Evidence Based Behavioral Practice (EBBP): An Exemplar of Inter-professional Collaboration

Abstract

In this department, Dr. Newhouse highlights hot topics in nursing outcomes, research, and evidence-based practice relevant to the nurse administrator. The goal is to discuss the practical implications for nurse leaders in diverse health care settings. Content includes evidence-based projects and decision-making, locating measurement tools for quality improvement and safety projects, using outcome measures to evaluate quality, practice implications of administrative research, and exemplars of projects that demonstrate innovative approaches to organizational problems. In this article, the author describes an inter-professional initiative to develop a model of evidence based behavioral practice, define basic competencies, and provide tools and resources to foster capacity to use research findings across professional boundaries in behavioral practice.

Inter-professional collaboration is essential to deliver unified, cohesive, patient care (1, 2) yet our work in evidence-based practice is often profession specific, without exchange of theories, models, or tools in a unified approach focusing on a specific patient outcome. Efforts of each individual profession are grounded in specific knowledge, value and belief systems, with resulting variations in forms of and values for specific types evidence. (3) Social boundaries result in poor diffusion across professions. (3) This status quo is intolerable if we are to advance the quality of care for patients in all settings.

Consider a patient requiring treatment for depression. Providers of care may include a clinical psychologist, psychiatrist, nurse practitioner, social worker, and Registered Nurse (RN) case manager. Treatment may be provided by a team if individual providers who use evidence specific to their professional domain, but may or may not access evidence from partner professions. Use of best evidence across professions by an inter-professional group will result in comprehensive guidelines for best practice.

Council on Evidence-Based Behavioral Practice

Under the leadership of Dr. Bonnie Spring, Principal Investigator, The Council on Evidence-Based Behavioral Practice (EBBP) was formed to collaborate, learn about discipline specific evidence-based practice, and create training resources for behavioral practice. The project is supported by National Institute of Health's (NIS) Office of Behavioral and Social Sciences Research (OBSSR). Council members represent the professional domains of medicine, nursing, psychology, social work, and public health (Table 1).

Table 1.

Members and Affiliation of the Evidence Based Behavioral Practice (EBBP) Council

Council Member	Professional Affiliation
Council Chair: Bonnie Spring, PhD	Director of Behavioral Medicine & Co-Program Leader in Cancer Prevention, Department of Preventive Medicine, Northwestern University, Chicago, IL
Associate Chair: Barbara Walker, PhD	Department of Psychological and Brain Sciences, Indiana University Bloomington, IN
Ross Brownson, PhD	Director, Prevention Research Center, Department of Community Health, Division of Epidemiology, St. Louis University, St. Louis, MO
Edward Mullen, DSW	Willma & Albert Musher Chair Professor, School of Social Work Columbia University, New York, NY
Robin Newhouse, PhD, RN	Assistant Dean, Doctor of Nursing Practice, School of Nursing University of Maryland, Baltimore, MD
Jason Satterfield, PhD	Director, Behavioral Medicine Unit, School of Medicine, University of California San Francisco, San Francisco, CA
Evelyn Whitlock, MD, MPH	Director for Research–Healthcare Integration, Kaiser Permanente Center for Health Research, Oregon Evidence-Based Practice Center Oregon Health Sciences Center, Portland, Oregon
Kristin Hitchcock, MSI	Department of Preventive Medicine, Northwestern University Chicago, IL

The overall aim of the project is to create an integrated EBBP that supports collaborative implementation of evidence-based health practices at the individual, community and population levels. (4) Specific goals of the project are included in Figure 1. To date, the Council has reviewed the progression of evidence-based practice in each profession, developed an integrated conceptual model and process for EBBP, authored a white paper describing the work which has been reviewed by stakeholders, constructed a website for pubic assess to the groups work and shared resources, and reviewed draft web based training to build the skills knowledge and abilities for providers engaged with behavioral health.

Figure 1.

Goals of Evidence Based Behavioral Practice

Conceptual Model and Process

The EBBP model uses an ecological framework, with decision making at the core of the model. (4) An ecological framework posits that by influencing multiple levels (interpersonal, organizational, community, and public policy), health is affected. Patient centered care and interprofessional collaboration are a basic tenet. Heath care decisions are a product of the best research evidence, practitioner expertise, resources, and patient state, needs, values and preferences. These decisions are made within a context or environment (such as a practice, unit or organization), which influence decision-making. Examples of these contextual variables include infrastructure (i.e. access to web-based resources or evidence), business agreements, state regulatory requirements, relationships or teamwork with collaborators or stakeholders. The process specified to answer a behavioral health question includes 5 steps: Ask, Acquire, Appraise, Apply, Analyze/Adjust. Providers who engage in EBBP possess 3 broad sets of skills: assessment, communication/collaboration, and engagement/ intervention.

Website and Education

The website is a source of education and information about the progress of the EBBP Council's work, providing competencies, documents, a publication list, and links to resources from multiple sources and professions. Council members provide video clips that are available for viewing, which discuss the origin, perspectives, issues and trends in each profession. Educational modules are in development and will be publicly available when completed.

The Insiders View

There were a number of insights gained through participation in the EBBP Council. The most striking were the profession specific perspectives of each member, the language we used, and the resource base that we draw from.

At the first Council meeting, members presented the state of evidence-based practice in each profession. It was clear that there are profession specific opinion leaders who have championed efforts to improve the link between research findings and practice application. The development of specific models, and tools in each profession support the scope of practice of providers. Differences exist between professions in the definition of evidence, how to frame a question, models and the level of interest (i.e. patient or population). All agree that the basic process includes asking a question, searching the best evidence, appraising the evidence using a rating and grading scale for individual and overall evidence, making recommendations, implementing recommendations and evaluating outcomes.

Each Council member uses profession specific language, terms and approaches to research-requiring the group to come to common definitions and meaning. For example, what is evidence? Public health research is grounded in epidemiology, with designs often reflecting natural experiments such as case-control design or cohort studies. randomized controlled trials (RCT) are conducted in medicine to test the effectiveness of interventions. Nursing uses multiple designs, incorporating experimental, non-experimental and qualitative approaches. Evidence for practice decisions are often generated through quality improvement processes, yet the data generated are often not included as evidence by other professions. Language used is rooted in each disciplines science, education and training.

The third insight was the availability of resources in each profession. There are diverse tools, training, and expertise specific to each profession. Without knowledge of these resources, each profession continues to work in isolation. The EBBP website provides links to resources from multiple professions, improving their availability and use.

Conclusion

Evidence-based practice is core to all health care professional practice and all academic programs that prepare health care professionals including nurses, physicians, social workers, and clinical psychologists. Despite the clear need to work together for a common patient centered goal, professions tend to approach improvements in care by setting boundaries around their scope specific activities. Profession specific patient goals are important, but must also be integrated into unified action.

In a recent review of inter-professional collaboration, the majority of studies (9 of 14) support positive outcomes associated with better inter-professional communication. (5) Authors propose that a shared evidence base among professions, of which all are aware, will result in detection and interception of decisions that lack an evidence base by other inter-professional team members. (5) The health care team must serve as the patient's safety net, holding each other to evidence based standards in an integrated approach.

The EBBP Council's work exemplifies an inter-professional effort to promote a shared evidence base. Nursing leaders in both practice and academia will need to focus efforts to prepare nurses with the skills, knowledge and abilities to fully engage in patient, population, organizational and public health forums that promote evidence-based inter-professional decision-making. The potential to affect improvements in the quality of care delivered through interdisciplinary teams informed by evidence is the opportunity of the decade.

Biography