Individual and organizational Uses of Evidence-Based Practice in healthcare settings

Abstract

In the three decades since its introduction, Evidence-Based Practice (EBP) has become standard clinical practice and the subject of targeted interventions at all levels of the health system. Despite its prevalence, EBP is frequently challenged on philosophical, practical, empirical, and normative grounds. And EBP is often underused in practice relative to the considerable investment in training and sophisticated organizational interventions to implement EBP. In this dissertation, I identify what the concept of EBP means to health system stakeholders as a partial explanation for this persistent gap in EBP use and implementation outcomes. Through interviews with clinicians and healthcare administrators, I identify how providers and organizations use EBP in practice to clinical ends and in inter-professional relationships. First, I find that in contrast to the theoretical model, stakeholders vary in how they operationalize EBP for individual-level clinical use.

Stakeholders endorse a range of what I call implicit mental models of EBP that imply different approaches to clinical decision-making. Respondents' implicit mental models of EBP each emphasize an incomplete aspect of the full EBP model: Resource-Based EBP emphasizes specific evidence artifacts, Decision-Making EBP emphasizes the decision-making process, and EBT-Based EBP emphasizes specific Evidence-Based Treatments. These implicit models represent the decision inputs, process, and outputs, respectively. Second, I describe how and why healthcare organizations conduct EBP interventions, despite its initial design as an individual-level clinical decision-making model. I document a range of different organizational EBP activities and interventions, including disseminating resources, training providers, and implementing local standards. These organizational EBP activities both support individual EBP use and address broader organizational ends, which may conflict.

Finally, EBP takes on social and inter-professional meanings beyond its intended scope as a clinical decision-making model, which emerge in context and affect how providers understand and use EBP. Specifically, providers may renounce their standing to evaluate evidence, demonstratively use EBP, and administrators claim standing to evaluate evidence. This dissertation therefore demonstrates the varied uses of EBP that emerge in practice, contributing to our understanding of the challenges and contradictions that arise in applying general knowledge to individual cases and systematizing strategies for the same at the organization level.