TerminologyTerminology in Evidence-Based Practice (EBP)
Best Practice: The concept of best practice rests on a continuum of scientific rigor. The quality of best practice can fluctuate based on the evidence used to support and form guidelines, protocols, and pathways. In application, best practice includes rigorous scientific evidence to support the effectiveness of specific clinical interventions for explicit patients, groups, or populations; implementation monitoring to assure accurate application; and outcome measurement to validate effectiveness. Finally the currency, comprehensiveness, validity, and applicability to patients, practice, and community must be considered in the context of the burden of illness, beliefs about the value of interventions, cost and energy, and barriers to implementation (Sackett, Straus, Richardson, Rosenberg, Haynes, 2000, p.179-181). As the quality of evidence increases, the methods of evidence synthesis become mainstream, and implementation guidelines and outcome measures are validated, evidence based practice will equal best practice (EBP = BP). When benchmarking for best practice, first ask, "...what is the source of the evidence, where does it ride on the opinion vs. evidence continuum?"
Bias: A source of sway that creates a distortion in studies results; bias can be occult. Publication bias addresses the publication of research findings based on the nature and direction of the results. Because studies producing positive results are more likely to be published than those producing negative results, systematic reviews that include only published studies may be susceptible to "publication bias," thus yielding results more positive than the true effect.
Clinical Practice Guideline: Systematically developed statements to assist clinicians and patients in making decisions about appropriate health care for specific clinical circumstances (IOM, 1995). It is essential that guidelines are scientifically valid and systematically searched and appraised (i.e., evidence based). (Dawes et al, 1999).
In the field of EBP, these guidelines are based on systematic reviews of the research evidence. Health professionals can consider EBP guidelines as generally recommended courses of intervention, supported by research, rather than fixed protocols or substitutes for clinical reasoning. As the unique needs of individual patients and variations in clinical settings and resources are considered, the clinician will apply the guidelines based on individual situation and professional judgment. Guidelines are presented in a variety of forms: protocols, clinical pathways, algorithms, computer-based protocols, practice parameters, and policy documents.
Central Issue in Clinical Questions: Clinical questions arise from central issues involved in patient care. Focused questions can address a single central issue or involve several. Examples of central issues: Clinical Findings - how do we obtain and interpret information from history and physical assessment; Etiology - how do we identify the cause of a disease; Diagnostic Test - how do we determine and interpret a diagnostic test to rule in or out a diagnosis; Therapy - how do we select treatments that have acceptable risk/benefit profiles; Prevention - how do you screen for early disease detection and what risk factors can be reduced to mitigate risk (Hamer & Collison, 1999; Sackett, et al, 2000).
Cost-Benefit Analysis: An economic analysis strategy that assesses whether the benefit of an intervention is worth the cost of the intervention.
Evaluation: In EBP, evaluation is the last step in the process. It connotes an assessment of the impact of the practice changes made, based on evidence. Evaluation may be expressed in terms of impact on patient health status, patient outcomes (such as satisfaction), efficiency of healthcare resources, and economic analysis.
Evidence Summary: An inclusive term for systematic review, evidence synthesis, and integrative review. It refers to a systematic, scientifically rigorous approach to summarizing knowledge across a number of research studies, so that the variations in studies and contradictory study results can be understood within a single conclusion; it provides a "state of the science" conclusion.
Evidence Synthesis: A type of evidence summary. Evidence synthesis is the term used by the Agency for Healthcare Research and Quality (AHRQ) and is synonymous with the term, systematic review (see below).
Evidence-based healthcare: Extends the application of evidence-based medicine principles to interdisciplinary health care.
Evidence-based medicine: "The integration of best research evidence with clinical expertise and patient values."
(Sackett, 2000, p. 1)
Evidence-based practice: A process finding, appraising and applying scientific evidence to the treatment and management of health care EBP is the discovery of underlying trends and principles developed from the accumulation and refinement of a large body of studies The processes of EBP creates new, state of the science knowledge, summarized and clarified for translation into best practice for clinical policy.
Evidence-based practice (EBP) Steps: (1) Original Research; (2) Evidence Summary; (3) Translation
(4) Implementation; and (5) Evaluation.
Integrative Review: A type of evidence summary The integrative research review is a combination of two elements: (1) a primary research focus (the research topic, replicated one or more times) on outcomes, methods, theories, or practices or applications; and, (2) a goal in the form of integration (generalization, conflict resolution, or linguistic bridge building), criticism, or identification of central issues (Cooper and Hedges, 1994). An integrative review may take the form of a meta-analysis on the topic using statistical procedures to integrate findings. Integrative reviews conclude with implications from the research for practice. The Online Journal of Knowledge Synthesis publishes integrative reviews in nursing.
Randomize Control Trial (RCT): Experimental comparison of outcomes between two or more groups randomly assigned to a treatment or diagnostic strategy versus placebo or another strategy. Blinding of group assignment to patients, providers, and outcome assessors can be done to minimize bias. (Ferrer et al, in press). RCT's are used in evidence-based medicine, particularly the Cochrane Collaboration, as the gold standard for production of valid and reliable research evidence.
Systematic Review: A type of evidence summary that uses a rigorous scientific approach to combine results from a body of original research studies into a clinically meaningful whole. A systematic review addresses sharply defined questions, systematically identifies pertinent evidence, and critically appraises and synthesizes studies. (Ferrer, in press) Systematic reviews provide the best evidence of effectiveness within the context of a question framed within a central issue. A systematic review can summarize many studies at once, focus on the question within the central issue, there by giving the provider or policy maker a more precise estimate of the effects within the central issue. The term is used by the Cochrane Collaboration and is synonymous with the term, evidence synthesis.
Translation: Translation is the process that transforms the evidence from a systematic review into clinical practice guidelines (see definition of Clinical Practice Guidelines above) and clinical policy. This process allows for integration of the evidence into clinical practice, health plans, clinical policies, and treatment decisions. The aim of translation is to provide useful, useable, and relevant packages of summarized evidence to clinicians in a form that suits the time, cost, and care standard imperatives of their clinical setting. Generically, these evidence-based clinical packages are called clinical practice guidelines. Translation transforms the advice from research evidence and may combine it with ethical, organizational, and other expert advice.
Copyright 2000 Ledbetter & Stevens. Reprinted with permission.