title: A review of evidence-based practice, nursing research and reflection: levelling the hierarchy.
abstract: OBJECTIVE
  This paper examines the evidence-based practice movement, the hierarchy of evidence and the relationship between evidence-based practice and reflective practice.
  
  
  BACKGROUND
  Evidence-based practice is equated with effective decision making, with avoidance of habitual practice and with enhanced clinical performance. The hierarchy of evidence has promoted randomized control trials as the most valid source of evidence. However, this is problematic for practitioners as randomized control trials overlook certain types of knowledge that, through the process of reflection, provide useful information for individualized and effective practice.
  
  
  METHODS
  A literature search was undertaken using CINAHL, medline and Ovid electronic databases in early 2006. The search terms used were: evidence-based practice, research evidence, evidence for practice, qualitative research, reflective practice, reflection and evidence. Other sources included handpicking of books on evidence-based practice, reflection and research. Only material written in English was included.
  
  
  RESULTS
  The hierarchy of evidence that has promoted randomized control trials as the most valid form of evidence may actually impede the use of most effective treatment because of practical, political/ideological and epistemological contradictions and limitations. Furthermore, evidence-based practice appears to share very similar definitions, aims and procedures with reflective practice. Hence, it appears that the evidence-based practice movement may benefit much more from the use of reflection on practice, rather than the use of the hierarchical structure of evidence.
  
  
  CONCLUSIONS
  Evidence-based practice is necessary for nursing, but its' effective implementation may be hindered by the hierarchy of evidence. Furthermore, evidence-based practice and reflection are both processes that share very similar aims and procedures. Therefore, to enable the implementation of best evidence in practice, the hierarchy of evidence might need to be abandoned and reflection to become a core component of the evidence-based practice movement.
  
  
  CONCLUSIONS
  Provides an elaborated analysis for clinical nurses on the definition and implementation of evidence in practice.
authors.affiliation: Institute of Health & Human Sciences, Thames Valley University, London, UK. smantzoukas@hotmail.com
authors.forename: Stefanos
authors.initials: S
authors.lastname: Mantzoukas
mesh_terms: D001291:Attitude of Health Personnel; D002983:Clinical Competence; D003657:Decision Making; D003661:Decision Support Techniques; D004059:Diffusion of Innovation; D019317:Evidence-Based Medicine / Q000458:organization & administration*; D006801:Humans; D033181:Information Dissemination; D019359:Knowledge; D016294:Models, Nursing; D024802:Nurse's Role / Q000523:psychology*; D009736:Nursing Process / Q000458:organization & administration*; D015399:Nursing Research / Q000458:organization & administration*; D009937:Organizational Objectives; D010687:Philosophy, Nursing; D033302:Postmodernism; D036301:Qualitative Research; D016032:Randomized Controlled Trials as Topic; D012107:Research Design; D013850:Thinking