Editorial Introduction: Evidence Based Practice How do we know i f what we do works? This ques­tion is a central concern to practitioners and re­searchers focused on the notion o f evidence based practice (E B P ). Since its introduction in the 1990s, many disciplines, especially in medicine and related health care professions, have embarked on a drive toward creating an evidence base to argue for their clinical decision-making. This volume o f the South African Journal o f Communi­ cation Disorders (S A JC D ) contains a focus on E B P and speech-language therapy and audiology. Three short, invited, opinion articles are shared for con­ sideration by this Journal’s readership. All three articles are written by editors o f professional speech pathology and/or audiology journals. P ro f Sharynne M cL eod (Australia) is editor o f the International Journal o f Speech-Language Pa­ thology. D r G eetha Mukundan (India) is editor o f the Jour­ nal o f the Indian Speech and Hearing Association and D r Laura Justice (United States o f America) is editor o f the American Journal o f Speech-Language Pathology. Laura Justice, P h .D ., is Professor in the School o f Teach­ ing and Learning at The O hio State University. In this role, Justice has appointments to the P h .D . areas o f Reading/ Literacy as well as Early Childhood and teaches doctoral courses on such topics as research methods and reading dif­ ficulties. D r Justice also directs the Preschool Language and Literacy Lab, a research lab in which a multidisciplinary staff conducts large-scale empirical studies o f child learning and development within various contexts, with a primary fo­ cus on children at risk. D r Justice is presentiy the E d itor o f American Journal o f Speech-Language Pathology, and pri­ or to this she held such appointments as Founding Editor o f E B P Briefs and Associate Editor o f Language, Speech, and Hearing Services in Schools. She is an ad hoc member o f the American Speech-Language-Hearing Association (A SH A ) Publications Board and until recently was also a member o f the A S H A Advisory Com mittee on Evidence- Based Practice. In addition to engaging in regular writing activities concerned with evidence-based practice, D r Jus­ tice has written more than 100 articles and chapters on top­ ics o f relevance to learning and teaching in early childhood, and is the author o f 9 textbooks on similar topics, including Scaffolding with Storybooks (International Reading Asso­ ciation), Shared Storybook Reading (Paul H . Brookes), and Clinical Approaches to Em ergent Literacy Intervention (Plural Publishing). Geeta Mukundan, P h .D ., is the Head o f the D epart­ ment o f Speech-Language Pathology at the A .Y .J. National Institute for the Hearing Handicapped, M umbai in India. D r Mukundan is mainly involved in training Speech-Lan- guage Pathologists/Audiologists at graduate and postgradu­ ate levels and is a recognized guide for the P h .D . (Speech and Hearing) programme o f her affiliating University. She is active in several research and developmental activities, as­ sesses Indian professional training institutions for the pur- M e rs h e n Pillay E d ito r-in -C h ie f, U n iversity o f C a p e T o w n , S o uth Africa poses o f recognition o f various programs for bodies such as Rehabilitation Council o f India, State Governments and the affiliating Universities. D r Mukundan also serves as Chair­ person o f the Scientific Com m ittee o f the Indian Speech Sc Hearing Association (IS H A ) and is Editor o f IS H A ’s jour­ nal. Sharynne M cLeod, P h .D ., is Associate Professor in Speech and Language Acquisition at Charles Sturt Univer­ sity, Australia. She is the current Editor o f the International Journal o f Speech-Language Pathology. She also serves as V ice President o f the International Clinical Linguistics and Phonetics Association and is a Fellow o f both the Am eri­ can Speech-Language-Hearing Association (A SH A ) and Speech Pathology Australia. Across their opinion articles, all authors refer to the E B P processes o f making clinical decisions with reference to pro­ fessional, clinical research; to clinical expertise and/or own experience, and to the inclusion o f clients/patients’ in their own clinical decision making. Justice and M cL eod make reference to Sackett, Rosenberg, Gray, Haynes and R ich ­ ardson (1996) who are credited with coining the popular definition o f evidence based medicine that has given rise to E B P (Sackett, et al, 1996:71): “E viden ce based medicine is the conscientious, explicit, a n d judicious use o f current best evidence in m aking decisions about the care o f in dividu al patients. The practice o f ev i­ dence based medicine means integrating in dividu al clinical expertise w ith the best a v a ila b le extern al clinical evidence fr o m systematic research. By in d iv id u al clinical expertise w e mean the proficiency a n d ju d g m en t th at in dividu al clini­ cians acquire through clinical experience a n d clinical practice. Increased expertise is reflected in many ways, bu t especial­ ly in more effective a n d efficient diagnosis an d in the more thoughtful identification a n d compassionate use o f in d iv id ­ u al p a tien ts’ predicaments, rights, a n d preferences in m ak­ ing clinical decisions about their care. By best av ailab le ex­ tern al clinical evidence w e mean clinically relevant research, often fr o m the basic sciences o f medicine, but especially fr o m p a tie n t centred clinical research into the accuracy a n d p reci­ sion o f diagnostic tests (including the clinical exam ination), the p o w e r o f prognostic markers, a n d the efficacy a n d safety o f therapeutic, rehabilitative, a n d p rev en tiv e regimens. E x ­ tern al clinical evidence both invalidates previously accepted diagnostic tests a n d treatments a n d replaces them w ith new ones th at are more pow erful, more accurate, more efficacious, a n d safer. ” The prime driving force for E B P has been rapid health care reforms in economically developed countries such as the Author Contact: School o f Health and Rehabilitation Sciences Faculty o f Health Sciences, F45 - Old Main Building Groote Schuur Hospital, Observatory 7925 Cape Town, South Africa Tel: +27 31 2611077 E-mail: mershen@hotmail.com 4 DIE SU ID -AFR IKA AN SE TY DSK R IF VIR K O M M U N IK A S IE -A FW Y K IN G S , V O L 55, 2 0 0 8 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) mailto:mershen@hotmail.com United Kingdom, the United States o f America and Aus­ tralia. As part o f these countries’ economic constraints, it has become vital for professions to prove their worth rela­ tive to economic concerns. In South Africa, the situation is no different albeit within a focus on the provision o f basic health care services. Indeed, in its fourteenth year o f democ­ racy, post-Apartheid South Africa remains strongly focused on establishing basic health, social and education services to the majority o f its citizenry. During the South African pol­ icy euphoria o f the early 1990s, one o f the first government policy documents to refer to E B P was the W h ite Paper for the Transformation o f the Health System in South Africa (Department o f H ealth [D O H ], 1997). As part o f an inte­ grated strategy for organizing and managing health-related research o f Essential National H ealth Research (E N H R ), it was emphasized that the research agenda should initiate a process involving “scientist decision-making” and popu­ lation representatives to serve as equal, inclusive partners (D O H , 1997). This strategy has been reiterated in sev­ eral later policies including the H ealth Research Policy in South Africa (D O H , 2 0 0 1 ). W h ile the policy context sup­ ports E B P, South African audiology and speech pathology practitioners’ involvement in E B P may best be described as confined to the realms o f academic interest. Currently, one will be hard-pressed to locate focused E B P publications for consumption by SA practitioners. In considering the American perspective, D r Justice ar­ gues for practitioners to further develop what she has re­ ferred to as structures (such as systematic reviews and meta­ analyses, treatment studies, and clearinghouses) so as to bolster the evidence base that ought to drive practice. Jus­ tice’s reference to ‘craft-based’ versus ‘evidence-based’ deci­ sion making models represents the broader discomfort typi­ cal o f most professions who have begun to consider their praxis. In the mainstream, audiology and speech-language pathology practitioners share this interest toward gather­ ing evidence to support their practice with their colleagues in medicine, dentistry, nursing, social work, psychology and in the other therapeutic disciplines such as physiotherapy. These disciplines hjave each defined and interpreted, some­ times subtly, what E B P means to their practice. For exam­ ple, in M ary Law ’S jE B P text for rehabilitation practitioners she has highlighted the notion o f ‘creativity’ (Law, 20 0 2 ) as essential for use in relation to practice realities. Additionally, Jane Gilgun - in divulging the parallels between qualitative research and E B P - has strongly advocated for a focus on the practitioner as a ‘person.T his person-centred focus on the practitioner is offered as a fourth component o f E B P - specifically highlighting what practitioners can, and can­ not, provide fully and ethically (Gilgun, 2 0 0 6 ). Therefore, disciplinary/professional foci and geo-political contexts, as may be noted within all three opinion articles, prescribe the nature o f E B P within audiology and speech-language ther­ apy. Continuing this train o f thought, D r Mukundan pro­ vides a review o f how E B P has developed within the Indian context. Interestingly, Mukundan argues that Indian prac­ tice cosmology lends itself to the study o f human behavior in holistic (versus reductionistic) frameworks. In referenc­ ing E B P to contexts where high case-loads place unrealistic demands on practitioners she questions the applicability o f E B P for all practice settings. Finally, M cL eod provides an examination o f how Aus­ tralian researchers and practitioners not only interact with data from their own practice sites but also with research from other countries. Particularly appealing in M cL eo d ’s review is her suggestion to consider the client’s voice within E B P In as much as it is relevant for Australian (and other) contexts, South African practitioners too have to configure the subjective nature o f clients’/patients’ stories o f disorder relative to their pursuit o f empirical, objective evidence. Similar dilemmas were discussed with reference to the development o f relevant research for South Africa in the editorial lead article o f last year’s volume o f the S A JC D (Kathard, et al., 20 07). Deliberations about what constitutes good’ research, may also be applied when considering what constitutes ‘good’ EBP. Predictably, the quantitative-qualita­ tive dichotomy has been raised (see for example, proceedings o f conferences such as the Qualitative Evidence Based Prac­ tice conference, 20 0 1 ; Goldsmith, Bankhead 8c Austoker, 2 0 0 7 ). Law (2002) has discussed myths/ realities pertaining to E B P such as that it is based on “cookie-cutter” medicine, and that it is no more than cost-cutting mechanisms to be reinforced by methods like randomized control trials. These, and other issues remain unchallenged as part o f a deeper epistemological debate that reflects what may be referred to as a crisis o f knowledge (Sm ith, 2 0 04). This so- called crisis, relevant to EBP, may be due to a heavy reli­ ance on technically-oriented, scientific (empirical) methods. Peers, e.g. Social W ork practitioners (see Trinder 8c Rey­ nolds, 20 0 0 ) question the kind o f science used when under­ standing evidence to develop practice within inter-subjec­ tive phenomena such as therapeutic contexts and complex phenomena such as human communication and its disor­ ders. Audiologists and speech-language therapists may wish to critically engage E B P by considering questions such as those listed below: Are the kinds o f evidence required to diagnose cancer, liver disease or cardiac arrhythmia valuable for diag­ nosing the lived experience or clinical phenomena o f hear­ ing disorders, aphasia, phonological processes and suchlike? W h a t is valid evidence? W h o decides what this is? Does the patient/client have a role in this process? C an we unequivocally identify the “thing that made the difference” when we look at complex therapies and rich interactions? Is good audiology/speech-language therapy the re­ sult o f a competent, ethical, hard working practitioner? O r does good practice result from the theory driving her/his work? Is E B P developing practice in audiology and speech-language therapy toward being more ordered, pre­ dictable and technically sound? I f so, do we risk minimizing its complexities and phenomenology? It is hoped that the following articles provide inspira­ tion, stimulate debate and develop practitioners’ engage­ ment with E B P in South Africa. TH E S O U T H A F R IC A N J O U R N A L O F C O M M U N IC A T IO N D ISO RD ER S, V O L. 55 2 0 0 8 | 5 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) References Department of Health (1997). The White Paperfor the Transforma­ tion o f the Health System in South Africa. Pretoria: South Afri­ can Government Printers. Department of Health (2001). Health Research Policy in South A f­ rica. Pretoria: South African Government Printers. Gilgun, J. (2006). The four cornerstones of qualitative research. Qualitative Health Research, 1 6 ,3,436-443. Goldsmith, M .R, Bankhead, C.R. 8c Austoker, J. (2007). Theory and Methods: Synthesising Quantitative and Qualitative Re­ search in Evidence-Based Patient Information. Journal o f Epi­ demiology and Community Health, 6 1,262-270. Kathard, H., Naude, E., Pillay, M. 8c Ross, E. (2007). Lead Ar­ ticle: Improving the Relevance of Speech-Language Pathology & Audiology Research and Practice, SAJCD, 54-55. Law, M. C. (2002). Evidence Based Rehabilitation: A Guide to Prac­ tice. Thorofare, NJ: Slack. Qualitative Evidence Based Practice: Taking a Critical Stance (2001). University of Coventry, Leeds: UK. Retrieved Au­ gust 16, 2008 from http://brs.leeds.ac.uk/~beiwww/BEIA/ qebp2001 ,htm#titl. Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., 8c Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn’t: It’s about integrating individual clinical ex­ pertise and the best external evidence. British Medical Journal, 312,71-72, Smith, D. (Ed.). (2004). Research Highlights in Social Work 45: So­ cial Work and Evidence-Based Practice. London: Jessica Kingsley Publishers. Trinder, L. 8c Reynolds, S. (Eds) (2000). Evidence-Based Practice: A Critical Appraisal. London: Blackwell Science. Walker, B.B. 8c London, S. (2007). Novel tools and resources for evidence-based practice in psychology. J Clin Psychol, 63, 633- 642. 6 | DIE SUID -AFR IKA AN SE TYDSKRIF VIR K O M M U N IK A S IE -A FW Y K IN G S , VOL. 5 5 ,2 0 0 8 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) http://brs.leeds.ac.uk/~beiwww/BEIA/