Defining the Evidence Based Practice Decision-Making Model

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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 1990's as evidence-based medicine (EBM). This “new paradigm” initially involved the practice of clinical medicine with the aim 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 can be taught, refined, and applied by all clinicians. Since then, various models and frameworks have been proposed in the healthcare setting that do not apply to the field of medicine only.

Revised Model of Evidence Based Practice

Read more about the first models of evidence based practice from Sackett et al. and Haynes et al.: Introduction and Overview of Evidence Based Practice

Satterfield et al. in 2009 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 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.

Read more: Toward a Transdisciplinary Model of Evidence-Based Practice. Figure 5 provides a schematic of this model.

Evidence Based Practice Steps

Although these steps are chronologically numbered, they don't always occur in the same sequence. Often it is necessary to go back a few steps before moving forward again. 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: Formulate the treatment plan
• Step 6: Implementing the treatment plan
• Step 7: Evaluate the effectiveness of the treatment plan and the evidence-based practice process

5 A’s of Evidence Base Practice

The evidence based practice steps are also often referred to as the 5 A's. Note that some text uses different terminologies (terms in bracket):

• 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 to be answered through the clinical decision-making process	Ask
Locating the knowledge resources	creating a search strategy, which databases and which type of resources to use	Acquire
Appraising the quality of the knowledge resources	clinical checklists methodological quality assessments	Appraise
Discussing the options with the patient	interactive discussion with 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. 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

In healthcare settings there are different ways to apply the EBP model. Some examples of typical clinical questions include:

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

Challenges of EBP

Lack of time to search for and apply the best available evidence – mostly due to heavy patient case loads.

Not enough or not good enough research available on all conditions and scenarios.

Finding the right resources between the masses is difficult H, Tabrizi JS, Azami‐Aghdash S. Barriers to evidence‐based medicine: a systematic review. Journal of evaluation in clinical practice. 2014 Dec;20(6):793-802.

Accessing the resources 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.

Lack of administrative support Naghibi et al

Not skilled in critical appraisal Naghibi

Not enough role models who practice evidence-based practice regularly

Advantages

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.”

Reduce variability of care

Increases healthcare provider empowerment and role satisfaction

Meets expectations of an informed public 

Resources

• bulleted list
• x

or

1. numbered list
2. x