Evidence, expertise, and patient preference in speech-language pathology

A consideration of evidence-based practice has led many to debate the nature of evidence. Rejecting the idea that randomized controlled trials should be the only legitimate source of evidence, writers have argued that other types of research and knowledge should be considered legitimate sources of evidence. This paper suggests that one should draw on systematic research, including qualitative research, for evidence, and that other types of knowledge such as craft and practice knowledge are part of the profession's expertise. This paper argues that evidence and expertise are both required for evidence-based practice to occur. Finally, a consideration of patients' values and expectations is explored as a third component of evidence-based practice. The paper argues that all three components are necessary for evidence-based practice.     

The development of evidence-based nursing

This paper argues that the current conception of evidence-based medicine has its limitations in the promotion of research which effects the quality of service in any health care system. It also poses something of a difficulty for the development of evidence-based nursing in particular. This paper advocates the more broad based concept of evidence-based practice and discusses its potential for addressing theory/practice problems and the uptake of nursing research. The broader conceptualization of evidence-based practice focuses on the integration of available evidence and the tacit knowledge of the investigator. An evidence-based practice project undertaken in Hong Kong is outlined as this provided the basis of many of the conclusions made in this paper. Three vignettes are given in order to demonstrate the nature of the evidence-based practice projects which have been conducted. The critical elements of evidence-based practice projects are outlined. Finally issues concerning the process of generating evidence, the relationship to continuous quality improvement and the cost effectiveness of evidence-based practice are discussed in more detail.     

Demystifying Research and Evidence-Based Practice for Consumers and Carers: Development and Evaluation of an Educational Package

Increasingly, consumers and carers are involving themselves in many aspects and levels of mental health services. However, one area in which active involvement has been less prominent is research. This paper describes an educational initiative that sought to increase consumers' and carers' understanding of the way research is conducted and its role in evidence-based practice. Information regarding participants' attitudes towards research, knowledge about research practice and participation was also examined. The findings provide evidence that workshop attendance increases knowledge and encourages participation in future research projects, particularly when participants have confidence in the researcher.     

Evidence and expertise

This paper evaluates attempts to defend established concepts of expertise and clinical judgement against the incursions of evidence-based practice. Two related arguments are considered. The first suggests that standard accounts of evidence-based practice imply an overly narrow view of 'evidence', and that a more inclusive concept, incorporating 'patterns of knowing' not recognised by the familiar evidence hierarchies, should be adopted. The second suggests that statistical generalisations cannot be applied non-problematically to individual patients in specific contexts, and points out that this is why we need clinical judgement. In evaluating the first argument, I propose a criterion for what counts as evidence. It is a minimalist criterion but the 'patterns of knowing', referred to in the literature, still fail to meet it. In evaluating the second argument, I will outline the powerful empirical reasons we have for thinking that decisions based on research evidence are usually better than decisions based on clinical judgement; and show that current efforts to rehabilitate clinical judgement seriously underestimate the strength of these reasons. By way of conclusion, I will sketch the ways in which the concept of expertise will have to be modified if we accept evidence-based practice as a template for health-care.     

Evidence-based practice: a deconstruction and postmodern critique: book review article

This paper discusses the significance of postmodernism for healthcare practice, specifically the discourse known as 'evidence-based practice'. It considers two texts, both of which present postmodern analyses of contemporary issues. One text presents a deconstruction of evidence-based practice in an attempt to reveal its 'true' nature, which is portrayed as one that does not respect research paradigms other than the randomised controlled trial, merely pays lip service to expertise and fails to connect with the real nature of clinical practice. The second text considers the accusation that absolute relativism implied by postmodern approaches may permit an 'anything goes' mentality and provide succour to those advocating unacceptable practices. A 'defence' of postmodernism in relation to the accusation that it encourages holocaust denial is used to consider further the nature and limitations of postmodern critiques of evidence-based practice. This review concludes that postmodernism fundamentally challenges the apparent 'objectivity' of evidence-based practice but it does not challenge the fundamental rules for acquiring and testing evidence. Rather it is the selection of questions to be asked and answered by evidence-based practice/practitioners that is the true limitation. This is the ground upon which fruitful argument can be had about the significance of evidence without undermining the requirement that there be evidence and standards to judge such evidence.     

Recognising relationships: reflections on evidence-based practice

This paper argues for a broadening of the way evidence is developed and used in health-care. It contends that the current political and policy imperatives and the evidence-based practice movement are in direct tension with the other major ideological movements that promote patient-centred healthcare services. Nursing is affected by this tension because it is more naturally focused on relationships with clients to achieve health outcomes. The unresolved and mounting tension could be alleviated by embracing a broader definition of what counts as evidence and by focusing more on patient-centred healthcare methodologies and acknowledging the interdependency of distinct ways of generating new knowledge. A number of case studies are used to illustrate how research focusing on patient perspectives and nurses' response to patient experiences can improve the evidence base for nursing.     

Wandering into the future: reconceptualizing wandering 'A natural and good thing'

There is still significant scope for improvement in knowledge on wandering in dementia and in the care of persons with dementia who wander. Although progress in research-derived knowledge is evident over the last 15 years, the current state of practice is influenced by an immature research base where the clarification of what wandering is still needs to be achieved. This is fuelled by research which to date, has framed wandering as a problem behaviour and generally starts from the premise that it needs to be prevented or severely controlled. People with dementia may think and feel differently about wandering, as will be suggested in this paper. The voices of those who have experiential expertise of dementia and wandering need to be included in the debate on wandering to influence both nursing research and practice. In regard to the practice context, it is suggested that there is little evidence to suggest that screening for wandering, assessment of wandering, person-centred and evidence-based care planning and interventions or evaluation are yet the norm for older persons with dementia. Thus, these areas must be the priorities for the immediate future. Whilst at a theoretical level, there are three key issues that require attention in the future: the orientation of research on wandering including reconceptualizing wandering to address the lack of theoretical frameworks to explain wandering, addressing the need some care settings might have with application of research and recognition of the experiential expertise of older persons with dementia.     

Insufficient evidence: the problems of evidence-based nursing

Evidence-based medicine was first proposed in the early 1990s as a means of integrating clinical expertise with the best evidence from research. It has recently gained a foothold in nursing, where despite calls for a broad and nursing-oriented definition of what should count as evidence, it appears to be propounding the randomized controlled trial (RCT) as the gold standard. This paper challenges the wisdom of basing nursing practice on the findings of large-scale statistical research studies, and offers a number of logical objections to the underpinning philosophy of evidence-based nursing and the randomized controlled trial. It concludes by arguing for a rethinking of what should count as evidence, and suggests a quasi-legal model based on reflection rather than research, in which evidence is employed to understand and justify practice after the event rather than being used deterministically to plan practice in advance.     

Research on knowledge sources used in nursing practices

This paper reports a questionnaire-based investigation into the knowledge sources used by nurses in two Turkish university hospitals, and whether these knowledge sources were related to sociodemographic variables. 78.5% of the nurses said that practice should be based on evidence and 75.9% stated that this evidence should come from research. 80.7% stated that evidence-based practice was useful. However, evidence that was not based on research constituted the first three most frequently used sources of knowledge. Sources of evidence-based on research were detected as being in the 4th, 5th, 6th, 8th, and 10th positions regarding the frequency of use. The nurses expressed a belief that nursing practices should be based on evidence, but did not reflect this belief in their behavior.     

Evidence-based practice and school nursing.

School nurses need to demonstrate that their practice is based on the best evidence available, which is usually data obtained from research. Evidence-based practice involves combining the best evidence available with nursing expertise and patient and family preferences to determine optimum care. Evidence-based practice guidelines are developed by carefully reviewing the available evidence on a topic and synthesizing this information into recommendations for practice. This article defines evidence-based practice and best evidence, describes the development of evidence-based practice guidelines, discusses factors that affect the use of research and evidence-based practice guidelines in school nursing, and reviews current sources of evidence-based practice guidelines for school nurses. Strategies that school nurses can use to incorporate evidence into their practice are discussed. One recommendation is that school nurses partner with nurse leaders and nurse researchers to develop evidence-based practice guidelines relevant to school nurse practice.     

Developing a culture of nursing research through clinical-academic partnership

Evidence based practice is essential to advanced practice nursing, enabling the delivery of quality care and improved patient outcomes. As the name suggests, it requires healthcare decisions to be based on the best available and current evidence. Advanced practice nurses need astute critical analysis skills to appraise the evolving literature, and require research skills to lead on scientific inquiry and develop the profession. Yet, advanced practice nurses may not recognize themselves as research leaders. Participation in a journal club can promote evidence-based practice, improve clinician's critical thinking skills, and expose members to different research methodologies, however, nurses continue to face barriers to participation in these clubs. Establishing a clinical-academic partnership appears to be both mutually beneficial for clinicians and academics and is a significant enabler in the sustainability and functioning of the club through sharing expertise and experience. A supportive workplace culture is favourable to research utilization and knowledge translation. This paper outlines the role, practicalities, challenges, and benefits of setting up a hybrid urology journal and research club for advanced practice nurses in a clinical-academic partnership.     

The role of qualitative research within an evidence-based context: can metasynthesis be the answer?

The increasing emphasis on evidence in the health care planning and policy context has fuelled considerable discussion and debate in nursing circles on the appropriate place of the less favourably placed knowledge forms within the conventional evidentiary hierarchy. In this paper, nursing's affinity for qualitative methods, and the species of knowledge they generate, are considered within the context of this evolving evidence-based practice movement. Noting conceptual and terminological confusions around the notion of evidence such as have arisen within the nursing literature, the author argues for clarity in our collective thinking about the role of research in a nursing or any other applied practice discipline. Toward this end, she points to some of the newer approaches to research synthesis and integration that may hold particular promise for enhancing our confidence about what might properly constitute a qualitatively-derived evidentiary knowledge claim. Such approaches may assist nurses to work more comfortably within the evidence-based movement, assured that reliance upon scientifically sound reference points need not compromise the complexity, richness and diversity they recognize as inherent in practice context excellence.     

Collaborating on the development and implementation of evidence-based practices: Advancing science and practice

Implementation Science has recently gained considerable attention for the discipline of Communication Sciences and Disorders as a promising means for closing the research–practice gap by proactively facilitating the use of evidence-based protocols in practice. One of the pillars of Implementation Science is collaboration between researchers and stakeholders. This article describes the benefits of researcher–stakeholder collaboration, along with the challenges. Different types of collaborative approaches are provided with specific examples. Guidelines for creating and sustaining successful collaborations are provided. The article concludes with an appeal for more research that brings together the talents and expertise of researchers and other stakeholders in conducting scientifically rigorous and practically important studies in ways that improves the likelihood of adoption and sustained use of evidence-based practices.     

What counts as evidence in evidence‐based practice?

BACKGROUND: Considerable financial and philosophical effort has been expended on the evidence-based practice agenda. Whilst few would disagree with the notion of delivering care based on information about what works, there remain significant challenges about what evidence is, and thus how practitioners use it in decision-making in the reality of clinical practice. AIM: This paper continues the debate about the nature of evidence and argues for the use of a broader evidence base in the implementation of patient-centred care. DISCUSSION: Against a background of financial constraints, risk reduction, increased managerialism research evidence, and more specifically research about effectiveness, have assumed pre-eminence. However, the practice of effective nursing, which is mediated through the contact and relationship between individual practitioner and patient, can only be achieved by using several sources of evidence. This paper outlines the potential contribution of four types of evidence in the delivery of care, namely research, clinical experience, patient experience and information from the local context. Fundamentally, drawing on these four sources of evidence will require the bringing together of two approaches to care: the external, scientific and the internal, intuitive. CONCLUSION: Having described the characteristics of a broader evidence base for practice, the challenge remains to ensure that each is as robust as possible, and that they are melded coherently and sensibly in the real time of practice. Some of the ideas presented in this paper challenge more traditional approaches to evidence-based practice. The delivery of effective, evidence-based patient-centred care will only be realized when a broader definition of what counts as evidence is embraced.     

Transforming Health Care from the Inside Out: Advancing Evidence-Based Practice in the 21st Century

Health care is in need of change. Major professional and health care organizations as well as federal agencies and policy-making bodies are emphasizing the importance of evidence-based practice (EBP). Using this problem solving approach to clinical care that incorporates the conscientious use of current best evidence from well designed studies, a clinician's expertise, and patient values and preferences, nurses and other health care providers can provide care that goes beyond the status quo. Health care that is evidence-based and conducted in a caring context leads to better clinical decisions and patient outcomes. Gaining knowledge and skills in the EBP process provides nurses and other clinicians the tools needed to take ownership of their practices and transform health care. Key elements of a best practice culture are EBP mentors, partnerships between academic and clinical settings, EBP champions, clearly written research, time and resources, and administrative support. This article provides an overview of EBP and offers recommendations for accelerating the adoption of EBP as a culture in education, practice and research.     

Developing best practice in critical care nursing: knowledge,evidence and practice

Because the current drive towards evidence-based critical care nursing practice is based firmly within the positivist paradigm, experimentally derived research tends to be regarded as 'high level' evidence, whereas other forms of evidence, for example qualitative research or personal knowing, carry less weight. This poses something of a problem for nursing, as the type of knowledge nurses use most in their practice is often at the so-called 'soft' end of science. Thus, the 'Catch 22' situation is that the evidence base for nursing practice is considered to be weak. Furthermore, it is argued in this paper that there are several forms of nursing knowledge, which critical care nurses employ, that are difficult to articulate. The way forward requires a pragmatic approach to evidence, in which all forms of knowledge are considered equal in abstract but are assigned value according to the context of a particular situation. It is proposed that this can be achieved by adopting an approach to nursing in which practice development is the driving force for change.     

Irish psychiatric nurses' self-reported barriers, facilitators and skills for developing evidence-based practice

Evidence-based practice places an emphasis on integration of clinical expertise with available best evidence, patient's clinical information and preferences, and with local health resources. This paper reports the findings of a study that investigated the barriers, facilitators and skills in developing evidence-based practice among psychiatric nurses in Ireland. A postal survey was conducted among a random sample of Irish psychiatric nurses and survey data were collected using the Development of Evidence-Based Practice Questionnaire. Respondents reported that insufficient time to find and read research reports and insufficient resources to change practice were the greatest barriers to the development of evidence-based practice. Practice development coordinators were perceived as the most supportive resource for changing practice. Using the Internet to search for information was the highest-rated skill and using research evidence to change practice was the lowest-rated skill for developing evidence-based practice. Nurses' precursor skills for developing evidence-based practice, such as database searching and information retrieval, may be insufficient in themselves for promoting evidence-based practice if they cannot find evidence relating to their particular field of practice or if they do not have the time, resources and supports to develop their practice in response to evidence.     

Examining health visiting expertise: combining simulation, interview and observation

BACKGROUND: Resource constraints and the drive towards evidence-based practice are currently prompting the review of health visiting services, which are a costly element of community health services in the United Kingdom. There is a shortage of evidence about effective domiciliary health visiting practice that can inform local and national decisions about developing and reforming this service. AIMS: This paper is based on a study which aimed to articulate the health visiting expertise involved in recognizing and responding to client need during home visits. The paper describes the innovative, multi-method approach used to articulate this expertise, and presents the rationale for this unusual approach. DISCUSSION: The study used the complementary methods of a 20-minute simulated visit to an actress-client, a postsimulation focused interview and subsequent observation of actual home visits with 15 study participants. Data-gathering took place between 2001 and 2002. The rationale, strengths and limitations of the methodology are discussed, and recommendations made for further development based on the work. CONCLUSIONS: The findings confirmed the utility of this unusual combination of methods, with their blend of control and naturalism, for articulating the knowledge and expertise which underpins assessment practice. Further research using a similar approach is recommended for the systematic examination of professional expertise in nursing and multi-disciplinary contexts.     

Hierarchies of evidence in education

The trend toward providing evidence-based education has emerged in part from the precedent set by the evidence-based practice movement in medicine. Historically, the medical model specified that evidence should be informed by experimental research. However, more contemporary models draw on a variety of evidence to determine best practices. Quantitative, qualitative, and mixed-methods designs, as well as the incorporation of professional expertise, are recognized as acceptable approaches to interpreting evidence in the educational arena. This article describes an integrated level of evidence model to assist educators in identifying the best evidence to inform teaching and learning practices.