Evidence-based Practice: The way forward
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Physiotherapy June 2003/vol 89/no 6 330 Evidence-based Practice The way forward by Jenny Morris MSc BA MCSP DipTP Programme Manager, Colchester Institute ‘Physiotherapy practice makes direct reference to published research evidence, as well as indicators of effective intervention in the form of clinical standards and clinical guidelines. Practice is informed by physiotherapy-specific research as well as the general scientific literature, and in this way engages in evidence-based practice’ (QAA, 2003). Introduction The statement quoted above from the Health Professions Council draft standards of proficiency clearly enshrines the imperative for evidence-based practice as a central activity, supporting the premise that physiotherapists have both a professional and ethical obligation to provide an evidence-based service (Bithell, 2000). However, the success with which this is achieved is the subject of debate (Turner, 2001). Many negative attitudinal and practical issues have been identified in the literature which act as obstacles to fulfilling the requirements of evidence-based practice in physiotherapy. These not only challenge the quality of service provided, but have created tensions among different occupational groups within the profession which a coherent and consistent approach to evidence-based practice would avoid. For example, educators are faced with dilemmas on what to teach students when the evidence does not support continued use of certain treatment modalities, but these are still used in practice (Turner and Whitfield, 1999). Although evidence-based practice is a complex concept with challenges to implementation, these should not be viewed as deterrents to engaging in evidence-based practice in physiotherapy. However, further development is needed to manage the variability in the quality of evidence as an encour- agement to change. Improvements in access to electronic and printed forms of high quality reviews of available research evidence have shown that often insufficient or in- adequate research has been published (Moseley et al, 2002). Available research evidence should be taken into account in decision-making, but the quality of that evidence should have a bearing on those decisions. The continuing use of treatment modalities which research evidence has demonstrated to be either ineffective or unjustifiable due to lack of scientific support is cause for concern (Baker et al , 2002; Robertson et al , 2002). This practice is potentially harmful to patients and may form the subject of litigation in the future. Attendance at short courses continues to be a popular form of continuing professional develop- ment, but many of these continue to be presented without reference to or support of evidence (Turner and Whitfield, 1999). Physiotherapists need to be discerning about which courses they choose to attend, an approach which should lead to improvements in the quality of courses offered. Strategies Many of the identified obstacles to evidence-based practice may be overcome by a positive attitude among managers and staff in both clinical practice and education, and efficient, effective use of available time and resources. Time allocated to in-service training in clinical departments could be used to disseminate and discuss research evidence and clinical guidelines rather than to communicate experiential or anecdotal learning not linked to research evidence. This approach has been suc- cessfully adopted by some departments. In addition to efficient use of time and the need for a positive departmental culture, it is important that practitioners have the resources needed to access evidence. Computer facilities in the workplace are improving as part of government funding for the National Health Service. Many clinicians already have access to libraries, computers and the Internet. This means that the sources needed to inform practice are becoming increasingly available. The success of the system relies upon dissemination of high quality, relevant research. Researchers have an obligation to facilitate this process by undertaking research which has relevance to clinical practice, preferably with collaboration between researchers and clinicians (Culham, 1998). Researchers also have a responsibility to present their findings in a user- friendly manner, facilitated by the discipline of academic style (Bithell, 2000). The findings of the survey by Turner and Whitfield (1999) suggested that selection of treatment tech-
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Transcript of Evidence-based Practice: The way forward
Physiotherapy June 2003/vol 89/no 6
330
Evidence-based Practice The way forward
by Jenny Morris MSc BA MCSP DipTP
Programme Manager, Colchester Institute
‘Physiotherapy practice makes direct reference to published research evidence, as well asindicators of effective intervention in the form of clinical standards and clinical guidelines.Practice is informed by physiotherapy-specific research as well as the general scientificliterature, and in this way engages in evidence-based practice’ (QAA, 2003).
IntroductionThe statement quoted above from the HealthProfessions Council draft standards of proficiencyclearly enshrines the imperative for evidence-basedpractice as a central activity, supporting the premisethat physiotherapists have both a professional andethical obligation to provide an evidence-basedservice (Bithell, 2000). However, the success withwhich this is achieved is the subject of debate (Turner,2001).
Many negative attitudinal and practical issues havebeen identified in the literature which act as obstaclesto fulfilling the requirements of evidence-basedpractice in physiotherapy. These not only challengethe quality of service provided, but have createdtensions among different occupational groups withinthe profession which a coherent and consistentapproach to evidence-based practice would avoid. Forexample, educators are faced with dilemmas on whatto teach students when the evidence does not supportcontinued use of certain treatment modalities, butthese are still used in practice (Turner and Whitfield,1999).
Although evidence-based practice is a complexconcept with challenges to implementation, theseshould not be viewed as deterrents to engaging inevidence-based practice in physiotherapy. However,further development is needed to manage thevariability in the quality of evidence as an encour-agement to change.
Improvements in access to electronic and printedforms of high quality reviews of available researchevidence have shown that often insufficient or in-adequate research has been published (Moseley et al,2002). Available research evidence should be takeninto account in decision-making, but the quality ofthat evidence should have a bearing on thosedecisions.
The continuing use of treatment modalities whichresearch evidence has demonstrated to be eitherineffective or unjustifiable due to lack of scientificsupport is cause for concern (Baker et al, 2002;Robertson et al, 2002). This practice is potentially
harmful to patients and may form the subject oflitigation in the future.
Attendance at short courses continues to be apopular form of continuing professional develop-ment, but many of these continue to be presentedwithout reference to or support of evidence (Turnerand Whitfield, 1999). Physiotherapists need to bediscerning about which courses they choose to attend,an approach which should lead to improvements inthe quality of courses offered.
StrategiesMany of the identified obstacles to evidence-basedpractice may be overcome by a positive attitudeamong managers and staff in both clinical practiceand education, and efficient, effective use of availabletime and resources. Time allocated to in-servicetraining in clinical departments could be used todisseminate and discuss research evidence andclinical guidelines rather than to communicateexperiential or anecdotal learning not linked toresearch evidence. This approach has been suc-cessfully adopted by some departments.
In addition to efficient use of time and the need fora positive departmental culture, it is important thatpractitioners have the resources needed to accessevidence. Computer facilities in the workplace areimproving as part of government funding for theNational Health Service. Many clinicians already haveaccess to libraries, computers and the Internet. Thismeans that the sources needed to inform practice arebecoming increasingly available.
The success of the system relies upon disseminationof high quality, relevant research. Researchers havean obligation to facilitate this process by undertakingresearch which has relevance to clinical practice,preferably with collaboration between researchersand clinicians (Culham, 1998). Researchers also havea responsibility to present their findings in a user-friendly manner, facilitated by the discipline ofacademic style (Bithell, 2000).
The findings of the survey by Turner and Whitfield(1999) suggested that selection of treatment tech-
Physiotherapy June 2003/vol 89/no 6
331Lead Article
niques is based primarily on what practitioners had been taught during their qualifying education.Undergraduate education should be considered asonly the start of professional learning. It is continuingprofessional development, with an inbuilt focus onevidence-based practice, which should inform theprofession and ensure professional growth.
Physiotherapy educators have an obligation to useevidence to support the academic knowledge andpractical skills they teach and inculcate an ethos ofevidence-based practice in students which transfersinto the clinical setting (Turner and Whitfield, 1999).Achievement of this goal is facilitated if a uniformapproach to the evidence is adopted by bothclinicians and educators. Research has found thatstudents follow the example set by their clinicaleducators above that of academic staff (Turner andWhitfield, 1999), highlighting the importance of anethos of establishing an evidence base in the clinicalenvironment.
Universal NeedIn summary, the requirement for evidence-basedpractice applies to the whole physiotherapy prof-ession and involves managers, researchers, educ-ators and students as well as clinicians. Althoughundertaking evidence-based practice is complex,none of the perceived obstacles is insurmountableand many solutions already exist. The physiotherapyprofession now needs to move forward from debate,adopt a universally positive attitude and be seen to beimplementing evidence-based practice in a coherentmanner across the profession.
References
Baker, K G, Robertson, V J and Duck, F A (2002). ‘A review of therapeutic ultrasound: Biophysical effects’,Physical Therapy, 81, 1352-58.
Bithell, C (2000). ‘Evidence-based physiotherapy: Some thoughts on “best evidence”’, Physiotherapy, 86, 58-60.
Culham, E (1998). ‘Evidence-based practice andprofessional credibility’ (editorial) Physiotherapy Theory andPractice, 14, 65-67.
Moseley, A M, Herbert, R D, Sherrington, C and Maher, C G (2002). ‘Evidence for physiotherapy practice: A survey of the Physiotherapy Evidence Database (PEDro)’,Australian Journal of Physiotherapy, 48, 43-49.
Quality Assurance Agency for Higher Education (2003).Health Professions Council Standards of Proficiency(Physiotherapy) draft documentation, QAA, London.
Robertson, V J and Baker, K G (2002). ‘A review oftherapeutic ultrasound: Effectiveness studies’, PhysicalTherapy, 91, 1339-50.
Turner, P (2001). ‘Evidence-based practice andphysiotherapy in the 1990s’, Physiotherapy Theory and Practice,13, 107-121.
Turner, P and Whitfield, T W A (1999). ‘Physiotherapists’reasons for selection of treatment techniques: A cross-sectional survey’, Physiotherapy Theory and Practice, 15, 235-246.
Address for Correspondence
Ms J Morris, Colchester Institute, Sheepen Road, ColchesterCO3 3LL
