Making the Case for Evidence-Based Practice

Part A left off with evidence-based practice established as an idea, a process and a history. This half is about why, with all of that in place, it so often does not happen. The temptation is to conclude that clinicians need to be told more firmly. Keep a tally as we go through the seven barriers, of how many an individual clinician could remove on their own. The answer decides who the case has to be made to, and it is the argument the last video in this unit makes. By the end you can name the barriers and the facilitators; distinguish evidence-based practice from research and from quality improvement, which is the most common conceptual error in this field; say what evidence-based quality improvement adds; and answer the three misconceptions people hold most confidently.

Two videos to set up the rest. What a unit has to be like for evidence to reach the bedside, and why handing a clinician a paper accomplishes nothing.

What a unit has to be like.

EBP 0039 An EBP Culture and Environment

A culture is what people believe evidence is for. An environment is whether the place makes acting on it possible. Both, or neither works.

Why telling people does not work.

EBP 0040 Changing Behaviour Is Complex

Changing clinical behaviour is complex, which is why handing someone a paper changes nothing. The rest of this unit is about what does.

Seven barriers. As you go, keep a tally of which ones an individual clinician could remove alone, because the answer shapes who the case has to be made to.

The barrier people assume is the only one.

EBP 0041 Barrier — Knowledge and Skills

Clinicians may not know how to search or appraise. Real, and the most fixable — which is why it gets mistaken for the whole problem.

The barrier that sounds like a personality.

EBP 0042 Barrier — Cultures Steeped in Tradition

A culture where the answer to why is that we have always done it. Not stubbornness — an absence of any expectation that anyone would ask.

The barrier cited most often.

EBP 0043 Barrier — Time and Resources

Clinicians report having no time to search or read. Note this is about the workload structure, not about willingness.

The barrier that grows every year.

EBP 0044 Barrier — Volume of Literature

The literature is far larger than anyone can read. This is what preappraised evidence and syntheses exist to solve — unit 3.

A barrier no individual can remove.

EBP 0045 Barrier — Organizational Constraints

Policies, systems and structures that block change. Important: this one is not a personal failing and cannot be trained away.

The barrier that comes from colleagues.

EBP 0046 Barrier — Resistance and Peer Pressure

Resistance from peers, and the pressure not to be the one doing things differently. It applies hardest to the person trying to stop a practice.

The barrier of nothing happening.

EBP 0047 Barrier — No Consequences, No Authority

No authority to change practice, and no consequence for not changing it. When nothing follows either way, nothing changes.

Seven facilitators, and they are not the barriers turned inside out. Watch the last one, which is what survives after the person who championed the change has gone.

Now what works. The first facilitator.

EBP 0048 Facilitator — EBP as the Norm

Evidence-based practice as the expected way of working rather than a special project someone runs.

The facilitator most often misread.

EBP 0049 Facilitator — Leadership Support

Leadership support that is active rather than permissive. Unit 12 shows that funding alone is not support.

Two things that have to line up.

EBP 0050 Facilitator — Alignment and Time

Organizational goals aligned with evidence-based practice, and time actually protected to do it.

The facilitator unit 16 is built on.

EBP 0051 Facilitator — EBP Mentors

Mentors who work alongside clinicians rather than teach at them. This is the mechanism the ARCC model turns on.

Putting evidence where the decision is.

EBP 0052 Facilitator — Tools at the Point of Care

Evidence available at the point of care, because a resource a clinician must leave the bedside to reach is a resource they will not use.

Facilitators built into a career.

EBP 0053 Facilitator — Curricula and Promotion

Teaching it in programmes, and recognising it in promotion. Units 18 and 19 are the teaching half of this.

The facilitator that outlasts individuals.

EBP 0054 Facilitator — Evidence-Based Policies

Policies and procedures that are themselves evidence-based. This is what survives the departure of whoever championed it.

Two videos on what competence means here and why one enthusiast is not enough.

What competence means here.

EBP 0055 The EBP Competencies

A defined set of competencies for evidence-based practice, so that competence is a checkable claim rather than a belief. Unit 11 is the full treatment.

How many mentors it takes.

EBP 0056 A Critical Mass of Mentors

Not one enthusiast. A critical mass, because below some threshold the change does not propagate — unit 17 puts a number on it.

Three videos on the activity next door and what happens when evidence is put inside it rather than beside it.

A neighbouring activity, defined.

EBP 0057 Quality Improvement

Improving local processes and outcomes. Local by design, and that is a feature rather than a limitation.

What happens when you combine them.

EBP 0058 Evidence-Based Quality Improvement

Quality improvement with appraised external evidence inside the plan rather than beside it.

Where exactly the evidence sits.

EBP 0059 EBQI Puts EBP Inside the Plan

The distinction is placement. Improvement work that consults the literature afterwards is quality improvement; work built on it is EBQI.

Four videos. The apparatus for watching whether anything changed, and then the distinction that this unit most wants you to leave with.

The apparatus for watching outcomes.

EBP 0060 Outcomes Management

A systematic approach to using outcome data to improve care. The next two entries are its phases.

The first half.

EBP 0061 Outcomes Management — Define and Identify

Define the outcome you care about and identify how it will be measured — before the change, which is what makes the measurement mean anything.

The second half.

EBP 0062 Outcomes Management — Compare and Analyse

Compare against a benchmark or against yourself, and analyse what the difference is telling you.

The distinction to carry out of this unit.

EBP 0063 EBP, Research and QI Are Three Activities

Three separate activities. Research generates generalisable knowledge, EBP translates it into practice, QI improves local processes. Confusing them is the most common conceptual error in the field.

Three videos, each naming a belief about evidence-based practice that is confidently held and wrong. Each one is answered by a component of the definition you already have.

The first of three canonical errors.

EBP 0064 Misconception: EBP Overrides Clinical Judgement

It does not override judgement. Clinician expertise is one of the three components, so a practice that removed judgement would not be evidence-based practice.

The second.

EBP 0065 Misconception: EBP Is Cookbook Care

The opposite of cookbook care. A recipe ignores the patient, and patient preferences are the third component.

The third, and the one unit 7 answers hardest.

EBP 0066 Misconception: Evidence Means Randomized Trials

Evidence is not only trials. Levels are question-specific, and a meaning question is answered by qualitative work no trial could produce.

One procedure, longer than the rest, which puts the whole unit together into a case made on a real unit.

The unit assembled into one case.

EBP 0067 Making the Case for Evidence-Based Practice

The case is made to an organization rather than to a colleague, because most of the barriers are ones no individual can remove. That is the argument of the whole unit in one line.

That completes unit one. Against the outcomes. You can name the barriers, and your tally should have come out lopsided: knowledge and skills is trainable, and time, organizational constraints, peer pressure and the absence of any consequence are not things one clinician can remove. You can name the facilitators, and the one that outlasts a champion is evidence-based policy, because a policy stays after the person who argued for it has moved on. You can distinguish the three activities. Research generates generalisable knowledge, evidence-based practice translates it, quality improvement improves local processes. Confusing them is the field's most common conceptual error. And you can answer the three misconceptions, each with a component of the definition: judgement is a component, patient preference is a component, and evidence is not only trials because levels are specific to the question asked. Unit 2 begins the process properly, at step one: how to ask a question a database can actually answer.