Evidence-based practice (EBP) is a scientific way of rationalizing the ever-increasing wealth of medical information that is available to the clinician. As this way of thinking is approaching the end of its second decade in practical application, we see it being applied to medicine, nursing, psychiatry, dentistry, social work, clinical research, and veterinary medicine just to name a few. Numerous Web sites are devoted to the subject, and evidence-based clinical guidelines now are considered the gold standards of care.
Surprisingly, there are many dissenting opinions and misconceptions about what EBP means to the practicing clinician. Some have called it institutionalized or cookbook medicine and express concern that adherence to clinical guidelines will devaluate individual judgment.
This was not at all the intention of the founders of the movement. The following is an extract from an editorial in the British Medical Journal written by the working group for the British National Health Service (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996, pp. 71-72):
Evidence based [SIC] medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients' predicaments, rights, and preferences in making clinical decisions about their care. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens. External clinical evidence both invalidates previously accepted diagnostic tests and treatments and replaces them with new ones that are more powerful, more accurate, more efficacious, and safer.
For the practicing nurse practitioner, EBP has many uses:
1. daily clinical practice;
2. evidence-based practice projects and research to change practice;
3. quality improvement;
4. writing or revising protocols for those who practice in states that require them;
5. writing or adapting guidelines, pathways, and standard orders;
6. writing patient information handouts; and
7. teaching and precepting students.
Keeping up to date with all of the clinical trials and case reports in the literature continues to be a daunting task for clinicians. The numerous EBP databases distill and organize the literature, assign strength of evidence to the research results which are based on the statistical strength of the study design, and assign a grade to the evidence so dissimilar studies may be evaluated side by side. In fields where the research is lacking, meta-analysis of the available case reports can also be graded and presented in an organized fashion.
A discussion of all of the aspects of EBP could fill volumes of this journal, so we invite the reader to explore the multiple resources available on the Web (Table 1). What we do know is that as nurse practitioners we must base our practice on evidence. We can no longer continue to practice because "it has always been done that way."
|TABLE 1. Evidence-Based Practice Web Sites|