CHAPTER 15 Clinical reasoning and evidence-based practice
After reading this chapter, you should be able to:
Evidence-based practice aims to improve outcomes for clients.1 This goal appears uncontentious and would generally be accepted by a range of stakeholders in health. Clients, health professionals, funding bodies and policy makers would all share in this aim. However, a range of issues make evidence-based practice problematic and the complexity of the problem becomes clearer when we question how best to achieve optimal health care.
Client outcomes are dependent on a range of factors, such as:
Professional practice is complex and health professionals need to consider the range of factors that impact upon client outcomes when planning and delivering services. They are required to make decisions about what services they can and should offer, given the particular needs of and circumstances surrounding the individual client and the broader organisational and societal context. Making these kinds of decisions requires complex thinking processes as the ‘problem’ or situation about which decisions have to be made is often poorly defined and the desired outcomes are often unclear.2 This thinking process is often referred to as clinical or professional reasoning, decision making and professional judgement.
This chapter aims to explore the relationship between clinical reasoning and evidence-based practice. As you have seen throughout this book, evidence-based practice is a movement in health that aims to improve client outcomes by supporting health professionals to incorporate research evidence into their practice. Evidence-based practice also recognises that research evidence alone is not sufficient for addressing the complex nature of professional practice and that the ability to integrate different types of information from different sources is also required. Therefore, to practice in an evidence-based way, health professionals need to integrate research with their clinical experience, the preferences of their clients and the demands of the practice context. Clinical reasoning is the process by which health professionals integrate this information. In this chapter, we explore the notion of an evidence-based practice and the roles that a variety of types of information play in providing evidence for practice and highlight how the concept of practice should be viewed as being embedded within particular contexts. We also explore the clinical reasoning processes that occur within practice and provide some brief suggestions for you to consider when critically reflecting on your own practice from the perspective of evidence-based practice.
What is an evidence-based practice?
The first question about whether basing practice on evidence does lead to better client outcomes has been examined widely in relation to specific interventions and specific outcomes. The broad assumption that basing practice on evidence leads to better client outcomes generally gives rise to the second question—what constitutes evidence? As much of the focus of evidence-based practice has been on the second question, ‘What constitutes appropriate evidence?’, the discussion of evidence-based practice in this chapter will consider that question. As we saw in Chapter 1, evidence-based practice evolved from its medical counterpart, evidence-based medicine and, as a consequence, many of the assumptions of medicine have been adopted by evidence-based practice. In the definition of evidence-based practice by Sackett and colleagues3 that was examined in Chapter 1, the term ‘current best evidence’ was introduced as the criterion for evidence. Predictably, clarifying the nature of ‘best’ evidence has become the central concern of the evidence-based practice and evidence-based medicine movements. As the empirico–analytic paradigm is the dominant philosophy that underpins medicine, this also became the assumed perspective of the evidence-based practice movement.
The empirico–analytic paradigm is also known as the scientific paradigm or the empiricist model of knowledge creation. According to Higgs, Jones and Titchen4 this paradigm ‘relies on observation and experiment in the empirical world, resulting in generalisations about the content and events of the world which can be used to predict the future’ (p 155). From the perspective of the empirico–analytic paradigm, the best form of evidence is evidence that is produced through rigorous scientific enquiry. It has been assumed that such rigour could be achieved best through the methods of research.5 Therefore, information that has been generated from research became the concept of evidence that is used by the evidence-based practice movement. Many people take this assumption for granted and this is highlighted by the fact that some professions use the term ‘research-based practice’ rather than ‘evidence-based practice’.
The position that scientific knowledge is the sole key to evidence has been questioned by a number of writers5–7 who have argued that research evidence alone is not sufficient for addressing the complexities of professional practice and that the ability to generate and integrate different types of evidence from different sources is also required. However, this was the intent of early definitions of evidence-based medicine which emphasised that, to practise in an evidence-based way, professionals need to integrate research findings with the practical knowledge derived from their clinical experience and the preferences of their client.
In some ways, the assumption that ‘evidence equals research’ has been problematic for the evidence-based practice movement and has probably contributed to a strong division between those who align themselves with the evidence-based practice movement and those who oppose it. Critics of evidence-based practice argue that there are problems with the production, relevance and availability of research evidence and that it has limited capacity to address the problems of practice and enhance decision making in the context of complex practice situations.8 Examples of criticisms include: that the research that is undertaken is often dependent on funding and, therefore, factors other than need and importance can influence what is researched; that the research undertaken can reflect what is easier to measure more than what is important to understand or most important to professional practice; and that, often, research findings are not presented in forms that are easily accessible to health professionals.
Perhaps the situation is summed up best by Naylor9 who, in relation to evidence-based medicine (and his comments are just as relevant to evidence-based practice), stated that, ‘A backlash is not surprising in view of the inflated expectations of outcomes-oriented and evidence-based medicine and the fears of some clinicians that these concepts threaten the art of patient care’ (p 840). Exploring the assumptions about what is meant by the notion of ‘evidence’ can be a good start to examining what an evidence-based practice is and we will do this in the next section.
Evidence of what?
What is evidence? The Heinemann Australian Student Dictionary defines evidence as ‘anything which provides a basis for belief’10 and the Macquarie Dictionary defines it as ‘grounds for belief’.11 Thus, using this definition evidence might be considered by some as information that supports some sort of belief and an evidence-based practice would be a practice that is based on such information. But whose beliefs are referred to? Is it an individual health professional’s beliefs, the beliefs of a particular health profession or the beliefs that underpin a particular health service or model of service delivery? Is it the beliefs of those receiving care from a particular service or those funding or providing the service? Are the beliefs of all of these stakeholders in health the same and of equal value?
From the perspective of the empirico–analytic paradigm
As explained in the previous section, the evidence-based practice movement has so far taken its understanding of evidence from the empirico–analytic paradigm that underpins the assumptions of medicine. This perspective aims to develop a knowledge base generated from information about ‘reality’ or ‘how the world is’. Therefore, the information that provides appropriate evidence about ‘how the world is’ tends to be observable (often with the assistance of technology), reliably generated and reproducible. To be dependable as evidence of how the world is, information needs to be free of bias when collected, the potential effects of the information collection process on the phenomena need to be minimised and any changes observed must be able to be reliably attributed to particular factors or variables.
To make the empirico–analytic concept of best evidence explicit, a number of hierarchies have been developed, based on the methodology that is used to generate the information. In Chapter 2 we explored the hierarchies and levels of evidence for questions about intervention, diagnosis and prognosis in detail. Developing levels of evidence was a strategy used to establish the degree to which information could be trusted as ‘evidence’. For example, the top two levels of evidence in the hierarchy for intervention effectiveness are randomised controlled trials and their systematic reviews. As we saw in Chapter 4, randomised controlled trials (individual and systematically reviewed) generate knowledge that is considered to have a high degree of validity. By eliminating potential bias and controlling for variables that might influence the outcome, the confidence that any observed change can be attributed to one particular factor is very high. Therefore, in the empirico-analytic paradigm this study design represents the most trustworthy type of information to use as ‘evidence’ of how the world really is.
The accepted way that this kind of information is generated is through research that requires careful planning and, often, adequate funding. Therefore, it makes sense that, when considering the need for practice to be based on evidence, the evidence-based practice movement conceptualised ‘best evidence’ as information that is generated through research that is conducted within an empirico–analytic paradigm. This helps to explain the origins of the evidence-based practice movement’s assumption of ‘evidence equals research’. Further, as explained in Chapter 1, the use of the term ‘evidence’ in evidence-based practice serves the purpose of highlighting the use of research as an important source for decision making that had previously been undervalued. Hence, for the purpose of this book, the position taken is that ‘evidence’ means evidence from research, but it is considered to be only one of the many types of information that must be integrated for decision making. However, it is also important to consider other interpretations of the term ‘evidence’ that have been discussed in the literature.
From the perspective of technical rationality
A second approach that has influenced what is considered to be appropriate evidence for professional practice is technical rationality. The main aim of this approach to improving client outcomes is to regulate practice in order to enhance its efficiency and cost-effectiveness. Schon12 claimed that, from the perspective of technical rationality, ‘professional activity consists in instrumental problem solving made rigorous by the application of scientific theory and technique’ (p 21). The major elements of this definition are problem solving and the rigorous use of scientific theory and technique. Whereas the empirico–analytic approach emphasises the trustworthiness of information in representing how things really are, this approach focuses on the problem solving of health professionals. Therefore, a major difference between these two approaches is that the former centres on the quality of the information whereas the latter targets the process of using the information.
From a technical rationalist perspective, human reasoning and judgement is understood in health care as problem solving, which requires the framing and definition of a problem and the search for a solution within a defined problem space. From this approach, efficiency and cost-effectiveness can be improved by providing tools that support the problem-solving process and minimise the likelihood of reasoning errors. As the technical rationalist approach values the rigorous use of the scientific method and technique, information that is generated using this method is incorporated into routines and procedures that aim to lessen the professional judgement required. The influence of technical rationality on health care is evident in the use of clinical pathways, protocols, decision trees and other tools that aim to systematise practice decisions. For example, the typical path to be taken by a health professional is clarified when a standard problem definition (often based on a medical diagnosis) can be used. Decision trees work in this way.
The technical rationalist approach shares a similar definition of evidence with the empirico–analytic approach. Both approaches value information that is generated using rigorous scientific methods and consider it to be appropriate evidence upon which to base clinical practice. While they share a concern for effectiveness, they often differ in relation to cost-effectiveness. In the empirico–analytic approach it might be argued that an intervention is essential, regardless of the cost. In all probability, the technical rationalist approach that incorporates the closest scrutiny of client outcomes and evidence would also include outcomes such as the reduction of health service costs and adverse incidents that occur during service delivery. However, a criticism of the technical rationalist approach is that it fails to give due attention to the complexity of professional practice and the individual nature of client experience.13 This criticism is derived from the argument that the problems of professional practice are both specific and varied, which makes it impossible to develop protocols and procedures to cover the variety of situations that health professionals face.
What information helps health professionals to address the dilemmas of their practice?
A third approach to the question of what constitutes evidence is to consider the question, ‘What information helps professionals to address the dilemmas of their practice?’ Health professionals use judgement to deal with the complexity of professional practice,14 which relies on their clinical or professional expertise. The concept of professional expertise is central to the evidence-based practice process. This is illustrated in Sackett and colleagues’ 19963 definition of evidence-based medicine that was presented in Chapter 1. The beginning of Sackett and colleagues’3 definition of evidence-based medicine, quoted earlier in the chapter, is well known. However, the section that follows has been quoted infrequently when definitions of evidence-based medicine (or practice) are presented. It reads (p 71):
As was pointed out in Chapter 1, this definition makes it clear that an evidence-based practice requires professional expertise, which includes thoughtfulness and compassion as well as effectiveness and efficiency.
Sociocultural theories of learning suggest that professional expertise is developed through interaction with communities of practice.15,16 Health professionals learn the practices, activities and ways of thinking and knowing of their profession through participation in the community of practice. Expertise develops ‘as an individual gains greater knowledge, understanding and mastery’ (p 24)16 in their practice area.
The work of Dreyfus and Dreyfus17 has been widely used to understand the concept of professional expertise developing with experience. The different ways that professionals think as they gain experience have been characterised into five stages, namely: novice, advanced beginner, competent, proficient and expert. Essentially these five stages reflect a movement from a practice that is based on context-free information and generalised rules to a sophisticated and ‘embodied’ understanding of the specific context in which the practice occurs. While the earlier stages focus on the application of generalised knowledge, in the proficient and expert stages health professionals are able to recognise (often subtle) similarities between the current situation and previous ones and use their knowledge of the previous outcomes to make judgements about what might be best in the current situation.
Professional expertise is difficult to quantify as it is partly determined by the understandings that are shared by members of the community of practice. For example, Craik and Rappolt1 selected health professionals who were ‘deemed by their peers to be educationally influential practitioners’ as a criterion for inclusion into their research study of ‘elite’ practitioners. In nursing, expertise has been associated with holistic practice, holistic knowledge, salience, knowing the client, moral agency and skilled know-how.18 Fleming19 reported that occupational therapists described videotapes of expert practitioners as appearing ‘elegant and effortless’ (p 27). Jensen and colleagues20 developed a grounded theory of expert practice in physiotherapy and proposed that expertise in physiotherapy is a combination of multidimensional knowledge, clinical reasoning skills, skilled movement and virtue and that all four of these dimensions contribute to the therapist’s philosophy of practice. It appears that members of a community of practice are able to recognise expertise, even thought it involves unstated and embodied knowledge, skills and attributes that can be difficult to quantify.
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