Implement the evidence
- Evidence Based Practice (EBP)
- Step1: Formulate an answerable question
- Step 2: Find the best available evidence
- Step 3: Appraise the evidence
- Step 4: Implement the evidence
- Step 5: Evaluate the outcome
Step 4 of EBP is integrating the evidence with our expertise and applying it at the point of care considering patient values. At this stage in the EBP process, we have in our hands the best available research evidence that is relevant to the clinical question we formulated! Once it has been determined through critical appraisal that a particular study or group of studies provides valid, applicable evidence that a treatment yields clinically meaningful benefits, the clinician should integrate the evidence into clinical practice
In step 3 of EBP we considered how critical appraisal of evidence involves a series of deliberate judgments about the relevance and applicability of the evidence to a specific patient. Next, in step 4, the practitioner must:
- integrate patient values, preferences, and expectations in shared decision making when selecting a particular treatment. The evidence will be relevant to a given patient only if outcomes measured in the clinical trial are consistent with the individual patient’s goals.
- integrate personal clinical expertise. Some treatments require specialty skills or specific equipment that may not be currently available and may not be obtainable in a reasonable amount of time to help a particular patient.
In EBP, the patient is part of the clinical decision-making process. The practitioner communicates with the patient to understand any circumstances, preferences or concerns that affect the extent to which the patient will be happy with the clinical decision and will comply (or be able to comply) with any recommended treatment.
Many patient related issues must be considered when implementing the evidence, such as anticipated frequency and duration of patient visits, cost of the treatment, possible discomfort or other adverse effects of the intervention of interest and of competing interventions (such as injections, surgery, or other noninvasive interventions), and how consistent the treatment is with patient expectations.
In the EBP context, clinical expertise is the knowledge and experience of the practitioner, which may have been acquired from education at undergraduate or postgraduate level, reading, observation, clinical experience and other aspects of practice and training. This expertise overlaps to some extent with research evidence, since research often forms the basis of education and clinical practice, but clinical expertise is accumulated from various sources, not only research.
Clinical Experise has been discussed well in relation to EBP physiotherapy by Cleland et al (2008). Expertise in physical therapist practice has been described as possession of professional values, decision-making processes, communication styles or skills, specialty certifications, and years of practice in physical therapy. It has been demonstrated that experienced physical therapists with orthopaedic or sports certifications demonstrate greater knowledge in managing musculoskeletal conditions than therapists without specialty certification. Despite these findings, one cannot infer that patients cared for by expert clinicians will achieve superior outcomes when compared to the outcomes of patients treated by novice clinicians. In fact, it has been demonstrated that expert clinicians are often resistant to changing their practice behaviours even when their treatment approaches have been disproven. Hence, while clinical expertise is important, it is insufficient to assure optimal outcomes. Reliance on clinical experience without including knowledge and application of evidence to clinical care is inconsistent with the principles of EBP. Therefore, seeking and incorporating the best available evidence should be an integral part of the clinical decision-making process.
Implementing organisation wide EBP
Four models (from nursing) for organizations are listed below to serve as resources for integrating the key components of EBP.
- The Iowa model
- Rosswurm and Larrabee’s model
- The Advancing Research and Clinical practice through close Collaboration (ARCC) model
- Kitson’s model
- Cleland, Noteboom, Whitman and Allison. A Primer on Selected Aspects of EvidenceBased Practice Relating to Questions of Treatment, Part 2: Interpreting Results, Application to Clinical Practice, and Self-Evaluation. Journal of Orthopaedic & Sports Physical Therapy, 2008, 38(8)
- Titler MG, Kleiber C, Steelman VJ, et al. The Iowa model of evidence-based practice to promote quality care. Crit Care Nurs Clin North Am. 2001;13(4):497–509.
- Rosswurm MA1, Larrabee JH.. A model for change to evidence-based practice.fckLRImage J Nurs Sch. 1999;31(4):317-22.
- Melnyk BM, Fineout-Overholt E. Putting research into practice. Reflections on Nursing Leadership/Sigma Theta Tau International, Honor Society of Nursing. 2002;28(2):22–5. 45.
- Alison Kitson, Gill Harvey, Brendan McCormack. Enabling the implementation of evidence basedfckLRpractice: a conceptual framework. Quality in Health Care 1998;7:149–158