Professional Should Justify His or Her Practice - Essay Example

Evidence is the Foundation on Which the Professional Should Justify His or Her Practice: A Critical Discussion Evidence-based practice has been defined as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett et al 1997: 71). Over the last two decades, incorporation of evidence-based decision making in all areas of health care including physiotherapy practice, has been greatly emphasized on. Based on the therapist’s clinical experience, external evidence and the client’s needs, evidence-based practice incorporates evidence of the effectiveness of interventions from results of both qualitative and quantitative research (Strong et al 2001). The main focus of evidence-based practice is to identify more clearly those healthcare interventions that can be proved to be effective on scientific grounds, from the results of research studies and surveys that are undertaken for the purpose. Evidence-based practice has become a corner-stone for the United Kingdom health policy, and is currently being examined and implemented throughout the British National Health Service (NHS). According to Elkan et al (2000), the main goal is to use research evidence for rationing scarce health care resources and finding feasible solutions to physiotherapy treatment challenges. Only those interventions that could be shown to be effective on the basis of scientific research and evidence would be priority candidates for NHS funding. This paper proposes to examine the principles of evidence based practice in physiotherapy, and to critically discuss whether evidence is the foundation on which the professional should justify his or her practice. Further, the part played by clinical experience, patient preferences, political agenda/ targets and guidelines of the National Institute of Clinical Excellence (NICE) and National Service Framework (NSF) for health will be included in the discussion. The requirement for evidence-based practice applies to the entire physiotherapy profession, and includes “managers, researchers, educators and students as well as clinicians” (Morris 2003:231). Evidence-based practice requires sound professional judgment as well as sound clinical reasoning. Reasoning is needed to evaluate the quality of evidence, to apply that evidence, “and to manage those patients whose unique clinical presentations fall outside the population characteristics where evidence does exist, known as the grey zones of practice” (Jones et al 2006: 2). It is essential that physiotherapists should demonstrate the efficacy of their interventions. The most recognized method is to use critically appraised tools (CATs) which are procedures that are confirmed to be effective from research evidence, to guide the practice of physiotherapists and other healthcare professionals. It is necessary to assess the validity of evidence about effects of intervention, and about attitudes and experiences. Also, the critical appraisal of evidence about prognosis and about diagnostic tests are essential (Herbert et al 2005). The evidence found in response to a clinical question are appraised by means of CATs, for assessing its validity. Similarly evidence based summaries which are reviews of the evidence about a specific clinical topic also help in assessing the validity of evidence (Heneghan & Badenoch 2006). Critically appraised tools include evidence-based clinical practice guidelines (EBCPGs), and validated measures of outcome, education and continuing professional development. Evidence-based clinical practice guidelines have been defined as “systematically developed statements to help practitioners and clients with decisions about appropriate health care for specific clinical circumstances” (Pickering & Thompson 2003:214). EBCPGs are a rapidly developing practical application which can alter the processes of clinical decision making. Both the process of patient care as well as client health outcomes improve considerably with the appropriate use of EBCPGs (Herbert et al 2005). “The process of using evidence-based decision-making can be intimidating for clinicians that are unfamiliar with the process” state Strong et al (2001: 155). Evidence-based practice can be developed by a process involving five basic steps: first developing a focused question that is based on the client’s health context; next collecting evidence from the literature that is relevant to the question, ensuring successful article retrieval by use of appropriate databases and search words; critically analysing the validity, reliability and generalizability of the research retrieved; integrating the evidence with clinical experience and client needs to develop an intervention program; and finally evaluating the programme. An understanding of the core features of evidence-based practice helps the physiotherapist in incorporating the concept in key aspects of professional practice and decision making. This includes distinguishing between research that has direct significance for clinical practice, and that which does not. Evidence-based practice (EBP) also helps to evaluate research evidence with a set of highly structured rules of critical appraisal. Moreover, EBP provides a framework for making clinical decisions on the basis of research findings, and for applying research findings to individual patients. EBP also calls for the professional responsibility of the clinician in making clinical decisions using their own judgment, professional experience and external evidence. Further, it focuses on the care of individual patients, and the primary relationship between the healthcare professional and each client. EBP also proposes that decision making in clinical practice should be transparent and thereby open to question and examination. Further, it is considered important that only the current best evidence should be used (Trinder & Reynolds 2000). There are several reasons for the growth in physiotherapy research work. In the last decade there has been considerable increase in physiotherapy research activity, states Bithell (2005). The globalization of physiotherapy as a discipline in higher education worldwide, and the drive for increased research output has been a helpful consequence. Concurrently, health services in developed countries have reacted to extensive increases in costs and have taken to the concept of evidence-based practice with great interest. National health policy has directed funding towards research programmes studying the effectiveness of several treatments and technologies with the purpose of improving healthcare and utilizing allocated resources more effectively. The increased opportunities and resources have enabled many scholars to develop physiotherapy knowledge through research. In the health policy contexts of practice, it is necessary that an evidence base for physiotherapy is developed. This is because, studies that establish a scientifically acceptable association between a specific therapy and a desirable outcome are essential. The lack of an established theoretical framework in physiotherapy is overcome by using borrowed theoretical concepts from the biomedical and physical sciences. Some other key factors that impact the planning of treatment include political agenda, national targets and guidelines. In the NHS a system of clinical governance functions in order to fulfill responsibilities towards the patient, and is based on the principle that health professionals must be responsible and accountable for their own practice (Porter 2003). Clinical governance emphasizes continuing professional development and life-long learning, accountability for quality, adhering to a philosophy of continuous improvement, and an aspiration to achieve consistency of services across the NHS. The formulation of national guidelines are also important. When planning treatments for individual patients, the physiotherapist has to take into consideration several other requirements besides adherence to research-based evidence. For instance, national guidelines based on research have been formulated for practising physiotherapy, which have to be complied with. Guidelines should be readily available to clinicians since they are the latest review of current knowledge about the diagnostic and therapeutic possibilities for specific health problems (Hendriks et al 2000). Guidelines act as benchmarks, and thus monitor continuous quality improvement and assurance, as well as maintain the framework and sustainability of physiotherapy practice. The standards of proficiency and standards of professional practice are laid out by the NICE guidelines as given by the Chartered Society of Physiotherapists (NICE 2007). Similarly there are standards for treatment and dosages as outlined by the National Service Framework (NSF 2006). These include the government’s targets for achieving improvement in healthcare practices, and need to be complied with. Increasingly, physiotherapy has adopted a philosophy of evidence-based practice, and is showing a growing interest in developing evidence from research, for use in clinical decision making. Since 1985, the trend towards promoting research based practice as a model for physiotherapy practice was observed to get increasingly established (Gibson & Martin 2003). Strong et al (2001) assert that in the best practice of physiotherapy, it is essential that besides evidence from research, evidence from other factors such as the practitioner’s clinical experience in which for example, a specific treatment resulted in a particular outcome and also the patient’s preferences are taken into account. Professional experience is a very important factor, since physiotherapists develop first-hand evidence from their own clinical practice. Evidence from research is usually integrated with the physiotherapist’s knowledge base founded on their own practical experiences which are also drawn upon, when making decisions regarding diagnosis and treatment. Patient’s preferences also have to be taken into consideration, since the practitioner cannot go against the wishes of the client in issues important to him or her, even at the cost of implementing practice based on research evidence. This is supported by Strong et al (2001) who believe that clients have critical knowledge about their own needs and intervention preferences, which the physiotherapist needs to take into account. Further, the need for evidence-based practice is acknowledged by practitioners. The standards of proficiency drafted by the Health Professionals Council (CSP 2008) clearly states the imperative for physiotherapists implementing evidence-based practice on the basis of both professional and ethical obligation to provide an evidence-based service. However, “many negative attitudinal and practical issues have been identified, which act as obstacles to fulfilling the requirement for evidence-based practice in phyiotherapy” (Morris 2003:330). These not only affect the quality of service provided, but also have created tensions among different occupational groups within the profession, with a lack of a consistent and coherent approach to evidence-based practice. As an encouragement to change, the quality of the research evidence needs to be improved by ascertaining that the methodological strength of the research is adequate, in order to provide accurate evidence. Stronger evidence of effectiveness is obtained from an intervention that has positive benefit with negligible or no harm in repeated randomized controlled trials, than an intervention that has not been researched in this way. Moreover, using larger random samples of patients and control groups from several different geographical locations, help to obtain more accurate results. Though qualitative research provides limited evidence of effectiveness for comparison by groups, “it does yield valuable information about the treatment programme and treatment effectiveness that is important for planning meaningful interventions” (Ritchie 1999: 251). Evidence-based practice can be encouraged in several ways. To promote evidence-based practice, better access to electronic and printed forms of reviews of high quality and extensive research studies should be facilitated (Moseley et al 2002). Moreover, it is a cause for concern that treatment methods which research evidence have demonstrated to be ineffective or unjustifiable due to lack of scientific support continue to be implemented (Baker et al 2002, Robertson & Baker 2002). This practice is potentially dangerous to patients and may lead to legal action against the practitioners. The inclusion of courses on evidence-based practice in graduate and undergraduate programmes is beneficial in practice. Another important factor is that the quality of education workshops and continuing professional development courses in Physiotherapy need to be improved by increased reference to and support of research evidence or clinical guidelines (Turner & Whitfield 1999). Establishing the effectiveness of evidence is also important. Growing compulsion from funders such as the NHS, as mentioned on page 1 above, to establish the effectiveness of physiotherapy, and the need to identify and justify practices that would be most beneficial to patients, supports an increasing move towards evidence-based practice. However, progression towards evidence-based practice depends on the kinds of knowledge that is counted as evidence. The nature of the evidence itself is of great importance. Evidence is an “observation, fact or organized body of information offered to support or justify inferences or beliefs in the demonstration of some proposition or matter at issue” (Upshur 2001:7). Different types of evidence are located along a continuum, with abstract or purely mathematical evidence at one pole and contextual or hermeneutic type at the other. The evidence in healthcare is neither exclusively abstract and general nor contextual and particular, it is a mediation and interaction of both types of knowledge, states Upshur (2001). The presence of a hierarchy of research design, and its implication on evidence-based practice are as follows. In clinical decision making applying only current best evidence in the care of individual patients means using a hierarchy of research design. The physiotherapist uses standardised levels of evidence, meta-analyses and systematic reviews to summarise multiple related studies. The inherent methodological limitations of randomized controlled trials and meta-analyses have been played down by some practitioners undertaking evidence-based practice “in order to justify and preserve the aberrant methodological philosophies which underpin their description of a hierarchy of evidence” (Miles et al 2000:79). Actually, the hierarchies of evidence have not done anything more than glorify the results of imperfect experimental designs on unrepresentative populations in controlled research environments above all other sources of evidence which may be equally valid or far more applicable in given clinical circumstances, states Miles (2000). The hierarchies of evidence have no scientific basis, but have been universally accepted by biostatistically minded practitioners. These simplified models of experimental philosophy cannot be used in a sustained manner, on a permanent basis. An extensive debate on the nature of evidence for clinical practice was fuelled by the requirement for evidence-based practice. Following this, practitioners are now calling for a rejection of the “hierarchy of evidence” as a tool of any real use in the advancement of the evidence debate (Miles et al 2000). This is supported by Djulbegovic et al (2000) who state that for effective practice, using the hierarchy of evidence is not recommended. This is because, the hierarchy of evidence cannot adequately encompass knowledge obtained from methodologically rigorous clinical trials as well as knowledge acquired from the full variety of evidence including practitioner’s experience, unique features of individual patients and other characteristics of evidence. Other arguments which are not in favour of using evidence based practice that are put forth by Leach (2006) are as follows: Some complex patient situations are oversimplified or inadequately addressed by the use of EBP. There is also a misrepresentation of research evidence as pure science, and other applications are considered to be unimportant. Another misconception among clinicians is that EBP is based on evidence from randomized control trials (RCTs), which can be less than useful for giving information about patient attitudes, experience, and other subjective factors. Hence, more than the actual principle behind the EBP, the criticism is sometimes focused on the type of evidence that was accepted. This means that physiotherapists need to understand that EBP does integrate other types of data such as qualitative findings along with data obtained from quantitative research. Therefore, for effective practice, the type of evidence adopted should be according to the case and the patient’s condition. A related concern is that EBP may result in dehumanized and routine care by ignoring clinical expertise and patient preference. In addition to taking patient’s choice into account, EBP also requires that research evidence should be considered concurrently with clinical expertise. This demonstrates that EBP is patient-centred, individualized and accommodating of both practitioner’s and client’s needs. In areas where data are not available, clinical experience and traditional evidence are still relied on. Thus, it is clear that EBP uses the best available evidence to help in making decision, and does not rely only on the data obtained from clinical trials. Some other factors that hinder physiotherapists’ use of EBP are a lack of motivation, lack of autonomy, lack of time, resources and authority to make changes, and inadequate skills for research and critical appraisal. However, EBP helps to alleviate the problems of lack of time, costs and resources which may be wasted on ineffective treatments, with improvement in patient outcomes and efficient use of clinician’s time (Leach 2006). All the obstacles to evidence-based practice can be overcome with a positive attitude, as well as judicious and efficient use of available time and resources. Time allocated for in-service training can be used to disseminate and discuss research evidence and clinical guidelines, rather than communicate experiential or anecdotal methods which are not related to research evidence. Further, practitioners require the provision of adequate resources to be able to access research evidence. Government funding for the National Health Service has improved computer facilities in the workplace. Many clinicians already have access to libraries (Morris 2003). The validity of research evidence plays a significant part in ensuring successful outcomes for interventions. One of the strengths of evidence-based practice is its comprehensive procedures for determining the rigour and trustworthiness of research findings, in order to determine the evidence that might suggest a change in physiotherapy practice. For evaluating the degree of validity of qualitative evidence, several procedures are available. Physiotherapy is to a large extent concerned with understanding the functions and roles of persons in their communities, hence the potential contributions of qualitative research to healthcare and policy are important. It is essential to remember that there is more to healthcare than the focused delivery of interventions. This is true especially for physiotherapy where the focus of care is often concerned with issues beyond the biological body to include the person situated within a specific home and larger community (Gibson & Martin 2003). Further, the main part of physiotherapy is focused on persons with chronic illness or disability who require continuing or intermittent care over a period of time (Gibson & Martin 2003). Formulating appropriate care for these populations necessitates research enterprises to take a comprehensive approach, with interventions focused on reintegrating persons into their community. For doing this, it is essential to look beyond impairment to understand the specific experiences and needs of patients. Hence, physiotherapists plan and implement treatments that are based on multiple factors such as “the patient’s unique circumstances, goals and values, the expectations and restraints of the facility and funders, and the practitioner’s clinical experience” (Gibson & Martin 2003:352). This paper has highlighted evidence-based physiotherapy practice, examined both sides of the argument on evidence as the foundation on which the professional should justify his or her practice, and determined the impact of clinical experience, patient preferences, political agenda/ targets and national guidelines, on the process of planning treatments for individual patients. Due to the significant contributions to effective physiotherapy practice offered by appropriate use of research evidence, it is concluded that the professional should indeed justify his or her practice on the basis of research evidence. Although there are several factors underscoring why evidence based practice should not be used, these impediments can be overcome with the help of determination and the judicious use of time and resources. Further, it is found that along with quantitative research, qualitative research also contributes valuable evidence to patient care, and is integral to evidence-based physiotherapy practice. The treatment plan should take into consideration the lived experience of patients within and outside the physiotherapy setting, in order to maximise patients’ integration into the community. A future theoretical knowledge base needs to be increasingly developed, to promote evidence-based practice. A framework of theory should encompass not only factual knowledge, but also the professional craft knowledge and personal knowledge of clinicians in ways encouraging debate and discussion. The framework of theory should be incorporated into the professional knowledge base, in order to be used as a guide for practice (Bithell 2005). The gap between theory from research evidence and its application in practice can thus be avoided. This will ultimately help to promote more effective physiotherapy practice towards achieving the highest outcomes in patient care. References Baker KG, Robertson VJ, Duck FA 2002 A review of therapeutic ultrasound: biophysical effects. Physical Therapy 81:1352-1358 CSP (The Chartered Society of Physiotherapy) 2008 Evidence based practice. Effective Practice. Accessed on 12th August, 2008 from http://www.csp.org.uk/director/effectivepractice/evidencebasedpractice.cfm Djulbegovic B, Morris L, Lyman GH 2000 Evidentiary challenges to evidence- based medicine. 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