You now have some level of comfort with the thinking and action processes involved in the experimental-type and naturalistic research traditions. These processes serve as your working tools to apply to a health or human service practice arena. In this chapter, we turn to the action of “application,” or applying research principles to the practice arena and visa versa. Although collaboration is part and parcel of research in both experimental-type and naturalistic inquiry, we see the intersection of research and practice and the most fertile ground for cooperation and conversely suggest that the critical relationship between research and practice can only be maximized through the collaborative efforts of professionals, clients, patients, and researchers. We discuss four approaches that attempt to bridge the research-practice gap: evidence-based practice, translational research, practice-based research, and evaluation practice.

Evidence-based practice

If you are a practicing health or human service professional, you most likely have heard of evidence-based practice. Most professional organizations highly espouse this practice as a critical way of basing treatment and clinical practices in research evidence. If you are not involved in a practice arena, you may be asking, “What’s all the fuss about?” After all, you probably assume that all health and human service practices are based in or derived from evidence or knowledge that has been systematically obtained, rather than from hearsay, trial and error, or casual decision making. However, this has not exactly been the case. At issue are the definition of evidence and what constitutes “adequate evidence” for informing practice decisions.

Evidence-based practice is not a research method or design. Rather, it is a model of professional practice that draws heavily on research that uses particular methodologies to draw conclusions from research literature. Major aspects of evidence-based practice include which research methods and conclusions should underpin practice, how to organize a clinical setting to engage in this form of practice, how to teach this approach, and the barriers to its implementation. However, our focus here is how evidence is defined in this approach and how evidence-based practice uses research principles to draw evidentiary-based conclusions to inform practice. We begin our discussion with a brief history, then define and provide critical comments on this contemporary practice approach.

Definitions and Models

Since early in the 20th century, policy makers, scholars, and practitioners have been debating the nature and role of research in professional practice.1 Numerous terms have been used in these discussions to describe professional activity that in some way uses or generates knowledge based on the principles of scientific inquiry. In part, the disagreements about what constitutes science (and by extension, scientific inquiry) and how or even if science should form the foundation of professional practice have contributed to the conflict about scientifically driven practice.² Remember that we define science as follows:

1. It is theory based or theory generating.

2. It is developed according to the rigor criteria of systematic use of inductive, abductive, and deductive logic structures in all phases of thinking and action processes.

3. It involves detailing the explicit evidence and reasoning on which knowledge claims are based.

Keep these definitional elements in mind as you learn more about evidence-based practice, because they form both its strengths and its limitations. Many terms are used to discuss models of scientific inquiry in professional practice. In general, all models posit the value of scientifically derived knowledge to support professional decision making and to examine the extent to which desired outcomes have been achieved.

Public health and education were the first professional fields to emphasize the importance of systematic evaluation for practice accountability.3,⁴ In the early 1950s, proliferation of federally supported programs resulted in the expansion of evaluation into a field unto its own, with its focus on fiscal accountability.⁵ Concurrently, debates emerged between those who espoused “empiricism” and those who opposed it in a “value-based” practice context.⁶ As evaluation was espoused by health and human service fields, debate increased about whether to conduct empirical inquiry to support practice. Discussion shifted away from polar arguments to a more expansive and complex analysis of the nature of evidence, when evidence is appropriate, and methods to generate it.⁷

The following definitions of evidence-based practice have been used in medicine,^8,⁹ nursing,¹⁰ and occupational therapy¹¹:

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.8

ent The conscientious and judicious use of current best evidence from clinical care research in the management of individual patients.9

ent [The] process by which nurses make clinical decisions using the best available research evidence, their clinical expertise and patient preferences, in the context of available resources.10

ent [A]n ethical, conscientious, discriminative process of applying the best research-based evidence to decisions regarding client care.11

As you can see, each definition emphasizes the use of research evidence in the context of clinical expertise, although they all differ slightly. According to Mullen,¹² two primary models have been reflected in these definitions. In one model, intervention is selected from an array of efficacious, empirically supported practices. In the second model, practitioner and client collaboratively consider best evidence to make decisions together.

In the 21st century, increasing debates about the nature of knowledge itself raise many questions about the meaning of evidence. Thus, current models of evidence-based practice are based on a broadened understanding of evidence as ranging along a continuum from anecdotal experience of providers and consumers, organizational guidelines, consensus groups or single-study review to highly structured systematic review of the literature (meta-analysis). Most prominent however is the traditional approach that remains grounded in the assumption of a “hierarchy of evidence” in which judgment about the value of knowledge is based on the methods of inquiry. The randomized controlled trial (RCT) is considered the highest level of evidence to support intervention efficacy, and other forms of knowledge are less valued. Thus, the true-experimental design to support claims about the efficacy of interventions remains as the methodological pinnacle of desirability, whereas other design approaches (e.g., quasi-experimental, naturalistic inquiry) tend to receive less acclaim, or they are not systematically considered in the evaluation of evidence.⁸

In general, all evidence-based practice models can be defined by their use of “best evidence” to guide practice decisions, thereby creating standard, valid interventions to the extent possible for specific conditions, diagnoses, and problem areas that are well researched.

Approaches to Identifying Evidence

As stated earlier, evidence-based practice is not a methodology, but it does label and thus use preferred methodologies for systematically reviewing evidence and linking the evidence to actual practice decisions. There are four methodological steps in applying evidence to clinical practice in this framework: reviewing the literature, rating the evidence, developing clinical guidelines, and applying or translating guidelines to a clinical case.

The key research action process in this form of practice is systematically reviewing published scientific literature, including clinical practice guidelines, meta-analysis (both qualitative and experimental type), and Web-based searches for relevant research-generated information. That is, key to the success of basing a clinical decision on the evidence is how investigators review the literature (see Chapter 5), including how they bound the topic or query through the selection of key terms and how they tailor the search. As in a search for any research inquiry, it is critical to know the limitations of the databases that are searched and how the bounding rules constructed will shape the evidence obtained. Given the complexity and time-consuming nature of conducting a comprehensive and adequate literature review, new search engines have been created, such as PubMed, which gives free access to MEDLINE databases (www.ncbi.nlm.nih.gov/PubMed), and SumSearch (http://sumsearch.uthscsa.edu), which searches databases that contain sources for evidence-based guidelines. We have found Google Scholar (www.scholar.google.com) valuable in locating sources as well.

After relevant research articles have been identified and retrieved, the next methodological step is applying a systematic rating to each type of research study and form of evidence retrieved (Box 24-1). Then, on the basis of the ratings that are derived, a series of clinical guidelines can be articulated (Box 24-2). The final step involves translating the evidence and guidelines to a particular clinical group or case. In this step, the researcher must ask numerous critical questions (Box 24-3). It is particularly important to determine whether differences exist between study populations and the particular clinical population or case and whether these may diminish the treatment response or change the risk-to-benefit ratio. This translational step draws on clinical knowledge and judgment.

BOX 24-1

Examples of Rating Systems in Evidence-Based Practice

“ABCD” System