What is Evidence-Based Practice?
Evidence-based practice (EBP) is essentially a clinical decision making framework that encourages clinicians to integrate information from high quality quantitative and qualitative research with the clinician's clinical expertise and the client's background, preferences and values when making decisions.1 For more on this read:
Sackett, D., Rosenberg, W., Gray, M., Haynes, R., & Richardson, S. (1996). Evidence based medicine: what it is and what it isn't. BMJ, 312, 71-72.2
Clinical decision making is a complex process. It is dynamic and fluid, involves gathering data from multiple sources, interpreting and reasoning about the information, collaborating with both the client and other professionals, choosing a course of action, and evaluating the outcomes of that choice.3 Evidence-based practice adds to our understanding of decision making by explicitly inviting health professionals to consider research in addition to other sources of information. To be able to do this requires a good understanding of the strengths and limitations of research:what it can and can’t tell us. However evidence-based practice is notjust about using research evidence. It is also about valuing and using the education, skills and experience one has gained over time as a health professional. Furthermore, it is also about considering the client’s context and values when making a decision, as thinking about the nuances of the specific practice context. This requires proficiency in clinical reasoning and the use of both science and artistry.4
A series of steps has been proposed to help facilitate evidence-based practice.1 These include:
- Identifying clinical questions relevant to your information needs. We have many clinical questions that arise during practice. Some can be informed by dialogue with our clients, others by reading textbooks for background information and others can be informed by research. This latter group often includes questions about the effectiveness of interventions, which assessments might be best to use, what the long term outcomes might be for our clients, and what the common issues and experiences are that our clients might experience.
For example, we might want to know whether comprehensive occupational therapy is effective for supporting occupational performance for people who have arthritis. Or, we might want to understand the experiences of people who have arthritis. We may also want to know the likelihood that they may sustain employment in the long term, and so on.
- Searching the literature to locate research relevant to the type of clinical question.
Clinicians aim to locate research evidence that is the most appropriate for answering particular clinical questions. This may be either quantitative or qualitative research depending on the type of question being asked. For example, the first question above is a question about treatment effectiveness and may be informed by systematic reviews or randomised controlled trials if available. The second question however, would best be informed by qualitative research because it is about people’s experiences.
- Critically appraise the research to determine how valid or believable it is, and to decide if the results are clinically important.
Not all research uses rigorous methodology and conclusions may be affected by bias or confounding. It is also important to look at the results to see if they are clinically significant, not just statistically significant. A detailed discussion about these issues relevant to randomised controlled trials is provided in the tutorial on critical appraisal.
- Consider how the information from the research can be applied in the clinical setting or with the client.
Occupational therapists need to determine whether the evidence 'fits' with the features of the client's context (person, occupation, and environment). Consideration must also be given to the practice setting, clinical expertise, and resources available to the therapist. Moving on to then decide what to do requires the integration of lots of pieces of information. Ideally a shared decision making approach will be used in making the final decision.
- Evaluate this process. To become more proficient at using evidence-based practice requires some practice and reflection on your use of it to date. Evaluating your use of the various skills and strategies involved can help you to refine the process.
To conclude, research is just one resource to draw on when making clinical decisions. Ultimately clinical reasoning and expertise, and considered dialogue with our clients remain at the heart of occupational therapy practice.
For more information read:
Bennett, S. & Bennett, J.W. (2000). The process of evidence-based practice in occupational therapy: Informing clinical decisions. Australian Occupational Therapy Journal, 47, 171-80. (PDF)
Hoffmann, T., Bennett, S & Del Mar, C (Eds.) (2013). Evidence Based Practice across the Health Professions (2nd ed). Sydney: Churchill Livingston.
- Sackett DL, Richardson WS, Rosenberg WM, Haynes RB. (1997).Evidence-Based Medicine: How to Practice and Teach EBM. 1st ed. New York: Churchill Livingstone.
- Sackett, D.L., Rosenberg, W.M., Gray, J.A., Haynes, R.B. & Richardson, W.S. (1996). Evidence-based medicine: what it is and what it isn't. British Meecial Journal,312(7023),71-72.
- Smith, M., Higgs, J. & Ellis, E. (2008).Characteristics and processes of physiotherapy clinical decision making: a study of acute care cardiorespiratory physiotherapy. Physiotherapy Research Internationl,.13(4):209-222.
- Hoffmann, T., Bennett, S & Del Mar, C (2013). Introduction to evidence-based practice. In Hoffmann, T., Bennett, S & Del Mar, C (Eds.). Evidence Based Practice across the Health Professions. Sydney: Churchill Livingston.