What is Evidence-Based Practice?

Pie chart of three evidence-based practice components

The Three Core Components of EBP (c) CJT Consulting & Education

Regardless of when you went to nursing school, you’ve heard the term, evidence-based practice or evidence-based nursing, in your clinical or professional practice. Evidence-based practice may even be a part of your job description — but do you really understand what it means to base your nursing practice on evidence?  

What evidence is acceptable?  How do you make sure that you are using the most current evidence in your nursing practice?  What questions should you be asking?   How do you find the best evidence – and once you’ve found it, how do you know if the evidence is valid?  Once you determine the evidence is valid, then what?  I’ll answer these questions and others for you in my blog series on Evidence-Based Practice starting this month.

By the way, one of my free resources is an Evidence-Based Practice guide — print it out and use it as a quick resource for clinical practice.  I’ll discuss each part of that handout in greater detail in my blog posts for this topic.  Download this guide now!

What is Evidence-Based Practice?

Evidence-based practice (EBP) is an umbrella term for clinical decision-making by the clinician and patient that is based on the best evidence available.  Though the term evolved from medicine, it is used by all the healthcare professional disciplines to specify an approach to best practice in a specific discipline, for example; evidence-based medicine (EBM), evidence-based nursing (EBN), evidence-based pharmacy practice, evidence-based physical therapy, etc.  When we consider the healthcare team – we expect that all team members are using the best evidence to inform their clinical opinions and treatment recommendations.  We even have evidence-based management and evidence-based teaching practice. 

Many clinical questions arise in the care of patients.  In general, EBP is a logical, systematic method of clinical decision-making that incorporates the best evidence available (for the clinical question of interest), clinical expertise (of the clinician), and the patient preferences (of the patient being treated).  

In nursing, EBP and EBN are commonly used interchangeably.  EBP is frequently understood to be research utilization or research-based practice, foundations for nursing practice promoted by nurse leaders for many decades (Scott & McSherry, 2009). Some nurse authors have modified the basic EBP definition to incorporate nursing issues, such as theory-guided practice, but the framework of best evidence, clinician expertise, and the patient’s preferences related to their situation and resources, prevails in most EBN definitions. 

Paradigm Shift: A Different Way of Thinking

The promotion of EBP has ushered in a new way of thinking in medicine.  Logical and systematic are key words in the definition.  While scientific evidence in the form of research studies certainly played a part in past clinical decision-making, the role of tradition and authority-based practice cannot be overlooked.    

Tradition-Based Practice.   This is the way we’ve always done it” is a familiar phrase to nurses and other healthcare professionals, unfortunately.  But this mindset clearly does NOT promote an evidence-based healthcare mentality.  Tradition-based practice also has carried forward from our initial degree programs. We know that clinicians practice what they learned during their academic and clinical training.  We also know that our knowledge deteriorates with time (Choudhry, Fletcher, & Soumeral, 2005; Straus et al., 2005).  

New evidence is being published daily, but the lag period between publication and clinical application can last many years. And while reading journals, networking, and attending conferences is important to life-long learning, it is not enough to keep up with the overwhelming amount of information from thousands of clinical trials and biomedical publications.  For example, Medline, the U.S. National Library of Medicine’s® (NLM) bibliographic database, added more than 806,000 citations in 2015 (Medline Fact Sheet, 2016). 

Authority-Based or Eminence-Based Practice.  Authority- or Eminence-based medicine is defined as “relying on the opinion of a medical specialist or other prominent health official when it comes to health matters, rather than relying on a careful assessment of relevant research evidence” (Cassels, 2012).  Cassels’ blog post on this topic on the Cochrane Blog is very revealing.  Whether you are a nurse, physician, respiratory therapist, or other healthcare professional, your preceptors and instructors were extremely influential in how you practice nursing, medicine, respiratory therapy, etc.  I did whatever my preceptors told me — and believed everything they said, without question. Didn’t you?  Be honest.  These people were our role models — they were the authorities, the experts.

It wasn’t until I was a preceptor and an orientee asked me why we did something a certain way that I realized that I was just parroting my former preceptor!  EBP wasn’t a “thing” then, but I still didn’t have a  research-based answer to her question. 

As a student or new orientee, you don’t always think to question your instructor or preceptor.  The EBP approach is one in which questioning and searching for answers is an essential part of the process!

Recalled, Vivid Memories are Not Equal to a full Data Set.  Keep in mind that “expert” opinion is not always expert.  Clinical intuition is imperfect and cognitive heuristics, or those “rules of thumb” we use in many situations, can be misinterpreted.  For example, we tend to remember experiences that made an impression on us (good or bad)(known as the Availability Heuristic); those extreme recalled experiences don’t reflect the full data set of all of one’s experiences on that topic, though (e.g., all diabetic patients you cared for, all patients who were treated with X, etc.).  Therefore, the recalled experiences are not representative of the problem and therefore, one’s “expertise” can lead to inaccurate predictions about patient outcomes. 

The EBP approach is a shift in thinking because it leaves tradition, authority, and eminence forms of information behind.  However, EBP does have the potential for harm if not used correctly.  We’ll delve into this and other EBP specifics in future posts. 

In the meantime, Don’t forget to download my free EBP guide!

References

Cassels, A. (2012, November 30). Eminence vs. evidence. Cochrane Blog. http://community-archive.cochrane.org/news/blog/eminence-vs-evidence  Accessed December 12, 2016.

Choudhry, N. K., Fletcher, R. H., & Soumeral, S. B. (2005). Systematic review: The relationship between clinical experience and quality of health care. Annals of Internal Medicine, 142, 260-273.

Medline Fact Sheet. (2016, June 23). https://www.nlm.nih.gov/pubs/factsheets/medline.html  Accessed December 12, 2016.

Scott, K., & McSherry, R. (2009). Evidence-based nursing: Clarifying the concepts for nurses in practice. Journal of Clinical Nursing, 18(8), 1085-1095. doi: 10.1111/j.1365-2702.2008.02588.x 

Straus, S. E., Richardson, W. S., Glasziou, P., & Haynes, R. B. (2005). Evidence-based medicine: How to practice and teach EBM (3rd ed.). Edinburgh, Scotland: Elsevier Churchill Livingstone. 

You also might enjoy this short, funny (but maybe more true than we’d like to admit), classic article:

Isaacs, D., & Fitzgerald D. (2001). Seven alternatives to evidence-based medicine. Oncologist, 6(4), 390-1. http://theoncologist.alphamedpress.org/cgi/reprint/6/4/390