CONTENTS
Abouttheauthorsvii
CHAPTER1
Introductiontoresearch,the researchprocessandEBP1
1.1Themeaningof‘evidence-based practice’2
1.2Apprehensiontowardsevidence-based practice5
Decisionmakingbyanecdote6
Decisionmakingbypresscutting6
Decisionmakingbyexpertopinion6
Decisionmakingbycostminimisation7
1.3Beforeyoustart:formulatetheproblem8
CHAPTER2
Askingquestionsand searchingforevidence11
2.1Differenttypesofsearching forevidence12 Informal12 Focusedlookingforanswers13 Searchingtheliterature13
2.2Differencesbetweenprimaryand secondaryresearch13
2.3Effectivesearchstrings13 Stepsforeffectivesearching14 One-stopshopping:federated searchengines16
2.4Otheravenuesforhowtosearch forevidence17 Searchingforinformationusing socialmedia19
CHAPTER3
Reviewingliterature21
3.1Isapaperworthreadingatall?23
Question1.Whowrotethepaper?23
Question2.Isthetitleappropriate andillustrative,andisthe abstractinformative?23
Question3.Whatwastheresearchdesign, andwasitappropriatetothe question?24
Question4.Whatwastheresearchquestion, andwhywasthestudyneeded?24
Question5.Dotheresultsorfindingsanswer thequestion?24
3.2Reviewingthemethodsofprimary researchpapers25
Sampleandsetting:whoaretheparticipants, andwhereisthestudybeing carriedout?25
Whatdata-collectionmethods wereused?26
Howwasthedataanalysed?26
3.3Reviewingthemethodsofsecondary (review)papers26
Question1.Whatisthefocusedclinical questionthatthereviewaddressed?27
Question2.Wasathoroughsearchofthe appropriatedatabase(s)carriedout,and wereotherpotentiallyimportant sourcesexplored?27
Question3.Whoevaluatedthestudies, andhow?28
Question4.Howsensitivearetheresults tothewaythereviewhas beenperformed?28
Question5.Havetheresultsbeeninterpreted sensibly,andaretheyrelevanttothe broaderaspectsoftheproblem?28
Meta-analysesandmeta-syntheses28
CHAPTER4
Qualitativeresearch32
4.1Qualitativeresearchexplained33
4.2Thedifferencebetweenqualitativeand quantitativeresearch34
4.3Qualitativemethodologiesanddata collectionstrategies35
Qualitativesampling36
Datacollection36
4.4Evaluatingpapersthatdescribe qualitativeresearch37
Question1.Didthepaperdescribean importantclinicalproblemaddressedviaa clearlyformulatedquestion?38
Question2.Wasaqualitativeapproach appropriate?38
Question3.Howwere(a)thesettingand (b)thesubjectsselected?38
Question4.Whatwastheresearcher’s perspective,andhasthisbeentaken intoaccount?38
Question5.Whatmethodsdidtheresearcher useforcollectingdata,andarethese describedinenoughdetail?39
CHAPTER10
Ethics106
10.1Ethicalprinciples107
Autonomy:patients/clientsarefreeto determinetheirownactions107
Beneficence:actingtobenefit humankind108
Justice:obligationtotreatfairly108
Non-maleficence:avoidingorminimising harm108
Respectforhumandignity108
Confidentiality:maintenanceofprivileged information,includingtherighttoprivacy andanonymity109
Veracity:obligationtotellthetruth109
10.2Theroleandfunctionofhumanresearch ethicscommittees109
10.3Judgingtheethicalaspectsofa publishedjournalarticle111
CHAPTER11
Gettingevidenceinto practice114
11.1Adoptionofevidence-based practice(EBP)115
Individualbarriers115
Organisationalbarriers116
11.2Encouragingindividualstoimplement evidence-basedpractice116
11.3Organisationalsupportofevidencebasedpractice117
Integratedcarepathways117
Clinicalpracticeguidelines118
11.4Theclientperspectiveinevidencebasedpractice119
Patient-reportedoutcomemeasures (PROMs)119
Shareddecision-making119 Optiongrids120
CHAPTER12
Challengestoevidencebasedpractice124
12.1Whenevidence-basedpracticeis donebadly126
12.2Whenevidence-basedpracticeis donewell126
Guidelinesdevalue professionalexpertise126
Theguidelinesaretoonarrow(or toobroad)127
Theguidelinesareoutofdate127
Theclient’sperspectiveisignored127
Therearetoomanyguidelines128
Practicalandlogisticalproblems128
Theevidenceisconfusing128
12.3Achievingevidence-basedpractice129
Index 133
ABOUTTHEAUTHORS
TrishaMGreenhalgh
DrTrishaGreenhalghisaProfessorofPrimaryCareHealthSciencesattheUniversityofOxfordand apractisingGP.ShecompletedaBAinSocialandPoliticalSciencesattheUniversityofCambridge in1980andamedicaldegreeattheUniversityofOxfordin1983.Trisha’sresearchaimstoapplythe traditionalaspectsofmedicinewhileembracingtheopportunitiesofcontemporarysciencetoimprove healthoutcomesforpatients.Sheistheauthorofmorethan240peer-reviewedpublicationsaswellas anumberofscholarlytextbooks.Trishahasreceivednumerousaccoladesforherwork,includingtwice winningtheRoyalCollegeofGeneralPractitionersResearchPaperoftheYearAward,andreceivingthe BaxterAwardfromtheEuropeanHealthManagementAssociation.In2001,shewasawardedanOBEfor servicestoevidence-basedmedicalcare.
JohnBidewell
DrJohnBidewellisaLecturerinResearchMethodsattheSchoolofScienceandHealthatWestern SydneyUniversity.Fromanearlycareerinschoolteaching,Johnmovedintopsychology,acquiringthree degreeswhilealwaysmaintaininganinterestineducation.Opportunitiesaroseinappliedsocialresearch anddataanalysis,leadingJohninthatdirection.Formanyyears,heprovidedtechnicalandinspirational supporttoacademicandstudentresearchers,coveringeverystageoftheresearchprocessfromconceptto publication,andespeciallydataanalysisandinterpretation,atWesternSydneyUniversity’snursingand midwiferyschool.Johnhasprovidedconsultancyservicesinresearchandstatisticstobusiness,industry andgovernments,andhastaughtresearchmethodsandstatisticstonursing,businessandalliedhealth studentsatundergraduateandpostgraduatelevels.
ElaineCrisp
DrElaineCrispisaRegisteredNurse(RN)andLecturerattheSchoolofNursingattheUniversity ofTasmania,whereshecoordinatesboththeBachelorofNursing(BN)courseandtheTranslational ResearchunitwithintheBN.ThisdualroleenableshertoensuretheBNhighlightstheconnectionbetween researchandclinicalpractice.Shehasalsotaughtresearchmethodstonursingandalliedhealthstudents atthepostgraduatelevel,encouragingclinicianstounderstandanduseresearchevidenceintheireveryday practice.ElaineworkedasanRNinagedcareandintheperioperativeareabeforecommencingherPhD, whichcombinedherloveofhistoryandnursing.Hermajorresearchinterestsarenursingandwelfare history,agedanddementiacare,andnurseeducation.
AmandaLambros
AmandaELambrosisaProfessionalSpeaker,AuthorandClinicalCounselloraswellasapastClinical Fellow.ShehascompletedaBachelorofHealthSciencesattheUniversityofWesternOntario(2001),a PostgraduateDiplomaofEthics(2002),aMasterofForensicSexology(2004)andaMasterofCounselling (2014).Amandahasdeveloped,coordinatedandtaughtevidence-informedhealthpracticetothousandsof InterprofessionalFirstYearHealthSciencesstudentsthroughouthercareer.Amanda’sprivatepractice focusesonrelationships,mentalhealth,andgriefandloss.Providingherclientswiththemostup-to-date andevidence-basedcareisimperativetoher,andshehasastrongfocusonEBP,ethicsandcommunication. Amandahasreceivednumerousaccoladesforherwork,includingNifNex100MostInfluentialBusiness Owners,aTelstraBusinessAwardnominationandaTelstraBusinessWomanoftheYearnomination.
JaneWarland
DrJaneWarlandisanAssociateProfessorattheSchoolofNursingandMidwiferyattheUniversity ofSouthAustralia(UniSA).Sheworkedasamidwifefrom1988to2007,andgainedherPhDfrom theUniversityofAdelaidein2007.JanewasappointedasanacademicstaffmembertotheSchoolof NursingandMidwiferyinFebruary2008,andteachesafoundationalresearchcourseintheundergraduate midwiferyprogram.HerownprogramofresearchisSTELLAR(stillbirth,teaching,epidemiology,loss, learning,awarenessandrisks).Janehasatrackrecordinresearchusingqualitative,quantitativeandmixed methods.ShehasastronginterestinresearchethicsandservedtwotermsasamemberoftheUniSA HumanResearchEthicsCommittee.Janehaswrittennumerousbookchaptersaboutresearch—shehas morethan90publications,includingbooks,chaptersandpeer-reviewedjournalarticles.
Imagineyouaretakingthetimetovisityourgrandfather,Wilf,whohasbeenlivingonhisownforthe pasttwoyears,andrecentlybeganseeingahealth professionalregardinghischronichipandknee pain.Whenyouwalkintohishouse,youseehimin thelivingroomfollowingalongtoatelevisedfitness program—youask:‘Heygramps,don’tyouthink youshouldavoidexercisebecauseofthepainfrom yourosteoarthritis?’.Hesitsyoudownandtells youthat,inshort,he’srecentlybeenexercisingat homeandattendingregularyogaclassesalongside hisstandardcaretodecreasethelevelsofpain inhishipsandknees.Hecontinuestotellyou thathe’salreadyfeelingmuchbettersincehehas startedexercising.Atfirst,youareabitscepticalof thisrevelation,butitturnsoutthatbydoingthese activities,coupledwithstandardcare,yourgrandfatherwillexperienceareductioninhishipandknee painsymptoms,whilegainingconfidenceanddecreasingdepressivesymptoms.1 Infact,thisadvicewas notgiventoyourgrandfather‘onawhim’orbasedonasimpleresearchpaperthatguidedthehealth professionaltoadviseyourgrandfatherofthis;itwasasystematicreview—thehighestlevelofevidence. (Moreonthisinthechapteronlevelsofevidence.)
Nowimaginethat you arethehealthprofessionalandWilfisyourclient.Ratherthanjustproviding ‘standard’practice,thinkaboutthewaysinwhichyoucouldprovide evidence-basedpractice(EBP) apracticethatissupportedbyscientificevidence,clinicalexpertiseandclientvalues—andhowthis practicewillhavesignificantlybetteroutcomesthan‘standard’careforyourclients.Isn’tthisthecarethat youwouldwanttoprovide?Idon’tknowaboutyou...butthat’sthetypeofcarethatIwouldnotonly prefertoprovideasahealthprofessionalbutalsoreceiveasahealthconsumer.Thisisjustthestart— EBPbecomessomuchmoreexcitingfromhereonin.Themoreyouknow,themoreyouwanttoknow. Thisisoneofthemostfascinatingtopicstolearnabout,becauseyoucan’t‘undo’yourlearning.Ifyou allowyourselftheopportunitytobecomeimmersedinthetopic,itwillchangeyourperceptionofnearly everythingyouhear,readanddofortherestofyourlife!
DISCUSSIONQUESTIONS
1. Haveyouvisitedahealthprofessionalinthepast12months?
(a)Ifso,doyoubelievethehealthprofessionalwasanevidence-basedpractitioner?
(b)Howcanyoubesurethatyouwerereceivingevidence-basedcare?
2. Howwouldyoudistinguishevidence-basedcarefromstandardcare?
1.1Themeaningof‘evidence-basedpractice’
LEARNINGOBJECTIVE1.1 Whatdoes‘evidence-basedpractice’mean?
Theaimofthischapterisforyoutostarttounderstand‘research’,the‘researchprocess’and‘evidencebasedpractice’asfundamentallycriticaltoyou—notonlyasanindividual,butalsoasahealthconsumer andahealthpractitioner.Thischapterwillgiveyoutheopportunitytoexploretheimportanceofevidencebasedpracticeandopenyourmindtocopiousreal-worldexamplesthatsurroundyouonadailybasis, whichyoumightnotevenrecogniseasEBP.
EBPismuchmorethanjustreadingpapers.Accordingtothemostwidelyquoteddefinition,itis‘the conscientious,explicitandjudicioususeofcurrentbestevidenceinmakingdecisionsaboutthecareof individualpatients’.2 ProfessorSackettcontinuedtoexplainthatEBPshouldbevisualisedasathreeprongedandoverlappingapproach,alsoknownasa triadapproach:thebestpossibleresearchevidence, clinicalexpertiseandpatientvaluesandpreferences.3
Let’stakeamomenttobreakdowneachoftheseareassoyoufullygraspwhatisbeingconsideredwhen explainingEBP.
1. Thebestpossibleresearchevidence.Asyouwilllearninthechapteronlevelsofevidence,thehigher thelevelofevidence,thebettertheevidenceis.Thinkofitthisway:wouldyoupreferimplementinga newexerciseregimebecauseyourcousintoldyouitworkedforher(Level5—anecdotalevidence),or becauseasystematicreviewofover450000people(Level1—systematicreview)demonstratedthatit wouldhavesignificantresults?Therefore,whenwearelookingat‘bestpossibleresearchevidence’,it isliterallylookingforthebestoptionscurrentlyavailable(becauseyoudon’twanttouseoldevidence). Typically,researchevidenceisupdatedatleastevery3–5years,dependingonthetopic,whichmeans youcouldcontinuouslyimproveyourpractice.
2. Clinicalexpertise.Thistakesintoconsiderationyourexperiences,bothpersonalandprofessional,to helpguideyouinhowtobestcareforyourclients.Youmighthavepreviouslyattemptedsomething yourself—itcouldbeassimpleasusingasalinerinsearoundallergyseasontoalleviateallergy symptoms.Youthenhaveaclienttellyouhowhorribletheirhayfeversymptomsareeachyearwhen theflowersstarttobloom,butarenotsurehowtoeffectivelymanagethis.Inthissituation,youmight explaintothemthatusingasalineirrigationforallergicrhinitisworksquitewellbecauseitthinsthe mucusinthenasalcavityandremovessomeallergens,4 andthatalthoughtheevidenceislow,it’scosteffective,availablewithoutaprescriptionandagoodalternativetosteroidandantihistamineuse.Later on,thatclientmightattemptthis‘remedy’andthenreporttheresultsbacktoyou—youthenbeginto buildyour‘clinicalexpertise’inthisarea.
3. Patientvaluesandpreferences.Therearetimeswhenyoumighthaveresearchedthe‘bestpossible treatment’foryourclient.Fromclinicalexperienceyouareawarethatitwouldworkquitewell,but whenyouexplainthetreatmentorproceduretotheclient,theymightpreferanalternativetreatment; ortheirvaluesorreligiousbeliefswillnotpermitthetreatmentyouhavesuggested.Asyouaretreating yourclients,theirvaluesandpreferencesshouldbethefirstthingthatyoutakeintoconsideration,as thereisnopointincontinuouslysuggestingtreatmentstheyarenotableorwillingtoengagewith. Ifyouareahealthpractitionerworkinginruralorremotelocations,youalsoneedtoconsiderwhether ‘bestpractice’isavailable—youmighthavetoseekalternativetreatmentsbecausetheEBPissimplynot accessibleinyourlocation.
Youmightnowbeasking‘Whatisresearch?’.Essentially,itis‘focused,systematicenquiryaimedat generatingnewknowledge’.Throughoutthisresource,itwillbeexplainedhowthisdefinitioncanhelp youdistinguishgenuineresearch(whichshouldinformyourpractice)fromthepoor-qualityendeavours ofwell-meaningamateurs(whichyoushouldpolitelyignore).
Ifyoufollowanevidence-basedapproachtoclinicaldecisionmaking,allsortsofissuesrelatingto yourclientswillpromptyoutoaskquestionsaboutscientificevidence(figure1.2),seekanswerstothose questionsinasystematicwayandalteryourpracticeaccordingly.
FIGURE1.2 Somethingstoconsiderwhenassessingclients
•Clientpreferences
•Symptoms
•Physical/diagnosticsigns
•Age,sexandethnicoriginoftheclient
•Benefitsversusrisks
•Cost-effectivenessofthetreatment
SackettandHaynessummarisedthefiveessentialstepsintheemergingscienceofEBP5 as:
1. toconvertourinformationneedsintoanswerablequestions(i.e.toformulatetheproblem)(ASK)
2. totrackdown,withmaximumefficiency,thebestevidencewithwhichtoanswerthesequestions— whichmaycomefromtheclinicalexamination,thediagnosticlaboratory,thepublishedliteratureor othersources(ACQUIRE)
3. toappraisetheevidencecritically(i.e.weighitup)toassessitsvalidity(closenesstothetruth)and usefulness(clinicalapplicability)(APPRAISE)
4. toimplementtheresultsofthisappraisalinourclinicalpractice(APPLY)
5. toassessourperformance(EVALUATE).
Hence,EBPrequiresyounotonlytoreadpapersbutalsotoreadthe right papersattherighttime,and thentoalteryourbehaviouraccordingly(and,whatisoftenmoredifficult,influencethebehaviourofother people)inthelightofwhatyouhavefound.Atnotimeshouldonestepbeseenasmoreimportantthan another—allstepsshouldholdequalimportance.Yetifyouhaveaskedthewrongquestionorsought answersfromthewrongsources,youmightaswellnotreadanypapersatall.Equally,allyourtraining insearchtechniquesandcriticalappraisalwillgotowasteifyoudonotputatleastasmucheffortinto implementingvalidevidenceandmeasuringprogresstowardsyourgoalsasyoudointoreadingthepaper.
Greenhalghaddedtothestepsabovetocreatewhatshedeemeda‘context-sensitivechecklistfor evidence-basedpractice’toincorporatetheclient’sperspective,resultingineightstages,asoutlinedin figure1.3.6
Thisresourcehasbeenstrategicallydesignedandwrittensothatyoucangetthebestpossibleoverview ofevidence-basedpractice,especiallyforthosewhoarenewtotheconceptofEBP.Ourgoalisforyouto beabletohaveanunderstandingofEBPsothatwhenyoubecomeapractitioner,youhavetheminimum skillsand knowledge toapplyevidenceandpracticeasanevidence-basedpractitioner.
FIGURE1.3 Ismypracticeevidence-based?Acontext-sensitivechecklistforindividualclinicalencounters
HaveIidentifiedandprioritisedtheclinical,psychological,socialandotherproblem(s),takinginto accountthepatient’sperspective?
HaveIperformedasufficientlycompetentandcompleteexaminationtoestablishthelikelihoodof competingdiagnoses?
HaveIconsideredadditionalproblemsandriskfactorsthatmayneedopportunisticattention?
HaveI,wherenecessary,soughtevidence(fromsystematicreviews,guidelines,clinicaltrialsand othersources)pertainingtotheproblems?
HaveIassessedandtakenintoaccountthecompleteness,qualityandstrengthoftheevidence?
HaveIappliedvalidandrelevantevidencetothisparticularsetofproblemsinawaythatisboth scientificallyjustifiedandintuitivelysensible?
HaveIpresentedtheprosandconsofdifferentoptionstothepatientinawaytheycanunderstand, andincorporatedthepatient’spreferencesintothefinalrecommendation?
HaveIarrangedreview,recall,referralorotherfurthercareasnecessary?
Incidentally,ifyouwanttoexplorethesubjectofEBPonline,youwillnotethatthroughoutthisresource, weprovideyouwithaplethoraofwebsitesthatcanhelpguideyouonthevarioustopics.Pleasedon’tfeel overwhelmedbythevastamountofliteratureavailable—mostofthesitesofferverysimilarmaterialand youcertainlydon’tneedtovisitthemall...justvisitthemifyouareinterestedindiggingalittledeeper intoeachtopic.
LEARNINGOBJECTIVE1.2 Whyarepeopleapprehensiveaboutevidence-basedpractice?
Unfortunately,somepeoplemightbeapprehensiveorgroanwhenmentioningevidence-basedpractice becausetheyhaveheardthroughthegrapevinethatit’sallaboutstatisticsandnumbercrunching.Before wegomuchfurther,let’sclarifysomethingandpopthatbubble!EBPisnot‘allaboutstatistics’.Although yes,statistics,numbers,equations,oddsratios,confidenceintervals,etc.areallwordsyouwillhearin EBP,understandinghowtointerpretandimplementEBPismuchmoreimportantatthispointintime. Numbersaregreatbut,inreality,ifyoudon’tunderstandwhatthenumbersmean,thenyouarenotreally abletoimplementEBP.Alternatively,ifyoudon’tunderstandhowtheresearcherscompletedthemath behindthenumbers,youcan’tdouble-checktheirwork—whichissometimesequallyasimportant.With thisinmind,GreenhalghandDonaldproposedanalternativedefinitionofEBP,whichdemonstratesthe useofmathematics.
Evidence-basedpracticeistheuseofmathematicalestimatesoftheriskofbenefitandharm,derived fromhigh-qualityresearchonpopulationsamples,toinformclinicaldecisionmakinginthediagnosis, investigationormanagementofindividualpatients.7
Studentsregularlyallowtheideaof‘numbers’anda‘newlanguage’toblurtheirexcitementforlearning aboutEBP—pleasedon’tletthishappentoyou.Beopentolearningaboutthetopic,whichwillstick withyoufortherestofyourlife.ThemoreopenyouaretolearningaboutEBP,thebetterthepractitioner youwillbecome!
Thesecondreasonthatpeopleoftengroanwhenyoumentionevidence-basedpracticeisbecausethere areplentyofdauntingnew(andoftenlong)wordsthatlooklikeaforeignlanguage.Whileitislikea newlanguage,absolutelyeverythinginEBPcanbebrokendownintosimpleandmanageablesteps.For example,studentsareoftenstumpedby retrospectivelongitudinalcohortdesign (whichyouwilllearn aboutinthisresource),butoncetheybreakitdown,itmakesperfectsense:
• retrospective —inthepast(thinkoftheword‘retro’)
• longitudinal —overalongperiodoftime
• cohort —agroupofpeople
• design —typeofstudy.
Nowthatit’sbrokendownintomanageablechunks,youinstantlyknowthat‘retrospectivelongitudinal cohortdesign’meansatypeofstudythatwasdoneoveralongperiod,lookingatagroupofpeoplein thepast.So,pleasedon’tfeeloverwhelmedbythewords—theyallmakesense,butsomejustneedtobe brokendownfirst.
Anyonewhoworksface-to-facewithclientsknowsthatitisnecessarytoseeknewinformationbefore makingaclinicaldecision.Healthpractitionersspendcountlesshourssearchingthroughlibraries,books andonlinetoinformtheirpractices.Ingeneral,wewouldn’tputaclientonanewdrugorthrougha newtreatmentwithoutevidencethatitislikelytowork—but,unfortunately,bestpracticeisnotalways followed.Therehavebeenanumberofsurveysonthebehavioursofhealthprofessionals.IntheUnited Statesinthe1970s,onlyaround10–20percentofallhealthtechnologiesthenavailable(i.e.drugs, procedures,operations,etc.)wereevidence-based;inthe1990s,thatfigureimprovedto21percent.8 Studiesoftheinterventionsofferedtoconsecutiveseriesofclientssuggestedthat60–90percentofclinical decisions,dependingonthespecialty,were‘evidence-based’.9 Unfortunately,duetovariousexcusesand limitations,wearestillsellingourclientsshortmostofthetime.
AlargesurveybyanAustralianteamlookedat1000clientstreatedforthe22mostcommonlyseen conditionsinaprimary-caresetting.Theresearchersfoundthatwhile90percentofclientsreceived evidence-basedcare forcoronaryheartdisease,only13percentdidsoforalcoholdependence.10 Furthermore,theextenttowhichanyindividualpractitionerprovidedevidence-basedcarevariedinthe samplefrom32percentofthetimeto86percentofthetime.Amorerecentstudyfoundthatonein threehospitalsarenotmeetingperformancemetrics.Oneoftheleadingreasonswasfailuretoimplement EBP.11 Followingthis,astudysuggestedthatmedicalerrorisnowthethirdleadingcauseofdeathinthe UnitedStates.12 Thesefindingssuggestplentyofroomforimprovement;therefore,withanewwaveof practitioners,hopefullywecanincreasetheapplicationofEBPsothatthemajorityofhealthconsumers arereceivingevidence-basedcare.
Let’slookatthevariousapproachesthatmanyhealthprofessionalsusetoreachtheirdecisionsin reality—allofwhichareexamplesofwhatEBP isn’t ...therefore,pleasedonotpractisethese!
Decisionmakingbyanecdote
WhenTrishaGreenhalghwasamedicalstudent,shewasabletojoinadistinguishedprofessoronhisdaily wardrounds.Onseeinganewclient,hewouldaskabouttheirsymptoms,turntothemassedranksof juniorsaroundthebed,andrelatethestoryofasimilarclientencounteredafewyearspreviously.‘Ah,yes. Irememberwegavehersuch-and-suchandshewasfineafterthat’.Hewascynical,oftenrightly,about newdrugsandtechnologies,andhisclinicalacumenwassecondtonone.Nevertheless,ithadtakenhim 40yearstoaccumulatehisexpertiseandthelargestmedicaltextbookofall—thecollectionofcasesthat wereoutsidehispersonalexperience—wasforeverclosedtohim.
Anecdote(storytelling)hasanimportantplaceinclinicalpractice.13 Itiscommonpracticeforstudents andpractitionerstolistentoprofessors,tutorsandclientsandmemorisetheirstoriesorscriptsinthe formofwhatwaswrongwithparticularclients,andtheiroutcomestouselater.Healthprofessionals gleancrucialinformationfromclients’illnessnarratives—mostcrucially,perhaps,whatbeingill means totheclient.Experiencedhealthprofessionalstakeaccountoftheaccumulated‘illnessscripts’ofall theirpreviousclientswhenmanagingsubsequentclients—butthatdoesn’tmeansimplydoingthe sameforclientBasyoudidforclientAifyourtreatmentworked,anddoingpreciselytheoppositeif itdidn’t!
Wewouldnotbehumanifweignoredourpersonalclinicalexperiences,butwewouldbebettertobase ourdecisionsonthecollectiveexperienceofthousandsofhealthprofessionalstreatingmillionsofclients, ratherthanonwhatweasindividualshaveseenandfelt.
Decisionmakingbypresscutting
Imaginesimplytrawlingtheinternet,magazines,newspapersandinformationpresentedthroughoutall formsofmediaandsimply‘cuttingandpasting’thencreating,forlackofabetteranalogy,ascrapbook oftreatments,cures,etc.—continuouslyalteringyourpracticeinlinewiththevariousconclusions.For example,‘probioticsimproveyourmood’,14 andadvocatingthatallclientstakeprobiotics.Theadvicewas inprint,anditwasrecent,soitmustsurelyreplacewhatwaspreviouspractice.
Thisapproachtoclinicaldecisionmakingis,unfortunately,stillverycommon.Howmanydoctorsdo youknowwhojustifytheirapproachtoaparticularclinicalproblembycitingtheresultssectionofasingle publishedstudy,eventhoughtheymightfailtotellyou:
• themethodsusedtoobtainthoseresults
• whetherthetrialwasrandomisedandcontrolled
• thenumber,age,sexanddiseaseseverityoftheclientsinvolved
• howmanywithdrewfrom(‘droppedoutof’)thestudyandwhy
• bywhatcriteriaclientswerejudged‘cured’
• ifthefindingsofthestudyappearedtocontradictthoseofotherresearchers;whetheranyattemptwas madetovalidate(confirm)andreplicate(repeat)them
• whetherthestatisticalteststhatallegedlyprovedtheauthors’pointwereappropriatelychosenand correctlyperformed(seethechapteronstatisticsforthenon-statistician)
• whethertheclient’sperspectivehasbeensystematicallysoughtandincorporatedviaashareddecisionmakingtool.
Therefore,healthpractitionerswholiketocitetheresultsofmedicalresearchstudieshavearesponsibilitytoensurethattheyfirstgothroughachecklistlikethisbeforesimplymakingdecisionsbypress cutting.
Decisionmakingbyexpertopinion
Inextremecases,an‘expertopinion’mayconsistsimplyofthelifelongbadhabitsandpersonalpress cuttingsofanageinghealthprofessional,whichcouldsimplymultiplythemisguidedviewsofanyone ofthem.Table1.1givesexamplesofpracticesthatwereatonetimewidelyacceptedasgoodclinical practice,butthathavesubsequentlybeendiscreditedbyhigh-qualityclinicaltrials.Seriousharmcanbe donebyapplyingguidelinesthatarenotevidence-based.ItisamajorachievementoftheEBPmovement thatalmostnoguidelinethesedaysisproducedsolelybyexpertopinion!
LEARNINGOBJECTIVE1.3 Howdowegetstartedwithevidence-basedpractice?
Ifmidwiferystudentsareaskedwhattheyknowaboutchildbirthandpainmanagement,theycantalkat lengthaboutthedifferentpainmanagementtechniques,howtheymeasurepainbyhavingaconversation withthewomaninlabour,whatthetextbooksdefineaspain—thelistgoeson.Theyaretrulyawareof theconceptof‘pain’anditsmanagementduringthelabouringprocess.
However,whenthestudentsareaskedapracticalquestionsuchas‘MrsJaneswantsthemosteffective, non-invasiveandnon-pharmacologicalpainmanagementtechnique—whatwouldyouadviseherasher options?’,theyappearstartled.Onestudentreplies‘MrsJanescanhaveabsolutelyanythingshewants tomanageherpain!’—agreatresponse,butitdoesn’tprovidethebestpossibleevidencetoMrsJanes, especiallyifshe’saskingdirectquestions.Theresponsecouldberelaxationtechniques,15 massageand reflexology,16 aromatherapy,17 andsoon—butthestudentwouldneedtorevisetheevidence.Theymay sympathisewithMrsJanes’spredicament,buttheyoftendrawablankastowheretodrawoninformation suchasthis,whichcouldpossiblybetheonethingthatMrsJanesneedsorwantstoknow.
ExperiencedhealthprofessionalsmightthinktheycananswerMrsJanes’squestionfromtheirown personalexperience,butfewofthemwouldberight.Eveniftheywererightonthisoccasion,theywould stillneedanoverallsystemforconvertingalloftheinformationaboutaclient(age,ethnicity,subjective painscale,etc.),theparticularvaluesandpreferences(utilities)oftheclient,andotherthingsthatcouldbe relevant(ahunch,ahalf-rememberedarticle,theopinionofamoreexperiencedcolleagueoraparagraph discoveredbychancewhileflickingthroughatextbook)intoasuccinctsummary.Thesummarywould needtocoverwhattheproblemis,andwhatspecificadditionalitemsofinformationweneedtosolvethat problemandcomeupwithadesiredoutcome.
Sackettetal.,inabooksubsequentlyrevisedbyStraus,18 explainedthatthepartsofagoodclinical questionshouldincludethreecomponents.
• First,defineprecisely whom thequestionisabout(i.e.ask‘HowwouldIdescribeagroupofclients similartothisone?’).
• Next,define which manoeuvre(treatment,intervention,etc.)youareconsideringinthisclient,and,if necessary,acomparisonmanoeuvre(e.g.placeboorcurrentstandardtherapy).
• Finally,definethedesired(orundesired) outcome (e.g.reducedmortality,betterqualityoflife,and overallcostsavingstothehealthservice).
Thus,inMrsJanes’scase,wemightask,‘Inathirty-year-oldCaucasianwomanwithahighpain threshold,twopreviouslabouring/birthingexperiences,nocoexistingillness,andnosignificantpast medicalhistory,whosebloodpressureiscurrentlyX/Y,wouldthebenefitsofsuggestingmassageand reflexologyprovideherwiththedesiredoutcomeofaneffective,non-invasiveandnon-pharmacological painmanagementtechniquetodecreasepainduringlabour?’Notethatinframingthespecificquestion,we havealreadyestablishedthatMrsJaneshaspreviouslyexperiencedlabourandbirthtwice.Knowingthis, werecognisethatshemayhavealsopreviouslyexperiencedinvasiveorpharmacologicalinterventionsand isawareofthediscomfortoflabouringandbirthing.
RememberthatMrsJanes’salternativetoaneffective,non-invasiveandnon-pharmacologicalpain managementtechniqueispotentiallyinvasiveandmayhavesideeffects—onnotonlyMrsJanes,but alsothebirthingprocessand/orthebabyabouttobeborn.Notallofthealternativeapproacheswouldhelp MrsJanesorbeacceptabletoher,butitwouldbequiteappropriatetoseekevidenceasto whether they mighthelpher—especiallyifshewasaskingtotryoneormoreoftheseremedies.
Beforeyoustart,giveonelastthoughttoyourclientinlabour.Inordertodetermineherpersonal priorities(howmuchdoesshevaluea10percentreductioninherpaintostillexperiencethelabourand birthingprocesscomparedtotheinabilitytofeelbelowherbellybutton?),youwillneedtoapproachMrs Janes,notanybodyelseinthatlabouringroom,andstartthedialoguetowardsprovidingevidence-based care.
SUMMARY
Evidence-basedpracticeismuchmorethan‘readinganacademicarticle’.Itincludes,ataveryminimum, thebestpossibleresearchevidenceavailable,clinicalexpertiseaswellasunderstandingtheclient’svalues andpreferences.EBPisnotaboutlearningatechnique,skillandtreatmentmethodologyonceandapplying itfortherestofyourcareer;itshouldbeacontinuousloopoflearningandimprovementbyusingtheAsk, Acquire,Appraise,ApplyandEvaluatemodel.Althoughsomestudents(andevenhealthpractitioners) attempttoavoidlearningaboutEBPbecausetheybelievethatit’sallmath-drivenandhardtounderstand, it’smuchmorethanjustnumbers.Onceyoulearnthetechniques,youwillbegintoseeevidence-based informationallaroundyouandwillcontinuetoapplyEBPthroughoutyourlifeasbothahealthconsumer andeventuallyahealthpractitioner.Whenthebestquestionisformulated,itbecomesmucheasiertofind thebestevidencetoanswerthequestion.
KEYTERMS
evidence-basedcare Carethatisbasedonevidence-basedpractice(supportedbyscientificevidence, clinicalexpertiseandclientvalues). evidence-basedpractice(EBP) Apracticethatissupportedbyscientificevidence,clinicalexpertise andclientvalues.
knowledge Anacceptedbodyoffactsorideasthatisacquiredthroughtheuseofthesenses,reasons orthroughresearchmethods. retrospectivelongitudinalcohortdesign Atypeofstudyconductedoveralongperiod,lookingata groupofpeopleinthepast.
WEBSITES
1 CentreforResearchinEvidence-basedPractice(CREBP):https://bond.edu.au/researchers/researchstrengths/university-research-centres/centre-research-evidence-based-practice
2 CentreforEvidence-basedMedicine:www.cebm.net
3 ‘Whatisevidence-basedmedicine?’, BritishMedicalJournal:www.bmj.com/content/312/7023/71
4 HPNAPositionstatements‘Evidence-BasedPractice’,HospiceandPalliativeNursesAssociation (US):https://advancingexpertcare.org/position-statements
5 JoannaBriggsInstitute:www.joannabriggs.org
6 AustralasianCochraneCentre:http://aus.cochrane.org
7 ‘Evidence-basedinformation’,QUTLibrary:www.library.qut.edu.au/search/howtofind/evidencebased
8 ‘AnsweringClinicalQuestions’,UniversityofWesternAustralia:www.meddent.uwa.edu.au/ teaching/acq
9 ‘Evidencebasedpractice’,UniversityofTasmania:https://utas.libguides.com/ebp
10 ‘Introductiontoevidence-basedpractice’,DukeUniversityMedicalCenterLibraryandtheHealth SciencesLibraryattheUniversityofNorthCarolina:https://guides.mclibrary.duke.edu/ebmtutorial
ENDNOTES
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ACKNOWLEDGEMENTS
AdaptingauthorforthisAustralianedition:AmandaLambros Photo:©Halfpoint/Shutterstock.com
