Concepts of Evidence-Based Practice: Analysis of Evidence-Based Practice and Its Debate

Abstract

Evidence-based practice (EBP) is a model for clinical decision-making, representing an interdisciplinary approach to clinical practice that aims to optimize clinical decision-making by emphasizing the use of evidence from well-designed research. An evidence-based decision is made by the individual clinician on basis of the best evidence available, in accordance with the patient’s preferences and circumstances. Since 1992, EBP has been a central concept within a growing range of professional fields of health care. At the same time, EBP has been subject to incessant criticism. EBP proponents have responded to criticism, and their responses have then become the object of further criticism. The basic principles of the EBP-model, along with the claims by proponents and opponents for and against these principles, which compose the EBP debate, are the main subjects of this thesis. The thesis has four chapters. In Chapter 1, the principles of Clinical epidemiology are presented as the main scientific framework of EBP. It is through this framework that epidemiologic, outcome-based data is considered the most reliable source of evidence for clinical interventions. In Chapter 2, the constitutive elements of EBP are analyzed, with particular attention to what kind of scientific knowledge (i.e., “research evidence”) and non-scientific knowledge and beliefs (i.e., “clinical expertise” and “patient preferences”) that are inherent in the concept of EBP. In addition, I differentiate between three theoretical concepts of EBP – “narrow”, “moderate”, and “maximal” – which differ relative to the degree to which “clinical expertise” and “patient autonomy” are included in the concept or not. I claim that only “moderate” EBP” is representative for an adequate understanding of the EBP model. Chapter 3 presents an analysis of central claims in the international EBP debate while Chapter 4 attends to central claims in the Norwegian EBP debate. I argue that the most relevant criticism pertains to the confidence in and the application of epidemiologic evidence-sources. This kind of criticism must be distinguished from the claim that EBP represents a narrow scope of evidence. The latter claim is based on a misunderstanding about what “evidence” entails in EBP literature and is representative to a narrow concept of EBP. Yet another kind of criticism, claiming that the EBP model ignores clinical expertise and patient autonomy, is also based on misunderstandings, largely due to lack of clarity in the EBP literature. A general conclusion is that the tendency to imply a narrow interpretation of EBP in much of the criticism, as well as the tendency to conceptual unclarities in much EBP literature, contribute to a less constructive debate. The thesis concludes by suggesting recommendations to both proponents and opponents, which can contribute to a more constructive basis for future EBP debates.