Evidence-based practice (EBP is the gold standard for cutting edge patient care and effective practice. Sackett et al.1 defined EBP as 'the integration of evidence with clinical expertise and patient values'. In reality, it is just not that easy to integrate evidence into practice. There may be several reasons for this. First, evidence is produced in large part through scientific research, most often conducted by scientists in academic roles with varying degrees of patient contact. Scientists are trained to be objective and to uncover truths by accumulating and evaluating evidence. Objectivity presents as a continuing cycle of posing questions, systematically answering those questions and publishing the results. The evidence for EBP is held in these publications. As a next step, a newer breed of clinical scholar/scientist may generate theoretical or clinical questions, search the literature using systematic processes to find and abstract evidence and synthesise evidence through formal meta-analysis or other systematic reviews. These scholars may work in teams composed of academic and clinical practitioners. The Joanna Briggs Institute (JBI) has developed strategies to assist individuals and teams in the systematic review of both quantitative and qualitative reports, and this is very important to understanding the whole picture in healthcare. The resulting reports, however, may or may not find a path directly into clinical practice. The individuals creating these synthesis papers serve clinicians in important ways, in that, the work of aggregating knowledge is done and should be more accessible for use in practice than single research reports. This issue presents four such reports, summarising: 'interventions that assist caregivers to support people with dementia living in the community', 'psychosocial spiritual experience of elderly individuals recovering from stroke', 'practices to control nosocomial MRSA in acute care' and 'psychometrics and expert opinion regarding assessment of faecal incontinence in older community-dwelling adults'. These reports are excellent, high-quality assessments of the state of the science related to these topics. As helpful as these reports are, other processes must occur before this knowledge can be translated into practice. Specific and detailed guidance should be provided prior to implementation.

JBI's Practical Application of Clinical Evidence System is instrumental in gauging the current practice against evidence-based practice. These processes guide clinicians in the use of findings from systematic reviews in their clinical practices, education and dissemination of practice changes (using the situational analysis, action planning and action taking outline in the Getting Research into Practice module) and evaluation of clinical practice. These approaches help to infuse findings of research into practice. Two papers reported in this issue used such approaches: 'to improve and ensure best practice in continence management in residential aged care', and 'advance care planning in an "ageing in place" aged care facility'. While awareness was raised and some practice improvement seen neither project produced the high level of response desired. The authors highlight the challenges of implementing change at the staff, patient and family levels and realise that change is an ongoing process.

Knowledge development and evidence synthesis are important to evidence utilisation, but this is a top down process. Knowledge is generated by a few, synthesised by small groups and disseminated to the large number of staff providing direct care. Those who are the recipients of knowledge may not be the same individuals who posed the original question. Thus, the role of educator, motivator and evaluator becomes important. What would happen, on the other hand, if a bottom up approach was used to knowledge? The approach described as practice-based evidence (PBE) focuses on questions generated by the interdisciplinary practice team and seeks answers from patient records.

Dr Susan Horn,2 a health services researcher, developed PBE as a clinical practice improvement research strategy and has completed more than 20 large studies using this approach. PBE research questions originate with clinicians of all disciplines in collaboration with researchers and statisticians. Data are collected prospectively and/or retrospectively and focus on patient variables, processes of care and outcomes important to many stakeholders. Data are analysed using sophisticated analytic strategies and discussed with the large investigative team. As an example, instead of testing the efficacy of one dressing versus another, it is possible to also add other processes of care to the equation. The end result may be the discovery of the effectiveness of many of the processes of care in a briefer time frame than required for RCTs. The approaches to PBE are novel, thought provoking, and described in more detail in the manuscript referenced above.

As a parting thought, electronic health records are beginning to emerge and will soon be state of the art. This new technology will set the stage for better documentation and storage of data. Once data are stored, they will need to be retrievable, and many new approaches to data and knowledge generation will unfold. The Council for the Advancement of Nursing Science, an organisation of the American Academy of Nursing, sponsored a work shop entitled, 'Practice-Based Evidence: Another Side of the Knowledge Development Coin', during the Fall of 2007.3 PBE approaches were discussed as another paradigm for studying and evaluating the effectiveness of our practice, for posing and answering questions with thousands of cases from diverse patient populations. PowerPoint presentations are available on the Internet site http://www.nursingscience.org/i4a/pages/index.cfm?pageid=3301. Randomised, controlled trials will remain the gold standard for many questions of efficacy. Other approaches need to be used to determine the effectiveness of practice and this may be an area that has been neglected. Searching for approaches to knowledge that moves from the bottom up may improve practice in new and important ways.

Nancy Bergstrom PhD RN FAAN

Theodore J. and Mary E. Trumble Professor of Aging Research and Director, Center on Aging, The University of Texas School of Nursing at Houston, Houston, Texas, USA

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