Introduction and Overview of Evidence Based Practice

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Introduction

Evidence-based practice is an integral part of healthcare, and it has become a key part of clinical training, research and rehabilitation practices. It is a problem-based approach where research evidence is applied to clinical reasoning and decision-making. Clinicians need to integrate multiple information snippets and pieces to be able to make a clinical decision. We are excellent at gathering information from our patients or their families and from the specific setting that we work within. However, evidence from research is also key to informing our practice and decision-making. Each element of the evidence-based practice model is important but it is imperative to realise that these concepts are to be applied together rather than divided into parts or categories to justify a clinical decision.

History of Evidence-Based Practice

Below is a short time-line of how evidence-based practice developed:

• 1025 – Persian healer Avicenna started to quantify disease and evaluate treatment methods
• Early 1700’s – Physicians in France and England started to link clusters of symptoms with specific medical conditions by observing patients with specific symptoms (start of epidemiology and differential diagnoses).
• 1941 – Pioneer physician Archibald Cochrane highlighted the need to be able to distinguish between treatments that are helpful from those which may do more harm, as well as the importance of being empathetic and caring healthcare providers.
• 1970s and 1980s The medical programme at McMaster University in Canada realised that it was impossible to teach medical students everything that they needed to know and hence focused on teaching students how to find what they needed to know – the start of evidence-based practice.

Examples of past medical practices that were harmful and unscientific and those that were (and still are) lifesaving are listed in Table 1.

Table 1. Examples of past medical practices

Past medical practices that were harmful and unscientific	Past medical practices that are lifesaving
trepanation bloodletting use of mercury use of radium arsenic used to treat psoriasis, eczema, leukaemia use of heroin as a cough medicine clearing the air	discovery of penicillin and antibiotics organ transplants vaccines anaesthesia medical imaging antiviral drugs stem cell therapy immunotherapy

What is Evidence-Based Practice?

Sackett et al.(1996) defined it as follows: “Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.”

There was a need to include research knowledge as part of the clinical decision-making process, however, this is one of the big criticisms of evidence-based practice. The fact that it seemed that research emphasis was weighing more than patient preferences and circumstances. It is key to understand that research is one part of several influences that shapes the decision-making model. A later definition from Sackett et al. describes evidence-based practice as "the integration of best research evidence with clinical expertise and patient values.”

The initial model of evidence-based practice included three overlapping domains:

• Clinical expertise
• Research evidence
• Patient preferences

Haynes et al. adapted and further developed the evidence-based practice model into four overlapping parts.

• The client’s clinical state and circumstances
• The best relevant research evidence
• The client’s values and preferences
• Clinical expertise is the golden thread or cement that holds the model together

In this model, research is key but it does not outweigh any of the other domains. The patient or client is also actively engaged in the decision-making process.

Drisko and Grady provide a simple yet clear summary of evidence-based practice:

"EBP refers to a practice decision-making process.”

The definition of evidence-based practice has evolved over time. Along with the integration of research, clinical expertise and patient values and circumstances, it is also necessary for the healthcare professional "to consider characteristics of the local and broader practice context.” Thus, it is not only about the research but also about the skills, education and experience of a clinician as well as the patient and their values, circumstances, preferences and clinical status. Furthermore, the clinician needs to consider the availability of resources, policies, cultural factors as well as socioeconomic factors in the decision-making process. Hoffman et al explain this eloquently as follows: “This requires judgment and artistry, as well as science and logic.” This whole process of integrating all these factors is known as clinical reasoning and when a healthcare professional is able to integrate all these domains so that decisions can be made with regards to the care of a patient, evidence-based practice is applied.

What Did We Rely on Before Evidence-Based Practice?

• Experience
  • Expertise of colleagues who were older and "better" or more experienced

• Education
  • What we were taught during our studies

The issue with these is that these sources of information can be flawed, outdated and can introduce bias.

However, clinical experience is a core factor in the evidence-based practice model, but rather than only relying on clinical experience it is better to use our clinical experience together with the other factors (clinical reasoning process) in the decision-making process.

Why is Evidence-Based Practice Important?

Reasons supporting the importance of evidence-based practice include:

• Helps healthcare professionals and patients make an evidence-based decision on what the best treatment or decision is for a specific patient at a specific point in time.

• Patients provide healthcare professionals with loads of information regarding their illness or injury or general health. Clinicians need to be able to assess the accuracy of this information, determine if a specific intervention is suitable for the specific patient and work with the patient if he or she buys into this decision.
• EBP cultivates an inquisitive attitude in healthcare providers (Why am I doing it this way? Is there evidence that may help me do this in a more efficient way?)
• EBP plays a role in professional accountability – as healthcare professionals we have the responsibility to provide services that are informed by the best available research whenever possible.
• Funding health services – EBP helps with wise usage of health resources and with the consideration of evidence in decision making (for example, if there is quality evidence that a specific treatment is harmful or ineffective, resources should not be wasted by providing such treatment.)

Goals of Evidence-Based Practice

The overall goals of evidence-based practice are:

• Increase the number of helpful interventions
• Reduce the use of harmless interventions that are ineffective
• Eliminate harmful interventions that does not lead to improvement and causes other harm
• Cost effective interventions are necessary (reducing costs)
• Reduce variations in practice
• Enhancement of quality of care
• Improve patient outcomes

Application of EBP from Different Perspectives

Evidence-based practice can be applied from different perspectives in the following ways:

• Clinical decision making process in selecting the best available intervention for a patient
• Diagnostic processes – assessing the reliability and validity of measurement tools and outcomes
• Selection of preventative interventions
• Determining aetiology of diseases and conditions
• Determining prognosis of diseases or conditions
• Determining policies and procedures as well as administration of healthcare services

Criticism of Evidence-Based Practice

Evidence-based practice has received criticism, below are some of these with responses to consider.

• Too reliant on quantitative research
  • Response to this : Qualitative research is important especially in learning how individuals manage and perceive their health or condition. There is a rise in the number of mixed-method research papers that focus on both quantitative and qualitative approaches

• Limited research available in certain areas
  • Response to this: Although there is limited evidence regarding some clinical questions, the best available evidence should be sought out. In these cases, clinical experience and patient perspectives should be relied upon more.

• The amount of research evidence is overwhelming
  • Response to this: using the pyramid of evidence-based information to guide you and developing critical appraisal skills will help healthcare professionals navigate this area.

• Often large randomised controlled trials over-emphasise and focus on achieving small gains.
  • Response to this – both the benefits and harms of interventions should be considered. Also not only focusing on statistical significance but also on the clinical significance and patient perspective.

• Clinicians (often newly qualified or inexperienced clinicians) may diligently follow the available evidence, rules and algorithms and not consider the patient's perspective.
  • Response to this: "Proper practice of EBP is not about following the rules." Clinical reasoning and judgement is an integral part of EBP as well as the consideration of patient preferences. Shared-decision decision-making is key in this process.

Barriers to Evidence-Based Practice

Some barriers t0 evidence-based practice are related to:

• organisational context
  • lack of time
  • lack of access
  • lack of support
• education
  • language skills
  • lack of research skills
  • lack of statistical analysis skills
• personal behaviour
  • lack of interest
• limitations of EBP
  • lack of generalisability of research

Patient, Client, Consumer, Survivor or Other in Healthcare Settings?

With the shift towards a patient-centred model of healthcare, a debate has been sparked about the terminology to describe “patients”. The term ‘patient’ may imply a ‘passive individual awaiting treatment’ whereas terms such as client, consumer, and customer may be more empowering and create a sense of equality between all participants involved in the decision-making process with regard to healthcare.

Costa et al. reported that overall healthcare recipients prefer the term patient with some liking the term consumer. It is indicated that the continued use of the term patient is acceptable when there is insufficient knowledge about an individual’s preferences. This can be applied to clinical and research settings. They also concluded that preference is often determined by:

• Familiarity
• Social identity
• Context of the role (specific healthcare setting)

However, these findings require further research. Read the scoping review here: Patient, client, consumer, survivor or other alternatives? A scoping review of preferred terms for labelling individuals who access healthcare across settings.

Knowledge Translation in Rehabilitation

Knowledge translation is defined as "a dynamic and iterative process involving professionals and patients in the synthesis, dissemination, exchange and ethical application of knowledge to improve health through the development of tools, guides, practical recommendations, and decision-making algorithms." Knowledge translation strategies are crucial in supporting evidence-based practice with the goal to decrease the gap between research, evidence and clinical practice. With the advances in science clinicians have access to evidence that can help with factors such prevention, rehabilitation outcomes and the quality of life of patients. However, it takes about 17 years for research evidence to make its way into clinical practice. Rehabilitation professionals needs to be equipped with knowledge about how to generate, share and apply knowledge. Knowledge translation and evidence-based practice is necessary in research and clinical practice to create value for rehabilitation and provide a culture of quality rehabilitation for all.

Resources

• Resources for Evidence-Based Practice: About EBP
• Center for Evidence-Based Medicine (CEBM)
• BJM EBM Toolkit
• Introduction to Evidence-Based Practice (University of Minnesota)