Evidence-based practice: Misconceived perceptions and warped realities
The term "evidence based practice” (EBP) is now firmly entrenched in the nomenclature of health care. For some, EBP reflects the use of best evidence to uunderpin health care decision making process, while for others it is seen as an alternate to clinical expertise and a cookbook approach to health care. While the optimal EBP framework lies in between these two extremes, we are often confronted with many misconceived perceptions and warped realities of what constitutes EBP in health care today.
Recently, the Australian Physiotherapy Association’s bi-monthly magazine, InMotion, featured an article titled "The parachute problem; exploring the space between evidence and experience." This article was built upon a well-publicised, tongue-in-cheek publication which asked the question "are parachutes effective in preventing major trauma related to gravitational challenge?” The InMotion article posed three difficult questions about the balance between research evidence and clinical practice to a handful of prominent and anonymous physiotherapists and their responses were then used to construct characterisations that support opposing views.
While the article highlighted barriers, and enablers, for EBP, it failed to recognise the complex relationship between research evidence, clinical expertise and patient values, the three key components underpinning EBP. Rather, the article seemed to pitch research evidence against clinical expertise. Therefore, in this commentary, we take the opportunity to define and demystify the concept of evidence based practice, from the perspective of clinicians, researchers and patients.
Evidence based medicine was most famously defined by Professor David Sackett and colleagues in a 1996 editorial for the British Medical Journal as "Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients." Evidence based practice in a health care setting has stemmed from this definition and can be thought of as the integration of clinical experience, individual patient values and research evidence. Rather than polarising research evidence versus clinical experience versus patient values, the original philosophy of EBP calls for integrating all three.
When researchers Gordon Smith and Jill Pell published their 2003 systematic review on the effectiveness of parachutes in preventing death and trauma in the British Medical Journal in 2003, their intention was to highlight the shortfalls of focussing too narrowly on the pointy end of research evidence, i.e. randomised controlled trials. The underlying message in this publication was that some questions (such as the parachute question), can be more effectively answered through other more appropriate methods of research. The parachute, for example, underwent extensive research, in terms of development and testing, before being trialled with a human being. Currently, there are different types of parachutes developed specifically for humans, aircrafts and ammunitions, all underpinned by years of research.
Focussing on EBP in health care, if research evidence and clinical experience are complementary, then debating whether one is superior to the other is futile. Misconceived perceptions and warped realities of EBP may stem from a lack of knowledge and understanding of EBP, and from the numerous barriers that confront clinicians who want to engage with EBP. Some of these barriers include being time poor, inadequate skills in interpreting and assessing the literature, poor access to the literature, and not knowing where to look for the evidence.
Increasingly, it is possible to marry research evidence with clinical practice. There are now numerous resources available to clinicians who wish to keep up to date with the evidence and maintain a balanced evidence based practice perspective. Examples include innovative journal clubs, ever increasing number of online open-access journals and clinical guidelines (such as NHMRC NICS guideline portal), freely available synthesised bodies of evidence (such as The Cochrane Library, PEDro, OT Seeker) and dedicated EBP research centres (such as the International Centre for Allied Health Evidence and The Joanna Briggs Institute). Many of these centres also offer freely available online education and resources for EBP.
Research evidence is an integral part of EBP as it provides rigorous, scientific evidence to inform health care practices. However, for research evidence to be implemented in clinical practice it is vital that clinical expertise and patient values are also considered. Successful integration of research evidence, clinical expertise and patient values can lead to improved quality and safety of health care practices, and favouring one over another will merely lead to ongoing confusion and continued poor practices.
- Sackett, D, L, Rosenberg, Gray, J, A, M, Haynes, R, B & Richardson, W, S, 1996, ‘Evidence based medicine: what it is and what it isn't’. British Medical Journal, vol. 312, pp. 71-72.
- Smith, G, C, S & Pell, J, P 2003, ‘Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials’, British Medical Journal, vol. 327.
Kumar S. Evidence-based practice: Misconceived perceptions and warped realities. The Internet Journal of Allied Health Sciences and Practice. 2010 Oct 01;8(4), Article 3.