Successful relationships are based on mutual understanding and respect. The same is true for the relationship between research and clinical practice. Research informs clinical practices, and clinical practices often guide research endeavors.
The call to enhance this symbiotic relationship has been amplified in recent years through discussions of evidence-based practices. Such practice requires speech-language pathologists and audiologists to combine their clinical expertise with a body of specific research findings that are valid, reliable, and clinically relevant. By consciously seeking out and using scientific evidence as the foundation for their clinical services, SLPs and audiologists become clinical scientists. They also may become partners with researchers.
Fidelity in Relationships
Fidelity in a relationship leads to stronger attachments based on feelings of mutual responsibility and shared principles. Similarly, reliance on evidence-based practices allows clinicians to be accountable, ethical, and responsible, not only to their clients, but to their profession and themselves. Evidence-based practices permit clinicians to account for their services when reporting to clients, their families, and third-party payers.
Clinicians should provide specific rationale for the clinical procedures they provide and develop hypotheses for the clinical phenomena they encounter rather than operating behind the thin veil of an "it works" attitude. Such an attitude often is based on individuals' or manufacturers' claims about the efficacy of a particular product. Without reliance on careful observations of the data that support practices, clinicians can never be sure why certain aspects of an evaluation tool or intervention program lead to success. Thus, pointless time, money, and energy may be expended needlessly.
ASHA's Code of Ethics dictates that SLPs and audiologists continue to update their education throughout their career and provide services that are based on careful, professional reasoning. By engaging in evidence-based practices, clinicians abide by these ethics codes while best serving their clients. Finally, when SLPs and audiologists engage in evidence-based practices, they not only demonstrate a commitment to the scientific rigor of their profession, they also open up opportunities to contribute to the science of their profession. Such commitment and opportunities serve to strengthen the profession by demonstrating members' dedication to the pursuit of science. Without scientific evidence guiding practice, clinicians run the risk of making "vows" they can't keep.
The Engagement Process
Before a marriage occurs, partners frequently engage in a process of learning more about one another and developing the standards upon which the relationship will be established. Likewise, before clinicians engage in evidence-based practice, they must "process" through several steps to ensure the high standards of their services over time.
Most authors suggest that evidence-based practice is implemented after clinicians first identify a clinical issue that occurs frequently in their clinical practice. For example, it may be that SLPs wish to use the most efficacious treatment paradigm for remediating written language disorders. In this case, their first steps down the aisle of evidence-based practice will be to gather information on different intervention approaches. Information may be obtained from a variety of sources (e.g., professional literature, Internet), although clinicians must be careful to be aware of the relevancy, accuracy, validity, and reliability of the information they obtain.
The information then should be documented and, if possible, recorded in a format or database that allows clinicians to describe and judge its quality. As part of this analysis, clinicians must be aware of the level of evidence they obtain from particular sources. Although different organizations use different rubrics for levels of evidence, all suggest a hierarchy of evidence levels, ranging from randomized controlled clinical trials to case studies and expert opinion.
What is most important to keep in mind is that clinicians are looking for a number of reliable, valid scientific endeavors that, as a whole, contribute to a data source that suggests that a particular assessment procedure or intervention strategy should be used. It is after this body of scientific evidence suggests that a particular clinical procedure leads to efficacious outcomes that clinicians can decide whether to "take the plunge" and implement the procedure.
Courting the Idea: One Program's Experiences
Although every relationship differs, it can be helpful at times to look to other partnerships as models of what can occur. The following section describes how a university-based speech-language-hearing clinic began to implement and encourage evidence-based practice.
More than a year ago, the department of communicative disorders and sciences at Wichita State University pledged to move all clinical services to evidence-based practices and to increase students' awareness of research-based assessment and intervention procedures. The faculty and clinical educators began this union of research and clinic by reading articles on evidence-based practice and holding discussion groups. Through these discussion groups and readings, they developed a schematic for how they viewed the evidence-based practice process, from asking a question to deciding whether to implement the clinical procedure.
As can be seen in this schematic, a search for evidence may lead to findings that, once evaluated, inform clinicians to either proceed with the procedure or not. Additionally, the schematic supports the careful use of theory-guided practice when there is no current evidence that substantiates or refutes the use of certain clinical procedures. What is important to note, and to practice, is that the process does not stop after the decision is made about whether to implement a procedure. As shown in the schematic, if an approach is implemented, clinicians can and should investigate whether the outcomes support previous research by either conducting the research themselves or pairing up with a researcher. If there is no evidence for the use of a procedure, or the evidence suggests the procedure should not be used, clinicians should continue to search for new evidence to support clinical work in the area of interest.
The department also constructed a worksheet for gathering the information that can inform decisions about whether to use certain clinical procedures. This worksheet, based on the work of other individuals and organizations with an interest in evidence-based practice, is used when department members review scientific literature. The worksheet allows a reviewer to document the source and purpose of a particular research study, and to identify and judge the appropriateness and relevancy of the participants involved in the study, the method used, the outcome measures chosen, and the significance of the results, including effect size. Once the worksheet is completed, the information then can be uploaded to a
department/clinic spreadsheet that is maintained on a shared server. As members add to this spreadsheet, the amount of evidence to support or refute the choice of certain clinical procedures grows.
'Til Death Do Us Part
The department is committed to increasing department members' and students' use and contributions to evidence-based practices. As the process emerged, for example, doctoral students were invited to observe and provide input to departmental members as they developed and assessed the tools they created for recording and sharing evidence that supported clinical practices. Additionally, some departmental members involved graduate students as they investigated clinical practices for the use of which there was little to no available evidence. Finally, members of the department intend to incorporate the process (worksheet and spreadsheet) into academic courses and clinical practica to further guide students in their understanding of the importance of evidence-based practices.
The call for evidence-based practices has been sounding for some time. For many in the profession, the call has not necessarily been answered. Perhaps it's time to acknowledge that the honeymoon is over and that clinicians should be using and contributing to evidence-based practices. The marriage of research and clinical practice should thus enjoy a long and happy life.