Defining the Evidence Based Practice Decision-Making Model

Original Editor - Wanda van Niekerk

Top Contributors - Wanda van Niekerk, Jess Bell and Angeliki Chorti

Introduction[edit | edit source]

Evidence-based practice (EBP) was first introduced in the early 1990s as evidence-based medicine (EBM).[1] This “new paradigm” initially involved the practice of clinical medicine. It aimed to develop and advance a transparent and rational process for clinical decision-making that did not exclusively rely on intuition and single clinical expertise, and it could be taught, refined, and applied by all clinicians.[2] Since then, various models and frameworks have been proposed in the healthcare setting that apply to more fields than just medicine.[3]

Revised Model of Evidence-Based Practice[edit | edit source]

To learn more about the first evidence-based practice models from Sackett et al.[4] and Haynes et al.,[5] please see: Introduction and Overview of Evidence Based Practice.

In 2009, Satterfield et al.[2] further developed the evidence-based practice model and provided it with a transdisciplinary perspective by adding each discipline's efforts towards addressing deficiencies and making advances. The aim was to provide a common language across disciplines. This model had a new external frame that provided environmental and organisational context.[2] The three inner pillars of this model involved the[2]:

  • best available research evidence
  • client's or population’s characteristics, state, needs, values and preferences
  • resources, including practitioner’s expertise

At the centre of this evidence-based model was clinical decision-making.[2]

If you would like to find out more about Satterfield et al.'s model,[2] please see: Toward a Transdisciplinary Model of Evidence-Based Practice. Figure 5 in this article provides a schematic of the model.

Evidence-Based Practice Steps[edit | edit source]

Although these steps are chronologically numbered, they don't always occur in the same sequence. It may be necessary to go back a few steps before moving forward again. Please keep this in mind when applying the evidence-based practice model in your specific setting.

  • Step 1: Determining the patient’s needs to formulate a clinical question
  • Step 2: Locating the knowledge resources
  • Step 3: Appraising the quality of the knowledge resources
  • Step 4: Discussing the options with the patient
  • Step 5: Formulating the treatment plan
  • Step 6: Implementing the treatment plan
  • Step 7: Evaluating the effectiveness of the treatment plan and the evidence-based practice process

5 'A's of Evidence-Based Practice[edit | edit source]

The evidence-based practice steps are also often referred to as the 5 'A's. These terms and the steps of evidence-based practice are described in detail in Table 1. Please note that some texts use different terminologies (these terms are given in the brackets)[6][7]:

  • Ask
  • Acquire (Access)
  • Appraise
  • Apply
  • Assess (Audit)
Table 1. The Steps of Evidence-Based Practice
Steps of Evidence-Based Practice Description of Steps Which A?
Determining the patient’s needs to formulate a clinical question
  • Thorough assessment - patient interview, history, physical assessment considering patient's needs, values, context, preferences and beliefs
  • This information is used to formulate the clinical question that needs to be answered through the clinical decision-making process
 Ask
Locating the knowledge resources
  • Creating a search strategy, identifying which databases and which type of resources to use
 Acquire
Appraising the quality of the knowledge resources
  • Clinical appraisal checklists
  • Methodological quality assessments
 Appraise
Discussing the options with the patient
  • Interactive discussion with the patient
  • These three steps link closely together, and you may need to sometimes move up and down between these steps
 Apply
Formulating the treatment plan
Implementing the treatment plan
Evaluate the effectiveness of the treatment plan and the evidence-based practice process
  • Revise
  • Review
  • Reflect
 Assess

Common Terminologies[edit | edit source]

Table 2 includes a list of terms frequently used in evidence-based practice.

Table 2. Common Terminology Related to Evidence-Based Practice
Term Definition
Empirically supported treatments "treatments or interventions that have a specific type of research support for their effectiveness or efficacy" on one specific disorder / condition / population[8]
Best practice "strategies, approaches or activities that have been shown (through research and evaluation) to be effective, efficient, sustainable and/or transferable, and to reliably lead to a desired result"[9]
Research informed practice decision-making through the "conscientious, explicit and judicious use of the best available evidence from multiple sources to increase the likelihood of a favourable outcome."[10] It does not include patient preferences, values, context and clinical expertise.

Evidence-Based Practice Applications[edit | edit source]

There are different ways to apply the evidence-based practice model in healthcare settings. Some examples of clinical questions you might consider are listed in Table 3.

Table 3. Examples of Clinical Questions Used in Evidence-Based Practice Application
Question What does it help determine?
How common is the problem? Incidence or prevalence
Is the diagnostic test or monitoring test accurate? Diagnosis
What will happen if we do not add a therapy? Prognosis
Does this intervention help? Benefits of treatment
What are the common harms? or What are the rare harms of a specific treatment? Harms of treatment
Can this test help with the early detection of a specific condition? Screening application

You can download the following documents from the Oxford Centre for Evidence-Based Medicine. These documents are really useful when implementing evidence-based practice.

Challenges of Evidence-Based Practice[edit | edit source]

  • Lack of time to search for and apply the best available evidence – this is often due to heavy patient case loads[14]
  • Not enough or not good enough research is available on all conditions and scenarios[15]
  • Finding the right resources among the masses is difficult[15]
  • Accessing the resources[16]
  • Lack of administrative support[14]
  • Not skilled in critical appraisal[14]
  • Not enough role models practising evidence-based practice regularly / organisations not fostering a culture of evidence-based practice[17]

Advantages of Evidence-Based Practice[edit | edit source]

  • It offers the surest and most objective way to determine and maintain consistently high quality and safety standards in medical practice[7]
  • It can help speed up the process of transferring clinical research findings into practice
  • It has the potential to reduce healthcare costs significantly[18][19]
  • It can improve patient outcomes[19]
  • It increases healthcare provider empowerment and role satisfaction[7]
  • It meets the expectations of an informed public[7] [20]

References[edit | edit source]

  1. ↑ Evidence-Based Medicine Working Group. Evidence-based medicine. A new approach to teaching the practice of medicine. JAMA. 1992 Nov 4;268(17):2420-5.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Satterfield J, Spring B, Brownson R, Mullen E, Newhouse R, Walker B, Whitlock E. Toward a Transdisciplinary Model of Evidence-Based Practice. Milbank Q. 2009 Jun; 87(2): 368–390.
  3. ↑ Dusin J, Melanson A, Mische-Lawson L. Evidence-based practice models and frameworks in the healthcare setting: a scoping review. BMJ Open. 2023; 13(5): e071188.
  4. ↑ Sackett DL, Rosenberg WM, Gray JM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. Bmj. 1996 Jan 13;312(7023):71-2.
  5. ↑ Haynes RB, Devereaux PJ, Guyatt GH. Clinical expertise in the era of evidence-based medicine and patient choice. BMJ Evidence-Based Medicine. 2002 Mar 1;7(2):36-8.
  6. ↑ Brettle A. Implementing evidence-based practice: a guide for radiographers. Radiography. 2020 Oct 1;26:S37-41.
  7. ↑ 7.0 7.1 7.2 7.3 Hoffmann T, Bennett S, Del Mar C. Evidence-based practice across the health professions. Elsevier Health Sciences; 2023 Sep 27.
  8. ↑ Drisko JW, Friedman A. Let’s clearly distinguish evidence-based practice and empirically supported treatments. Smith College Studies in Social Work. 2019 Oct 2;89(3-4):264-81.
  9. ↑ Fauci AJ, D’Angelo D, Coclite D, Napoletano A, Gianola S, Ferrara C, Di Nitto M, Gensini G. Exploring the definition and methodology of “best practice” in the health care literature: a scoping review protocol. JBI Evidence Synthesis. 2023 Oct 1;21(10):2134-41.
  10. ↑ Barends E, Rousseau DM, Briner RB. Evidence-Based Management, The Basic Principles. In Search of Evidence. 2011 Sep 3.
  11. ↑ OCEBM Levels of Evidence Working Group*. “The Oxford Levels of Evidence 2”. Oxford Centre for Evidence-Based Medicine. https://www.cebm.ox.ac.uk/resources/levels-of-evidence/ocebm-levels-of-evidence * OCEBM Levels of Evidence Working Group = Jeremy Howick, Iain Chalmers (James Lind Library), Paul Glasziou, Trish Greenhalgh, Carl Heneghan, Alessandro Liberati, Ivan Moschetti, Bob Phillips, Hazel Thornton, Olive Goddard and Mary Hodgkinson
  12. ↑ Howick J, Chalmers I, Glasziou P, Greenhalgh T, Heneghan C, Liberati A, Moschetti I, Phillips B, Thornton H. “The 2011 Oxford CEBM Levels of Evidence (Introductory Document)”. Oxford Centre for Evidence-Based Medicine. https://www.cebm.ox.ac.uk/resources/levels-of-evidence/ocebm-levels-of-evidence
  13. ↑ Howick J, Chalmers I, Glasziou P, Greenhalgh T, Heneghan C, Liberati A, Moschetti I, Phillips B, Thornton H. “Explanation of the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence (Background Document)”. Oxford Centre for Evidence-Based Medicine. https://www.cebm.ox.ac.uk/resources/levels-of-evidence/ocebm-levels-of-eviden
  14. ↑ 14.0 14.1 14.2 Naghibi D, Mohammadzadeh S, Azami-Aghdash S. Barriers to evidence-based practice in health system: a systematic review. Evidence Based Care. 2021 Jul 1;11(2):74-82.
  15. ↑ 15.0 15.1 Sadeghi-Bazargani H, Tabrizi JS, Azami-Aghdash S. Barriers to evidence-based medicine: a systematic review. J Eval Clin Pract. 2014 Dec;20(6):793-802.
  16. ↑ Ibikunle PO, Onwuakagba IU, Maduka EU, Okoye EC, Umunna JO. Perceived barriers to evidence‐based practice in stroke management among physiotherapists in a developing country. Journal of Evaluation in Clinical Practice. 2021 Apr;27(2):291-306.
  17. ↑ Craig, J.V. and Dowding D. Evidence-Based Practice in Nursing, Edition 4. Elsevier Health Sciences. 2020
  18. ↑ Drisko JW, Grady MD. Evidence-based practice in clinical social work. Springer; 2019.
  19. ↑ 19.0 19.1 Connor L, Dean J, McNett M, Tydings DM, Shrout A, Gorsuch PF, Hole A, Moore L, Brown R, Melnyk BM, Gallagher‐Ford L. Evidence‐based practice improves patient outcomes and healthcare system return on investment: Findings from a scoping review. Worldviews on Evidence‐Based Nursing. 2023 Feb;20(1):6-15.
  20. ↑ Herbert R, Jamtvedt G, Hagen KB, Elkins MR. Practical Evidence-Based Physiotherapy. Elsevier Health Sciences; 2022 Jul 18.
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