Understanding Research Methods For Evidence-Based ... - (Getting Evidence Into Practice)

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“c11GettingEvidenceIntoPractice_print” — 2019/4/26 — 2:53 — page 114 — #1

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CHAPTER 11
Getting evidence
into practice
LEARNING OBJECTIVES
11.1 Why are health professionals slow to adopt evidence-based practice?

11.2 How can we encourage individuals to implement evidence-based practice?
11.3 How can organisations support evidence-based practice?
11.4 How can we include the client perspective in evidence-based practice?
Copyright © 2019. Wiley. All rights reserved.
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Greenhalgh, Trisha M.. Understanding Research Methods for Evidence-Based Practice in Health, 2nd Edition, Wiley, 2019. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/ecu/detail.action?docID=5880746.
Created from ecu on 2023-02-22 12:52:58.
© John Wiley & Sons Australia, Ltd. Not for resale or distribution. Any unauthorised distribution or use will result in legal action.
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OPENING SCENARIO
You’re on practical placement in an aged-care

facility, and you’re caring for a resident who has
an ulcer on his lower leg. You’ve been shown how
to clean and debride the wound, and have done
some investigation into the best type of dressing
to use to speed healing. One morning there is a
different registered nurse (RN) on duty, who tells
you that your efforts are a waste of time and she
knows a better way to treat it. She fetches a little
bottle of hydrogen peroxide and pours some on the
resident’s ulcer. It fizzes up and when she wipes it
away, the ulcer ground is pink and clean of pus and
dead tissue. The resident is thrilled — it looks so
much better! — and demands that you do this from now on. You’re pretty impressed as well . . . until you
do some research into the effects of hydrogen peroxide. You discover it doesn’t just get rid of the dead
cells, it kills all the healthy new cells that are developing — basically, it’s bleach. If you keep using it, the
ulcer will never heal.
In this situation, there are two difficulties you face in getting evidence into practice — the RN’s firm
belief in the way she’s always done things, and the resident’s desire to follow the outdated treatment.
............................................................................................................................................................................
DISCUSSION QUESTIONS
1. Why would an RN continue to carry out a treatment that is outdated and that evidence shows is
actually harmful?
2. What could the facility do to ensure that best practice is used in the care of their residents?
3. How could the resident be encouraged to accept a more evidence-based treatment plan?
4. If the resident’s ulcer is chronic, does it really matter if the ‘bleach’ treatment doesn’t work and he is
happier with the pink clean look of his wound?
11.1 Adoption of evidence-based practice (EBP)

LEARNING OBJECTIVE 11.1 Why are health professionals slow to adopt evidence-based practice?
In Australia, all health professionals registered with the Australian Health Practitioner Regulation Agency
(AHPRA) are required to use evidence to underpin their practice.1 Each profession has a code of conduct
requiring members to practise in accordance with the current and accepted evidence base of their respective
discipline. In addition, several of the NMBA Registered Nurse Standards for Practice include the need to
access, analyse and use the best available evidence that includes research findings, and failing to do so
can result in deregistration. Similarly, New Zealand RNs are also expected to ‘demonstrate evidence of
application of evidence-based research in practice’.2 So, why do we still face delays in implementing new
discoveries, or even refusal to use evidence in practice?
Today, most health professionals are very positive about EBP and try to use it wherever possible.
However, they often face a number of barriers in finding and using evidence, at both an individual and
an organisational level.
Individual barriers
Before health professionals can use evidence, they need to know how to find it and how to understand it.
Some lack the ability to find evidence resources (because computers weren’t common in healthcare settings
until relatively recently), and they don’t have the IT skills to access or search specialist databases.3 They
may also be unfamiliar with how research is carried out and have never had an opportunity to learn about it,
which makes the whole concept seem very alien — something for doctors and scientists rather than nurses
or allied health professionals. Others lack confidence in how to read research articles, interpret findings
or adapt guidelines, so they avoid them altogether. Lack of time is also a commonly mentioned barrier —
heavy workloads and busy lives mean few health professionals have the luxury of time to explore resources
during work hours or at home.4
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Perhaps the strongest individual barriers, however, are personality based. Some clinicians dislike the
entire concept of EBP and place little value on research.5 Like the RN in the opening scenario, they think
that it’s unnecessary or irrelevant to their practice. Even for those who aren’t completely against EBP,
readiness to adopt healthcare innovations can depend on several factors. These include their attitudes to
change; for example, some people are trendsetters and like to try new things, others prefer to follow once
a new practice has become established, and some will resist change under any circumstance. Change is
risky, and it takes effort to move out of your comfort zone and learn new things.
New evidence can also seem quite threatening on a personal level. Being told that the way you have
been practising isn’t the best way can be very challenging to a person’s self-esteem and feelings of
competence — and the more experienced you are, the more threatening it is. The RN or therapist who
has a wealth of knowledge may greatly resent having this brushed aside for new ideas.
Organisational barriers
While there are many individual barriers to using EBP, the main reasons why clinicians don’t use evidence
tend to be down to the organisations they work for.6 The major organisational barriers to EBP include a
lack of resources and support, and a workplace culture that devalues research. Time is again a problem;
many facilities are short-staffed and workloads are heavy, so health professionals have little opportunity to
research new ways to treat clients. While most workplaces are now computerised, staff don’t always have
access to these resources, or to the databases that hold the evidence. Subscriptions to some databases are
very expensive, and smaller organisations in particular may not be able to afford it. Even in workplaces
with good resources, staff often need support to find and use evidence, from knowledge workers and from
management. If this support is missing, or if the organisation has no interest in becoming evidence-based,
the clinician will find it hard, if not impossible, to implement EBP themselves.
11.2 Encouraging individuals to implement

evidence-based practice
LEARNING OBJECTIVE 11.2 How can we encourage individuals to implement evidence-based practice?
All healthcare degrees now include content on research and EBP. This helps to familiarise students and new
practitioners with the research process, makes them more comfortable with reading and using research,
and enables them to satisfy their professional organisation’s requirements upon graduation. There are
also continuing professional education courses and workshops available through professional bodies and
educational institutions to help already qualified practitioners upgrade their knowledge and skills. Again,
this is mandated in the various codes of conduct and professional standards. Although these can address
the barriers that come from lack of knowledge, we know that simply telling people to use evidence doesn’t
necessarily change their practice. Taking an ‘instructional’ approach to promoting professional behaviour
change is built on the flawed assumption that people behave in a particular way because (and only because)
they lack knowledge, and that imparting knowledge will therefore change behaviour. However, this isn’t
always the case; while information may be necessary for change, it is rarely, if ever, sufficient.
While we can’t change a person’s character traits to make them happy and willing to accept change,
we can make it simpler and more attractive for them to make those changes. One way is to ensure
that good evidence is made readily available, for example through professional journals that focus on
EBP for particular specialties and practice areas. These allow clinicians to find useful and relevant
information quickly and easily. Abstraction journals such as Evidence-Based Nursing, which summarise
high-level studies and systematic reviews into a single page, make understanding the research even more
straightforward. Researchers are also moving away from the statistics and jargon-heavy format they once
used in their articles, towards a more readable and understandable way of writing. Some databases, such
as the Cochrane Library, insist that all systematic reviews include a summary in layman’s language, and
most journals now require authors to make their conclusions and implications for practice explicit, so it’s
easier for readers to put the findings into practice.
Motivation is also an important factor in whether a clinician chooses to make changes. When they can
see the benefits of the new evidence, whether it’s a clear improvement in client health outcomes, or a
personal advantage such as reduction in workload or greater ease of use, they are more likely to adopt a
new practice.
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FIGURE 11.1 Example of a plain language summary
Nurses as substitutes for doctors in primary care

The aim of this Cochrane Review was to find out what happens when primary healthcare services are
delivered by nurses instead of doctors. We collected and analysed all relevant studies to answer this
question and found 18 studies for inclusion in the review. . . . [W]e searched for studies that compared
nurses to doctors for delivery of primary care services. We looked at whether this made any difference in
patients’ health, satisfaction, and use of services. We also looked at whether this made any difference in
how services were delivered and in how much they cost.
Our review shows that nurse-led primary care may lead to slightly fewer deaths among certain groups of
patients, compared to doctor-led care. However, the results vary and it is possible that nurse-led primary
care makes little or no difference to the number of deaths. In addition, patients probably have similar or
better results in areas of health such as heart disease, diabetes, rheumatism, and high blood pressure.
Patients also are probably slightly more satisfied with their care and may have a slightly better quality of
life when treated by nurses.
Delivery of primary healthcare services by nurses instead of doctors probably leads to similar or
better patient health and higher patient satisfaction. Nurses probably also have longer consultations with
patients. Using nurses instead of doctors makes little or no difference in the numbers of prescriptions and
tests ordered. However, the impacts on the amount of information offered to patients, on the extent to
which guidelines are followed and on healthcare costs are uncertain.
Source: Laurant et al. 2018.7
11.3 Organisational support of evidence-

based practice
LEARNING OBJECTIVE 11.3 How can organisations support evidence-based practice?
Even when health professionals are positive about EBP, it will be difficult if the organisation doesn’t
support them. A workplace culture that values and supports EBP depends on strong and visionary
leadership that expects decision-making to be based on the best available evidence, and supports staff
to make decisions in this manner.8
Most workplaces are now computerised to some extent, making it possible to provide high-quality, up-
to-date information sources to staff. Although some databases are very expensive, several of the best (such
as Cochrane Library and MEDLINE database) are free to use in Australia and New Zealand, making
them a great resource. Ideally, staff should be given protected time and encouragement to use these.
This support can come from knowledge workers such as librarians and IT helpdesk staff, and change
champions — key individuals who will back an innovation or practice change and help get it up
and running. Many organisations, particularly the larger teaching hospitals, have dedicated research
departments and have formed partnerships with universities to carry out clinical research and promote
the translation of research into practice. Journal clubs are also growing in popularity, allowing staff to get
together to share, appraise and interpret articles and evaluate the applicability of this evidence to their own
work area. There are also tools that organisations can use to help implement EBP across the workplace.
Two of the most commonly used are integrated care pathways and clinical practice guidelines.
Integrated care pathways

A good integrated care pathway combines evidence-based recommendations with the realities of local
services, usually via a multi-professional initiative that engages both clinicians and managers. The care
pathway states not only what intervention is recommended at different stages in the course of the condition
but also whose responsibility it is to undertake the task and to follow up if it is missed. It is often the process
of developing the pathway as much as the finished product that engages staff across an organisation to
focus on evidence-based care in the target condition. The process of developing a care pathway can build
a surprising amount of goodwill and buy-in to the principle of EBP, which can be drawn upon in rolling
out the idea more widely.
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Clinical practice guidelines

A growing ‘accountability culture’ around the world has led to the development of clinical practice
guidelines for the management of many conditions and treatments, with more coming out every day. Many
health professionals are required to use them to assist their daily practice; for example, the Australian and
New Zealand nursing Standards for Practice require nurses to use evidence-based procedural guidelines.
There are many benefits of guidelines — to client, practitioner and organisation. These are shown in
figure 11.2.
Many organisations also produce their own guidelines, often based on officially produced or sanctioned
guidelines found through national bodies, such as the National Health and Medical Research Council
of Australia (NHMRC), the UK National Institute of Health and Care Excellence (NICE), and the US
National Guideline Clearinghouse. Local teams produce more robust guidelines if they draw on the range
of national and international resources of evidence-based recommendations and use this as their starting
point, but local guidelines are often more acceptable to clinicians — especially those who resist change.
Health professionals will oppose changes that they perceive as threatening to their self-esteem, sense of
competence or autonomy, so involving them in setting the standards against which they are going to be
judged helps promote ‘ownership’, and generally produces greater changes in client outcomes than if they
are not involved.
FIGURE 11.2 Benefits of guidelines
For the client

• To learn about current best practice to enable an informed choice about treatments
• To improve consistency of care
• To improve health outcomes and service delivery
For the practitioner
• To make evidence-based standards explicit and accessible
• To make decision-making easier and more objective
• To delineate the division of labour between health professionals involved in the care of the client
• To give support in medico-legal situations
• To bridge the gap between research and practice
For the organisation
• To improve the cost-effectiveness of health services
• To improve efficiency and standardise care
• To increase public trust in the service
• To provide a benchmark for professional performance
• To provide external control
Input from local teams is not about reinventing the wheel in terms of summarising the evidence, but about
taking account of local practicalities and circumstances. For example, a nationally produced guideline
about epilepsy care might recommend an epilepsy specialist nurse in every district. However, in one district,
the healthcare teams might have advertised for such a nurse but failed to recruit one. The ‘local input’ might
be about how best to provide what the epilepsy nurse would have provided, in the absence of a person in
the position. Figure 11.3 presents an abstract from a journal article that outlines the implementation of
evidence-based guidelines for Maori ̄ health needs.
FIGURE 11.3 Example of an abstract for a paper on evidence-based guidelines
Reducing inequality in health through evidence-based clinical guidance:

is it feasible?
Evidence-based guidance and guidelines need to include the voices of the most disadvantaged groups
in society; doing so is a significant challenge, but one which is critical to a responsive healthcare system.
Addressing ethnic disparity (and other types of disparity) in health via evidence-based guidance is likely
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to be less effective if approaches are singular and do not address issues of participation by those groups
who have the greatest stake in improved health outcomes. This paper presents a multifaceted framework,
which has been developed in New Zealand to ensure health inequalities experienced by Maori ̄ (the
indigenous population within New Zealand) are addressed when developing evidence-based guidance.
The framework has two overarching goals. These are: (i) to ensure the explicit identification of Maori ̄
health needs occurs during each formal stage of guideline development; and (ii) to ensure there is full
̄
Maori participation in the guidance development process. The steps to achieving these two goals are
described in detail. The framework presented is evolving and intended to be flexible dependent upon
healthcare environments and resourcing. This paper is intended to provide some focus and discussion
for the role of evidence-based guidance in both addressing and entrenching health inequalities in
vulnerable groups.
Source: Berentson-Shaw 2012.9
The quality of guidelines can be variable, so it is important for practitioners to be able to evaluate
them properly (see the chapter on reviewing literature). A flawed guideline can lead to inappropriate care,
particularly for clients who have multiple morbidities and may need more than one guideline applied. (This
is covered in more detail in the chapter on challenges to evidence-based practice.)
11.4 The client perspective in evidence-based practice

LEARNING OBJECTIVE 11.4 How can we include the client perspective in evidence-based practice?
There is no such thing as the client perspective, of course. At times in our lives, often more frequently the
older we get, we are all clients/patients. Some of us are also health professionals — but when the decision
relates to our health, our medication, our surgery, the side effects that we may or may not experience with
a particular treatment, we consider that decision differently to the one we make in our professional role.
The individual experience of being ill can be told as a story, and everyone’s story is different. The ‘same’
set of symptoms or piece of news will have a host of different meanings depending on who is experiencing
them and what else is going on in their lives. It is important to remember that EBP is not only about using
research evidence; it also needs to include the wishes of the client (or their family/carers), and the particular
context of the client’s situation. Evidence-based client choice allows the client to select the option most
appropriate and acceptable to them10, and there are several ways to help with this.
Patient-reported outcome measures (PROMs)

Before looking at how clinicians can involve clients in decision-making, it’s worth looking at how
researchers can make this easier. A relatively new approach is to use patient-reported outcome measures
or PROMs. An ‘outcome measure’ is the aspect of health or illness that researchers choose to evaluate
to demonstrate (say) whether a treatment has been effective. Death is an outcome measure. So is blood
pressure. So is the chance of leaving hospital with a live baby when you go into hospital in labour. So is
the ability to walk upstairs or make a cup of tea on your own. The point is that in any study the researchers
have to define what it is they are trying to influence. Unlike most outcome measures, PROMs look at what
matters most to patients or clients, rather than what researchers or clinicians think are the most important
aspects. PROMs allow researchers to gain insight from the client’s perspective about what matters to them
about their health, their disease, and the effect the treatment has on their lifestyle and quality of life. So
far, they have mainly been used in medical research, but are becoming more popular in studies carried out
in other health disciplines.11
Shared decision-making
While PROMs are important, they only tell us what patients or clients, on average, value most, not what
the client in front of us values most. To find that out, you would have to ask the client — and there is now a
science and a methodology for this.12 The idea is based on the notion of the client as a rational chooser, able
and willing (perhaps with support) to join in the deliberation over options and make an informed choice.
Not every client will want to do this; many prefer to let the clinician as expert decide for them. For
those who do wish to be involved, health professionals need to help them understand the situation as
clearly as possible, and know their options and the consequences of these. One challenge is maintaining
equipoise — that is, holding back on what you feel the course of action should be and setting out the
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different options with the pros and cons presented objectively, so the client can make their own decision.13
Using a decision aid is a good way to do this.
Many decision aids are available online, allowing the client to click through different steps in the
algorithm (with or without support from a health professional). The best way to get your head round
shared decision-making tools is to look at a few — and, if possible, put them to use in practice. The
Australian Commission on Safety and Quality in Health Care website (www.safetyandquality.gov.au) has
more information on decision aids and a link to a comprehensive range of decision tools.
FIGURE 11.4 Example of an abstract for a paper on decision aids
Decision aids for people facing health treatment or screening decisions

Background
Decision aids are interventions that support patients by making their decisions explicit, providing infor-
mation about options and associated benefits/harms, and helping clarify congruence between decisions
and personal values.
Objectives
To assess the effects of decision aids for people facing treatment or screening decisions.
Authors’ conclusions
Compared to usual care across a wide variety of decision contexts, people exposed to decision aids feel
more knowledgeable, better informed, and clearer about their values, and they probably have a more active
role in decision making and more accurate risk perceptions. There is growing evidence that decision aids
may improve values-congruent choices. There are no adverse effects on health outcomes or satisfaction.
New for this update is evidence indicating improved knowledge and accurate risk perceptions when
decision aids are used either within or in preparation for the consultation. Further research is needed on the
effects on adherence with the chosen option, cost-effectiveness, and use with lower literacy populations.
Source: Stacey et al. 2017.14
Option grids
Most discussions about treatment options do not require — and may even be hindered by — an exhaustive
analysis of probabilities, risks and preference scores. What most people want is a brief but balanced list
of the options, setting out the costs and benefits of each and including an answer to the question ‘What
would happen if I went down this route?’
The option grid does just this.15 The information is presented in a table with the different options
appearing as columns, with each row answering a different question such as ‘What does the treatment
involve?’, ‘How soon would I feel better?’ and ‘How would this treatment affect my ability to work?’ The
grid can be used online or printed off and given to the client so they can go away and consider the options
before returning for a further consultation. And unlike the previous generation of shared decision-making
tools, they are very simple and easy to use.
Table 11.1 shows an option grid to help clients and practitioners decide what treatment they would like
to undertake for tonsillitis.
TABLE 11.1 Tonsillectomy option grid
Frequently asked
questions Tonsillectomy Active management
What does it involve? The tonsils are removed under general Your GP will prescribe appropriate
anaesthetic. treatment if your child has further
tonsillitis. Your child will be referred for
a tonsillectomy if necessary.
How long does it The operation will take about 30 minutes. Until other treatment is considered
take? Your child may need to stay in the necessary.
hospital for one night.
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How long does it About two weeks. During this time your As with previous episodes, it will take
take to recover? child will need to stay at home to prevent 3–7 days to recover from each event.
infection.
Will my child stop Yes, but they may still have episodes of Possibly, 30 in every 100 children
having tonsillitis? sore throat. Tonsillectomy can reduce (30%) stop having tonsillitis without
sore throats by up to 9 episodes in the an operation. They may still have
2 years following surgery. sore throats.
What is the risk from As with all operations there is a small Serious complications of tonsillitis are
the procedure or risk of serious complications. More very rare.
process? common problems include pain, vomiting,
bleeding, infection and dental damage.
What is the risk of 1 in every 100 children (1%) will have Bleeding from tonsillitis (haemorrhagic
bleeding? serious bleeding immediately after the tonsillitis) is very rare.
operation. Most of these will need to have
another operation to stop the bleeding.
3 in every 100 children (3%) will have
serious bleeding in the first two weeks
after the operation. Some will need
to have another operation to stop the
bleeding.
Will it reduce the Possibly. It depends on how much time Possibly. As children get older, they often
number of days your child has been missing from school. have fewer attacks of tonsillitis.
missed from school?
Can I change my Yes, you can be re-referred by your GP at

mind? any time.
Are other parents Yes, studies show that parents are happy Yes, if their child gets better without the
happy with their with the surgery and its effects on their need for an operation.
decisions? child’s health.
Source: Trustees of Dartmouth College.

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SUMMARY
Despite a legal requirement for health professionals to use evidence to underpin practice, it can still take
time for research findings to filter through to the workplace, due to personal and organisational barriers that
prevent clinicians from implementing evidence-based practice. Personal barriers include lack of knowledge
and skills to find and interpret research, lack of time, and issues of confidence, self-esteem and autonomy.
Organisational barriers include lack of support or resources, and a disregard for the use of EBP. These
barriers can be addressed through education, accessibility of information and support, and the use of tools
such as integrated care pathways and clinical practice guidelines. Client decision aids can also be used to
include the client more fully in their own care.
KEY TERMS
clinical practice guidelines Systematically developed statements to assist practitioner decisions about
appropriate healthcare for specific clinical circumstances.16
decision aid Evidence-based tools designed to help clients to participate in making specific and
deliberated choices among healthcare options. Client decision aids supplement (rather than replace)
clinicians’ counselling about options.17
integrated care pathway A pre-defined plan of client care relating to a specific diagnosis (e.g. suspected
fractured hip) or intervention (e.g. hernia repair), with the aim of making the management more
structured, consistent and efficient.18
option grid A one-page table covering a single topic, to help clients and clinicians compare alternative
treatment options to find the most suitable.
patient-reported outcome measure (PROM) The outcome from a research study that matter most to
the client/patient rather than those the researchers think are the most important. Identified through
qualitative research methods prior to the quantitative study.
WEBSITES
1 Australian Clinical Practice Guidelines (NHMRC): www.clinicalguidelines.gov.au
2 National Institute for Health and Care Excellence (UK): www.nice.org.uk
3 National Guideline Clearinghouse (USA): www.guideline.gov
4 The Effective Practice and Organisation of Care (EPOC): http://epoc.cochrane.org
5 Australian Commission on Safety and Quality in Health Care: www.safetyandquality.gov.au/our-
work/shared-decision-making/other-resources
6 OHRI patient decision aids: http://decisionaid.ohri.ca
7 Option grids for client decisions: www.optiongrid.org
ENDNOTES
1. See the AHPRA (www.ahpra.gov.au) website for Codes of Conduct for 15 health practitioner groups, including Chinese
medicine, occupational therapy, physiotherapy and podiatry, and the NMBA Registered Nurse Standards for Practice.
2. See the New Zealand Nurses Organisation website (www.nursingcouncil.org.nz) for the Code of Conduct and Standards of
Professional Nursing Practice.

3. G. Malik, L. McKenna, and V. Plummer, ‘Perceived knowledge, skills, attitude and contextual factors affecting
evidence-based practice among nurse educators, clinical coaches and nurse specialists,’ Journal of Nursing Practice 21,
suppl. 2 (2015): 46–57.
4. H. Sadeghi-Bazargani, J. S. Tabrizi, and S. Azami-Aghdash, ‘Barriers to evidence-based medicine: a systematic review,’
Journal of Evaluation in Clinical Practice 20 (2014): 793–802; F. Timmins, C. McCabe, and R. McSherry, ‘Research
awareness: managerial challenges for nurses in the Republic of Ireland,’ Journal of Nursing Management 20 (2012): 224–35;
A. C. Pighills et al., ‘Positioning occupational therapy as a discipline on the research continuum: results of a cross-sectional
survey of research experience,’ Australian Occupational Therapy Journal 60 (2013): 241–51; N. Rydland Olsen et al.,
‘Evidence-based practice exposure and physiotherapy students’ behaviour during clinical placements: a survey,’
Physiotherapy Research International 19 (2014): 238–47; M. Stronge and M. Cahill, ‘Self-reported knowledge, attitudes and
behaviour towards evidence-based practice of occupational therapy students in Ireland,’ Occupational Therapy International
19 (2012): 7–16.
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5. K. E. Harding et al., ‘Not enough time or a low priority? Barriers to evidence-based practice for allied health clinicians,’
Journal of Continuing Education in the Health Professions 34, no. 4 (2014): 224–31.
6. K. Samuelsson and E. Wressle, ‘Turning evidence into practice: barriers to research use among occupational therapists,’
British Journal of Occupational Therapy 78, no. 3 (2015): 175–81; K. A. Abrahamson, R. L. Fox, and B. N. Doebbeling,
‘Facilitators and barriers to clinical practice guideline use among nurses,’ American Journal of Nursing 112, no. 7 (2012):
26–35. doi: 10.1097/01.NAJ.0000415957.46932.bf.
7. M. Laurant et al., ‘Nurses as substitutes for doctors in primary care,’ Cochrane Library of Systematic Reviews 7 (2018). doi:
10.1002/14651858.CD001271.pub3.
8. J. Rycroft-Malone, ‘Evidence-informed practice: from individual to context,’ Journal of Nursing Management 16 (2008):
404–8; A. Thomas and M. Law, ‘Research utilization and evidence-based practice in occupational therapy: a scoping study,’
American Journal of Occupational Therapy 67 (2013): e55–65. doi: 10.5014/ajot.2013.006395.
9. J. Berentson-Shaw, ‘Reducing inequality in health through evidence-based clinical guidance: is it feasible? The New Zealand
experience,’ International Journal of Evidence-Based Healthcare 10 (2012): 146–53.
10. A. Edwards and G. Elwyn, Shared decision-making in health care: achieving evidence-based patient choice (New York:
Oxford University Press, 2009).
11. J. Dawson et al., ‘The routine use of patient reported outcome measures in healthcare settings,’ BMJ: British Medical Journal
(Clinical Research ed.) 340 (2009): c186; K. McGrail, S. Bryan, and J. Davis, ‘Let’s all go to the PROM: the case for routine
patient-reported outcome measurement in Canadian healthcare,’ Healthcare Papers 11, no. 4 (2011): 8–18; K. A. Meadows,
‘Patient-reported outcome measures: an overview,’ British Journal of Community Nursing 16, no. 3 (2011): 146–51.
12. Edwards and Elwyn, Shared decision-making in health care; G. Makoul and M. L. Clayman, ‘An integrative model of shared
decision making in medical encounters,’ Patient Education and Counseling 60, no. 3 (2006): 301–12.
13. G. Elwyn et al., ‘Shared decision making and the concept of equipoise: the competences of involving patients in healthcare
choices,’ The British Journal of General Practice 50, no. 460 (2000): 892–9.
14. D. Stacey et al., ‘Decision aids for people facing health treatment or screening decisions (review),’ Cochrane Database of
Systematic Reviews 4 (2017). doi: 10.1002/14651858.CD001431.pub5.
15. G. Elwyn et al., ‘Option grids: shared decision making made easier,’ Patient Education and Counseling 90 (2013): 207–12.
16. M. J. Field and K. N. Lohr, eds., Guidelines for clinical practice: from development to use (National Academies Press (US),
1992).
17. Stacey et al., ‘Decision aids,’ 7.
18. T. Rotter et al., ‘Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs,’
Cochrane Database of Systematic Reviews 3 (2010). doi: 10.1002/14651858.CD006632.pub2.
ACKNOWLEDGEMENTS
Adapting author for this Australian edition: Elaine Crisp
Photo: © Miriam Doerr Martin Frommherz / Shutterstock.com
Figure 11.1: © M. Laurant et al., ‘Nurses as substitutes for doctors in primary care,’ Cochrane Library of
Systematic Reviews 7 (2018). doi: 10.1002/14651858.CD001271.pub3.
Figure 11.3: © PubMed / Public Domain
Figure 11.4: © D. Stacey et al., ‘Decision aids for people facing health treatment or screening decisions
(review),’ Cochrane Database of Systematic Reviews 4 (2017). doi: 10.1002/14651858.CD001431.pub5.
Table 11.1: © Trustees of Dartmouth College
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“c11GettingEvidenceIntoPractice_print” — 2019/4/26 — 2:53 — page 114 — #1

11.1 Why are health professionals slow to adopt evidence-based practice?

“c11GettingEvidenceIntoPractice_print” — 2019/4/26 — 2:53 — page 115 — #2

You’re on practical placement in an aged-care

11.1 Adoption of evidence-based practice (EBP)

CHAPTER 11 Getting evidence into practice 115

“c11GettingEvidenceIntoPractice_print” — 2019/4/26 — 2:53 — page 116 — #3

11.2 Encouraging individuals to implement

116 Understanding research methods for evidence-based practice in health

“c11GettingEvidenceIntoPractice_print” — 2019/4/26 — 2:53 — page 117 — #4

FIGURE 11.1 Example of a plain language summary

Nurses as substitutes for doctors in primary care

11.3 Organisational support of evidence-

Integrated care pathways

CHAPTER 11 Getting evidence into practice 117

“c11GettingEvidenceIntoPractice_print” — 2019/4/26 — 2:53 — page 118 — #5

Clinical practice guidelines

FIGURE 11.2 Benefits of guidelines

For the client

evidence-based guidelines for Maori ̄ health needs.

FIGURE 11.3 Example of an abstract for a paper on evidence-based guidelines

Reducing inequality in health through evidence-based clinical guidance:

118 Understanding research methods for evidence-based practice in health

“c11GettingEvidenceIntoPractice_print” — 2019/4/26 — 2:53 — page 119 — #6

11.4 The client perspective in evidence-based practice

Patient-reported outcome measures (PROMs)

CHAPTER 11 Getting evidence into practice 119

“c11GettingEvidenceIntoPractice_print” — 2019/4/26 — 2:53 — page 120 — #7

FIGURE 11.4 Example of an abstract for a paper on decision aids

Decision aids for people facing health treatment or screening decisions

TABLE 11.1 Tonsillectomy option grid

120 Understanding research methods for evidence-based practice in health

“c11GettingEvidenceIntoPractice_print” — 2019/4/26 — 2:53 — page 121 — #8

Can I change my Yes, you can be re-referred by your GP at

Source: Trustees of Dartmouth College.

CHAPTER 11 Getting evidence into practice 121

“c11GettingEvidenceIntoPractice_print” — 2019/4/26 — 2:53 — page 122 — #9

Professional Nursing Practice.

122 Understanding research methods for evidence-based practice in health

“c11GettingEvidenceIntoPractice_print” — 2019/4/26 — 2:53 — page 123 — #10

CHAPTER 11 Getting evidence into practice 123

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