Evidence-informed decision-making: Health care’s crème de la crème
Evidence-based practice home, evidence-based medicine,
evidence-based nursing and evidence-informed decision-making began with
Florence Nightingale in the 1850s during the Crimean War. She noted a
connection between poor sanitary conditions in the hospital and rising death
rates among wounded soldiers (Bite-Sized History of Mathematical Resources,
n.d.). “It is Nightingale who developed the coxcomb, a visual display to demonstrate
how military deaths could be prevented” (Morin, 2010, p. 2). Her subsequent
efforts to sanitize hospitals to save soldiers led to dramatic drops in patient
Much of the original work on evidence-based practice (EBP) focuses on EBP in medicine. Although the term “evidence-based medicine” (EBM) reportedly was first used in the 1980s, the practice gained wide recognition in 1992 when the Journal of the American Medical Association published an article by the evidence-based medicine working group on its role in medical education. According to Montori and Guyatt (2008), that article brought both the term and the concept to the attention of a wider medical community. The working group published a series of 25 articles between 1993 and 2000 that outline criteria to evaluate current evidence to support clinical decisions. This body of work forms the basis of most of the critical appraisal tools used today (Guyatt & Rennie, 2002).
Read varying definitions of evidence-based practice, evidence-informed decision-making, and other related terms.
Evidence-based practice home (EBP) and evidence-informed decision-making can be defined in many ways, and the terms themselves can vary. One of the most commonly cited definitions is by Sackett and colleagues who define evidence-based medicine as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett, Rosenberg, Muir Gray, Haynes & Richardson, 1996, p. 1).
For Newhouse and colleagues, evidence-based practice is “a problem-solving approach to clinical decision-making within a health-care organization that integrates the best available scientific evidence with the best available experiential (patient and practitioner) evidence. EBP considers internal and external influences on practice, and encourages critical thinking in the judicious application of evidence to the care of the individual patient, patient population, or system” (Newhouse, Dearholt, Poe, Pugh, & White, 2007, pp. 3-4).
Recently, Melynk and colleagues defined evidence-based practice within the context of nursing as a “problem-solving approach to the delivery of health care that integrates the best evidence from well-designed studies and patient care data, and combines it with [clinical expertise and] patient preferences and values” (Melnyk, Fineout-Overholt, Stillwell & Williamson, 2010, p. 51).
According to the OAPN Canadian Centre of Excellence (2010, p. 1), evidence-informed decision-making is the “purposeful and systematic use of the best available evidence to inform the assessment of various options and related decision making in practice, program development, and policy making.”
In its position statement on evidence-informed decision-making and nursing practice, the Canadian Nurses Association defines evidence-informed decision-making as “a continuous interactive process involving the explicit, conscientious and judicious consideration of the best available evidence to provide care” (Canadian Nurses Association [CNA], 2010, p. 1).
It then defines evidence as “information acquired through research and the scientific evaluation of practice. Types of evidence include information derived from a broad range of rigorous methodologies including quantitative studies (such as randomized controlled trials, observational studies) qualitative studies (such as case studies, ethnography, phenomenology) and meta-analysis. Evidence also includes expert opinion in the form of consensus documents, commission reports, regulations and historical or experiential information”...Further, “it is imperative to acknowledge that no level of evidence eliminates the need for professional clinical judgment or for the consideration of client preferences” (CNA, p. 1). “Decision-making in nursing practice is influenced by evidence and also by individual values, client choice, theories, clinical judgment, ethics, legislation, regulation, health-care resources and practice environments” (CNA, p. 3). For CNA, “evidence-informed decision-making is an important element of quality care in all domains of nursing practice and is integral to effect changes across the health-care system” (CNA, p. 1).
Karen Morin summarized it nicely: “irrespective of the definition employed, key elements of evidence based practice include addressing a clinical problem or question by examining the ‘best available scientific evidence’ and then integrating that evidence with patient preferences and practitioner expertise” (Morin, p. 1). She adds that is it not to be confused with the term “research utilization” from the 1970s and 1980s, which Newhouse and colleagues (2007) distinguish as being only focused on published literature produced through research and ignoring grey literature, organizational data and that produced through quality improvement projects and experts.
Evidence-based medicine “has expanded to include many disciplines such as evidence-based nursing” and policy-making. In every case, evidence-based healthcare involves practitioners or policy makers using their expertise to combine the best available evidence, knowledge of available resources with patient or population circumstances, values and preferences in decision-making” (National Collaborating Centre for Methods and Tools [NCCMT], 2010, para. 3).
Evidence-based medicine has been criticized in large part due to myth that the only acceptable evidence is from randomized controlled trials or meta-analyses. Donald Berwick, a Harvard-based quality-improvement expert, declared in 2008 that employing evidence-based medicine methods must sometimes take a back seat to patient-centered care (Rahman & Applebaum, 2010). Evidence-based medicine has also been criticized for ignoring a clinician’s instincts and experience. As a result, the term evidence-informed decision-making (EIDM) began to be used “to attempt to get beyond some resistance to evidence-based practice, and to acknowledge that other types of evidence are useful and important in making decisions.” (NCCMT, 2010, para. 4)
According to the Canadian Nurses Association, “the distinction between the terms ‘evidence-based’ and ‘evidence-informed’ is important. The concept of evidence-informed decision-making builds on evidence-based health care. It acknowledges that there are many factors other than evidence – for example, available resources or cultural and religious norms – that influence decision-making” (CNA, 2010, p. 3).
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