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Evidence-Based Practice

  1. Bonnie Spring,
  2. Kristin Hitchcock

Published Online: 30 JAN 2010

DOI: 10.1002/9780470479216.corpsy0330

Corsini Encyclopedia of Psychology

Corsini Encyclopedia of Psychology

How to Cite

Spring, B. and Hitchcock, K. 2010. Evidence-Based Practice. Corsini Encyclopedia of Psychology. 1–4.

Author Information

  1. Northwestern University

Publication History

  1. Published Online: 30 JAN 2010

Evidence-based practice (EBP) describes a process of decision making for high-quality client care. The idea of basing practice on evidence was introduced in medicine as a way to promote clinical decision making that followed a rational process rather than intuition (Evidence-Based Medicine Working Group, 1992). EBP was defined as “the conscientious, explicit, judicious use of current best evidence in making decisions about the care of individual patients” (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). From the outset, EBP was seen as based on more than research alone. Research was depicted as one of three overlapping circles or data streams to be considered in clinical decision making. Sackett and colleagues (1996) defined EBP as “the integration of best research evidence with clinical expertise and patient values.”

The forces that gave rise to the evidence-based movement date back to the early 1900s. The 1910 Flexner Report initiated an effort by the medical community to ground medical training and practice on a firm scientific foundation. The randomized clinical trial (RCT), championed by Archibald Cochrane 1972, gradually became accepted as the most valid method to determine which treatments work. Nevertheless, it became recognized that clinical practice too often departs from the ideal, prompting a call for infrastructure to disseminate evidence-based best practices. One tool introduced to help close the gap between research and practice was the systematic review, which is a comprehensive overview of primary research studies conducted according to an explicit, transparent protocol. Systematic reviews offered a means to synthesize and consolidate the evidence across many clinical trials. Dissemination infrastructure emerged via the Cochrane Collaboration, founded in 1992 and now an international network that prioritizes, performs, and regularly updates systematic reviews. An emergent tool even more directly applicable to practice is the evidence-based practice guideline, which applies systematic review methodology to evaluate the management options for a clinical condition or problem. Currently, the National Guidelines Clearinghouse (http://www.guidelines.gov) serves as a repository for more than 2,000 evidence-based practice guidelines, many of which are updated regularly.

1 Evidence-Based Practice in Psychology

  1. Top of page
  2. Evidence-Based Practice in Psychology
  3. Elements of Evidence-Based Practice
  4. Implementing Evidence-Based Practice
  5. References

Psychology is a relative latecomer to the evidence-based practice movement, following medicine (Sackett et al., 1996), nursing (Craig & Smyth, 2002), social work (Gibbs, 2003), and public health (Brownson, Baker, Leet, & Gillespie, 2003). Not until 2006 did the American Psychological Association (APA) adopt evidence-based practice as policy for psychology. APA defined EBP as “the integration of best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (American Psychological Association, 2006).

Psychologists expressed some of the same hesitancies about EBP that were voiced in other disciplines, and they expressed some different ones as well. In most fields, a period of debate has preceded general acceptance of EBP. Researchers and practitioners squared off to argue whether greater weight should be given to research or to clinical expertise (Sackett et al., 1996; Spring, 2007; Spring & Pagoto, 2005). Across disciplines, practitioners worried that EBP really meant disguised cost cutting and erosion of professional autonomy (Spring & Pagoto, 2005; Pagoto et al., 2007). A reaction largely unique to psychology was the misinterpretation that performing EBP is entirely synonymous with delivering empirically supported treatments (ESTs) (Luebbe, Radcliffe, Callands, Green, & Thorn, 2007).

The confusion between EBP and ESTs is understandable. Practitioners who engage in performing EBP often do implement ESTs. Presumably, that is because the treatments designated as ESTs by APA Division 12's Dissemination Subcommittee of the Committee on Science and Practice are the ones supported by the best available research evidence. However, what defines clinical practice as evidence-based is not the delivery of any specific treatment but rather the performance of the evidence-based practice process. The EBP process is one whereby the practitioner decides on a course of action by integrating best available research evidence with other specific considerations.

2 Elements of Evidence-Based Practice

  1. Top of page
  2. Evidence-Based Practice in Psychology
  3. Elements of Evidence-Based Practice
  4. Implementing Evidence-Based Practice
  5. References

The multidisciplinary Council for Training on Evidence-Based Behavioral Practice (EBBP) proposes a harmonized cross-disciplinary EBP model that is applicable when choosing psychosocial interventions at the individual, community, or population level (Council for Training in Evidence-Based Behavioral Practice, 2008). The council's free online training modules about the evidence-based practice process, systematic reviews, and searching for evidence are available at its web site (http://www.ebbp.org). Its model, depicted in Figure 1, shows three data streams to be integrated when deciding on a clinical course of action: evidence, client characteristics, and resources.

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Figure 1. Elements that need to be integrated into EBP

Council for Training in Evidence-Based Behavioral Practice, 2008, http://www.ebbp.org

2.1 Evidence

Evidence in EBP is research findings derived from the systematic collection of data through observation and experiment and the formulation of questions and testing of hypotheses. Practitioners ask many different kinds of practical questions, not only about the benefits of treatments but also about assessment, prevalence, prognosis, etiology, costs, and even harms associated with treatments. The optimal research design to answer a question depends on the nature of the question being asked. Systematic reviews and meta-analyses can provide high-quality evidence for answering many different kinds of questions. Well-designed cohort studies provide the best evidence to answer questions about prognosis, incidence, or risk factors for a condition. Qualitative studies or sample surveys offer an excellent tool to understand client or community experiences. Cost–benefit questions call for economic analyses.

The evidence available to answer a question can be arrayed as an evidence hierarchy, with the most comprehensive, systematic, least biased types of data at the top. At the apex of the evidence pyramid for a treatment question is a well-conducted systematic review, followed by randomized controlled trials, followed by observational studies, and finally by anecdote, opinion, or indirect evidence from basic mechanistic research.

2.2 Client Characteristics

Except for single case studies, research evidence describes the average responses of individuals or groups. The core challenge addressed by EBP is how to optimize outcomes by applying the averaged data to an individual client. Decision making is needed to contextualize the evidence to the particular circumstances at hand. Client characteristics are one set of key contextualizing factors that need to be taken into account. Relevant client attributes include state and trait variations in condition, needs, history of treatment response, values, and preferences. Contextualizing the evidence by client characteristics is critically important in deciding whether available research evidence is truly relevant to the client. In implementing an intervention, some tailoring to client characteristics (e.g., literacy level of materials) can often be implemented. Such adaptations can enhance treatment feasibility and acceptability, without undermining fidelity to the core treatment elements that make a treatment effective (National Cancer Institute, 2006).

Client preferences warrant special mention as a contextualizing variable. EBP has done much to highlight the importance of shared decision making in the health care delivery process (Krahn & Naglie, 2008). Engaging clients in decision making that acknowledges their preferences is justifiable on sociopolitical grounds of equity. Shared decision making is also justified on evidentiary grounds, because of the association between shared decision making and improved health outcomes (Say & Thomson, 2003; Spring, in press).

2.3 Resources

Universally, resources are a contextualizing variable that factors into evidence-based decisions. The most efficacious treatment is irrelevant to any but theoretical EBP if there is no trained practitioner accessible to deliver treatment or no resources to pay for it. The creation of resource-sensitive practice guidelines is a new development in EBP (see Fried et al., 2008). Such guidelines review the quality of evidence supporting alternative practice recommendations. Decision makers can use the guidelines to gauge the level of intervention intensity that makes the best use of available infrastructure, human capital, and financial wherewithal.

3 Implementing Evidence-Based Practice

  1. Top of page
  2. Evidence-Based Practice in Psychology
  3. Elements of Evidence-Based Practice
  4. Implementing Evidence-Based Practice
  5. References

The diagram in Figure 1 might make it appear that integration of the three data streams processed in evidence-based practice (evidence, client characteristics, resources) could occur simultaneously, but that is not the case. The evidence-based practice process proceeds through the five clearly defined steps shown in Figure 2: Ask a question; acquire the evidence; appraise the evidence; apply the evidence; analyze and adjust practice.

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Figure 2. Steps in the Evidence-Based Practice process

The steps of the evidence-based practice process are performed in a specific order. After the presenting condition or problem has been assessed, the practitioner begins the EBP process by posing a relevant, well-formulated question and conducting a search for the best research evidence to answer it. The “best available research evidence” refers to relevant findings that have been critically appraised, either by systematic reviewers with expertise in critical appraisal or by the individual practitioner, using EBP techniques and standards. To find the best evidence to address the target question, the interventionist needs to know which kinds of research evidence best answer different types of questions and how to appraise the quality and applicability of that evidence.

After finding and appraising the evidence, the interventionist assesses what resources, including trained practitioners, are available to be able to offer what the research shows to be the intervention(s) best supported by evidence. The practitioner also considers any stakeholders' characteristics and contextual factors that bear on the likely applicability, acceptability, and uptake of the intervention(s) best supported by evidence. The practitioner also evaluates relevant stakeholders' values and preferences and engages appropriate stakeholders in the process of collaborative decision making.

After interventions have been implemented, the EBP practitioner assesses their impact and engages stakeholders in the process of evaluation and quality improvement. Using an iterative, cyclical process, the practical outcomes of intervention decisions are then used to develop and/or refine local decision-making policies, generate new questions, inform future searches for best evidence, and/or identify needed research.

Evidence-based practice represents a step forward toward rational, systematic, high-quality health care. All major health professions have adopted the principles of evidence-based practice. The Institute of Medicine (IOM) identifies EBP as a cornerstone in the effort to reverse the glacial rate at which research discoveries translate into practice (IOM, 2001). The IOM also characterizes evidence-based practice as a core competency for health professions (Greiner & Knebel, 2003). For the interprofessional health care teams in which psychologists participate, the shared EBP framework supports jointly held foundational assumptions, vocabulary, and practice principles (Greiner & Knebel, 2003). Continued development of infrastructure remains needed to make evidence accessible at the point of care and to further systematize the EBP decision-making process.

References

  1. Top of page
  2. Evidence-Based Practice in Psychology
  3. Elements of Evidence-Based Practice
  4. Implementing Evidence-Based Practice
  5. References
  • Brownson, R. C., Baker, E. A., Leet, T. L., & Gillespie, K. N. (2003) Evidence-based public health. Oxford, England: Oxford University Press.
  • Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685716.
  • Cochrane, A. L. (1972). Effectiveness and efficiency: Random reflections on health services. London: Nuffield Hospitals Trust.
  • Council for Training in Evidence-Based Behavioral Practice. (2008, March). Definition and competencies for evidence-based behavioral practice. Retrieved September 19, 2008, from http://www.ebbp.org./Competencies.html.
  • Craig, J. V., & Smyth, R. L. (2002). The evidence-based practice manual for nurses. London: Churchill Livingstone.
  • Evidence-Based Medicine Working Group. (1992). Evidence-based medicine: A new approach to teaching the practice of medicine. Journal of the American Medical Association, 268, 24202425.
  • Fried, M., Quigley, E. M. M., Hunt, R. H., Guyatt, G., Anderson, B. O., Bjorkman, D. J., et al. (2008). Can global guidelines change health policy? Nature Clinical Practice Gastroenterology & Hepatology, 5, 120121.
  • Gibbs, L. (2003). Evidence-based practice for the helping professions. Pacific Grove, CA: Brooks/Cole–Thomson Learning.
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  • Krahn, M. K., & Naglie, G. (2008). The next step in guideline development: Incorporating patient preferences. Journal of the American Medical Association, 300(4), 436438.
  • Luebbe, A. M., Radcliffe, A. M., Callands, T. A., Green, D., & Thorn, B. E. (2007). Evidence-based practice in psychology: Perceptions of graduate students in scientist–practitioner programs. Journal of Clinical Psychology, 63(7), 643655.
  • National Cancer Institute. (2006). Using what works: Adapting evidence-based programs to fit your needs. USDHHS, NIH Publication No. 06-5874. Washington, DC: Author.
  • Pagoto, S. L., Spring, B., Coups, E. J., Mulvaney, S., Coutu, M. F., & Ozakinci, G. (2007). Barriers and facilitators of evidence-based practice perceived by behavioral science health professionals. Journal of Clinical Psychology, 63(7), 695705.
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  • Spring, B. (2007). Evidence-based practice in clinical psychology: What it is; why it matters; what you need to know. Journal of Clinical Psychology, 63(7), 611631.
  • Spring, B. (in press). Health decision-making: Lynchpin of evidence-based practice. Medical Decision Making.
  • Spring, B., Pagoto, S., Whitlock, E., Kaufmann, P., Glasgow, R., Smith, K., et al. (2005). Invitation to a dialogue between researchers and clinicians about evidence-based behavioral medicine. Annals of Behavioral Medicine, 30(2), 125137.