Evidence Based Practice in the clinical setting

As professional clinicians we are responsible and accountable for our own clinical practice (1) and are expected to offer interventions that maximise benefit and minimise harm to our patients (2). Evidence-based practice (EBP) can help us achieve these aims by underpinning clinical decisions, while, delivering both clinical and economical benefits. EBP involves applying contemporary research (3) to provide a service derived from the best available evidence (4) whilst keeping abreast of developments in professional practice (5). According to Sackett (6) EBP; “is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” It is a process of turning clinical problems into questions and then systematically locating, appraising, and using contemporaneous research findings as the basis for clinical decisions (3). Unsurprisingly, failure to provide EBP may lead to possible claims of negligence and malpractice which would be difficult to defend (7). Potential consequences are well documented, for example; poor decision-making (3), inadequate clinical effectiveness (4), harmful to the athlete (8) and poor cost effectiveness (9).

 

Evidence-based-practice

Evidence-based practice has developed from the principles of evidence-based medicine and is primarily about the interaction between practitioner and individual (10). EBP is derived from empirical research rather than anecdotal evidence. EBP develops self-confidence and clinical competence. Competence being, “the complex synthesis of knowledge, skills, values, behaviour and attitudes that enable individual professionals to work safely, effectively and legally within their particular scope of practice” (11). EBP must stand on a base of research using the best available external clinical evidence from systematic research findings (12). “It is no longer good enough to say something works; the evidence is needed that it does work” (2).

EBP is crucial to the professional survival of ‘therapy’ e.g. physiotherapy (13), sports therapy (14), physical therapy (15) and massage therapy. In the past decade, evidence based medicine has contributed to how we teach, deliver, and think about clinical services. The uptake of appropriate research evidence into clinical practice remains a priority for politicians, managers and professionals alike within the National Health Service (NHS) and private practice (16). The need for evidence-based practice has been highlighted for several decades. However, implementing research into practice has often shown to take 20 years or more. This produces suboptimal care for patients; therefore moving evidence more quickly into practice requires strategies (17).

Naylor (18) suggests, at times, evidence alone may not be sufficient to guide actions. Therefore, interventions may need to be based on inference and clinical reasoning, with its reliance on experience, analogy and extrapolation, to traverse these grey zones of practice. This includes eliciting and respecting the preferences of patients. Clark (19) refers to clinical reasoning as the organisation of thought processes, the prioritisation of interventions strategies, and the application of clinical skills in the evaluation, diagnosis, and treatment of a patient’s problem.

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Clinical Audits

As part of the evidence-based cycle, clinicians should evaluate their own performance (20). Clinical audits is one of the main vehicles for implementing protocols into everyday practice (21) monitoring the results of effects to changes in practice (9) and to ‘benchmark’ standards in practice (7). Clinicians employed within the NHS are generally routinely monitored, audited, and critically appraised. However, therapists working in private practice are often left to their own devices, thus, can potentially become more vulnerable to stagnation and loss in clinical performance.

 

Conclusion

Evidence-based practice is here to stay; therefore clinicians must accept and understand the concept of EBP. Thereafter, they can begin to appreciate the clinical and economical benefits on offer, also, while realizing the potential consequences associated with failure to apply it. Consideration must be given to the ever expanding scholarly databases of research information, the continual changes in technology and protocols. Not to mention the emphasis on more stringent legislation, civil cases of malpractice, and patients’ increasing demands and expectations. For the more vulnerable clinicians in private practice, a concerted and ongoing effort is needed to avoid becoming insular within a confined private clinic environment stagnated by lack of change. Finally, therapists should be proactive towards EBP and CPD. In the future, simply complying with minimum standards may not be sufficient.

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References

  1. Bannigan K. (2000). To serve better: Addressing poor performance in occupational therapy. British Journal of Occupational Therapy, 63(11): 523-528.

  2. Alsop A. (1997). Evidence-based practice and continuing professional development. British Journal of Occupational Therapy,  60(11): 503-550.

  3. Rosenberg W, & Donald A. (1995). Evidence based medicine: an approach to clinical problem-solving. British Medical Journal, 310:1122-1126.

  4. Turner PA, & Whitfield AW. (1999). Physiotherapists’ reasons for selection of treatment techniques: A cross-national survey. Physiotherapy Theory and Practice, 15(4): 235-246.

  5. Eakin P. (1997). The casson memorial lecture 1997: shifting the balance - evidence-based practice. British Journal of Occupational Therapy, 60(7): 290-294.

  6. Sackett, DL. (1998). Evidence-based medicine. Spine, 23(10): 1085-1086.

  7. Turner PA, Harby-Owen H, Shackleford F, So A, Fosse T, Whitfield TW. (1999). Audits of physiotherapy practice. Physiotherapy Theory and Practice, 15: 261-274.

  8. Druss B. (2005). Evidence based medicine: does it make a difference? Use it wisely. British Medical Journal, 330: 92-94.

  9. Cape, J. (2000). Clinical effectiveness in the UK: Definitions, history and policy trends. Journal of Mental Health, 9(3): 237-246.

  10. Bury T, & Mead J. (1998). Evidence-based healthcare: a practical guide for therapists. Butterworth Heinemann.

  11. Roberts S. (2004). Continuing professional development: what the future might hold. Journal of Sportex Medicine, 19:14-16.

  12. Coopey, M., Nix, M.P., Clancy, C.M. (2006). Translating research into evidence-based nursing practice and evaluating effectiveness. Journal Nurse Care Quality, 21(3):195-202.

  13. Turner, PA. (2001). Evidence-based practice and physiotherapy in the 1990s. Physiotherapy Theory and Practice, 17:107-121.

  14. The Society of Sports Therapists’ Codes of Professional Conduct (2005). Competences and scope of practice for sports therapy.

  15. Rothstein JM. (1996). Outcomes and survival. Physical Therapy, 76(2):126-127.

  16. Humphris D, Littlejohns P, Victor C, O’Halloran P, Peacock J. (2000). Implementing evidence-based practice: factors that influence the use of research evidence by occupational therapists. British Journal of Occupational Therapy, 63(11):516-522.

  17. Evrin, NE. (2005). Clinical coaching: a strategy for enhancing evidence-based nursing practice. Clinical Nurse Specialist, 19(6):296-302.

  18. Naylor, CD. (1995).  Grey zones of clinical practice: some limits to evidence-based medicine. Lancet, 345;840-842.

  19. Clark, N. (2004). Principles of injury rehabilitation. Journal of Sportex Medicine, 19, 6-10.

  20. Straus SE, & Sackett DL. (1998). Using research findings in clinical practice. British Medical Journal, 317:339-342.

  21. Buttery, Y. (1998). Implementing evidence through clinical audit. In: T Bury, J Mead. (eds) Evidence-based healthcare: a practical guide for therapists. Butterworth Heinemann.

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