Evidence-based Practice: Has It Delivered on Its Promise?

Abstract

I was recently asked to deliver a presentation on Evidence-based Practice in Oncology Nursing at the Sixth Asian Oncology Nursing Society Conference. I thought it would be a relatively straightforward talk. Having taught evidence-based practice to nurses for many years, I assumed we had it all sorted. As I researched more about the topic, I started to question whether evidence-based practice had evolved in nursing since it was introduced in the 1990s and whether it had lived up to its promise of reducing variation in care and improving health outcomes. Evidence-based medicine was first defined as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.”1 Importantly, the original definition emphasized the importance of patient values and clinical expertise alongside rigorous evidence. The term evidence-based practice soon followed to reflect the broader application that the concept has to all health professions. Evidence-based practice was subsequently enthusiastically embraced by the nursing profession. It continues to be well established as an essential element of nursing education programs and as a fundamental expectation of professional standards of practice that is necessary for health services to meet accreditation and regulatory requirements. Given its central role in the nursing profession over the past few decades, I went to the literature to ask, “Does evidence-based nursing practice make a difference to health outcomes?” I located a recent scoping review that asked the question, “When patients receive care based on evidence, what are the outcomes?”2 The review presented some interesting conclusions that suggest more still needs to be done to optimize the benefits of evidence-based practice in health care. First, of the 636 articles included in the review, almost 63.3% were published in the United States.2 The impact of evidence-based practice across low- and middle-income countries continues to be a major gap that contributes to ongoing inequities in cancer care. Around 90% of the studies included in the review took place in the acute care setting.2 This limited scope does not reflect the reality that cancer care is largely delivered in outpatient and community settings. I was also surprised to see that only 5 involved interventions in the oncology setting. The authors of the review commented on the substantial heterogeneity in study designs and outcomes.2 The lack of consistent frameworks to support evidence implementation and the variation in quality of research are major barriers if evidence-based practice is to deliver on its promise. Importantly, only 19% of the included studies measured return on investment.2 This failure to address the value of nursing intervention limits the influence nursing research can have on resource allocation and system change. Despite the major gaps identified, it was notable that the review concluded that evidence-based practice improves patient outcomes and health care system return on investment, with 94% of those studies that assessed return on investment, reporting a positive return.2 There is no doubt we continue to face significant challenges to realizing the potential of evidence-based practice in nursing. This is reflected in the growing movement to improve research quality by challenging selective reporting, publication bias, and the slow nature of research implementation.3 We also continue to struggle to produce, translate, and apply evidence in ways that respect contextual factors and individual values and that truly enable shared decision-making. Evidence-based practice has admirable goals but is complex. There are a few important steps we can take to address the challenges that evidence-based practice faces in delivering on its promise. First, we should continue to develop innovative research designs that involve codesign with consumers and take more pragmatic approaches to ensure research better reflects context and the real world. We need to pay more attention to research quality, while at the same time developing skills across the profession in how to critically appraise and apply research findings. We should also embrace the new opportunities provided by technology and artificial intelligence. While artificial intelligence raises many new ethical and practical issues for health care, such developments will help to accelerate the process of evidence synthesis and enable living systematic reviews.4 Imagine systematic reviews produced in the way we have over recent times being replaced by artificial intelligence tools? There is also great potential to develop new approaches to shared decision-making through decision aids supported by technological advances.4 My overall conclusion as I prepared to deliver my talk: while evidence-based practice has its limitations, we must continue to evolve its role in nursing and in patient empowerment as it provides one of the most important tools we have to achieve equitable and high-quality cancer care for all.