Evidence-based clinical decision-making: combining experience with data

Good decisions amount to safe care and improved patient and public health outcomes. For clinicians, they are critical to delivering best practice and the highest standards of medical care in healthcare settings.

Clinical decisions arise continuously in daily medical and healthcare practice. As the biggest staffing group within healthcare organisations, a great number of these decisions fall on nurses. Let’s look in more detail at evidence-based medicine (EBM) and evidence-based practice (EBP) in relation to decision-making, and what this means in practice for nurses and other healthcare professionals.

What are clinical decisions?

Medical and healthcare professionals will be required to make any number of decisions regarding a patient’s health and wellbeing journey during an interaction. How much medication should a patient receive, and which type would be most effective? What tests or scans should be requested? When do harms outweigh benefits? What could be done to improve quality of life at this moment? Is it time to seek a second, or third, opinion?

Clinical decisions exist on a spectrum: on one hand, some decisions are made quickly, grounded in intuition, and heuristic; on the other, they’re highly analytical, evidence-based and based on comprehensive reasoning. The former is more effective when large volumes of relatively simple decisions are required, and the latter where situations are complex, highly uncertain and carry greater weight of outcome. Decisions can also be short-term, for example patients visiting A&E with minor injuries, to long-term, such supporting internal medicine patients to manage lifelong conditions.

The foundation of clinical decisions is combining awareness, knowledge and experience with relevant assessment tools, evidence-based practice, information-gathering skills and the expertise of others.

The clinical decision-making process contains stages such as:

• using cues and gathering and analysing patient data in a systematic way
• making judgements
• making decisions
• evaluating outcomes.

Nurses are generally involved – either directly or indirectly – across all stages of the decision-making process. Whether operating in primary care, secondary care or other settings, they are tasked with making numerous decisions of their own, within the context of broader ones regarding patient care.

Rational diagnosis and evidence-based clinical decision-making

The British Medical Journal (BMJ) defines EBM as, ‘the application of the best available research to clinical care, which requires the integration of evidence with clinical expertise and patient values.’ EBM uses relevant, patient-orientated clinical research that takes into account:

• precision and accuracy of diagnostic tests
• prognostic markers
• safety and efficacy of therapeutic, rehabilitative or preventative healthcare strategies
• patient experiences.

In essence, it’s using scientifically proven, critically appraised evidence – based on the critical reading of medical journals – to provide medical care to a specific population.

The topic is covered in depth in Peter C. Gøtzsche’s seminal text, Rational Diagnosis and Treatment: Evidence-Based Clinical Decision-Making. Currently in its 4th edition, it advocates that, whenever possible, clinical decisions must be based on the evidence from clinical research.

Gøtzsche explores key aspects of evidence-based decision-making, such as:

• patient examination
• reliability of clinical data
• logic of diagnosis
• fallacies of uncontrolled experience and therapeutic alternative medicine
• need for clinical trials, including randomised controlled trials, placebos and meta-analyses
• insufficient reporting of harms of interventions
• advantages and limitations implicit in different research designs
• increasing medicalisation
• the difficulties and challenges posed by applying evidence from group studies to individual patients.

Overall, Gøtzsche highlights the nuance and methodology of balancing and integrating statistical approaches and scientific context with the humanism of real-world clinical practice. The best decisions are those made against a backdrop of data and knowledge, but with patient-focused, experiential wisdom and application.

What skills are key to clinical decision-making?

Effective decision-making requires medical and healthcare practitioners to combine specialist skills with experience. There are  a number of key skills that will support this approach:

• Pattern recognition. Where have you encountered similar symptoms? How does this fit in with the wider context of the patient’s health? For this disease classification, what has worked previously? Pattern recognition relies on learning from experiences and using learnings to enhance practice and support patients.
• Communication. Practising active listening skills helps to uphold a patient-centred approach that is at the heart of quality care. As well as listening to patients and colleagues, communication extends to sharing information and remaining mindful of the ways in which you are communicating in different situations.
• Knowing when to draw on evidence. Use the best practice guidelines, the relevance of clinical data and other available evidence available to inform clinical decisions. For example, practitioners could draw on resources such as the Cochrane Database of Systematic Reviews (CDSR), a database of high-quality, independent evidence that helps inform medical decision-making.
• Critical thinking. Examine assumptions, separate emotion from reasoning, evaluate evidence, clarify goals and remain unbiased and open-minded regarding care.
• Teamwork and collaboration. Seek help, advice and support from both colleagues and wider multidisciplinary teams to enhance patient care, and use your expertise to help them in return. Running decisions past others, where useful and relevant, is highly beneficial.
• Reflection. Taking the time to reflect on one’s own practice is critical to developing and improving future practice. This can include gathering feedback from others, reflecting on decisions – and reasons behind decisions – and learning from experience.

Each skill supports the synthesis of effective healthcare and clinical practice and offers a firm foundation from which to make both straightforward and more complex decisions in the interests of patients.

Are there barriers to the adoption of EBP?

While research into nurses’ attitudes towards EBP are broadly positive – more than 64% expressed their support of it – it also raised fundamental and systemic issues in its widespread adoption in practice.

Nurses cited reasons such as heavy workloads and the time constraints of keeping up-to-date with the latest evidence in the field. Even where time is available, difficulties in accessing clinical research – due to the inclusion of medical jargon and complex statistical terms – present issues.

Professional training, mentoring by nurses with EBP and EBM experience, and scheduled, ring-fenced time in which to study, will all go a long way towards encouraging nurses to implement the approaches in their practice.

Use clinical reasoning as the basis for high-quality care

Learn how to lead with person-centred practice to improve patient health, wellbeing and quality of life with Queen Margaret University’s online MSc Nursing programme.

This course is designed to enhance existing experience, skills and expertise across nursing practice, and further develop individuals as evidence-based, socially conscious and adaptable healthcare practitioners. Through flexible study that fits around your lifestyle and existing commitments, you’ll be supported to develop research in areas that interest you, and choose from topics spanning clinical judgements and decisions, interpreting evidence, supporting vulnerable individuals, families and groups, professional practice, reflexive practice, and more.