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Understanding and Implementing Evidence Based Practice
Evidence Based Practice (EBP) is the integration of clinical expertise, patient preferences and patient situation, and the best available research evidence into the decision-making process for patient care. It is nothing new or complicated or mind-blowing, and it will help you to make better decisions. To achieve this, clinical expertise refers to the clinician’s cumulated experience, education, and clinical skills, while the patient brings their personal preferences and concerns, expectations, and values to the encounter. The best research evidence is usually found in clinically relevant research that has been conducted using sound methodology.
Rating the Strength of Evidence
EB Practitioners must determine the strength of the evidence they find in the literature. Systems for rating the strength of evidence vary widely, such as the Johns Hopkins Nursing Evidence Rating Scales. These levels of evidence are determined by several critical factors:
| Criteria | Definition |
|---|---|
| Strength of Evidence | Confidence that the evidence is a true measure. |
| Quality of Evidence | Minimization of bias. |
| Statistical Precision | Degree of certainty about the existence of a true measured effect. |
| Size of Effect | How much of an effect is above 'No Apparent Effect' for clinically relevant benefits. |
| Relevance of Evidence | Appropriateness of the outcome measure; usefulness in measuring benefits / harms. |
The Hierarchy of Evidence
Research is often organized into a hierarchy, frequently visualized through an Evidence Pyramid. The typical structure includes:
- Highest Level of Evidence: Systematic review of all relevant randomized controlled trials (RCTs).
- Next Highest Level of Evidence: At least one RCT on effectiveness.
- Intermediate Levels: A pseudo-randomized trial that assigns participants by alternating between groups by date of admission.
- Lower Levels of Evidence: Non-randomized studies with control group running concurrently with intervention group, or studies compared to historical information.
- Single-case studies: Often representing the lower threshold of clinical evidence.
Additionally, clinicians should consider the Confidence Interval (CI), which covers the likely range of true effect, as the play of chance can skew results.
Barriers to Successful Implementation
Whilst evidence-based practice is the gold standard for decision making, effective implementation of evidence-based practice presents a series of real challenges to many organisations. A number of studies show that whilst many specialists look upon the idea of EBP in a favourable way, there are barriers in understanding how to translate evidence and apply it to practice. The four major barriers to successful implementation include:
- Access to resources: Access to professional resources required to develop EBP is often quite difficult and time consuming.
- Time constraints: These are regularly cited in every profession as being a key barrier to the application of EBP, specifically the time needed to source, obtain and translate research studies.
- Lack of expertise: A lack of experience and knowledge regarding implementation and evidence-based practice leadership significantly reduces the chances of success.
- Lack of an implementation model / strategy: Failing to have a strategy limits the longevity, embededness and integration of the practice into working lives.
Another key issue is a lack of support at organisational and managerial levels to give people the time to engage with the research needed to implement EBP properly. At the bottom of all of the barriers to implementation is usually a simple lack of knowledge and understanding.