Defining the Evidence Based Practice Decision-Making Model

Original Editor - Wanda van Niekerk

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

Introduction

Evidence-based practice (EBP) was first introduced in the early 1990s as evidence-based medicine (EBM). 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. Since then, various models and frameworks have been proposed in the healthcare setting that apply to more fields than just medicine.

Revised Model of Evidence-Based Practice

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

In 2009, Satterfield et al. 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. The three inner pillars of this model involved the:

• 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.

If you would like to find out more about Satterfield et al.'s model, 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

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

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):

• 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

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
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"
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." It does not include patient preferences, values, context and clinical expertise.

Evidence-Based Practice Applications

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.

• The levels of evidence
• Introductory document
• Background document

Challenges of Evidence-Based Practice

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

Advantages of Evidence-Based Practice

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