What is evidence-based practice
Within the field of bioveterinary science and veterinary practice and care, evidence and knowledge are forever changing. With continuing research consistently making fresh and exciting new break throughs for animal health, it is becoming increasingly difficult to keep up with what is recent and appropriate evidence. Evidence based medicine is a term that was first adopted in the 1990’s and was best defined as “a systemic approach to analyse published research as the basis of clinical decision making.” Although first adopted for use in the human medicine profession, evidence-based practice (EBP) has developed into many methodologies and tools that can be used by a variety of different professions within a diverse amount of clinical practices. EBP is a process where by a practitioner takes it upon themselves to evaluate and appraise the best evidence available to them to enhance their decision making within a clinical setting. EBP is critical for practitioners to remain competent, relevant and clinically effective. However, acquiring evidence does not always mean scanning through pages of research journals and sifting through systematic reviews. Evidence can also consist of expert opinion, stakeholder characteristics and differing scenarios. Asking a colleague for their opinion on a situation can also be regarded as acquiring evidence. This being said, EBP has come a long way from making decisions solely based on the opinions of those who are deemed as experts or following through with a decision because “that’s the way its always been done”. The purpose of EBP is to encourage those working in the field of bioveterinary science to actively accumulate sources of evidence, evaluate and appraise that evidence, and then make appropriate decisions based on the knowledge and understanding they have gained that will be most beneficial to them and any stakeholders involved. The purpose of EBP is to reduce the risk of human bias, provide opportunities for clinicians and practitioners to become more individualised, define best practices that is supported by the most relevant forms of evidence and to overall improve the work practitioners and the services provided to involved stakeholders by allowing them to create sound and informed decisions using methodologies designed to decipher and appraise what is to be deemed as best evidence.
So where do bioveterinary practitioners acquire evidence from? What constitutes to make something a good and valid source of evidence? The hierarchy of evidence is a tool designed for evidence-based practitioners that guides users in the appraisal of what can be deemed as best evidence for use in decision making. The hierarchy allows users to take a top-down approach to locating best evidence. In theory, this approach assumes that when practitioners are searching for evidence, they start by looking for a well-conducted and recent systematic review to answer the clinical question in hand. If a systematic review is not available, then the user will move down to the next tier of evidence and so on. The lower down the tier a piece of evidence falls, the lesser its ability to constitute towards what is deemed as best evidence. Although the hierarchy of evidence is an effective tool for evaluating physically published sources of evidence, it does not consider other constituents that make up EBP as a whole. Effective clinical decision making should always consider the best available evidence but make no assumptions that one type of evidence has overall superiority. The type of evidence needed by practitioners will vary depending on the clinical question in hand. Evidence needed will depend on the nature and activity of its purpose, so considerations must be made when determining what evidence is best for a particular clinical scenario. Clinical feasibility is the consideration of whether an activity or purpose is practical and practicable within a given context. Research into best available evidence may highlight a practice or activity as being superior to others, but if this activity cannot be performed by the practitioner then it is not the best form of evidence. The appropriateness of an activity goes hand in hand with evaluating the feasibility. Evaluating appropriateness relates to how ethical or suitable an activity relates to the context in which it is being used. Considerations into the benefits and effects is also paramount to determining best evidence. Evidence can be seen to be advantageous if those involved have gained a positive experience regarding the evidence used in a particular situation. A well-rounded evidence-based practitioner should always consider other stakeholders and factors that could have an influence in the type of evidence used in their decision making and clinical thinking.
Tools for evidence-based practice
Methodologies and EBP guidelines are a structural and efficient way to engage in evidence-based practices. One of the most commonly used EBP guidelines is the 5 steps of evidence-based practice.
- Step 1) Practitioners are encouraged to first convert their need for information, what ever the topic or scenario may be, into a structured and answerable question. Phrasing a question correctly allows for a more organised search for evidence and reducing the chance of any important information being missed from a search.
- Step 2) Once a clinical question has been constructed, the search for the best available evidence can then begin. The hierarchy of evidence can be used within during this step to assess the validity of evidence that has been searched for.
- Step 3) Critical appraisal of acquired information and evidence is then necessary to evaluate considerations that may affect the use of the evidence. These include considering the feasibility and appropriateness of the evidence as well as how beneficial it will be to all stake holders involved.
- Step 4) This step involves integrating critically appraised and appropriate best evidence with existing clinical practices and expertise. Incorporation of past experiences with current best evidence can aid in enhancing current practices. Integration of these two factors should also involve the integration of external stakeholders such as clients and patients. Considering the needs, values and opinions of external stakeholders will help to further evaluate the feasibility and appropriateness of evidence.
- Step 5) The final step is to evaluate the effectiveness of steps 1-4. Reflecting on the process can help an evidence-based practitioner assess the effects that evidence had on influencing their final decision. Reflection may involve consideration into different application of the process, essentially refining the process for better use in the future.
How to implement EBP in the work place
It is recognised that there are barriers than can affect the process of evidence-based practice within the work place. Information available to provide best evidence is usually spread over a variety of different sources and can make it very time consuming for practitioners to find information that can be used as best evidence, as well as practitioners having limited time to analyse information especially in a clinical care environment. Challenges surrounding evaluating the value of information should also be considered, even if EBP methodologies are used. To overcome these barriers, opportunities should be given to practitioners that aid in advancing their evidence-based practice skills. Such opportunities could involve educational work shops into how to correctly use EBP methodologies and how to improve skills such as; searching for appropriate literature in a timely manner, and critical appraisal of information. Providing education on how to correctly and effectively use methodologies with in turn save practitioners time in the future. Online resources such as the evidence based veterinary medicine (EBVM) toolkit, provided by RCVS knowledge, provided free information for veterinary practitioners who wish to learn more about EBP within their field of bioveterinary science. Another resource provided by RCVS knowledge is the online Knowledge Summaries. Knowledge summaries are designed to provide concise conclusions to clinical questions that be easily and quickly accessed by staff. They are summarised resources used to address knowledge needs by providing best available evidence on defined clinical questions. Knowledge summaries are particularly useful for overcoming the barrier on not being able to able EBP in a clinical care setting.
EBP is an ever-expanding topic that has many benefits for bioveterinary practitioners if it is implemented correctly. If readers wish to expand their knowledge on the topic and explore into the processes of EBP further, the following further reading resources have been provided:
Giuffrida, M. A. (2017) ‘Practical Application of Evidence-Based Practice.’ Veterinary Clinics of North America: Exotic Animal Practice. (Evidence-Based Clinical Practice in Exotic Animal Medicine), 20(3) pp. 737–748.
La Caze, A. (2016) ‘The hierarchy of evidence and quantum theory.’ Journal of Clinical Epidemiology, 72, April, pp. 4–6.
Paravattil, B., Shabana, S., Rainkie, D. and Wilby, K. J. (2019) ‘Evaluating knowledge, skills, and practice change after an accredited evidence-based medicine course for community pharmacy preceptors.’ Currents in Pharmacy Teaching and Learning, April.
Saunders, H., Vehviläinen-Julkunen, K. and Stevens, K. R. (2016) ‘Effectiveness of an education intervention to strengthen nurses’ readiness for evidence-based practice: A single-blind randomized controlled study.’ Applied Nursing Research, 31, August, pp. 175–185.
Sullivan, K. J., Wayne, C., Patey, A. M. and Nasr, A. (2017) ‘Barriers and facilitators to the implementation of evidence-based practice by pediatric surgeons.’ Journal of Pediatric Surgery, 52(10) pp. 1666–1673.