Introduction

It is now increasingly expected that health professionals caring for older people base their practice on research evidence (Kelly et al 2005; Mott et al 2004; Nolan 1994; Zeitz & McCutcheon 2003). The move to EBP has been driven by changing professional, government and consumer expectations as well as a need to justify the care given in terms of effectiveness and cost.

However, the uptake of research evidence into practice across all health disciplines and clinical specialities remains inconsistent (Kitson et al 2008) and often dependent on tradition (‘this is how we have always done it’), expert power (‘no one dares disagree with the top surgeon!’), and the knowledge and understanding of the individual health professional. Much has been written as to why this is so, and the literature identifies the barriers to implementation of research evidence and provides guidance for the development of strategies to overcome these (Nay & Fetherstonhaugh 2008). What is evident is that multi-faceted approaches are required for successful implementation and should include: (i) increasing the health professional’s understanding and appreciation of evidence-based practice, and (ii) ensuring the health professional has a good understanding of the clinical issue and facilitation.

This chapter provides an overview of EBP and its application to the care of older people. Techniques for implementing research evidence are discussed and possible barriers to implementation examined. Strategies to overcome barriers are discussed in the context of an approach to the implementation of clinical practice change developed by the Australian Centre for Evidence Based Aged Care (ACEBAC).

This approach (Translating Evidence into Aged care Methods, known as TEAM) is a dynamic, evolving methodology that is responsive to the practice context and draws on our many successful and unsuccessful efforts to change practice. Often only ‘successful’ research is reported. It is hoped that the lessons learnt from both success and ‘failure’ will inform and guide others attempting to translate research evidence into practice. Although the approach was designed to assist uptake specifically in residential and subacute hospital environments, the principles are likely to be applicable across all health settings.

What is evidence-based practice?

With its foundations in the move to evidence-based medicine (EBM) in the1990s, EBP is essentially the use of research evidence to inform all clinical practice. Perhaps the most well-known and accepted definition is that given by Sackett and colleagues (1997: 2), which states that EBM is ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients’. Sackett and colleagues (1996) stress that EBM means integrating the health professional’s judgment with the best available research evidence and the wishes of the individual client in stating that (p 72):

A more recent definition by Rycroft-Malone and colleagues (2004: 82) further emphasises the notion of EBP as the integration of research evidence with the health professional’s expertise and the choice and wishes of the client in stating that it is:

In essence, EBP involves using research evidence to inform decisions rather than support the ‘blind’ application of evidence.

The nature of the evidence

Perhaps because EBP arose from EBM, the primary source of research evidence has been that obtained through the conduct of randomised controlled trials (RCTs) and systematic review and meta-analysis of RCTs continues to be viewed as the ‘gold standard’ for medical research evidence of effectiveness. However, the need to adopt a broader view of what constitutes research evidence is now increasingly acknowledged. Socioeconomic research, qualitative studies, the tacit knowledge and experience of health professionals, and the past experiences and preferences of the individual client can all be considered as evidence (Aldrich et al 2003; Lin & Gibson 2003; Pearson 2003; Rycroft-Malone et al 2004; Traynor 2002; Zeitz & McCutcheon 2003). Another issue to be aware of when considering the nature of the evidence is that evidence is often looked at solely in terms of the effectiveness of a treatment or intervention, but if the above perspective is accepted, then appraisal of the evidence should also include an examination of the meaning, feasibility and applicability of the treatment or intervention. The meaning is especially important when taking account of client preferences and/or trying to get practitioners to change long-held practices. For example, if management sees alcoholism as the responsibility of the alcoholic, efforts may be directed at changing the individual; however if staff see it as a result of social factors they may prefer to focus on social change. Feasibility relates to whether the treatment or intervention is realistically able to be implemented in the specific context or situation; do clinicians have the necessary expertise and experience; are the resources needed to implement it available and is it acceptable to the client? Applicability relates to whether a specific intervention is applicable to the particular context, situation or setting. For example, an intervention may be effective in a 45-year-old female but is it applicable to an 85-year-old male?

Criticisms of evidence-based practice

Critics of evidence-based practice often argue that it takes a very restrictive view of the meaning of evidence and inhibits client choice and restricts the ability of the clinician to adapt to the context, the circumstances and to the individual client (Conn et al 2002; Pearson 2003; Rycroft-Malone et al 2004; Sackett et al 1997; Zeitz & McCutcheon 2003). From the discussion above it can be seen that these criticisms can be overcome if the broader view of evidence described is considered and the concept of EBP as the integration of the clinician’s expertise and client preferences adopted (Conn et al 2002; Sackett et al 1997; Sidani et al 2006).

It has also been argued that EBP is not compatible with a person-centred approach as it limits the ability of the client to make their own choices and decisions regarding treatment options. Again, if the broader view of EBP is accepted in its entirety, it is evident that the two approaches are compatible and can be integrated by ascertaining the evidence, presenting treatment options to the client and identifying their preference (Coyler & Kamath 1999; Nay 2003).

Locating and utilising the evidence

Further criticisms of EBP are that the large numbers of research papers being published annually make it unrealistic for clinicians to be able to keep abreast of the latest evidence and, in many instances, research papers provide contradictory evidence. It is therefore important that evidence is presented in a form that clinicians find readily accessible and understandable (Sherriff et al 2007). Systematic reviews of the literature and the development of clinical practice guidelines are two ways in which evidence can be made more accessible.

There are a number of organisations, such as the Cochrane Collaboration, that undertake systematic reviews of the literature relating to a specific area of clinical practice. These rigorous reviews, using a methodical and replicable way of searching the literature, appraise and summarise the evidence into one document and provide guiding statements as to the strength of the evidence supporting or refuting a particular intervention.

Evidence-based clinical practice guidelines are perhaps the most accessible form of research evidence, in that they utilise the information gained from a systematic review and expert opinion to formulate practice recommendations (Institute of Medicine [IOM] 2000). Clinical practice guidelines provide clinicians with practical advice as to ‘best practice’ actions in a given situation and clearly inform the clinician of the strength of the evidence supporting each practice recommendation through the use of a hierarchical grading system, such as that developed by the National Health and Medical Research Council (NHMRC) in Australia (NHMRC 2000). It is important to note that evidence grading systems typically reflect the RCT as the ‘gold standard’ of evidence and apportion less weight to other forms of evidence. The NHMRC, however, is reviewing its approach to grading evidence to encompass research that does not accommodate an RCT model, and to consider the generalisability and applicability of the available evidence (NHMRC 2008).

There are numerous clinical practice guidelines for a multitude of interventions and medical conditions and it is vital that clinicians are able to distinguish a reliable guideline from a poor guideline, as the application of poorly developed clinical practice guidelines may be costly to the organisation, result in the implementation of ineffective treatments, and even cause harm to the client. The National Institute for Clinical Studies (NICS) and the NHMRC in Australia provide guidance on how to review and appraise clinical practice guidelines and there are many tools available to assist in the process. Essentially, a reliable clinical practice guideline should be clear and understandable and provide the reader with the information as to:

Good quality clinical practice guidelines, where they exist, provide clinicians with easy access to the evidence but are not intended to be applied without consideration being given to contextual factors such as comorbidities, the wishes of the individual client, clinician judgment, staff expertise and the particular setting or situation. It is important to consider if the evidence is applicable to older people, as research often excludes people with comorbidities, which we know represents the majority of the old-old. Clinical practice guidelines can be adapted and contextualised to a specific client or setting by giving attention to the appropriateness of the guideline recommendations to the setting, the feasibility of implementing the recommendations in the setting, and whether the recommendations are congruent with the values and experiences of the client group.

Evidence-based strategies for implementation of EBP

Ultimately, the implementation of evidence-based practice involves changing clinical practice and the behaviour of health professionals. However, real change requires a whole of organisation commitment. Much has been written about implementing practice change and the many barriers confronted and strategies developed to address them (Hannes et al 2007; Kresse et al 2007; National Institute of Clinical Studies [NICS] 2006).

The aspects of the organisation and/or individuals that may hinder or help the implementation of EBP can be summarised as follows.

2. Leadership

2.1 Visionary leadership is vital to the change process. Staff are more likely to accept and endorse change if they have role models who value EBP and sell it enthusiastically rather than view it as simply another burden of compliance with government or accreditation expectations.

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