Facilitating Evidence-Based Practice: Process,Strategies,and Resources

Step 1: Formulating the Clinical Question

New clinicians or clinicians who have switched to a new practice area frequently ask background questions, or questions that refer to general aspects of a phenomenon (i.e., who, what, where, when, how, and why; Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). For example, in working with a client diagnosed with a rare disorder, the clinician unfamiliar with this disorder may ask a broad question such as “What is occupational therapy's role with people who have this disorder?”

Experienced clinicians tend to ask foreground questions, specific questions that affect treatment (Onady & Raslich, 2003). Such questions usually follow a format called PICO, specifying a patient or problem, intervention, comparison intervention (if relevant), and outcome (Glasziou, Irwig, Bain, & Colditz, 2001; Institute of Medicine, 2008). The most efficient method of answering foreground questions is to find a relevant systematic review (SR) or meta-analysis. If no SR for the clinical question exists, clinicians can either look for intervention studies and single-subject–design studies, in which the participants serve as their own control, or conduct their own SR. Several resources are available for clinicians conducting a SR (Glasziou et al., 2001; Wright, Brand, Dunn, & Spindler, 2007). Partnerships between clinicians and academicians are recommended to conduct SRs that not only answer relevant clinical questions but are also of high quality.

Formulating a good clinical question depends on the purpose behind the question. If a clinician is asking a background question, the question may be broad or open ended. However, if the clinician is asking a foreground question, using the PICO format facilitates asking a focused, clinically relevant question by specifying the four components: patient, interventions, comparison group, and outcomes (Counsell, 1997). Evidence from a well-formulated research question will provide useful information for practice, whereas a search based on a weak clinical question may yield vague conclusions, limiting its applicability in practice (Onady & Raslich, 2003).

Step 2: Searching Efficiently for the Best Available Evidence

Clinicians may have limited time and resources to search for the best available evidence, so searching for reviews from trustworthy sources is an efficient strategy. Different types of reviews provide different information. If a clinical question is broad, narrative reviews, qualitative studies, and observational research may be helpful. If the question concerns intervention effectiveness (e.g., does treatment A affect outcome B?), then a traditional SR is considered the best approach to evaluating evidence.

SRs refer to “an extensive, systematic process of identifying, appraising, and summarizing all research on the review topic” (Evans & Kowanko, 2000, p. 35) and may contain a quantitative synthesis of study results, such as in the case of a meta-analysis. In terms of research quality, a well-conducted SR is stronger than a narrative review. One distinguishing characteristic of SRs is a method section describing the criteria for searching and selecting studies.

Narrative reviews are useful if a clinician asks a broad practice question, such as understanding a particular diagnosis or therapeutic treatment if few studies exist or if existing studies are flawed (Cook, Mulrow, & Haynes, 1997). In contrast to SRs, narrative reviews are less focused on a specific clinical question; often do not use literature that was sought in a systematic, reproducible manner; and may be influenced by author bias (Montori, Swiontkowski, & Cook, 2003). Thus, relying solely on narrative reviews for practice decisions may lead to incorrect conclusions regarding best practices (Montori et al., 2003; Wright et al., 2007).

Other useful sources of evidence are practice guidelines or clinical guidelines, which often incorporate SRs. A practice guideline can be viewed as an “amalgam of clinical experience, expert opinion, and research evidence” and can be helpful to the busy clinician by distilling evidence into practice recommendations (Cook, Greengold, Ellrodt, & Weingarten, 1997, p. 210). Other popular review formats are critically appraised topics and critically appraised papers, which are brief summaries and appraisals of a specific question or study (Law et al., 2007).

If clinicians cannot locate a review to answer their clinical question, then they may consider conducting their own review of the evidence. However, a significant barrier to EBP is that clinicians may lack access to the literature. Fortunately, an increasing number of medical journals and SRs are accessible online (Goldstand, 2006; Law et al., 2007). Although some Web sites list free journals or articles, these lists do not represent all journals available, so one should search carefully for relevant sources.

Clinical Example

We now consider an example of the first two steps of EBP, formulating the clinical question and searching for evidence. An occupational therapist working in an outpatient rehabilitation setting has finished evaluating a woman with rheumatoid arthritis (RA). If this diagnosis is unfamiliar to the therapist, she might start by asking background questions such as “What interventions do occupational therapists typically use with people who have RA?” Narrative reviews, case studies, and qualitative studies can describe interventions but generally do not answer questions about their effectiveness. If the occupational therapist could not find literature about interventions for people with RA, she might expand the diagnostic category to include arthritis or autoimmune disorders. By broadening her search, she can then determine which interventions were used for which symptoms and design an intervention plan.

If the occupational therapist is more experienced or familiar with RA, she may ask more foreground questions. For example, she may ask a PICO question—“Is there evidence to support the use of splints to increase daily functioning in adults with RA?” She could search the Cochrane Library's Web site, typing in rheumatoid arthritis and finding 59 reviews. Browsing the list, she would find a review called “Splints and Orthosis for Treating Rheumatoid Arthritis” (Egan et al., 2001) and learn that there is insufficient evidence to support splint use to increase function for people with RA. Although many adverse effects have not been reported, such as decreased range of motion (ROM), a risk is that some splints decrease grip strength and dexterity. The review also states that resting hand and wrist splints do not seem to affect ROM, although participants preferred wearing a resting splint to no splint. After discussing the review with her client, the occupational therapist fabricates a resting hand splint to be worn during sleep because the therapist was concerned about the possibility of decreased grip strength and dexterity.

Step 3: Critically Analyzing the Evidence for Its Validity and Usefulness

The third step is to critically evaluate the evidence by analyzing the research design and determining whether the evidence yielded has high internal and external validity. Internal validity refers to the strength and quality of the research design and method and whether the outcomes are unlikely to be caused by extraneous variables (Black, 1999). EBP and clinical guidelines are based on a research hierarchy in which articles that have high levels of internal validity are most important to treatment recommendations. For example, randomized controlled trials are rated as providing the highest levels of evidence because they have high internal validity as a result of their design, randomization, existence of a control group, and tight control of the intervention. However, with high internal validity, external validity or generalizability is weaker. Frequently, studies with high levels of internal validity are difficult to translate into a setting with different clients and may not be as relevant to clinicians seeking treatment options for a specific client problem.

In Step 3, the critical appraisal of the evidence involves asking questions regarding how trustworthy the findings are or whether they could be the result of error (see Figure 1). To integrate evidence into practice, clinicians should determine whether the findings are clinically useful by differentiating between statistical significance and clinical significance. Often researchers note that a certain statistical test was significant, with p < .05. However, the p value indicates the likelihood that a finding was the result of chance, not clinical significance. For example, if a study found that a new intervention resulted in increased shoulder ROM in adults who recently had a cerebrovascular accident compared with standard therapy, and this increase was statistically significant, clinicians may be interested in learning more about this new therapy. However, a closer examination of the study may reveal that the new intervention requires expensive equipment and the average gain in ROM was only 3°. In other words, the results are not clinically meaningful and may not justify the expense.

OPEN IN VIEWER

Figure 1.

Guide to evaluating research evidence: Guiding questions.

Although some clinicians may find this step of EBP daunting, many resources are available to help them appraise the evidence (see Table 1). Clinicians may form journal clubs, contact nearby occupational therapy programs, or use research groups and online forums to learn more about evaluating research (Craik & Rappolt, 2003).

Step 4: Integrating the Appraisal With Personal Clinical Expertise and Client's Preferences

One common misperception of EBP is that the quest for answers or treatment decisions ends with the research results. However, best practice requires three critical ingredients: (1) best available external evidence; (2) clinical expertise; and (3) consideration of client's contexts, rights, and preferences (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). Occupational therapists, like other health care providers, tend to base clinical decisions on experience, continuing education, and colleagues’ advice (Bennett et al., 2003). Clinical expertise plays an important role for several reasons. First, evidence to support a particular intervention for a particular client in a particular setting may not exist. Second, if evidence exists and the results are conflicting, or if clients’ preferences differ from the recommended intervention, clinical knowledge can help construct a coherent meaning and determine how best to proceed (Tickle-Degnen, 2000b). Finally, research and systematic reviews are not infallible; the process may contain flaws or bias. Clinicians and clients need to feel empowered not only to understand and use research but also to reject or dispute existing findings. This critical step differentiates research use from EBP; the former focuses on applying research findings and the latter is a tailored, client-centered approach based on integrating best evidence with professional judgment and expertise and with client preferences.

Step 5: Evaluating One's Performance or Outcomes of Actions

One of the final steps in the EBP process includes reflection on the process (Straus et al., 2005) or outcomes (Law et al., 2007). How efficiently and effectively did the clinician follow the EBP steps? What effect did the intervention yield? How does the intervention compare with others? If a new intervention is easier to implement but does not adequately improve clients’ functional outcomes, then clinicians may want to return to the standard intervention.

Step 6: Disseminating and Communicating Knowledge

Students, clinicians, and researchers who have performed a SR or developed EBP tools could greatly contribute to the profession's knowledge base by communicating the results to colleagues (Law et al., 2007). After prominent researchers and leaders met in a 2004 International Conference on Evidence-Based Occupational Therapy (Ilott, Taylor, & Bolanos, 2006) sponsored by the American Occupational Therapy Association and the American Occupational Therapy Foundation, the Evidence-Based Occupational Therapy Web portal (www.otevidence.info/) was created on the World Federation of Occupational Therapists’ Web site. This portal provides access to strategies, knowledge, and many resources to promote and facilitate EBP. Although the online resources developed by many countries and organizations are promising, clinicians still find it cumbersome to search through each resource. If the reviews were standardized and placed in a centralized repository with a search feature, clinicians, educators, students, and consumers would benefit.

One challenge for occupational therapy practice and incorporation of EBP principles is the possibility that some clinicians may not understand the goal and steps of EBP. Even when clinicians try to implement EBP, they may become uncertain or discouraged at any of the steps, (e.g., formulating a focused question, searching and evaluating the research literature or presenting their knowledge to others).

Educators

Educators face challenges and opportunities when teaching students about EBP. “Educators can foster an excitement about research and communicate its applicability, or they can foster indifference to, and even dislike for, the subject” (Fineout-Overholt & Johnston, 2005, p. 39). Occupational therapy faculty should be proponents of EBP by incorporating it into the curriculum across courses (Tickle-Degnen, 2000c) and having the necessary knowledge and skills (Melnyk & Fineout-Overholt, 2004). For example, faculty members need to have resources such as access to databases for searches, knowledge about evidence-based processes, commitment to integrate evidence-based principles throughout the curriculum, and basic computer and search strategy skills.

One strategy to promote the use of research during clinical reasoning is to offer case-based pedagogies and reflective analyses (Craik & Rappolt, 2003; Welch & Dawson, 2007). Faculty could evaluate students’ clinical skills in a simulated scenario such as being able to retrieve and evaluate relevant research for a case study or actual client within a set time period.

Other useful strategies include evidence-based synthesis papers, small-group evidence-based projects, journal clubs, and educational prescriptions (which teach the EBP process). An educational prescription involves identifying the clinical problem; formulating a searchable, answerable question using PICO; looking for the relevant evidence; appraising the evidence and using the best evidence; and presenting how the evidence was found, what was found, its validity and applicability, and how it will alter clinical practice (Melnyk & Fineout-Overholt, 2004).

Clinicians

Clinicians work tirelessly to provide the best services for their clients, despite increasing demands for productivity or challenges regarding reimbursement. Although some clinicians may view EBP as an additional required task, it can be a powerful tool to help clinicians and their clients as treatment questions arise. However, clinicians need to be able to access the literature and have EBP tools. One option is to assertively ask employers for Internet access and subscriptions to databases such as Medline, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature, citing greater efficiency in finding research to inform best practice. Alternatively, clinicians could join a professional organization to access EBP resources. In-services or department meeting times can be a mechanism for investigating answers within a group whose members have varying levels of research and clinical expertise. Clinicians can brainstorm with peers and managers about how to incorporate evidence into practice and documentation (e.g., modify protocols, include patient-specific reminders in electronic documentation, use opinion leaders, create toolkits; Davis et al., 2003; Grol & Grimshaw, 2003; Pipe, Cisar, Caruso, & Wellik, 2008). If clinicians are unsure of their EBP skills, they can invite an expert in their practice area who is familiar with EBP. Ideally, using a case study approach combined with access to a knowledgeable peer can demonstrate the value of EBP (Glasziou et al., 2001; Institute of Medicine, 2008; Ketelaar, Russell, & Gorter, 2008). Practitioners can also ask occupational therapy faculty to collaborate on research projects or EBP training (Pipe et al., 2008). Finally, clinicians could join special interest sections or form networks to share their resources, such as research summaries justifying interventions or documentation methods that incorporate data collection on interventions and outcomes.

Researchers

Researchers were trained to conduct rigorous research, but some researchers may not consider multiple audiences when they design or disseminate research for multiple audiences (Glasgow & Emmons, 2007; Laupacis & Straus, 2007). When appropriate, researchers should consider studying cost-effectiveness analyses or health care use so that policymakers and reimbursement companies can understand that coverage for occupational therapy can not only improve health outcomes but also save money or resources. In addition, researchers may not be tackling problems that directly benefit clinicians’ care of clients. Sudsawad (2005) reminded researchers to consider whether their research is clinically relevant during the research planning phase. Obtaining clinicians’ input during the research design process will engender clinically relevant and generalizable research.

In addition, researchers who perform SRs need to communicate the knowledge gaps to other researchers and the profession at large so that appropriate types of research are conducted as quickly as possible. Designing the studies needed to inform clinical practice and policy decisions will help the profession become proactive and prepared. Finally, researchers could develop new formats to disseminate evidence for consumers and busy clinicians. For example, Laupacis and Straus (2007) suggested producing SRs in 20-s, 2-min, and 2-hr versions for consumers, clinicians, researchers, and policymakers.

Managers, Administrators, and Policymakers

Managers and administrators can support EBP by allotting time and providing resources to occupational therapists, such as access to computers and literature databases (see Table 2). If employers offer a clinical ladder or promotions, these programs could offer incentives to facilitate EBP, such as providing reimbursement for professional memberships and journal subscriptions, allotting time for research, establishing a mentoring program, and providing reimbursement for books and training about EBP (Pipe et al., 2008).

Policymakers and funders of research could communicate the type of data they need from researchers before research implementation. For example, researchers could incorporate research questions about cost analyses or functional outcomes into their studies.

Associations and Organizations

Occupational therapy organizations (e.g., associations, foundations) should be commended for making EBP a priority, but more work is still needed. The implementation of an evidence-based approach involves numerous steps and players, including attention to organizational change strategies. The organization's needs and barriers to and resources needed for implementation of EBP must be assessed. A strategic plan and timeline for implementing the changes and a committee responsible for setting goals, implementing changes, and refining the implementation plan are vital to successful organizational change. An ongoing issue is determining who will fund the SRs. A reproducible, well-done SR is considered to be a research project because of the time and rigor needed, but it is unlikely to be funded by an outside agency as a stand-alone research study. Organizations and researchers who produce SRs have made progress in recent years, adopting requirements for reporting characteristics, such as search strategies, inclusion and exclusion criteria, funding sources, and determination of whether the SR was an update (Moher, Tetzlaff, Tricco, Sampson, & Altman, 2007). To reach a broader audience, organizations could continue to explore nontraditional ways of disseminating evidence and clinical guidelines, such as videos on Web sites, podcasts, and online training. If financially feasible, organizations could increase the availability of evidence-based resources by making SRs free, at least to their members.