. The companies had done testing internally, but the Food and Drug Administration did not require clinical trials on wheelchair seating products.

We developed proposals that described a research design that would provide verifiable and reproducible information about a product meant to reduce pressure ulcer risk. These proposals described specific quantitative and qualitative criteria that would be assessed and the anticipated outcomes. A budget to cover the costs of the research was included, and the protocols were submitted to the Institutional Review Board (IRB) for Human Subjects Research.

Companies as far away as Israel asked for our clinical evaluation of their products. This is proof that good clinical science is in demand worldwide and that skilled practitioners create a market for the translation of scientific results into clinical advances. A degree of imagination and openness to change are essential tools in the armamentarium of the therapist with a prepared mind.

Initially, the reactive acute care model, consisting of medically or surgically treating the ulcer once it appeared, was the standard approach. This model of care resulted in extremely high recurrence rates and high costs among at-risk populations. A new model was needed. In medicine, primary prevention was emerging as a more cost-effective treatment paradigm in chronic disease management. As a clinician, I recognized that primary ulcer prevention would not only reduce costs but potentially improve people’s quality of life. Until we, within the REC, devised individualized pressure ulcer prevention and management programs, there was no precedent for comprehensive, multidisciplinary approaches to prevention and management.

Because the occurrence of pressure ulcers among people with spinal cord injury is a lifelong risk, we began to investigate primary prevention as the best approach long term. Tissue pressure management and ulcer prevention are, in fact, the proper purview of the occupational therapist because they involve quality of life, daily living activities, and occupational concerns across the lifespan. In many ways, this was an early example of the so-called personalized medical care that has become de rigueur.

Perhaps the most significant question to emerge was, Why was there so much secondary pressure ulcer recurrence among people with spinal cord injury? One answer was the lack of any coordinated post–pressure ulcer treatment follow-up. As with many chronic diseases, patients were expected to become their own care providers after discharge. Although pressure ulcer prevention strategies were reviewed with every patient and caregiver following hospitalization or outpatient treatment, patients were discharged back to their communities with minimum or no support for continuing relevant strategies to prevent recurrence.

Tissue Pressure Management Program

We had identified that pressure ulcer prevention and treatment were about much more than quantifying interface pressure, providing wheelchair cushions, timing weight shifts, and performing skin inspection. Therefore, we created the tissue pressure management clinical program, the focus of which was prevention through individualized patient assessment, education, and follow-up care (Krouskop, Noble, Garber, & Spencer, 1983).

This outpatient program provided a venue in which a multidisciplinary team worked with people with spinal cord injury to reduce or eliminate the revolving-door effect that had kept patients returning to the hospital with ulcer recurrence. The tissue pressure management team consisted of a plastic surgeon, occupational therapist, nurse, case manager, and, later, a psychologist. As an occupational therapist, this was the crowning achievement of my collaboration with the engineers in the REC.

The tissue pressure management clinic provided many opportunities to identify the causes of pressure ulcers that, until then, had not been studied within a program of comprehensive care. Social support, depression, inability to translate knowledge about pressure ulcer prevention into effective preventive behaviors, and maintenance of equipment emerged as important concerns. These insights were derived, at least in part, from a background of broad occupational therapy skills and experience. Without them, recognition of important factors might have escaped the REC staff.

Patients were seen in the clinic to have their skin checked, receive treatment of existing pressure ulcers, have their wheelchair and seating systems assessed for utility and condition, identify existing social and psychological support, and provide additional information on prevention. All patients were given contact information of a professional care provider to answer questions regarding their skin care and were strongly encouraged to take an active role in preventing pressure ulcers. Educational programs and printed materials were developed for inpatients, outpatients, families, and caregivers (Figure 1).

Figure 1.

Tissue pressure management clinic protocol.

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The multidisciplinary tissue pressure management program was exported to area hospitals through lectures and demonstrations. We presented workshops, courses, and posters describing this comprehensive program at state and national meetings and shared our findings and experiences with other professionals. Pressure ulcer prevention and management lesson plans for patients were distributed as handouts at professional meetings and used at many facilities. Eventually, I had them copyrighted.

I developed a pressure ulcer knowledge test to learn what patients knew about pressure ulcers. Knowledge did not always translate into preventive behaviors; patients often were able to answer the questions correctly but still developed pressure ulcers. Studies were designed that incorporated knowledge about pressure ulcers with structured follow-up counseling. These studies provided opportunities to identify and study individual prevention and treatment strategies for reducing recurrent ulcers. Pressure ulcer research was gaining momentum; an occupational therapist could contribute significantly to this growing body of knowledge (Garber et al., 1996).

Over the course of the first 2 years of the program (1976–1978), the ulcer recurrence rate declined from 32% to 9%. By 1979–1980, with the introduction of psychological counseling and education programs, we reduced the rate further to 4%. These results were far better than our expectations (Krouskop et al., 1983). The program outlined a philosophy for the patient and family education we believed would reduce recurrence. The development of clinically relevant and practical pressure ulcer education programs was essential to the concept of secondary prevention. The tissue pressure management program empowered patients to be part of their own care team, a relatively novel concept for people with spinal cord injury at that time.

Pressure ulcer prevention and treatment education programs for patients and clinicians evolved with structured formats in an attempt not only to teach the facts about pressure ulcers but, more importantly, to encourage behaviors that would result in better outcomes. Initially, education programs were developed for nurses in hospitals and long-term care and rehabilitation facilities. Several rehabilitation hospitals with large spinal cord injury populations developed their own structured lesson plans and education sessions for their inpatients and handouts for outpatients. At TIRR, the inpatient program was called “RAP” sessions because after a formal presentation, the speaker (nurse, occupational therapist, physical therapist, social worker, or psychologist) would encourage discussion among the attendees.

The clinical program created by the REC and implemented at TIRR was built on the philosophy that prevention and treatment are inextricably woven into the continuum of care of people with spinal cord injury. The patient education programs were individualized to each patient with consideration of such factors as knowledge about pressure ulcers, risk, current occupations, pressure ulcer history and recurrence, and relevant equipment. It was essential that we identified prevention strategies compatible with each person’s lifestyle and barriers that might interfere with implementing effective approaches. Short- and long-term goals were set, and support systems—family, friends, and attendants—were identified. Patients were provided with written material developed under the auspices of the REC. Perhaps the most important element of any education program must be a mechanism to measure the extent to which the education was effective. In this case, the outcome measured was a reduction of pressure ulcer recurrence.

Influencing Practice

In addition to the RECs, large research grants began to focus on community integration and preventing secondary complications among people with spinal cord injury. These studies provided the opportunity to develop and study new approaches to pressure ulcer prevention and expanded occupational therapy’s role in this area of care. Several times each year, funding agencies (federal and Veterans Affairs [VA]) put out calls for proposals, each with a central focus. Often I was part of the team that put together these large-scale, multiproject grants and included occupational therapy students and clinicians as participants.

The tissue pressure management clinic was the translational product of the basic advances made by the REC clinical research team. It became a standard of care for patients with a spinal cord injury and an early example of clinical translation from a research initiative. As the results of these clinical efforts were published in professional journals and presented at national meetings, they became a convincing demonstration of research translation that provided better models of care and improved clinical outcomes (Garber & Rintala, 2003).

Changing professional habits through the diffusion of new knowledge is a slow and tedious process. Initially, it depends on the recognition of existing treatment inadequacies, something very difficult to admit. Then, it requires mechanisms for the packaging and delivery of new knowledge in teachable quantized units of education. Finally, it requires therapists around the world with their own prepared minds who are willing to try these new methods and adapt them to their own special clinical situations.

Throughout the years, occupational therapists have worked with engineers to improve the health and well-being of people with disabilities. From pressure ulcers to robotics, from seating and mobility to upper-extremity assistive devices, from pressure-reducing materials to environmental control switches, occupational therapists have worked side by side with engineers to provide the clinical and occupation-based components of developing, implementing, and evaluating devices and services that improve the lives of people with disabilities (DiSante, 1978; Gordon & Kozole, 1984; Taylor et al., 1984). We have looked beyond the obvious, have asked difficult questions, and have been open to new and innovative solutions. The REC was the perfect environment to encourage the prepared mind.

Part III. Occupational Therapy and Tissue Pressure Management

In wisdom gathered over time, I have found that every experience is a form of exploration.

—attributed to Ansel Adams (n.d.)

Developing Clinical Practice Guidelines

Occupational therapy became nationally recognized in pressure ulcer prevention and treatment in 1990, when the Agency for Health Care Policy and Research (AHCPR) sought an occupational therapist to participate on two panels developing clinical practice guidelines for the prevention and treatment of pressure ulcers in vulnerable populations. My publications and presentations brought me to the attention of the American Occupational Therapy Association (AOTA) and AHCPR, and so began a new and challenging part of my career that continues until today.

I was a member of two guideline development panels focusing on older adults, people in long-term care, hospitalized patients, and postsurgery patients. As the only occupational therapist on these panels, I brought to the process new research and clinical experiences.

Our challenge was to review all of the published literature on pressure ulcers, evaluate their scientific merit, and analyze their relevance to the development of guidelines for pressure ulcer prevention and treatment. My primary contribution to the AHCPR guidelines was to review the literature that dealt with the role of education in preventing and treating pressure ulcers. After reviewing several hundred abstracts and full published papers, I discovered that rarely were the educational models for either patients or health care professionals evaluated for their effectiveness in either preventing or healing ulcers. Even well-designed protocols for teaching nurses about prevention or treatment did not have a mechanism in place to determine knowledge acquired or retained over time or a measure to determine a desired outcome (Bergstrom et al., 1992, 1994).

The AHCPR guidelines soon were followed by a request from the Paralyzed Veterans of America’s (PVA’s) Consortium for Spinal Cord Medicine to represent AOTA on its consortium. The PVA was forming panels to develop guidelines specifically for people with spinal cord injury, and guidelines for pressure ulcer prevention and treatment were among the first. I was appointed to the consortium and later was named chair of the pressure ulcer guideline development panel. These guidelines were published in 2000 and updated in 2014 (Garber, Biddle, et al., 2000; Garber, Bryce, Gregorio-Torres, Ho, & Rader, 2014).

The PVA panels used the same process to identify relevant literature as the AHCPR panels: Identify, review, and grade the literature. Each guideline was directive and supported by relevant graded evidence, even if it was not the highest level. In many cases, “expert clinical opinion” was the only support given for prevention and treatment strategies because the scientific evidence did not exist. Rarely were there randomized controlled trials, the gold standard for research evidence. Each guideline reflected the highest quality of care without reference to cost. These guidelines were not standards; rather, they were “recommendations” that could be implemented in patient care protocols.

Unfortunately, guidelines are not easily implemented. Changing the culture of an institution is never easy. Barriers to implementation include resistance by administrators, nurses, and physicians; cost; difficulty in changing practice; and lack of confidence in the evidence. The challenge was to introduce the guidelines as based on the best available scientific evidence and work with all stakeholders (Clark, 2003; Thomason et al., 2007). It took a great deal of patience and perseverance to convince them that implementing the guidelines, especially the ones pertaining to prevention, had the potential to reduce costs and improve outcomes. The result was worth the effort, however, because the quality of care improved and occupational therapists became even more involved in pressure ulcer prevention. In 2013, AOTA published its first position paper on occupational therapy and wound management.

Expanded Research Opportunities

Significant advances in pressure ulcer prevention and treatment were the result of our work in the REC. Occupational therapists became directly involved in spearheading the evaluation and prescription of pressure-redistributing devices, wheelchairs, and seating systems and in providing important information about pressure ulcer prevention and management to patients, families, and caregivers. Pioneering computer-based education programs were being developed from Australia to Virginia, and I participated as a consultant, content expert, or coinvestigator on these projects. Collaboration with other health care professionals and, yes, a new generation of engineers enabled me to broaden the scope of my work with new questions to ask and answer.

Large-scale investigations that addressed community integration and underserved populations included independent pressure ulcer research projects. Some tested interventions for changing patients’ behavior and enabling them to take a more active role in their pressure ulcer prevention. Some evaluated new technology in pressure-reducing devices and telemedicine as a means of assessing tissue and skin status (Rintala et al., 2004). Among the studies were the following:

Houston VA Rehabilitation Research and Development Center of Excellence on Healthy Aging With Disabilities under the leadership of Arthur Sherwood (Garber, Rintala, Holmes, Rodriguez, & Friedman, 2002; Rintala, Garber, Friedman, & Holmes, 2008)
Rehabilitation Research and Training Center on Community-Oriented Services for Persons With Spinal Cord Injury under the leadership of Marcus Fuhrer at Baylor College of Medicine (Fuhrer et al., 1993)
Spinal Cord Injury Model System Program at TIRR under the leadership of R. Edward Carter (Donovan, Carter, Bedbrook, Young, & Griffiths, 1984)
Pressure Ulcer Prevention Study at the University of Southern California under the leadership of Florence Clark (Clark et al., 2014)
Rehabilitation Engineering Research Center on Spinal Cord Injury at the University of Pittsburgh under the leadership of David Brienza (Wu, Garber, & Bogie, 2015).

Over time, my research activities took me beyond the realm of pressure ulcers, yet pressure ulcers continued to dominate my professional life. Among the more unusual research projects for an occupational therapist were VA studies of exercise and fatigue among patients with prostate cancer undergoing radiation (Monga et al., 2007); sexuality in persons with lower-limb amputations (Bodenheimer, Kerrigan, Garber, & Monga, 2000); sexual functioning in prostate cancer patients before and after radiotherapy (Monga, Kerrigan, Garber, & Monga, 2001); association of decreased hemoglobin levels, age, and comorbidities with rehabilitation outcomes following total knee replacement (Wang, Rintala, Garber, & Henson, 2005); and the effects of cardiac ejection fraction on functional outcomes after stroke.

I also had the opportunity to participate in studies of robotics for both therapy and function, such as the VA multisite clinical trial on robot-assisted upper-limb therapy in acute rehabilitation after stroke, led by Dr. Charles Burgar at the VA Palo Alto Health Care System (Burgar et al., 2011). I always have been interested in device utilization and satisfaction and, as a result, developed studies to determine long-term use of and satisfaction with upper-extremity assistive devices for people with spinal cord injury (Garber & Gregorio, 1990) and wheelchairs for people with stroke (Garber, Bunzel, & Monga, 2002).

I jumped at every opportunity to study clinical areas outside the sphere of pressure ulcers. Once trained in scientific methodology, a therapist with a prepared mind is free to examine multiple new opportunities in other areas as they arise. Research techniques become the tools for generalized problem-solving approaches.

Part IV. Incorporating Research Into Practice

Each time an occupational therapist treats a patient, a clinical experiment is performed in which the objective is to replicate a successful outcome of a past experiment.

—Joan C. Rogers (1983, p. 607)

Practice Drives Research

Research in occupational therapy did not begin as formalized sponsored inquiries but rather from questions that arose from clinical practice. In her 1983 Eleanor Clarke Slagle Lecture, Joan Rogers observed that a clinical experiment is performed each time an occupational therapist treats a patient. The earliest occupational therapy scholars and scientists sought answers to questions that evolved or emerged from their clinical experiences, especially those that were unsatisfactory. These questions resulted in the development and testing of theories, models of care, assessments, and interventions:

A. Jean Ayres, observing a relationship between sensory processing problems and motor and academic learning problems in children, developed the theory of sensory integration (Ayres, 1963, 1977). This theory resulted in numerous tests and interventions therapists would use to understand the inadequacies of current practice with children with sensory insufficiency.
In the 1950s, Margaret Rood used cutaneous stimulation to improve function in patients with neuromuscular impairments (Rood, 1954, 1958).
Josephine Moore studied the limbic system and its effect on behavior (Moore, 1976).
Shereen Farber developed theories on occupational therapy and neuroscience (Farber, 1989).
Laura Gitlin, a social scientist, collaborated with occupational therapists to study adaptive processes in old age (Gitlin, Corcoran, & Leinmiller-Eckhardt, 1995).
Wilma West encouraged us to think about our role in prevention and the socioeconomic and cultural causes of disease and dysfunction outside hospital settings (West, 1968; Wiemer & West, 1970).
Florence Clark developed the concept of occupation in lifestyle redesign in her Well Elderly Study (Clark et al., 2001; Jackson, Carlson, Mandel, Zemke, & Clark, 1998) and later in the Pressure Ulcer Prevention Study (Clark et al., 2014).
David Nelson and Gary Kielhofner developed models of care (Kielhofner, 2008; Nelson, 1997; Parkinson, Forsyth, & Kielhofner, 2006).
Theories such as occupational adaptation were examined (Schultz & Schkade, 1992).
Joan Rogers advocated for us to use clinical reasoning skills when collecting and using data and making patient care decisions (Rogers, 1983).

Throughout the years since the 1970s, many other occupational therapists have embraced scientific inquiry. In her Slagle Lecture last year, Helen Cohen (2015) urged occupational therapists to base their careers on inquiry on a daily basis, making inquiry an ADL for all occupational therapists.

Researchers develop a passion for a particular area of study because current interventions are less than satisfactory in helping their patients (Kielhofner, 2006). Early occupational therapy investigators did not begin their careers knowing how to do research. They pursued advanced degrees in related fields to develop the skills necessary to design sound methods to study topics they chose. They took chances by challenging current practice. They spent long hours and reams of paper writing and submitting grants and, with great skill and a little luck, received funding to translate their ideas into valid assessments and effective interventions for their patients and clients. They developed manuscripts for publication in professional journals and presented their work at numerous conferences. Acceptance of some of their ideas was not always easily won, and at times, controversy followed them everywhere. But they persevered.

Challenges to Incorporating Research Into Practice

Incorporating new clinical evidence into practice is challenging. We must recognize the relationship between the data obtained and a particular patient group, develop new intervention directions for practitioners, and overcome resistance to adopting new treatments. Of utmost importance is a conscientious appreciation of the environment in which the practice change is needed. Effectiveness studies are difficult to conduct because they must be structured to include randomization, control of variables, sample size and power considerations, use of valid and reliable measures, IRB regulations, and a great deal of time to develop and implement (Gutman, 2009). Finally, in an environment in which productivity standards must be met, clinicians find that the competing responsibilities of teaching, supervision, and mentoring may become secondary.

Integrating research into occupational therapy practice is essential if the profession is to continue to grow and be recognized. Our profession has a long history of trying to prove its worth by moving away from crafts and traditional ADL training toward what were perceived as more scientific approaches. New therapists find that explanations are rare as to why media and methods come and go.

In her 1986 Eleanor Clarke Slagle Lecture, Kathlyn Reed asserted that culture sets the major parameter for change because it determines the occupations in which we participate (Reed, 1986). However, progress in technology and medicine has altered aspects of our culture and required major changes in the way occupational therapists are educated and practice. Today, academic institutions are challenged to keep pace with these advances so that students receive the latest information and new practitioners understand and implement the most current and relevant treatments.

As a practice profession, occupational therapy has faced additional challenges in conducting and implementing research. Identifying and using relevant research models and determining the compatibility between scientific methods and practice are just two of those challenges. At times, models of scientific investigations may be in conflict with our profession’s service mission. Nevertheless, within our repertoire of expert clinical skills exists the scholarly behaviors necessary for research. Therefore, a dual mission of research in a practice profession exists: Research must contribute to the development of a body of knowledge, and research must sustain and improve clinical practice (Llorens & Gillette, 1985).

Facilitating research in the occupational therapy clinic may be a goal of many fieldwork and clinical supervisors. Yet, students and clinical staff get the impression that this goal is not essential and does not relate directly to their current practice. Because occupational therapy students may not acquire research skills during their entry-level academic programs, fieldwork supervisors should make acquiring such skills an important component of the fieldwork experience. Level II fieldwork students at TIRR were required to develop and implement a short-term research project and present it to the staff. Some of these efforts resulted in publications in professional journals or were presented at state or national meetings (Garber et al., 2002; Garber & Dyerly, 1991; McKenzie & Garber, 1997). Residents in departments of physical medicine and rehabilitation conducted research in which occupational therapists participated (Wang et al., 2005; Wu et al., 2015). An elective fieldwork experience in research was also created.

Practitioners need encouragement to develop ideas and conduct clinically relevant investigations in clinical environments despite significant obstacles. The clinical occupational therapist must meet productivity standards, acquire continuing education credits to maintain licensure, deal with shorter lengths of stay for hospitalized patients, and face denial of reimbursement for services provided, all within the context of providing care within new health care delivery models (Figure 2). At this time, we do not know what the long-term effect of these issues will be on quality of care, functional outcomes, or professional growth. Still, occupational therapists should be able to recognize and take advantage of clinical research opportunities in their clinics if they are to grow professionally.

Figure 2.

Challenges to conducting research in the clinic.

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For the academician, the challenge continues to be developing and adapting courses that address an ever-expanding scientific and clinical base and better preparing occupational therapy students to function in a variety of settings. Academicians need to identify better ways of facilitating the transition from student to clinician and continue to encourage students to identify and participate in research directly linked to their clinical practice. It is important to identify the changing roles in which we will find ourselves. Changing trends in health maintenance and the power of advancing technology have catapulted us into uncharted waters (Burke, 1984). Adaptation is the key to preparing occupational therapy students, and practicing clinicians, for the challenges ahead.

Part V. Advances in Research

Chance favors the prepared mind.

—Louis Pasteur (cited in Gelson, 1965)

Advances in research can be translated into clinical strategies if a person with a prepared mind encounters opportunity. Therefore, clinicians must have an adequate background, realize that existing assessments and interventions are less than satisfactory, and understand that patients require new and creative therapeutic interventions. The person with a prepared mind takes advantage of new concepts and applies them to existing practice, which, initially, may not be accepted. How, then, does one prepare one’s mind to meet challenges and take advantage of unexpected opportunities? What prepares the minds of students, educators, and practitioners to go forward in productive and meaningful ways? For the occupational therapist, what constitutes a prepared mind?

We begin with our basic education transition to student clinician, and move on to employment, usually within clinical environments. New learning must be continuous throughout all of our educational and clinical experiences. Yet, professional education can fulfill only part of the need. Life’s experiences and our adaptation to social, economic, occupational, and psychological changes all contribute to preparing the mind to meet challenges.

Individually and as a profession, we need courage, focus, persistence, patience, and perseverance. Being adaptable and open to new ideas and new methods are the keys to our success as a profession. Drive, enthusiasm, and a willingness to be challenged are essential characteristics of a prepared mind. We need knowledge of our own skills, assets, deficiencies, and limitations. Our past has important lessons: Learn from it, embrace it. We must have a sense of ourselves as competent human beings and be willing “to boldly go where no man”—or woman—“has gone before.” Never settle for the status quo (Figure 3).

Figure 3.

Characteristics of the person with a prepared mind.

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Throughout our history, the challenge for occupational therapists has been to identify and define our role within expanding health care frameworks. Education of occupational therapy students and the practice of occupational therapy in the years ahead will have little resemblance to what we have experienced in the past. Setting professional goals in a very uncertain health care environment is both daring and frightening. As educators, we must develop and implement curricula that are relevant to current issues; as clinicians, we must adapt to an ever-changing market. As researchers, we must rigorously evaluate the effects of our efforts; this evaluation must be an integral part of both academic and clinical experiences.

Today, education and practice must equip us with skills that generate answers to questions and translate research results into improved strategies for patient care. New knowledge is the dominating force behind professional growth. The measurement of outcomes often has not been scrupulously studied. Often we have been unable to prove that an intervention was effective, putting us on the defensive. Educators and clinicians must introduce research into the clinical practice paradigm. Lacking rigorous, meticulous, and thorough proof of effectiveness has inhibited professional growth, recognition, and respect.

As a profession, we must incorporate new knowledge into improved treatment approaches and provide evidence of the effectiveness of new techniques (Burke & Gitlin, 2012). Formal occupational therapy education has provided only the foundation. However, our education programs have not been static; they have evolved not only in content but also in intensity as medicine and technology have expanded exponentially. The results have been the elimination of entry-level baccalaureate programs in favor of entry-level master’s programs and consideration of the entry-level doctorate.

Within the profession, there always has been a move to upgrade education and clinical training for practitioners, meaning additional education and degrees. We must be prepared to look at things differently on the basis of evolving concepts and new knowledge gained and the recognition that current therapeutic strategies are inadequate for dealing with certain clinical problems. Courses that teach research methodology should encourage research participation and demystify the research process.

A hierarchy of “products” is derived from occupational therapy education programs. This concept was introduced in 1987 by the AOTA Entry-Level Study Committee. This hierarchy is intended to stratify and define the roles of our professional workforce so that its members can be trained accordingly. I have taken the liberty of modifying the original hierarchy on the basis of our current education structure:

At the first level, the entry-level student becomes the skilled practitioner trained in current occupational therapy philosophy, methodology, and theory.
The second level consists of clinical supervisors who can incorporate new knowledge and techniques into practice methods. These are the people who take new advances and integrate them into existing, traditional practice models and see them implemented by clinicians.
The third level includes the people who develop new knowledge, both fundamental and translational. They generate new knowledge through rigorous study and translate it into proven superior clinical practice interventions.

This hierarchy does not mean that entry-level-trained occupational therapists are not able to generate new knowledge or develop and conduct rigorous research: Occupational therapists at every level are on the front line of inquiry because each patient presents them with unique questions that require answers.

Occupational therapy students today are deluged with enormous amounts of scientific, theoretical, and clinical information. They participate in a variety of fieldwork experiences that focus on confronting disability and disease. Yet, disease prevention and health maintenance now have emerged as extremely important additional considerations for occupational therapists whose patients are returning to their homes and communities. Moreover, our patients are living longer with their physical and cognitive impairments and are subject to the same aging effects as the general population. Longer lifespans also increase their risk of more serious secondary complications. In many ways, our patients must become their own caregivers and advocates. Occupational therapists are in a position to develop better models for patient education and treatment so that the prevalence of these existing and new complications can be reduced.

A new therapist will not generate a research project de novo. Instead, therapists with a prepared mind first should learn the literature in an area of interest and then find a skilled academic or clinical mentor whose interests they share. If a new question is of sufficient interest, it can be pursued as a joint endeavor. Develop your interests over time during the early years of clinical practice. Read and learn to analyze the scientific literature in both the occupational therapy literature and other professional journals and related fields of interest. Be inquisitive. Look for research opportunities within your facilities. Approach people who are working on projects that are of interest to you, and put forth an occupational therapy perspective. Be creative; be flexible; be willing to recognize the inadequacies of current practice and make changes. Learn that association is not proof of causality. Be persistent, especially as research funds continue to dwindle and competition for grant funds expands. Most important: Your clinical experiences over time will evoke the area of research that captures your enthusiasm and energy (Figure 4).

Figure 4.

Guidelines for entry into research.

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The person with a prepared mind shows initiative, is organized and systematic, and is open for the challenges patients present. Initially, simple questions with appropriate protocols and methods are best. Don’t try to address major issues all at once, and don’t expect to always get the answers you seek. Documentation, whether in clinical notes or when collecting and entering data, requires precision and consistency. Research rarely, if ever, occurs in a vacuum. Collaborate. Ask colleagues in other fields to work with you. The collaboration between clinician and researcher provides collective resources that will expand the efforts of both (Mortera, 2007). When attending conferences, look for symposia, workshops, or lectures on research design, implementation, grant writing, and funding.

Over almost 100 years, our profession has evolved from craft-based occupations to a scientific and evidence-based health care profession devoted to the restoration of function. This transition—this evolution—did not occur by chance or overnight but rather by the hard work and scrupulous thought of skilled occupational therapy researchers, practitioners, and educators who have generated the new knowledge to produce the desired better outcomes for patients. These early researchers laid the foundation for future professional development. The rigor of engaging in research trains and prepares the mind to reject the status quo. In other professions, doctoral degrees are conferred for research projects that train and prepare the mind to understand and analyze new clinical advances. In designing and implementing research, we use critical skills to translate these advances into improved clinical models that become the stimuli for the advancement and enhancement of the occupational therapy profession. Therefore, one of the primary goals of occupational therapy education must be to prepare students to create and innovate through scientific inquiry.

In every generation of our profession’s knowledge expansion, educators, clinicians, and researchers have advanced the scope and practice of occupational therapy. Some of the earliest Slagle Lectures have cited research as an essential component of both education and practice. We must continue to build on that heritage.

I have always considered myself an “accidental scholar” because my early career planning certainly had not included a focus on pressure ulcers or research per se. It was unplanned and unintentional and occurred by chance. Yet, I was in the right place at the right time and took a chance on a promising project that led me, ultimately, to this lecture today. I also had tremendous support at home and mentors on the job; I developed professional relationships that have lasted until today and have continued to learn from my colleagues, mentors, and patients. In my work with the engineers, I have learned to apply scientific principles in the clinic where few had previously existed and translated the research results into clinical protocols. I did not plan to have a career in research; yet, when the position became open, it took a tremendous amount of courage to take on something new and uncharted and make it my own. This, too, is a characteristic of the prepared mind.

What we have created in almost 100 years will be enhanced and ennobled by our future efforts to establish and maintain a rigorous foundation for occupational therapy practice. This foundation for the profession did not develop or arise fully formed like Athena from the brow of Zeus. Rather, occupational therapy has evolved as the result of research and critical assessment of practice. Occupational therapists have the capacity to create environments that will facilitate fundamental inquiry and critical thinking.

I have had, and continue to have, a very interesting professional career, one in which I have been able to take advantage of many opportunities traditionally and historically not available to occupational therapists. I had the rare, uncommon, and unusual opportunity to work in a milieu of established scientists and engineers, an environment with a clear research focus. These interactions and collaborations allowed me to consult with experienced clinical investigators, biostatisticians, and other academically oriented investigators. For the occupational therapist in training, or the new occupational therapist in practice, such an environment may not be readily apparent, but the therapist with a prepared mind will find opportunities to create such an environment.

Seize those opportunities! They will make you a better occupational therapist and a critical thinker, not only in the occupational therapy clinic or academia, but in everyday life.

Dedication and Acknowledgments

2015 marked three significant milestones in my life. In January 2015, I celebrated 50 years as an occupational therapist. In April 2015, at the AOTA Annual Conference & Expo, I received the Eleanor Clarke Slagle Lectureship Award; I am deeply honored to have been nominated by Joan Rogers. In December 2015, I celebrated my 50th wedding anniversary. I dedicate this lecture to my husband, Alan Joel Garber, for his wisdom, strength, encouragement, and inspiration and for 50 years of an incredible adventure.

I am of the generation of occupational therapists in which Helen S. Willard was my earliest mentor. She supported and guided my academic coursework through my first 2 years of college, even though I was not at her university. Gail S. Fidler was my teacher. She was dynamic and mesmerizing and passionate about occupational therapy. After sitting in her classes, students believed that there was no other area of occupational therapy except psychiatry. She was an extremely strong advocate for relevant professional education. Clare S. Spackman was my clinical supervisor for my second “affiliation,” as it was called. She was very tall, wore pop-it beads in her hair, and had a deep voice that commanded attention in any room. At the end of my 3-month rotation at the Philadelphia Curative Workshop, she told me that she wanted to offer me a job when I completed my affiliations, but she knew that, most likely, I would get married and have babies. So much for history, although Ms. Spackman wasn’t entirely wrong.

I thank Theresa Gregorio-Torres for the very fine introduction. I also want to thank Kathlyn Reed for providing me with important historical information and Mindy Heckler (Wilma West Library) for obtaining reference material. To Helen Cohen, thank you for all of your support and friendship throughout the years and especially during the past year. And finally, thank you to all of the patients I had the privilege of helping overcome the devastating effects of pressure ulcers.

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Susan L. Garber, MA, OTR, FAOTA, FACRM

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Figure 1.

Tissue pressure management clinic protocol.

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Figure 2.

Challenges to conducting research in the clinic.

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Figure 3.

Characteristics of the person with a prepared mind.

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Figure 4.

Guidelines for entry into research.

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