Key Points
• Evidence based practice is described as “a problem-based approach where research evidence is used to inform clinical decision-making”.
• EBP incorporates the best available research with clinical experience to provide the best patient care
• Practitioners should also take into account the individual patients beliefs and circumstances
• Hierarchies of evidence can be used to determine the best, most authoritative evidence
• Many nurses report lack of time and inability to interpret research materials as barriers to EBP


Evidence-based practice (EBP) is a term that is familiar to nursing, allied health and other health professionals, and increasingly there is an expectation by health services, managers, patients and other consumers that the ‘best available evidence’ is used to underpin clinical decision-making. How achievable is this in the contexts in which we work? This article provides an overview of the principles of EBP, identifies the main steps and skills necessary for effective EBP, and discusses some of the challenges faced by health professionals to undertake and apply EBP in the provision of patient care.

The roots of EBP are in medicine. In 1972, Archie Cochrane, a Scottish-born doctor and researcher, highlighted gaps between research and clinical practice and advocated for international collaboration and the systematic review of clinical trials (1). The term "evidence-based medicine" was introduced by Guyatt et al in 1992 to shift the emphasis in clinical decision-making from "intuition, unsystematic clinical experience, and pathophysiologic rationale" to scientific, clinically relevant research (2). In 1996, D. L. Sackett, a Canadian doctor and founder of the first department of clinical epidemiology at McMaster University in Ontario, explained that evidence-based clinical decision-making is a combination of not only research evidence but also clinical expertise, and taking into account the patient’s preferences (3).

Hoffmann, Bennett and Del Mar (2010) describe evidence-based practice as “a problem-based approach where research evidence is used to inform clinical decision-making. It involves the integration of the best available research evidence with clinical expertise, our client’s values and circumstances, and consideration of the clinical (practice) context” (4). This definition confirms that EBP is much broader than just finding and using research from journals and other publications. It highlights that clinical expertise and judgment are essential to any clinical decision-making process, as are the values and beliefs of the patient or patient group. Clinical, cultural and even geographical contexts may influence any decisions made. Examples of such contexts might include traditional beliefs or cultural taboos amongst indigenous peoples, beliefs around blood products for patients who are Jehovah’s Witnesses, or limited access to resources in remote communities. A fundamental element of evidence-based clinical decision-making is personalizing the evidence to fit a specific patient’s [or population’s] circumstances (5).

That said, EBP poses the question, “Am I doing the best possible thing for my patient?” EBP facilitates the delivery of care that has reliable, proven and predictable outcomes, as well as offering equity to patients through standardized care that is based on the best available evidence. This evidence rises from research.

Significant national and international investment is made into all forms of health-related research for the purpose of improving outcomes for patients. This has yielded a huge volume of information that is ever increasing. From genetics, physiology and biomechanics to nursing, allied health and medical therapeutic interventions, and health promotion and social planning, all aspects of care are proactively researched. Finding a way through the information, keeping up to date, learning from relevant studies and applying the knowledge is time-consuming and can be overwhelming.

Skills in searching, appraising, applying, implementing and evaluating research may be acquired and developed, and various tools exist to support EBP. Hoffman et al describe the approach to EBP as being “quite structured” and outline its five key steps as:
1. Asking a [clinical] question
2. Searching for evidence to answer it
3. Critically appraising the evidence
4. Integrating the evidence with clinical expertise, the client’s values and circumstances, and information from the practice context
5. Evaluating the effectiveness and efficiency with which steps 1–4 were carried out and thinking about ways to improve your performance of them next time (6)

The process of EBP is motivated by a need for clinical information. This information may relate to a specific patient (or population group) and/or an intervention, and/or an outcome, or you may wish to compare, for example, one intervention with another. From this information need, a specific clinical question is developed, which can then be researched. Findings from that research may offer an ‘answer’ to the question and/or an approach to care and management.

Simply using findings from a few journals that you subscribe to is unlikely to be effective. Part of the skill of EBP is being able to efficiently locate the type of documentation or study design that provides the ‘best’ evidence available to make a clinical decision (7). Understanding the different publication types and different study designs will help you determine what each has to offer, how authoritative each is, and where shortcomings may be. Information about study types and designs may be readily found in articles, textbooks and online resources for EBP (see ‘References’ below for starting points).

‘Best’ evidence refers to the highest quality research that is available to the clinician, and ‘highest quality’ refers to grading of published research based on the extent to which it can be considered reliable. One such grading system comes from the Australian National Health and Medical Research Council (NHMRC). NHMRC has developed handbooks, tables, tools and papers to support the development of EBP, including detailed explanations of types, levels, quality and relevance of evidence, along with the NHMRC Hierarchy of Evidence (8).

‘Hierarchies of Evidence’ are often expressed diagrammatically with a pyramidal structure to demonstrate the value of the various types of research evidence, with the peak of the pyramid being the most authoritative form of evidence – Systematic Reviews. The Cochrane Library (9) and Joanna Briggs Institute (10) contain collections of systematic reviews, and are ideal places to start searching for evidence. A systematic review may not be available for your particular question; therefore you will need to work down the hierarchy of evidence for findings. This may require appraisal of the findings to determine whether the study methods are sound enough to inform your clinical decision-making. Appraising evidence is a skill that can be developed by drawing on EBP resources as previously mentioned.

In busy clinical workplaces, finding the time, resources and support to develop EBP skills and to undertake EBP research and implement it in practice are challenging. Majid et al (2011) undertook a study of Singaporean nurses’ knowledge and awareness of EBP and factors influencing adoption or creating barriers. Majid et al report that despite strongly positive attitudes to EBP, nurses stated that heavy workloads prevent them from keeping up to date with new evidence (11). Lack of time, inability to understand statistical terms, and inadequate understanding of the jargon used in research articles were the top three barriers reported.

Sir Muir Gray writes, “Evidence-based decision-making is common to all professions and provides an ideal platform for multidisciplinary work. Different professions bring different perspectives to bear on the evidence, on relating the evidence to the individual and on helping the individual reflect on their values as they consider how the evidence affects the options presented to them” (12).

For the future, it must be recognized that the delivery of EBP requires the investment of time and resources within our workplace structures; that is, the value of EBP must be acknowledged in practical ways, such as in time and support at work for skills development and research activities. Support through mentorship and supervision programs, partnerships with hospital libraries, training opportunities, multidisciplinary collaborations, practice development activities and other creative strategies may help us meet and advance the challenges of EBP.


References


1. http://community.cochrane.org/about-us/history/archie-cochrane
2. Guyatt G H. Evidence-based medicine. ACP J Club. 1991;114 (suppl 2):A-16. Cited in http://journalofethics.ama-assn.org/2013/01/mhst1-1301.html
3. https://www.eboptometry.com
4. Hoffmann T, Bennett S, Del Mar C, Evidence-Based Practice Across The Health Professions, 2010 Elsevier Australia. p14
5. DiCenso A, Guyatt G, Ciliska D, Evidence-Based Nursing: A Guide to Clinical Practice, 1st ed. Accessed through Nursing Consult: http://www.nursingconsult.com/nursing/books/0-323-
6. Hoffman et al, op cit, p8
7. Ibid p9
8. http://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/stage_2_consultation_levels_and_grades.pdf
9. http://www.cochranelibrary.com
10. http://joannabriggs.org
11. Majid S, Foo S, Luyt B, Zhang X, Theng Y, Chang Y, Mokhtar I, Adopting evidence-based practice in clinical decision-making: nurses’ perceptions, knowledge and barriers, J Med Libr Assoc 2011 99(3)
12. Hoffman et al, op cit v11