Evidence Based Practice (EBP)

Original Editor - Rachael Lowe

Lead Editors - Your name will be added here if you are a lead editor on this page.  Read more.

What is EBP?

Evidence based practice (EBP) is 'the integration of best research evidence with clinical expertise and patient values' which when applied by practitioners will ultimately lead to improved patient outcome. 

There are three fundamental components of evidence based practice.

• best evidence which is usually found in clinically relevant research that has been conducted using sound methodology
• clinical expertise refers to the clinician's cumulated education, experience and clinical skills
• patient values which are the unique preferences, concerns and expectations each patient brings to a clinical encounter.

It is the integration of these three components that defines a clinical decision evidence-based.  This integration can be effectively acheived by carrying out the five following steps of evidence based practice.

The 5 Steps

1. Formulate an answerable question

One of the fundamental skills required for EBP is the asking of well-built clinical questions. By formulating an answerable question you to focus your efforts specifically on what matters. These questions are usually triggered by patient encounters which generate questions about the diagnosis, therapy, prognosis or aetiology.

2. Find the best available evidence

The second step is to find the relevant evidence. This step involves identifying search terms which will be found in your carefully constructed question from step one; selecting resources in which to perform your search such as PubMed and Cochrane Library; and formulating an effective search strategy using a combination of MESH terms and limitations of the results.

3. Appraise the evidence

It is important to be skilled in critical appraisal so that you can further filter out studies that may seem interesting but are weak. Use a simple critical appraisal method that will answer these questions: What question did the study address? Were the methods valid? What are the results? How do the results apply to your practice?

• See: Grades & Levels of Evidence

4. Implement the evidence

Individual clinical decisions can then be made by combining the best available evidence with the your clinical expertise and your patients values. These clinical decisions should then be implemented into your clinical pra into your practice which can then be justified as evidence based.

5. Evaluate the outcome

The final step in the process is to evaluate the effectiveness and efficacy of your decision in direct relation to your patient. Was the application of the new information effective? Should this new information continue to be applied to practice? How could any of the 5 processes involved in the clinical decision making process be improved the next time a question is asked?

Resources

Cleland JA, Noteboom JT, Whitman JM, Allison SC (2008) A primer on selected aspects of evidence-based practice relating to questions of treatment, part 1: asking questions, finding evidence, and determining validity, J Orthop Sports Phys Ther. 2008 Aug;38(8):476-84

Noteboom JT, Allison SC, Cleland JA, Whitman JM (2008) A primer on selected aspects of evidence-based practice to questions of treatment, part 2: interpreting results, application to clinical practice, and self-evaluation, J Orthop Sports Phys Ther. 2008 Aug;38(8):485-501

Evidence based practice learning objects that have been developed by the School of Nursing and Midwifery at Nottingham University as part of the RLO-CETL.

Determining the clinical importance of trial results - a learning object developed by the School of Nursing and Academic Division of Midwifery, University of Nottingham

Designing a Questionnaire - a learning object developed by the School of Nursing and Academic Division of Midwifery, University of Nottingham

Advanced Literature Searching - a learning object developed by the School of Nursing and Academic Division of Midwifery, University of Nottingham

Online databases

There are an increasingly large number of online databases that serve as useful resources for both practising physiotherapists and students. They have content from a wide variety of journals, which saves researchers the sometimes painful job of trawling through individual publications. The following list is not comprehensive.

PEDro

The Physiotherapy Evidence Database is an initiative of the Centre for Evidence-Based Physiotherapy (CEBP) and was developed "...to give rapid access to bibliographic details and abstracts of randomised controlled trials, systematic reviews and evidence-based clinical practice guidelines in physiotherapy".

For randomized controlled trials (RCT), PEDro rates studies on a 0-11 scale (a higher number is better).

The links page on PEDro contains links to other useful resources for anyone interested in exploring the evidence base in health-related literature.

The Cochrane Library

The Cochrane Collaboration is an organisation that provides a reliable source of evidence based health information that it publishes in the Cochrane Library. From their website, "It includes reliable evidence from Cochrane and other systematic reviews, clinical trials, and more. Cochrane reviews bring you the combined results of the world’s best medical research studies".

The Cochrane Library also publishes podcasts, which are mostly medical in nature but which also contain content relevant for physiotherapists. For example, a podcast on rehabilitation after lumbar disc surgery.

The Centre for Evidence Based Physiotherapy (CEBP)

The Centre for Evidence Based Physiotherapy has a "...mission is to search, collect and disseminate available scientific evidence in the physiotherapy domain for physiotherapists, health care workers, patients and financiers of health care". All of the papers on it's website are freely available.

PubMed

Pubmed "...is a service of the US National Library of Medicine that includes over 18 million citations from MEDLINE and other life science journals for biomedical articles back to the 1950s. It also includes links to full text articles and other related resources".

BioMed Central

BioMed Central is an open access online publisher of medical studies, meaning that all of it's content is freely available. The downside is that it's publications are not accredited, only peer-reviewed.

Clinical guidelines

Traditionally, clinical guidelines have been viewed with suspicion by anyone interested in working from the evidence base, as "guidelines" were often little more than one individual's personal opinion. Over the past 5 years however, the approach to producing clinical guidelines has radically changed, with vast amounts of time and resources being poured into their development.

A clinical guideline focuses on the current understanding of a particular condition and makes use of a diverse range of academic literature to establish an approach to best practices, based on the outcomes of a large number of the studies available. They also inform the reader what level of evidence has been used to establish "best practice", from systematic reviews of the literature (Level A) to expert clinical opinion (Level D). This allows the clinician to make up their own mind about how solid is the foundation upon which the guideline is built and how much weight to allocate it.

A few of the organisations responsible for developing guidelines are presented below (in no particular order). Since different organisations are tasked with developing different guidelines, you might have to look around until you find what you're looking for. It should also be borne in mind that not only are new guidelines being developed all the time but old ones are typically reviewed every 2-3 years, so it's always useful to ensure you have the latest version.

• National Guideline Clearinghouse (NGC)
• New Zealand Guidelines Group
• National Institute of Clinical Excellence (NICE) guidelines
• Open Clinical Practice Guidelines
• Australian Clinical Practice Guidelines publications
• Scottish Intercollegiate Guidelines Network (SIGN)
• OpenClinical (Clinical guideline applications for handheld devices)

Recent Related Research (from Pubmed)

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