Clinical Reasoning: Combining Research and Knowledge to Enhance Client Care
Making sound and client-centered clinical decisions in an area that demands accountability and evidence-based practice requires not only scientific knowledge, but also a deep knowledge of the practice of one’s profession and of what it means to be human in the world of combined strength and vulnerability that is health care. Every clinician must understand the importance of applying best research evidence to client care, the essence of evidence–based practice, to improve the overall quality of healthcare.
Research continues to find that using evidence-based guidelines in practice, informed through research evidence, improves patients’ outcomes (Dykes et al, 2005).
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The literature is replete with definitions of evidence-based practice. Simply stated, evidence-based practice is the process of applying research to practice. Originating from the medical field in 1991, the term evidence-based medicine was established to ensure that medical research was systematically evaluated in a manner that could “inform medicine and save lives and that is superior to simply looking at the results of individual clinical trials” (Wampold & Bhati, 2004).
An evidence-based practice is considered any practice that has been established as effective through scientific research according to a set of explicit criteria (Drake, et al, 2001). The term evidence-based practice is also used to describe a way of practicing, or an approach to practice. For example, evidence-based medicine has been described as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett, Rosenberg, Gray, et al, 1996).
Evidence-based medicine is further described as the “integration of best research evidence with clinical expertise and patient values” (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). Rather than a relationship based on asymmetrical information and authority, in evidence-based practice the relationship is characterized by a sharing of information and of decision-making. The clinician does not decide what is best for the client, but rather the clinician provides the client with up-to-date information about what the best-evidence is regarding the client’s situation, what options are available, and likely outcomes.
With this information communicated in culturally and linguistically appropriate ways clients are supported to make decisions for themselves whenever and to the extent possible. According to Burns and Grove evidence-based practice is nothing more than a problem-solving approach to the care that we deliver that takes into consideration the best evidence from research studies in combination with clinical expertise and the patient’s preferences and values (Burns & Grove, 2004).
Pierce described in “Evidence-Based Practice in Rehabilitation Nursing” that “making patient-care decisions with current information and one’s clinical expertise enhances the ability to provide the best practice”. The author added that “evidence-based practice is a process that begins with knowing what clinical questions to ask, how to find the best evidence, and how to clinically appraise the evidence for validity and applicability to the particular care situation”.
Then, the best evidence must be applied by a clinician with expertise in considering the patient’s unique values and needs. As stated by Law& MacDermit, “evidence for practice is not only about using research evidence, but using it in partnership with excellent clinical reasoning and paying close attention to the client’s stated goals, needs, and values”(Law & MacDermit, 2008). Although the terms best practices and evidence-based practice are often used interchangeably, these terms have different meanings.
Evidence-based practice can be a best practice, but a best practice is not necessarily evidence-based; best practices are simply ideas and strategies that work, such as programs, services, or interventions that produce positive client outcomes or reduce costs (Ling, 2000). In order to bring research and knowledge into someone’s practice, it’s necessary to think critically. Becoming a critical thinker is a prerequisite of becoming an evidence-based clinician. But what is critical thinking?
Critical thinking involves the application of knowledge and experience to identify patient problems and to direct clinical judgments and actions that result in positive patient outcomes. Critical reflection requires that the thinker examine the underlying assumptions and radically question or doubt the validity of arguments, assertions, and even facts of the case. Critical reflective skills are also essential for clinicians; however, these skills are not sufficient for the clinician who must decide how to act in particular situations and avoid patient injury (Wheatley DN, 1999).
Critical reasoning is a process whereby knowledge and experience are applied in considering multiple possibilities to achieve the desired goals (Noll et al, 2001) while considering the patient’s situation (Fowler, 1997). According to Simmons it’s a process where both inductive and deductive cognitive skills are used (Simmons et al, 2003). Each client’s problem is unique, a product of many factors, including the client’s physical health, lifestyle, culture, relationship with family and friends, living environment, and experiences.
Thus, a health care professional does not always have a clear picture of the client’s needs when first meeting a client. Because no two clients have identical problems, a clinician is always challenged to observe each client closely, search for and examine ideas and inferences about client problems, consider scientific principles relating to the problems, recognize the problems and develop an approach to client’s care. When clinicians make healthcare decisions for a population or group of clients using research evidence, this can be described as evidence-based healthcare practice.
Another prerequisite to becoming an evidence-based clinician is to be a reflective professional. Reflection is an important aspect of critical thinking. As described by Miller & Babcock reflection is “the process of purposefully thinking back or recalling a situation to discover its purpose or meaning. With reflection, a clinician seeks to understand the relationships between theoretical concepts and real-life situations. The importance of reflecting on what you are doing, as part of the learning process, has been emphasised by many researchers.
The concept of reflective practice was introduced by Donald Schon in his book named “The Reflective Practitioner” edited in 1983, however, the concepts underlying reflective practice are much older. John Dewey was among the first to write about Reflective Practice with his exploration of experience, interaction and reflection (Dewey, 1933). Schon described the concept as a critical process in refining one’s artistry or craft in a specific discipline. The author recommended reflective practice as a way for beginners in a discipline to recognize consonance between their own individual practices and those of successful practitioners.
He also stated that reflective practice “involves thoughtfully considering one’s own experiences in applying knowledge to practice while being coached by professionals in the discipline” (Schon, 1996). As it was earlier said, there are a few steps toward evidence-based practice and rehabilitation. The first and the most important step in evidence-based practice is to determine a well-designed question that not only affects quality care but is of interest to the rehabilitation clinician and is encountered in practice on a regular basis. A useful ramework for formulating an appropriate clinical question is suggested by Sackett & colleagues. (Sackett, 2000). They proposed that a good clinical question should have at least three and sometimes four components: Patient or Problem; Intervention; Comparison (not mandatory); Outcome of interest. This has been referred to as the PICO (Patient /Problem, Intervention, Comparison, Outcome) or PIO (Patient / Problem, Intervention, Outcome) approach. The question usually comes from diverse sources. As stated by Pierce, “the most common source is the rehabilitation practice itself”.
Once the question in searching of evidence was formulated, the next and probably the most important step is to find the relevant evidence in the literature that will help in answering the question. It can be difficult to distinguish relevant from irrelevant information and to decide which source contains the most credible information and research data. Using research findings in practice improves care. Research utilization occurs at three levels—instrumental, conceptual, and symbolic: 1. Instrumental utilization is the direct, explicit application of knowledge gained from research to change practice (Gills & Jackson, 2002). 2.
Conceptual utilization refers to the use of findings to enhance one’s understanding of a problem or issue in nursing (Gills & Jackson, 2002). 3. Symbolic utilization is the use of evidence to change minds of other people, usually decision makers (Profetto-McGrath, Hesketh, Lang, & Estabrooks, 2003). According to Hameedullah & Khalid, “all evidence must be appraised in the following areas: validity, importance and applicability to the clinical scenario” (Hameedullah & Khalid, 2008). Performing the previous steps will result in the appearance of a concrete piece of evidence which should be valid and important for the question in consideration.
Now is the time to combine the clinical expertise and experience with the evidence generated to improve the outcome of specific client scenarios. It is also important to remember client’s values and circumstances while making such decisions. The evidence regarding both efficacy and risks should be fully discussed with the client in order to allow them to make an informed decision. This approach allows the formation of a decision in consultation with the client in the presence of good evidence and is consistent with the fundamental principle of evidence-based practice i. e. ntegration of good evidence with clinical expertise and patient values (Hameedullah & Khalid, 2008). Whether the intervention was appropriate and resulted in good clinical outcome for a certain group of clients, in a particular clinician’s hands, will only be answered by careful prospective outcome research. As Strauss and Sackett have suggested, we need to ask whether we are formulating answerable questions, finding good evidence quickly, effectively appraising the evidence, and integrating clinical expertise and patient’s values with the evidence in a way that leads to a rational, acceptable management strategy (Straus & Sackett, 1998).
Although the importance of research-based practice was identified decades ago and has gradually been adopted by rehabilitation professions, there are a number of challenges for clinicians who are attempting to be use research to aid in clinical decision-making. According to Bohannon and Leveau most challenges can be grouped under one of three areas: research methods, clinicians’ skill, and administrative factors (Bohannon & Leveau, 1998).
The research procedures of randomly assigning patients to an experimental or control group, using standardized outcomes measures that may not have real-world relevance, and the difficulty of blinding investigators and clients to the research procedures all make research results difficult to be implemented, interpreted and utilized clinically (Ritchie, 2001). Evidence-based practice requires clinicians to read current research literature, understand research methodology, and incorporate best evidence into practice as appropriate.
As Sumison noted in one of his studies, it may be difficult to use in client-centered practice. The research literature may be difficult to access and relevant information is often not compiled in one place (Sumison, 1997). Interpreting and implementing research evidence also requires clinical skill, judgement, and experience. Deciding what constitutes evidence that justifies a change in practice can be challenging and the opportunity for bias exists at every stage of the process as Pomeroy observed in one of his articles from 2003 (Pomeroy, 2003).
There are many other factors that present challenges to clinicians who are attempting to use evidence to guide their practice. Time constraints are almost universally identified as a primary limiting factor. Schreiber and Stern stated that “clinicians refer to pressures of today’s health care environment and administrators’ emphasis on productivity as factors that directly inhibit their ability to seek out, gather, read, and integrate cientific information relevant to daily practice” (Schreiber and Stern, 2005). The concept of evidence-based practice is of great importance for rehabilitation and physiotherapy to allow for increased insight for all involved including patients, clinicians, third-party payers, and government and health care organizations, into the clinical decision-making processes. The purpose of promoting this paradigm is optimum quality of care with conservation of professional autonomy.