What Counts As Evidence In Evidence Based-Practice?


Evidence Based Nursing

     Nurses are under increasing pressure to keep up to date and to take decisions more firmly on evidences in contrast to the anecdotal information of the past. The most important aspect of evidence-based practice is that it provides a scientifically accountable method for making best-practice decisions that ensures professional transparency. Evidence based practice provides nursing practice with a stronger application of scientific methods (Baum, 2003). Evidence based practice is the conscientious, explicit and judicious use of current best evidence in making decisions about the case of individual patients (Sackett, 1996). Trisha Greenhalgh et.al (2003) view evidence based practice as a sequence of framing a focused question followed by a thorough Search for research derived evidence supported by the appraisal of the evidence for its validity and relevance incorporating the user's values and preferences.
Evidence in Evidence based Practice
     The best evidences are based on the conviction that a systematic documenting of a large number of high quality RCTs (Randomized with Concealment, Double blended, complete follow-up, intention to Treat analysis) gives the least biased estimate. Thus, this becomes level 1 evidence and recommendations based on level 1 evidence are Grade A (Baum, 2003). Various terminologies aid evidence based medical practice such as ‘Clinical practice guideline’ which assists practitioner and patient make decisions about appropriate health care and ‘Randomized controlled clinical trial’ where a group of patients is randomized into an experimental group and a control group(Baum, 2003). Evidence-based practice demands clinical judgment about the validity and applicability of research evidence. Since, the factors that influence an evidence-based decision in the clinical context differ from those in the broader policy context, evidences lead to legitimate differences in recommendations for a complex problem and every individual case becomes a powerful tool to illustrate complex clinical decisions (Browman, 1999).
Components of Evidence
     Clinical judgment, Patient preferences, Systematic review, Clinical practice guidelines and Case report are some of the important components of evidence (Browman, 1999). Clinical judgment is a vital component of an evidence-based decision especially when there is no direct evidence from rigorous studies to inform a clinical decision. Most often evidence is contextual in the sense that there may be different legitimate conclusions from the same evidence. Patient preferences and participation in clinical decisions, where, the patient analyzes the clinical situation and accepts or rejects the evidence is a vital component. Systematic review includes writing of a protocol defining the systematic review process and rigorous predefinition of the study eligibility criteria. The utility of the systematic review in evidence based practice is as a decision tool rather than as an object of scientific inquiry. Thus, the more rigorous the systematic review, the more valuable it is as a clinical decision tool. Clinical practice guidelines can be defined as systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. Thus, these guidelines are tools and not mere rules that substantiate clinical judgements and decisions without replacing them. Case report adds accountability to the clinical decisions by documentation (Browman, 1999).
Utility of the Evidence
     Research Evidence can be utilized into nurse practices before an intervention is offered by restricting to evidence sources that have already undergone critical appraisal such as evidence-based guidelines or evidence summaries and by taking expert opinion before intervention (Straus et.al, 2000). Evidence is thus, a contrast data that is based on a more accurately defined problem investigated efficiently and validated scientifically for their clinical relevance (Casado et.al, 1999). The actual challenge to the nurses lies in bringing this evidence and practice together bridging the gap between evidence-based medicine and actual practice. Systematic reviews, Practice guidelines and health care technology assessment reports play an important role in bridging the gap (Ramaekers, 2005). Rogers' theoretical model of the Diffusion of Innovations is a useful tool in understanding the problem of the slow diffusion of the application of research evidence in clinical nursing practice and the evidence –nurse practice gap (Taylor,1998). Deborah J (1999) has also highlighted the theory practice gap that exists in nursing today as a barrier to evidence based nursing.Pravikoff et.al (2005) on close examination of nurses' perceptions about their access to tools and the skills to obtain evidence in their practice, using a stratified random sample of 3,000 RNs across the United States, have found that nurses frequently need information for practice on specific tasks but do not understand research nor have received any training in the use of tools that would help them find evidence to base their practice.
    Henderson et.al have developed an instrument, suggested by Guba's Model of Trustworthiness of Qualitative Research, to evaluate the methodological rigor of qualitative papers expanding Sackett's Rules of Evidence Model  for qualitative studies in clinical decision making and have proved that the appraisal instrument and the methodology straightforward, simple to use, and helpful in clinical decision making (Henderson et.al , 2004). According to Judith Green et.al (1998), Qualitative methods can help bridge the gap between scientific evidence and clinical practice, provide rigorous accounts of treatment regimens in everyday contexts, help us understand the barriers to using evidence based medicine, and its limitations in informing decisions about treatment. Qualitative findings as discussed are often the first type of evidence available relating to innovations and contextual constraints relating to existing practice (David R. Thomas, 2000). Influential role models that explain the degree of complexity of the change, compatibility with existing values and needs, and the ability to test and modify the new procedures before adopting also effectively bridges this gap (Sanson-Fisher,2004). Research studies have shown that it is possible to change healthcare provider behaviour and improve quality of care (Grimshaw et.al, 2004). Studies have also indicated that potential barriers at various levels need to be addressed taking into account the nature of the innovation, characteristics of the professionals and patients involved, the social, organisational, economic and political context to achieve maximum utility of evidence (Grol and, Wensing 2004).


     Thus, Evidence based practice is all about scientifically defendable decisions. Lincoln and Guba (1985) have shown that various techniques are necessary for improving and documenting the credibility of data  Absence of support structures for sustained evidence, lack of commitment to the process, insufficient evidence for too many problems do pose some challenges. But, this also provides all groups involved in providing health care with a rigorous and acceptable frame work for making complex decisions, at a time when effective decision is badly needed (Baum, 2003). The ultimate goal of nursing profession is to care keeping in view the trust issues in dealing with the patient. The nurse’s primary commitment is to the patient and evidence based practice is a step towards this goal. Simple acts of nurses like having the participants together and encouraging sharing of views builds trust and good rapport between the patient and the nurses adding more credibility and reliability to the evidence.                                 



• Baum Neil H (2003). Support your decisions with Evidence based Medicine, “Urology Times” Feb 1.
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• Deborah J. Upton (1999). How can we achieve evidence-based practice if we have a theory–practice gap in nursing today? Journal of Advanced Nursing.29 (3):549-555.
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• Henderson, Roberta, Rheault, Wendy (2004) Appraising and Incorporating Qualitative Research in Evidence-Based Practice, Journal of Physical Therapy Education, Winter.
• Judith Green and Nicky Britten (1998). Qualitative research and evidence based medicine, BMJ, 316:1230-1232.
• Pravikoff, Diane S, Tanner, Annelle B., Pierce, Susan T (2005). Readiness of U.S. Nurses for Evidence-Based Practice: Many don't understand or value research and have had little or no training to help them find evidence on which to base their practice. AJN, American Journal of Nursing. 105(9): 40-51.
• Ramaekers D (2005). The Gap between evidence-based medicine and practice: how is the "evidence" brought together? Verh K Acad Geneeskd Belg. ; 67(4):219-22.
• Sackett (1996) “Evidence based medicine: what it is and what it isn't”, BMJ; 312: 71-72.
• Sanson-Fisher RW (2004). Diffusion of innovation theory for clinical change. Med J Aust. 180(6):55-6.
• Sharon E. Straus and Finlay A. McAlister (2000). Evidence-based medicine: a commentary on common criticisms. CMAJ • October 3, 2000; 163 (7).
• Taylor-Piliae RE (1998). Establishing evidence-based practice: issues and implications in critical care nursing. Intensive Crit Care Nurs. 14(1):30-7.
• Trisha Greenhalgh et.al. (2003). Transferability of principles of evidence based medicine to improve educational quality: systematic review and case study of an online course in primary health care. BMJ ; 326:142-145.


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