Using evidence-based practice to inform decision making
By Margaret Adolphus
Evidence-based practice (EBP) is accepted in a number of professional areas, and is best defined as the use of research to inform practice and improve decision making.
The most widely accepted definition of EBP is based on Sackett's description of evidence-based medicine:
" ... the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients" (Sackett et al., 1996, quoted in Gu et al., 2004).
The concept of EBP first originated in the health-care sector over 30 years ago, and has been routinely used by health professionals ever since. Its use has subsequently spread to other disciplines, including physical therapy, education, management, librarianship and literacy development (Clyde, 2006).
The librarianship version first emerged in the late 1990s as evidence-based information practice (EBIP), which has been defined as:
" ... evidence-based practice with information as both its subject and object" (Booth and Bryce, 2005).
Clyde (2006) sees EBIP as improving practice and highlighting relevant service outcomes, using documented evidence from professional practice and research to solve professional problems and plan for the future.
Librarians as knowledge managers
With the knowledge revolution, librarians have seen several changes in their roles. One of these, although not evident in every sector, is a move towards them becoming "knowledge managers".
It's a role which sees the librarian not just reacting to enquiries, but rather embedding themselves in the engine of the organization and helping ask questions and anticipate information needs. As Palmer (2004) writes, it's about managing knowledge, explicit and tacit, rather than just information (documents and data).
Librarians in the British civil service are tending to move towards knowledge management, as are some specialist business librarians. And in the health and medical sectors, clinical librarians are starting to work with clinical teams, accompanying them on ward rounds, carrying out complex literature searches and, above all, acting as facilitators and catalysts for good, evidence-based practice.
A useful way of describing the work of clinical librarians and others who work with EBP is through case studies. The following example demonstrates how one National Health Service (NHS) Trust was able to improve its patient safety services and make cost savings by using research to inform strategy and practice.
The author is grateful to Catherine Ebenezer for her help with this article.
Evidence-based practice in action: a case study
Providing knowledge support for senior managers
This case study is based in the north-west of England, at the Blackpool, Fylde and Wyre Hospitals NHS Foundation Trust.
The British National Health Service has seen many changes over the last ten years, resulting in a keen interest in better management and leadership. Subsequently, the Blackpool, Fylde and Wyre library service found that its clinical librarian (CL) was receiving a considerable number of requests relating to managerial rather than clinical decisions.
In order to both support these requests and not overburden the CL, who still had to carry out clinical searches, a management librarian (ML) role was developed with the aim of applying the same evidence-based principles used by the CL to management.
Service was provided at the point of need: enquiries came by telephone and e-mail, but the ML was also able to attend high-level meetings including those of the Trust board of directors, and the monthly meetings of the executive and divisional directors.
Over an eight-month period, the ML received 65 requests for information searches from senior managers. When the origin of these requests were analysed, it was found that over one-third (39 per cent) came from informal meetings, one-to-ones or informal chats before and after formal meetings. Formal meetings accounted for only 20 per cent of requests, however the librarian received many e-mail requests in the days following them.
Putting research into practice
The intention was for the ML to provide relevant evidence not only for day-to-day decisions, but also to support the change process (see Figure 1 below), so that adjustments could be based on sound evidence of what worked.
Figure 1. Diagram showing the evidence-based change process (© Centre for Clinical Effectiveness, 2008)
Evidence was drawn from a number of management journals, with a good proportion coming from the Emerald database. Changes were implemented on the basis of this research with notable results of greater efficiency and improved patient care.
As Debra Thornton, knowledge and library services manager at Blackpool Teaching Hospitals, commented:
" ... the research published in Emerald journals has been extremely valuable when gathering all the facts to support important strategic decisions. This fits with the hospital’s culture to ground its strategy in evidence-based practice. The impact so far has been highly positive for the hospital during a time of great change".
Here are some examples of searches, along with a summary of evidence and description of the changes implemented as a direct result of the research evidence.
Initiative: Can closing wards improve health care?
The closing of wards can allow staff to be redirected to areas of most need, resulting in higher quality care, which in turn leads to shorter length of stay and thus lower costs.
Two wards, which had been opened during the winter flu crisis and then remained open later into the year, were closed, resulting in identified savings on bank staff being brought in to cope with these additional wards.
Emerald articles referenced for evidence for this query
Gilligan, S. and Walters, M. (2008), "Quality improvements in hospital flow may lead to a reduction in mortality", Clinical Governance: An International Journal, Vol. 13 No. 1, pp. 26-34.
Panis, L.J.G.G., Verheggen, F.W.S.M., Pop, P. and Prins, M.H. (2004), "The impact of hospital discharge on inappropriate hospital stay", International Journal of Health Care Quality Assurance, Vol. 17 No. 4, pp. 189-193.
Initiative: In what ways can patient experiences be used to improve safety?
Using patients' own stories, told in their own words, allows nursing and medical staff to relate more closely to the patients they are treating and results in fewer errors and higher quality care.
Patients' or relatives' stories are recorded on video and played back to staff at regular meetings, as well as being made available on the Trust intranet.
Patient safety has increased and the Trust won the Patient Safety Award for communication in March 2010.
Emerald articles referenced for evidence for this query
Hyde, P. (2008), "Working with stories: diverse tales of organizational life", Qualitative Research in Organizations and Management: An International Journal, Vol. 3 No. 2, pp. 147-158.
Pickles, J., Hide, E. and Maher, L. (2008), "Experience based design: a practical method of working with patients to redesign services", Clinical Governance, Vol. 13 No. 1, pp. 51-58.
Initiative: How can we best restructure hospital departments to provide optimum care, reflecting care pathways?
Using the framework of a care pathway or organizing activities by patient and information flow (value streams), change can occur without the need to "manage" it directly.
The Trust strategic development team used the evidence provided to review different hospital structures that concentrated on the flow of patients through the service. The Trust is now implementing a major restructure focusing on "scheduled care" and "unscheduled care".
Not yet known, but savings of around 5 per cent per annum of management costs are expected, as well as savings due to reduced length of stay and readmission rates.
Emerald articles referenced for evidence for this query
Crocker, T., Johnson, O. and King, S. (2009), "The suitability of care pathways for integrating processes and information systems in healthcare", Transforming Government: People, Process and Policy, Vol. 3 No. 3, pp. 289-301.
Towill, D.R. (2009), "Enabling effective change in healthcare delivery systems. Did Gerry Robinson teach us anything new?", Leadership in Health Services, Vol. 22 No. 2, pp. 176-188.
Whittle, C. and Hewison, A. (2007), "Integrated care pathways: pathways to change in health care?", Journal of Health Organization and Management, Vol. 21 No. 3, pp. 297-306.
To read more on the Blackpool, Fylde and Wyre Hospitals NHS Trust's initiative, visit the Emerald news page.
What are the skills and personal qualities needed to be a successful clinical librarian?
Clearly, the clinical librarian model can be an effective way of stimulating evidence-based practice and can be applied to subject disciplines outside of a purely clinical setting – with extremely positive results.
But what are the skills and personal qualities needed, and how does the CL carry out their role?
A CL needs excellent interpersonal skills and to be quick thinking. Some domain knowledge is useful, although not all CLs have a biomedical background.
The CL will start off the process by being a facilitator – being a person of a different background and with an objective approach, able to spot knowledge gaps or enable others to spot them, and then formulate the necessary questions to answer them.
The librarian must not just be concerned with present requests, he or she must act as knowledge manager, anticipating future information requirements. This can be done through current awareness services, RSS feeds, e-mail alerts, formatted summaries in key areas, and horizon scanning (looking at future developments).
They will also need to have excellent search strategies. A key problem experienced by many professionals in trying to find information is lack of time and limited skills in searching the literature. The CL can help here by carrying out the search him or herself, or by training others to do so.
Catherine Ebenezer works as a librarian for an NHS Foundation Trust in the north-east of England. She regularly carries out complex searches to answer questions such as, "Which is more effective for treating depression, cognitive-behavioural therapy, anti-depressant drugs, or a combination of the two?"or "How effective is CBT for treating psychosis?".
She uses the Patient Intervention Comparison Outcome search model (PICO) see Table I.
|People with psychosis||Cognitive behavioural therapy||Control group||Relief of symptoms/improvements in functioning (as demonstrated using rating scales)|
PICO gives her search terms which she can then map onto the controlled vocabulary of a medical database such as MEDLINE or PsycINFO. Most databases have a thesaurus of terms for keywords; all offer the option of free text searching. Some databases have an "explode" function which will include narrower terms within a broader search. She then runs the search, using AND to combine the PICO components and OR for alternatives within these.
When the search is complete, there will probably be a large number of results. She advises quickly scanning more than 70 to 80. Here are some ways of narrowing down the search (available options can vary):
- Limit by study design, date, population group, language (e.g. English), locality (e.g. United Kingdom), or to "core" journals.
- Limit search to "reviews" (SUMSearch2 has a results option for this); good reviews will cover the important primary literature.
Presenting the search results
Having found the key pieces of evidence, the next thing is to present them in such a way that the originator of the query has all the facts he or she needs, but in an easily digestible form.
The librarian attending mental health teams produced summaries of 500-1,000 words, based on key evidence from bibliographic databases such as Cochrane, MEDLINE and Embase.
The management librarian from Blackpool Fylde and Wyre Hospitals NHS Foundation Trust produced a PDF with his summary (with links to full-text articles) which he then e-mailed to the requester. An intranet site was also created on Microsoft SharePoint that allowed access to all searches.
The role of clinical librarian is a major outreach role: the library needs to be taken to where people are, physically as well as (or in some cases instead of ) virtually. This is one step on from enabling the user to access library resources in situ, for example through handheld devices. The librarian needs to be there in person, on the ward or in the significant meetings, stimulating as well as answering questions.
One aspect of outreach is to proactively seek out those people who will need one's services, to determine their information needs which calls for analytical skills.
This article has looked at the way that librarians can work in the health field to help clinicians and managers make better decisions, informed on sound evidence.
There is no doubt that those who have worked with librarians in this way find their help beneficial in acting as a catalyst to come up with the right questions, and make better use of evidence-based practice.
EBP has been accepted in health care for at least 40 years; however, as the Blackpool, Fylde and Wyre Hospitals NHS Trust case study showed it can also be applied to strategic management decisions with great benefit.
There is no doubt that capable librarians will be there to help provide the evidence – and indeed, there will also be many practically oriented research articles in the Emerald database to help in the search. For a list of Emerald's main practitioner titles, please visit: "How to write for a practitioner audience".
From 2011, even more evidence-based research titles will be added to the Emerald portfolio with its recent acquisition of 23 journals in health and social care. As Rebecca Marsh, publishing director at Emerald, comments:
“ ... Emerald’s acquisition of the titles is an important step in forging stronger links with both researchers and practitioners in these areas. Emerald values and encourages the exchange of ideas between practice and research and the titles from Pier Professional fulfil this important objective”.
Adler, N. and Harzing, A.W. (2009), "When knowledge wins: transcending the sense and nonsense of academic rankings", Academy of Management Learning and Education, Vol. 8 No. 1, pp. 72-95
Booth, A. and Brice, A. (Eds) (2005), Evidence-based Practice for Information Professionals: A Handbook, Facet Publishing, London.
Clyde, L.A. (2006), "The basis for evidence-based practice: evaluating the research evidence", New Library World, Vol. 107 No. 5/6, pp. 180-192.
Gorring, H., Turner, E., Day, E. and Vassilas, C., Aynsley, M. (2010), "A clinical librarian pilot project in psychiatry", The Psychiatrist, Vol. 34 No. 2, pp. 65-68.
Gu, P., Dyserinck, H., Loep, M. and Frijns, J. (2004), "Finding the evidence for therapeutic PICO questions on four electronic resources", Library Review, Vol. 53 No. 3, pp. 142-149.
Määttä, S. and Wallmyr, G. (2010), "Clinical librarians as facilitators of nurses' evidence-based practice", Journal of Clinical Nursing, Vol. 19 No. 23/24, December, pp. 3427-3434.
Palmer, J. (2004), "Future-proofing the profession", SCONUL Focus, Vol. 33, Winter.
Spoor, P. and Neilly, L. (2010), "Preparing for practice: a higher education perspective. Commentary on ... A clinical librarian pilot project in psychiatry", The Psychiatrist, Vol. 34 No. 2, pp. 68-70.
Thornton, D. (2010), "Knowledge support for senior managers – improving service delivery and quality", IFMH Inform, Vol. 22 No. 1.