This past summer, ASHA conducted a Knowledge-Attitude-Practices (KAP) survey on evidence-based practice (EBP) among members. Most members could identify the definition of EBP. Most also thought that EBP was a good idea-it's just a shame we don't have enough time to actually do it.
One question asked respondents to go through a list of potential barriers to their ability to engage in evidence-based practice, and characterize each as a major, moderate, or minor barrier, or not a barrier. "Insufficient time" was cited as a major or moderate barrier by over 70% of respondents, more than any other barrier.
The time crunch was felt most acutely by clinical service providers: 81% of speech-language pathologists cited insufficient time, as did 70% of audiologists. Among supervisors and administrators, 54% cited insufficient time as a major or moderate barrier, and among faculty the figure was 42%. A "lack of available evidence" was the most commonly cited barrier by supervisors/ administrators and faculty. Sixty-five percent of administrators/supervisors cited a lack of evidence. Among faculty, 69% of speech-language pathology faculty cited this barrier, compared with only 48% of audiology faculty. Nonetheless, it was still the most cited barrier in each group.
There are a number of possible explanations for the discrepancy in the responses from clinical service providers and other groups. One may be that clinical service providers feel that they have less ability to control how their time is spent. A second may be different perceptions among the groups as to what "engaging in evidence-based practice" truly means for them. Finally, attitudes toward the relative importance of EBP may explain some of the differences.
The figure on p. 14 (PDF format) shows the overall responses to the question of perceived barriers. In addition to insufficient time, the most frequently cited barriers were those related to the evidence itself (whether there simply was little or no evidence, the evidence was irrelevant to everyday clinical practice, and/or the evidence was conflicting) and to the cost of continuing education offerings.
Identifying the barriers is the easy part. But now that we know what they are, what can be done about them? We'll look at the three most frequently cited barriers and discuss how they might be overcome.
Time. There is very little published literature on this question specific to professionals in communication sciences and disorders. Much of what has been published comes from the field of primary care medicine. That literature suggests that anywhere from 0.3 to 0.7 clinical questions arise per patient encounter (Cogdill et al., 2000; Covell, Uman, & Manning, 1985; Dee & Blazek, 1993; Gorman & Helfand, 1995). One widely publicized study found that, of 1,102 clinical questions arising among "family doctors" during patient consultations, a total of two (!) resulted in the doctor conducting a formal literature search. Doctors in the study spent an average of one minute and 42 seconds pursuing an answer to each question (Ely et al., 1999).
Another study of primary-care physicians found that keeping current with the peer-reviewed literature in primary care medicine would take a physician 627.5 hours per month, or 21 hours per day seven days per week (Alper et al., 2004). Even though these findings were not from SLPs or audiologists, it is clear that a formal literature search for every clinical question that arises is not practical. In fact, what may be most interesting about the ASHA survey's findings is that there were 30% of respondents who did not feel that insufficient time was a major or moderate barrier.
The implication, then, for overcoming this barrier is that the evidence must either be bundled into a manageable package, or it will be ignored. A manageable package in this case likely means an evidence-based systematic review or a practice guideline. A systematic review is a formal assessment of the body of scientific evidence available on a clinical topic, whereas a practice guideline takes a systematic review and uses it to make recommendations about best clinical practice.
ASHA has produced a number of these in its Desk Reference, and the National Center for Evidence-Based Practice in Communication Disorders (N-CEP) is ramping up to undertake a series of new systematic reviews in 2006. A number of other organizations (e.g., the Academy of Neurologic Communication Disorders and Sciences, Cincinnati Children's Hospital, and others) have also developed some very high-quality systematic reviews and guidelines, and N-CEP is currently developing a searchable registry of these to be housed on the ASHA Web site by the end of this year.
Evidence. It is hard to do much about nonexistent, irrelevant, or conflicting evidence in the short term. The most obvious short-term solutions are the evidence reviews and guidelines mentioned above, as well as educational efforts to develop the critical skills of ASHA members to make sure that they are discriminating consumers of evidence, whether that evidence comes in the form of peer-reviewed literature, ASHA Convention or other continuing education offerings, or from any other source.
In the medium-to-long term, ensuring that the evidence that is generated in the fields of audiology and speech-language pathology is relevant to clinical practice and addresses the most pressing needs for evidence will require closer partnerships than currently are the norm between researchers and clinicians. Researchers will need to allow clinicians to have a voice in setting the research agenda, and clinicians will need to enroll their patients in research studies.
Cost of continuing education. The KAP survey mentioned above found that 50% of respondents reported being "very likely" to use continuing education offerings as a source of information to help make clinical decisions, second only to "colleagues" (68%). By contrast, only 37% were very likely to turn to the peer-reviewed literature and 25% to ASHA policy documents.
It is difficult to fully understand the role of continuing education (CE) costs as a barrier to evidence-based practice solely from this survey. Many of the most popular (and costly) CE offerings involve how-to instruction for specific treatment or diagnostic techniques.
One hears all too often clinicians saying they are "doing" evidence-based practice because they are delivering intervention X, and intervention X has been proven to work.
While delivering interventions that have been "proven" to work (but on whom? under what circumstances?) is generally a good thing, it is something short of evidence-based practice. The latter implies a thoughtful integration of scientific evidence, clinical expertise, and client perspective into the best possible clinical decision for an individual client.
Continuing education, of course, does have a vital role to play in helping ASHA members gain the skills necessary to identify and assess the quality of research. This year's ASHA Convention has the theme of "Using Evidence to Support Clinical Practice" and promises to be full of instructional sessions on some of these skills. In addition, N-CEP staff are trying to use the EBP section of the ASHA Web site both as a place to learn about these skills and for links to additional tutorials and resources.