PHYS THER
Vol. 87, No. 10, October 2007, pp. 1305-1306
DOI: 10.2522/ptj.20070040.ar
Author Response
Nancy M Salbach and
Nicol Korner-Bitensky
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Introduction
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Duncan has produced a thought-provoking commentary on the current state of evidence-based practice (EBP). Although we agree with her that multiple factors must be favorable to implement EBP effectively, the practitioner is clearly the primary player. Duncan points out that preparing practitioners to implement EBP "may be a valid initial step" toward achieving this process, but this is arguably an understatement. The practitioner is the cornerstone of EBP, and thus education regarding EBP is an essential responsibility of the profession’s educators and of the practitioner as a lifelong learner. Even if an organization mandated the use of a specific therapy that research had shown to be effective, the evidence-based practitioner would be expected to understand the research context in which the therapy was evaluated and use clinical judgment informed by an understanding of patient values and preferences when deciding whether to use the treatment or not.
As Sackett et al1 emphasized, "Research findings should not be regarded as a prescription for clinical care. Instead, they should be combined with clinical expertise and patient preferences to enlighten clinical decisions." The clinician must have knowledge of the research findings, the clinician must use expertise based on past experience, and the clinician must solicit the client’s values and treatment preferences and understand these preferences in the context of decision making. She or he must integrate knowledge from these primary sources when making the diverse clinical decisions required in any practice setting, and this makes preparing the practitioner with EBP skills more than simply a valid first step.
Given the complex nature of EBP behavior, the solution to changing behavior is equally complex. A notable number of physical therapists in the United States2 and in Canada3 have reported that they lack the ability to search, appraise, or apply the research literature to individual clients. What is the best way to improve these skills? Duncan indicates that, based on reflections from colleagues, professional preparation at a higher degree level is one answer. Certainly our survey findings support a positive association between degree level and academic preparation in EBP, training in critical appraisal skills, and perceived ability to implement EBP. However, we cannot wait until doctoral programs are widely implemented to address this issue. Although doctoral-level degree programs are increasingly available in the United States, it is unclear whether Canada or other countries will follow suit. We, therefore, must act now to integrate sufficient opportunities to learn the breadth of EBP skills in existing physical therapy programs. This poses a challenge, given the necessary focus on development of clinical knowledge and skills. To address the needs of practicing physical therapists, we propose continuing education as the solution, given that more than 84% of American2 and Canadian3 physical therapists surveyed expressed interest in learning or improving their EBP skills. Physical therapists who make a substantial financial investment to advance their clinical skills through continuing education courses and workshops may find the quality of their practice enhanced after investing to improve their EBP skills.
Educators must move beyond teaching traditional search and appraisal EBP skills, given the rapidly emerging wealth of information posted on the Internet. Findings from in-depth interviews that we conducted with 23 of our survey respondents show that we need to familiarize physical therapists with what is available. For example, StrokEngine (www.strokengine.org) and the Evidence-Based Review of Stroke Rehabilitation (www.ebrsr.com) are impressive Web-based resources presenting results of systematic reviews relevant to stroke rehabilitation. Without educational opportunities to explore such resources, many busy clinicians will remain unaware of their existence. Only the technologically savvy practitioner will access and use this synthesized information. We appreciate, however, that awareness of a resource does not ensure its use. Based on the theory of self-efficacy,4 educators also must provide practitioners with opportunities to effectively use EBP resources, to see their peers use these resources, and to receive positive verbal feedback about their EBP skills in a nonthreatening environment. These strategies are designed to elevate perceived ability to perform EBP activities, which then should increase implementation of EBP.5
We agree with Duncan’s comments that a practitioner skilled in EBP may have limited success in performing EBP without a health care environment that facilitates the process. Organizations must provide technology and a system of care that will enable the practitioner to access needed information in the right place and at the right time in order to have an impact on the quality of health care services. Consider the community-based physical therapist who delivers services in the client’s home and who has access to the Internet on a desktop computer located in a central office that she or he visits once a week. The technology to facilitate EBP in this setting exists, but managers and policy makers must be convinced that the benefits outweigh the cost. Creating an appropriate organizational infrastructure and resources to enable EBP may reduce the number of practitioners who report "lack of time" as a barrier to updating their clinical practice with new knowledge.
A final matter to address is the state of our "innovations," that is, the body of research literature that investigators hope will inform clinical practice. This issue is incredibly complex, and we support Duncan’s emphasis on the need to develop interventions that are feasible in and relevant to the clinical setting. But there is also the issue of the weight of the evidence that is needed before recommending a change in practice. Clinicians are commonly aware that, compared with other study designs, a randomized controlled trial of an intervention yields the strongest evidence. But is evidence from one trial enough? Or evidence from 2 trials? Take body-weight–supported treadmill training as an example. Practitioners considered "early adopters" may have implemented this intervention to optimize gait outcomes poststroke after only one study showing effectiveness. Despite intense interest in this method of gait retraining, authors of a 2003 Cochrane systematic review6 concluded that it was no more effective than other interventions in improving walking speed and independence.
Although the strength of a finding based on a synthesis of the research literature is considered greater than that from a single study, there is another important issue that relates to the presentation of results averaged over a heterogeneous group of people with stroke. For an individual or a subgroup of individuals, a treatment may indeed be effective. Referring again to the example of body-weight–supported treadmill training, evidence from subgroup analyses suggests that this intervention is indeed effective for enhancing endurance and walking speed for people with subacute stroke and low ambulatory status,7 a finding that clinicians using this intervention likely surmised based on their clinical experience.
In closing, we would like to reiterate that the practitioner remains the champion of EBP. It will take a strong collaboration among practitioners, researchers, educators, health care organizations, policy makers, and clients to optimize the integration of high-quality research findings into clinical practice, improve the quality of health care services, and—most importantly—have a favorable impact on the health and well-being of people with stroke.
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References
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- Sackett DL, Rosenberg WM, Gray JA, et al. Evidence based medicine: what it is and what it isn’t.
BMJ. 1996;312:71–72.[Free Full Text]
- Jette DU, Bacon K, Batty C, et al. Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists.
Phys Ther. 2003;83:786–805.[Abstract/Free Full Text]
- Salbach NM, Jaglal SB, Korner-Bitensky N, et al. Practitioner and organizational barriers to evidence-based practice of physical therapists for people with stroke.
Phys Ther. 2007;87:1284–1303.[Abstract/Free Full Text]
- Bandura A. Self-efficacy: toward a unifying theory of behavioral change.
Psychol Rev. 1977;84:191–215.[CrossRef][Web of Science][Medline]
- Bandura A.
Self-Efficacy: The Exercise of Control. New York, NY: WH Freeman; 1997.
- Moseley AM, Stark A, Cameron ID, Pollock A.
Treadmill Training and Body Weight Support for Walking After Stroke (Cochrane Review) [Update Software]. Oxford, United Kingdom: The Cochrane Library, The Cochrane Collaboration; 2003:4.
- Barbeau H, Visintin M. Optimal outcomes obtained with body-weight support combined with treadmill training in stroke subjects.
Arch Phys Med Rehabil. 2003;84:1458–1465.[CrossRef][Web of Science][Medline]
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Copyright © 2007 by the American Physical Therapy Association.
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