Evidence Based Practice (EBP) is made up of three components -scientific research, clinical expertise and patient preference- and each of these components have issues which could cause limitations to EBP as an effective practice method. There is also the additional component of health service limitations which is sometimes included in EBP, and this can also also pose its own barriers.
Greenhalgh et al. (2014) described authentic EBP as:
Makes the ethical care of the patient its top priority
Demands individualised evidence in a format that clinicians and patients can understand
Characterised by expert judgement rather than mechanical rule following
Shares decisions with patients through meaningful conversations
Builds on a strong clinician-patient relationship and the human aspects of care
Applies these principles at community level for evidence-based public health
And she says that good EBP can be achieved by:
Patients must demand better evidence, better presented, better explained, and applied in a more personalised way
Clinical training must go beyond searching and critical appraisal to hone expert judgement and shared decision making skills
Producers of evidence summaries, clinical guidelines, and decision support tools must take account of who will use them, for what purposes, and under what constraints
Publishers must demand that studies meet usability standards as well as methodological ones
Policy makers must resist the instrumental generation and use of “evidence” by vested interests
Independent funders must increasingly shape the production, synthesis, and dissemination of high quality clinical and public health evidence
The research agenda must become broader and more interdisciplinary, embracing the experience of illness, the psychology of evidence interpretation, the negotiation and sharing of evidence by clinicians and patients, and how to prevent harm from over-diagnosis
Barriers to EBP could be:
- Quality of the research itself only poor quality literature available; literature sponsored by drugs companies who manipulate inclusion criteria/definitions of diseases/statistical significance to align with their own agendas and then only publish positive results whilst purporting unbiased research; research that doesn’t take into account a holistic approach; a ‘textbook’ approach that isn’t applicable to the differences in individual patients
- My ability to evaluate the research lack of time/competing higher priorities; lack of access to library/computer; problems finding the literature or an overwhelming amount available; jargon making it difficult to understand
- My skill in applying the research findings into practice culture of getting job done and not spending time accessing research; managers having other priorities; problem too complex to be solved by research eg patient has comorbid diseases
- The patient’s own understanding from what they’ve read on the web, or their own preferences & values
- The health system and resources within which I can implement practice – information only valued from more senior colleagues; students being influenced by practice educators more than the evidence; no clear strategy within organisation; colleagues demonstrating out-of-date ritualistic practice, challenging them is difficult.
Possible solutions are:
- Time management – a top reason why EBP not carried out. Use strategies to consider what is urgent/ important such as the Eisenhower Matrix. Spending time on important/non-urgent tasks now will save time responding to tasks that have become urgent later on.
>> Incorporate EBP as part of your daily work and not an add-on. Use sites that summarise research rather then reviewing individual articles yourself. Set aside time each month for your development/research (example of an important/not-urgent task). Give yourself motivational goals eg journal clubs or working on research with others.
>> Ask managers at your job (and at interview!) whether you will have time or funding put aside for you to research evidence/keep up to date with the latest evidence through CPD events.
- Organising research– keep notes of research you have read, and prepare journals that are ready to read for when you have time.
>> You could produce evidence from your practice for other colleagues to use (Swisher 2010). This is particularly useful in areas where it is too expensive or unethical to carry out research trials, but clinicians still need some kind of data to base their clinical reasoning on! Rather than grouping patients according to strict RCT inclusion/exclusion criteria, they are grouped according to common factors, which reflect the complex individuals they are! By recording the outcomes of interventions and processes in this way, and creating practice-based evidence, you can create protocols as a starting point for other clinicians to then begin creating interventions for other patients. There is not much published evidence for practice-based evidence (especially) for OT however, as they are not often reported after they are carried out!
- Organisational culture – develop a questioning culture with colleagues. Ask students what they are learning or to investigate a clinical issue if they have time. Start a journal club to share knowledge with colleagues. Feedback to colleagues if you attend a conference/a conference could be fastest way of updating your knowledge on a subject.
- Finding research effectively – use PICOT questions, learn to use databases and the internet effectively, learn the difference between research methods and their hierarchy (grade according to quality), learn how to use appraisal tools and learn how to interpret statistics.
What happens when there is an absence of EBP where you work?
You should develop a rationale for your own actions and not just carry out a task in a certain way because you have been told to. Challenge whether behaviours you see are ritualistic or evidence-based by asking what the evidence rationale behind it is. If they are unable to give a rationale, discuss how you could work on this together.
Ask managers if they value evidence research, and ask for work time to be allocated for you to carry it out. You could highlight the dangers of you or other staff becoming out-of-date and ritualistic clinical role-models if you do not have adequate resources to maintain your evidence knowledge. It can be useful in highlighting the benefits of EBP if you can monitor the changes to practice through using evidence based research, such as by recording baseline information, monitoring changes locally or against national standards/targets, or evaluating research on cost benefits though clinical improvements.
Amongst your peers you could start a journal club, and encourage a team-approach to problem solving and for colleagues to see challenging practice as way of everyday professional development rather than personal criticism. If there are similar clinical situations repeated often at work, you could work to create evidence-based guidelines for everyone to use for these most common interventions.
When qualified, you could speak with OT students on placement or volunteer at a local university to access information about the most current theories and evidence.
How do I challenge bad practice?
Discuss with practice educators or your manager in advance about what you should do if you see out-of-date or unsafe practice happening. Avoid challenging someone in public or in front of the client; speak to them in a private setting.
Think about what evidence you have and whether you might be unaware of a context or different patient values? Ask a question wanting to clarify the reasons behind the bad practice, rather than making dramatic accusations- perhaps outline what your observations were and then ask what their perspective is. Then give the person a chance to consider your view or question!
Some guidelines on challenging behaviour while you are a student on placement are here: http://www.hls.brookes.ac.uk/images/pdfs/plu/guidance-re-freedom-to-speak-up-2015-faecse-27-august.pdf
Aveyard, Helen & Sharp, Pam (2013) A beginners Guide to Evidence-Based Practice in Health and Social Care. Maidenhead : McGraw-Hill Open University Press. Available at: https://www.dawsonera.com/abstract/9780335246731 [Chapter 7- How to implement evidence-based- practice]