Name: MJ Leach
International Journal of Nursing Practice 2006; 12: 248–251
✠
S C H O L A R LY PA P E R
✠
Evidence-based practice: A framework for clinical
practice and research design
Matthew J Leach PhD BN(Hons) ND RN
Program Director, School of Health Sciences, University of South Australia, North Terrace, Adelaide, South Australia, Australia
Accepted for publication April 2006
Leach MJ. International Journal of Nursing Practice 2006; 12: 248–251
Evidence-based practice: A framework for clinical practice and research design
The evidence-based practice (EBP) framework emerged in the early 1970s as a means of improving clinical practice. This
shift towards EBP allowed health professionals to move from a culture of delivering care based on tradition, intuition
and authority, to a situation where decisions were guided and justified by the best available evidence. Despite the many
advantages of EBP, many practitioners remain cautious about embracing the model. Part of this opposition is due to a
misunderstanding of EBP, which this paper aims to address.
Key words: decision-making; evidence, evidence-based medicine.
INTRODUCTION
Evidence-based practice (EBP) is a formal problemsolving framework1 that facilitates ‘. . . the conscientious,
explicit, and judicious use of current best evidence in
making decisions about the care of individual patients’.2
Apart from the implications on clinical practice, the
capacity of EBP to link study findings to a professions body
of knowledge also indicates that EBP is a useful theoretical
framework for research, and might therefore provide an
effective solution to the research–practice divide.3,4
Archibald Cochrane, a Scottish medical epidemiologist, conceived the concept of best practice in the early
1970s.5,6 However, it was not until after Cochrane’s death
in the late 1980s that medicine began to demonstrate an
interest in the EBP paradigm with the establishment of the
Cochrane collaboration.5,7 Since then, professional interest in EBP has grown.8–12 This shift towards EBP has
allowed health professionals to move from a culture of
delivering care based on tradition, intuition, authority,
unsystematic clinical experience and pathophysiological
rationale, to a situation where decisions are guided and
justified by the best available evidence.1,3,4,6,11,13–15 EBP
therefore limits practitioner and consumer dependence
on evidence provided by privileged persons and authorities by bestowing clinicians with a framework to critically evaluate claims.4 Even so, there remains some debate
over the definition of evidence in the EBP paradigm.14
DEFINING EVIDENCE
Correspondence: Matthew J Leach, School of Health Sciences, University of South Australia, North Terrace, Adelaide, SA 5000, Australia.
Email: matthew.leach@unisa.edu.au
Evidence is a fundamental concept of the EBP paradigm.
Even so, there is little agreement between practitioners,
academics and professional bodies as to the meaning of
evidence. Indeed, the insufficient definition of evidence
and the different methodological positions of clinicians
and academics might all contribute to these discrepant
viewpoints. From the broadest sense, evidence is defined
as ‘. . . any empirical observation about the apparent relation between events’.1 Whereas this definition suggests
that most forms of knowledge could be considered evidence, Romyn et al. assert that the evidence used to guide
practice should be ‘. . . subjected to historic or scientific
© 2006 The Authors
Journal compilation © 2006 Blackwell Publishing Asia Pty Ltd
doi:10.1111/j.1440-172X.2006.00587.x
Evidence-based practice
249
Table 1 The hierarchy of evidence16
Identify a problem
Search for a solution
Level I
Level II
Level III-1
Level III-2
Systematic reviews
Well-designed randomized controlled trials
Pseudo-randomized controlled trials
Comparative studies with concurrent controls, such
as cohort studies, case–control studies or
interrupted time series studies
Comparative studies with historical control, two or
more single-arm studies, or interrupted time
series without a parallel control group
Case series and pretest/post-test studies
Level III-3
Level IV
Assess patient
situation
Apply the
evidence
Critically appraise
evidence
Formulate an
answerable
clinical question
Search and
acquire evidence
Figure 1. The evidence-based practice paradigm (modified from
Leung9).
evaluation’.14 Hence, not all evidence is considered the
same. These differences in the quality of information are
known as the hierarchy of evidence.
The hierarchy of evidence informs practitioners which
information is likely to provide the greatest impact on
clinical decisions.1 According to Table 1, decisions based
on findings from randomized controlled trials (RCTs)
might therefore be more sound than those guided by case
series results. However, when findings from controlled
trials are unavailable or insufficient, decisions should be
guided by the next best available evidence.2,8 The hierarchy of evidence can also be used to identify research findings that supersede and invalidate previously accepted
treatments and replace them with interventions that are
safer, efficacious and cost-effective.2,3 For these reasons,
clinical decision-making might benefit from using EBP and
the hierarchy of evidence.
THE EBP FRAMEWORK
The EBP paradigm consists of a series of steps that assist
the practitioner in finding a solution to a clinical problem
(see Fig. 1). The five-stage process begins with the identi-
Evaluate the solution
Is the treatment
clinically
effective?
Randomized
controlled trial
For whom is the
treatment most
likely to benefit?
Comparative
case study
Is the treatment
cost-effective?
Is the treatment
feasible?
Cost–benefit
analysis
Descriptive
survey
Make a conclusion about findings
Apply findings where appropriate
Figure 2. The relationship between the evidence-based practice
paradigm and clinical decision-making.
fication of a clinical problem and the subsequent formation of a structured and answerable question.6,8,9
Following the problem stage, the literature is searched for
the best available evidence to answer the proposed question.2,6,8,13 The evidence is then critically appraised for its
validity, quality and generalizability.8,10,15 Once evaluated,
the best available evidence is integrated into clinical practice in conjunction with clinical expertise and available
resources.10
In addition to considering the availability of resources,
the EBP paradigm also ‘. . . requires the judicious application of research findings in the patient context . . . and
an understanding of the values of persons involved
in . . . clinical decisions’.1 Hence, studies only investigating the clinical efficacy of an intervention might not meet
all the requirements of the EBP framework. This is
because clinical evidence provides only one element of the
decision-making process.1,17 Clinical decisions should
therefore take into account client preferences, values and
expectations.1,10 In other words, effective decision-making
depends on the provision of professional expertise, clinical
evidence, economic justification and consumer perspective. Figure 2 further illustrates the relationship between
the EBP paradigm and clinical decision-making.
RATIONALE FOR EBP
There are many benefits to practitioners, consumers and
the health-care system in adopting the EBP paradigm. For
instance, EBP gives rise to a more transparent clinical
decision-making process.7 Although practitioners might
not welcome this increased level of scrutiny, greater
accountability over decision-making is likely to benefit
consumers. So, as patient expectations increase and practitioners become more accountable for their actions,6,8,17
© 2006 The Authors
Journal compilation © 2006 Blackwell Publishing Asia Pty Ltd
250
Name: MJ Leach
LIMITATIONS OF EBP
complex patient situations.4,21 There is also an assumption
that hard science is the only evidence accepted in the
model.8,21,23 However, the belief that EBP relies only on
evidence from RCTs is a common misconception.
Although the RCT is particularly useful for evaluating the
effects of an intervention, it can be less effective in
answering questions about patient attitudes, experience,
prognosis and diagnosis.6,10 Therefore, the criticism
towards EBP might not necessarily be directed at the
model, but with the type of evidence accepted. A major
challenge for EBP is to then recognize that other types of
data, such as qualitative findings, are also valid forms of
evidence.4 To address these concerns, the type of evidence adopted should therefore be dictated by the type of
question asked.7
There is related concern that EBP might also produce
dehumanized, routine and decontextualized care14 by
ignoring clinical expertise and client preference.8,13,21 Yet,
in addition to respecting patient choice,17 EBP also
requires research findings to be considered alongside
clinical expertise.2,8,22 EBP is therefore patient-centred,18
individualized3 and accommodating of practitioner and
client needs.
The paucity of high-quality, coherent and consistent
scientific evidence in nursing and wound care might
explain why some clinicians have difficulty engaging in
EBP.3,6,8,10 Although systematic reviews have attempted to
resolve this problem, clinical experience and traditional
evidence are still relied on in areas where data are absent
or ambiguous.9,10 EBP therefore uses the best available evidence to guide decisions, and does not just rely on the use
of data from clinical trials.6,10 In fact, if nurses only used
techniques that were based on sound clinical evidence,
nursing practice would be considerably limited.6
Other barriers to adopting EBP are a lack of motivation, disagreement with findings, lack of autonomy, and
inadequate research and critical appraisal skills.3,4,10,11,19
The lack of time, resources and authority to make changes
are also major obstacles to the introduction of
EBP.3,4,6,10,11,19 Yet, the delivery of EBP might eliminate
the time, costs and resources allocated to harmful or ineffective treatments4,7,10,18 and, in effect, improve patient
outcomes and the future demand on clinician time.
There are many critics of EBP, but as yet, these arguments
hold little coherence or strength.4 Some of the resistance
in accepting EBP has been attributed to the underlying
positivist philosophy of EBP with concerns that a reductionist approach oversimplifies or inadequately addresses
Even though some health professionals are cautious about
embracing EBP,23 these practitioners need to be assured
that EBP simply provides a useful and ‘. . . scientific
the traditional sourcing of inconsistent and incomplete
information from peers and procedure manuals might
become outdated.1,18 EBP therefore challenges existing
procedures and facilitates the integration of new and
effective interventions into clinical practice. Yet, unless
practitioners are adequately informed and motivated
about EBP, and resources are made available for staff
to access evidence-based material, clinicians might have
difficulty in adopting an EBP approach.19,20
Evidence-based practice might also improve client outcomes and the quality of care, and reduce the costs of
treatment, the risk of medical error and patient mortality
through improved decision-making.2,6,9,11,12,14,21 Although
these cost savings might be attributed to the elimination of
unnecessary and ineffective interventions,9 the provision
of high-quality evidence does not necessarily equate to
cost reductions.2 Instead, the cost-effectiveness of alternative interventions should be evaluated using cost–
benefit analysis.
The disparate practices across institutions are another
concern in health care. According to Montori and Guyatt,
the need for more consistent approaches to patient problems is long overdue.1 To address the inconsistencies in
clinical practice, practitioners should be encouraged to
adopt an EBP approach.1,9,15,18 Failure to use EBP might
delay the integration of innovative treatments into clinical
care,3,8 which could contribute to adverse client outcomes.11 In addition to EBP, new interventions might be
more readily incorporated into practice by identifying and
addressing barriers to implementation through the use of
feasibility studies.
Failing to deliver EBP might also reduce the credibility
of a profession14 and, in turn, isolate members of the profession from the multidisciplinary team. In other words,
practitioners choosing to ignore EBP might not confidently justify the continuation or changing of clinical
practices.3,14,22 Hence, EBP might not only improve
multidisciplinarity4 and consistency of clinical care, but
also more effectively meet the health-care needs of individuals.14 Despite the benefits to both practitioners and
consumers, however, EBP is not without limitations.
© 2006 The Authors
Journal compilation © 2006 Blackwell Publishing Asia Pty Ltd
CONCLUSION
Evidence-based practice
251
framework within which to identify and answer priority
questions about the effectiveness of . . . health care’.15 As
well as guiding clinical practice, the EBP paradigm also
helps to close the research–practice divide. Integrating
findings into clinical practice, however, might only eventuate if practitioners undergo further education, and if
future trials examine a wider range of treatment aspects,
including the clinical efficacy, cost–benefit and feasibility
of an intervention.
ACKOWLEDGEMENTS
I would like to thank Professor Jan Pincombe and Dr Gigi
Foster for their valuable feedback on this paper.
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© 2006 The Authors
Journal compilation © 2006 Blackwell Publishing Asia Pty Ltd