By Robert Mullen, Director, National Center for Evidence-Based Practice in Communication Disorders, ASHA
Evidence-based practice (EBP) has emerged as an important principle in the delivery of speech-language pathology and audiology services in the past decade. ASHA uses the following definition of EBP: the integration of research evidence with practitioner expertise and client preferences and values into the process of making clinical decisions. Note that although this is referred to as "evidence-based" practice, the roles of clinician expertise and client preferences and values are equally important. The notion that external research evidence somehow "trumps" all other considerations is one of the big myths surrounding EBP.
In 2005, ASHA's Coordinating Committee on EBP laid out the following framework for incorporating EBP into speech-language pathology and audiology practice.
In making clinical practice evidence-based, audiologists and speech-language pathologists:
These concepts provide both opportunities and challenges for providers of continuing education (CE).
In 2005, ASHA's National Center for Evidence-Based Practice in Communication Disorders conducted a Knowledge-Attitudes-Practices survey of ASHA members. As you can see from the table below, CE plays a very important role in shaping clinical practice.
|Resources Cited by Clinicians as Useful in Making Clinical Decisions|
|Resource||% of respondents|
|Practice guidelines/policy documents||12%|
With the importance of the role of CE comes some challenges. In fact, another question on the survey asked respondents to identify the most significant barriers to their ability to engage in EBP (see table below).
|Barriers Cited by Clinicians as Somewhat or Greatly Limiting Their Ability to Engage in EBP|
|Barrier||% of respondents|
|Cost of continuing education||59%|
|Lack of evidence||53%|
|Evidence irrelevant to clinical practice||48%|
|Lack of supervisory support||47%|
|Limited access to continuing education||43%|
|Difficulty interpreting scholarly literature||40%|
|Lack of access to scholarly literature||17%|
It is clear, then, that CE plays a large role in clinical decision making, a role that could be even larger were it somehow made more accessible and more affordable.
What exactly is it that audiologists and SLPs want from CE offerings? To some extent, they want help in obtaining some of the skills needed to deal more confidently with the research evidence part of the triangle. This same survey found that only 8% of master's level clinicians felt confident that they could identify the study design in a scholarly journal article, 12% felt confident that they could assess the quality of a journal article, and 24% felt confident in their ability to find evidence using an Internet search engine such as Medline.
To an even greater extent, however, SLPs and audiologists want information about effective practices. For audiologists and for health care-based SLPs, that most often means learning treatment techniques. In 2005, when asked which clinical questions were most in need of more evidence, audiologists tended to cite the question of analog versus digital hearing aids, or of the effectiveness of directional microphones. Among SLPs, the interest was in the extent to which emerging treatment approaches such as electrical stimulation (E-stim) and nonspeech oral-motor exercises were effective for which clients under which circumstances.
School-based SLPs were less interested in specific treatment techniques and more interested in what are the best ways to deliver treatment. Topics related to frequency and intensity of treatment and of individual versus group and pull-out versus other models of treatment predominated. When the question is asked again in 2008, topics related to response to intervention (RTI) are likely to be very popular.
The final challenge to CE providers is that ASHA is trying to help develop a generation of clinicians who will prove to be a tough audience. Whether it is at the ASHA Convention, a state association meeting, a teleconference, or any other venue where CE offerings are available, ASHA is encouraging clinicians to be discriminating consumers of CE. In particular, ASHA is encouraging clinicians to consider the extent to which the information that is being given is-or isn't-based on scientific evidence.
This is not to say that there is some threshold of evidence needed on a topic before it should ever be part of a CE offering. CE clearly has a valuable role in the growth of the discipline and in the emergence of new treatment and diagnostic techniques. To stifle innovation in the name of EBP would be a serious step backward for the discipline. What is important, however, is transparency. Whether what is being taught has a bevy of clinical trials supporting its efficacy, or whether it is at the point of a really good idea that the presenter thinks could work, that needs to be made clear to the audience. If it's not clear, the audience needs to demand to know.
For most CE providers, this won't represent anything new. For the others, this new world of EBP will necessitate some changes in order to be able to take advantage of the additional demand for CE offerings brought about by EBP.