Evidence by proxy: How do healthcare practitioners engage with research?

Roman Kislov

Dr Roman Kislov talks about his research into implementation of evidence-based practice which he conducted with an international and interdisciplinary team of collaborators from Australia, Canada, Sweden and the UK. This work has recently received the prestigious William E. Mosher and Frederick C. Mosher Award which is presented by the American Society for Public Administration to the authors of the best research article published in Public Administration Review in the previous year.

Nowadays, there is an expectation that healthcare practice should be informed by the best available scientific evidence about the effectiveness of the interventions used. Clinical guidelines, which summarise this research evidence, are widely seen as a cornerstone of evidence-based healthcare. However, our work shows that the reality of evidence-based practice is more complex and nuanced than this.

In our study, we found that most frontline nurses did not directly consult clinical guidelines but relied instead on various shortcuts to evidence, which we call ‘evidence by proxy’. These shortcuts, which were only informed by research evidence partly or indirectly, included performance standards, organisational policies and procedures, and local data.

This has both positive and negative consequences. On the one hand, different complementary forms of ‘evidence by proxy’ are extremely useful because they make research evidence more ‘digestible’, enable its application to unique local contexts and, in some cases, help to incorporate elements of quality improvement.

On the other hand, there is a risk that over-reliance on such shortcuts, most of which are produced by a small group of senior clinicians, can lead to the ‘dumbing down’ of frontline practitioners and jeopardise clinicians’ critical thinking. We also found that the transfer of information from a clinical guideline to various forms of ‘evidence by proxy’ is highly selective, and may lead to prioritising certain patient populations or clinical variants of a condition at the expense of others.

In order for it to be used in actual practice, research evidence usually has to be simplified, contextualised and reinforced. As a result, it ends up being transformed. This key finding, observed in all of the four countries taking part in the study, has several practical implications:

• Firstly, implementation of research evidence may be enhanced by multi-level change interventions, deploying different tools, techniques and forms of evidence to engage with both frontline and ‘elite’ professionals and to minimise the loss of information involved in the process of transforming evidence.

• Secondly, moving from over-reliance on evidence by proxy towards embracing the basic principle of “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” would require making the development of fundamental competencies of evidence-based practice a key component of continuing professional education.
• Finally, executive and senior clinical leaders need to balance external regulatory requirements with internal processes and infrastructure in order to create an evidence-based culture and encourage critical thinking at the level of frontline practice, with the ultimate aim that all patients receive care informed by best available evidence as well as their needs and preferences.

Date Published: 17/02/2020