Evidence Based Practice or Practice Based Evidence what is the ...

Evidence Based Practice or
Practice Based Evidence:
what is the difference ?
Dr Anne Payne
Associate Professor of Dietetics

Overview
1. What is Evidence Based Practice
(EBP)?
2. What is Practice Based Evidence .. a
practitioners view?
3. Current view and critique of the EBP
model.
4. What next…..how do we change
practice?
5. Conclusions

Evidence-based Practice (EBP)
What is it?
“............the conscientious, explicit
and judicious use of current best
evidence in making decisions
about the care of individual
patients”
(Sackett et al 1996)

EBP – Why do we need EBP?
• EBP helps patients and
practitoner’s to make
informed decisions about
health-care and so
promotes better quality
care.
• EBP helps healthcare
providers to understand the
effectiveness, and
comparative effectiveness
of different types of care to
ensure best use of
resources.

EBP – Why?
In essence we are asking………
‘Is the right person
doing the right thing,
at the right time, in
the right place in the
right way, with the
right result ?’

Evidence Triad – Fundamental Principles of EBP
Adapted from: Sackett DL, Rosenberg MC, Gray JA, Haynes RB,
Richardson WS. Evidence based medicine: what it is and what it isn't.
BMJ. 1996;312: 71-72.

Evidence Based Practice….
• Integrates best available external
clinical evidence from systematic
research ……with
• Practice Based Evidence/ Individual
clinical expertise …..while
• Taking into account patient
preferences/values

The 5 stages of EBP
1. Formulate a clinical question: eg
use of the PICO format
(Population Intervention
Comparison Outcome)
2. Search for relevant evidence:
define a research strategy and key
words
3. Critical appraisal /Evaluation of the
evidence for validity and
usefulness to identify best practice
4. Implement change: your Action
Plan
1. Audit the impact of change

Hierarchies of Evidence
1. Systematic reviews (including
meta-analyses)
2. Randomised Controlled Trials &
other experimental research
3. Non-experimental research e.g.
surveys, qualitative research
4. Conference & seminar reports,
examples of good practice
5. Expert opinion

The research evidence: key tools
•Systematic reviews &
meta analysis:
– eg. The Cochrane
Collaboration
•Clinical guidelines
– eg. SIGN and NICE

Patient
Clinical Records
Patient
preference
& needs
Ethical Principles
&
Professional
Codes
Research
&
Systematic
review
Audit
&
Evaluation
of change
EBP
informed
clinical decision
making
Clinical
Guidelines
(in UK NICE/SIGN)
NSFs
Practice Based
Evidence:
clinical
judgement
& expertise
Care Pathways

Practice Based Evidence:
the practitioners expertise…
Defined by Sackett et al as:
‘the ability to use our clinical skills & past
experience to rapidly identify each patient’s
unique health state & diagnosis, their
individual risks & benefits of potential
interventions, & their personal values &
expectations.’

Practice Based Evidence
Practice Based Evidence can take many
forms:
•personal experience and theoretical
knowledge
•reflective practice (practitioner derived
knowledge)
•audit evaluation of practice and practice
based research.

Personal experience and knowledge
For example:
•University education
•Diversity of clinical
experience
•Continuing
Professional
Development (CPD)

Reflective practice
Reflection on practice:
•A powerful clinical tool
to inform and enhance
our clinical practice. It is
a key tool in our undergraduate
programmes
•Gibbs reflective cycle is
a popular model, as
pictured.

Reflection in practice
• Dynamic process:
sound communication skills
• Immediate
outcome
• Informs decision
making process
• Requires
experience and
confidence

Practice based research and
audit
• Clinical audit:
the audit cycle is a key
component of effective
evidence based practice
• Clinical research:
The identification of
appropriate clinical
outcome measures
/criteria is now recognised
as essential to assess the
effectiveness of clinical
care, whether by audit or
original research (BDA
2011)

Critique of EBP
• Too focused on research
evidence: Systematic Reviews
and RCT’s
• Patient needs not adequately
addressed (each is unique)
• Does not take adequate
account of Clinical Expertise
• Should we use the term
Evidence Informed Practice
‘EIP’ rather han EBP ?? (Nevo &
Slonim-Nevo (2011)

What next....how do we change practice?
Having identified best practice how do
we now change practice?
What are the barriers to change? Are they personal
or institutional and how can we overcome these?
What are the key steps to implement change?
Are dietitians being taught EBP in University or ‘on
the job’ as CPD? Do we need to learn new skills?

Personal barriers to change
• Time to read
original research
papers
• Time to do
research and audit
• Knowledge of the
EBP process
• Confidence in the
interpretation of
statistics
• Reference: Heiwe S et al (2011)

Individual barriers…do you
recognise this person………..
• Continues to work only with
knowledge gained when
qualified
• Uses of out of date textbooks
• Is not aware of new research
• Works in isolation from
interested colleagues
• Does not see value of EBP to
clinical practice
• Feels threatened by change

Institutional barriers to
change….
• Lack of authority to make changes to
existing policy
• Lack of resources and budgets
• Lack of co-operation from others e.g. the
Multi-disciplinary Team
• Lack of time to implement
the change & train staff

How do we overcome barriers?
• Team leader with
sound knowledge of
relevant evidence
base
• Academic support
• Multidisciplinary
working groups
• Developing research
culture.
• Training in management
and leadership to
implement change
• Managerial support
• Dedicated time out for
study

Helpful levers for change.........
• The ‘Expert Patient’ can prompt the
most resistant practitioner to update
their practice
• Opinion leaders and clinical
champions can raise awareness of
the need for change in practice
• Public opinion can influence health
policy
• EBP requires organisational
commitment

Key Steps
to Implementing Change
Analyse the change required to identify a strategy……
1. Identify the key elements of change…..
◦ Do you plan to introduce a new assessment tool
◦ A new care-pathway
◦ A novel nutritional supplement?
2. Identify the economic, material and staffing
resources required to implement change.
3. Identify key stakeholders………..

Key Stakeholders?
• Fellow professionals
e.g. MDT
• Boss/Line Manager
• Media
• Research funders
• Health service
management
• Director of research
• Policy makers
• Patients

Key Steps
to Implementing Change
1. Assess whether key stakeholders &
individuals are prepared for change
Identification of potential barriers to
change
Identification of enabling factors e.g.
clinical champions
2. Set an time-limited Action Plan for change
3. Evalute the impact of change via the audit cycle

Do dietitian’s need to learn new skills?
The key skills to be an effective practitioner of
EBP are:
oComprehension of the EBP process
oKnowledge of audit and research methodology,
including the interpretation of statistics
oUse of reflection in clinical practice
oWell developed client communication skills to
ensure that the patients view is heard.
oWell developed team communication skills
and presentation skills to implement
change……

Conclusion
Evidence Based Practice and Practice Based
Evidence:
what is the difference??
In my view the majority of our clinical practitioners are working
to implement ‘Best Practice’ via PBE and so are already
engaged in the ‘EBP’ process, even if they are not fully aware of
it.
They need to recognise their skills, abilities and achievements
and strive to build a strong EBP culture in their workplace.
New tools are being developed to help us do it even better and
this is the subject of this afternoons presentations on the PEN
tool.

References
• British Dietetic Association (2011) Model for Dietetic Outcomes.
Birmingham, UK.
• Craig JV and Symth RL (2007) The Evidence-Based Practice Manual
for Nurses (2 nd edition); Churchill Livingstone, Elsevier, UK.
• Heiwe S et a (2011) Evidence Based Practice: attitudes, knowledge
and behaviour among allied health care professionals. Int J for Quality
in Health Care; 23(2): 198-209
• Livingston EH and McNutt RA (2011) The hazards of evidence-based
medicine – assessing variation in care. JAMA; 306 (7): 762-763.
• Nevo I and Slonim-Nevo E (2011) The myth of evidence-based
practice: towards evidence informed practice. B J Social Work; 1-22.
• Palisano RJ (2011) Practice Knowledge: the forgotten aspect of EBP.
Physical and Occupational Therapy in Pediatrics 30(4) 261-263
• Payne A and Barker H (eds) (2010) Advancing Dietetics and Clinical
Nutrition; Churchill Livingstone, Elsevier, UK.
• Sackett DL, Rosenberg MC, Gray JA, Haynes RB, Richardson WS
(1996) Evidence based medicine: what it is and what it isn't. BMJ; 312:
71-72.