This post was written by Ravi Ladani as part of the final assignment for the module EDM122 at City, University of London

Evidence based practice (EBP) is a foundational cornerstone in my working life as an optometrist, as it is for all healthcare practitioners. In my role as a lecturer, it is a skill I (and my colleagues) teach, as well as it influencing the content that I teach. When learning about open practices, I was intrigued by the impact that open access could have on EBP, not only in optometry but in healthcare as a whole.

What is EBP and open access?

Evidence-based practice (EBP) in healthcare involves the combination of clinical expertise, patient’s values, and the best evidence to inform clinical decision making to provide the best clinical outcome or management for a patient¹. Fundamental elements to employ best evidence are the ability to search and synthesise information, but importantly how available is the best information, i.e. is it accessible².

Open access is defined by the Joint Information Committee Systems (JISC) as “making research publications freely available so anyone can benefit from reading and using research”³.

So why is open access important for EBP?

It is useful to consider what we mean by “best” and “available” evidence. Traditionally, knowledge has been imparted via textbooks and lectures. However, these mediums are quickly outdated⁴. They are still valuable tools to provide theoretical and foundational knowledge, but do not provide the most recent knowledge, and therefore not the best knowledge.

Research articles allow the most up to date research to be published, which is a vital step to EBP⁵, but this leads to the consideration of access. When I now reflect on how I have accessed research in my career to date, there are two distinct time periods. Since becoming a lecturer, I have had the privilege of accessing a large range of articles and databases via an institutional login.

Studies have shown that most peer-reviewed research has traditionally been published in subscription based journals⁶, and that having institutional access allows access to 75% of articles that would not otherwise be available unless one was willing to pay for them⁷. The reason for this is due to the extreme costs associated with subscription⁸.

Healthcare practitioners that do not have access via an institution, as was the case for myself earlier in my career, are faced with theses subscription costs or paywalls⁶. Subscription costs are unfortunately expensive, Furthermore, should the article not actually be what the practitioner was after, refunds cannot be requested⁵.

To me, this highlighted some obstacles to EBP. Firstly, by holding information behind a fee, the availability of the “best” research is reduced, therefore limiting the pool of evidence that a practitioner would ideally need to make the best clinical decision. An article published in the British Medical Journal (BMJ) showed that open access publications received 89% more full-text downloads, 42% more PDF downloads and 23% more unique visitors⁹, highlighting the link between open access and availability. This issue is exacerbated for practitioners in low income countries. However, many publications will be made accessible to countries in low income countries, but raises the question of how well known it is.

Secondly, students benefit from institutional access whilst studying at university. We teach students how to access the information, how to reinforce there studies with the latest research, and how to use this research and evidence to inform their clinical decision making. Once a student has left education, they have lost a significant amount of resource, and their knowledge as a result can potentially become quickly outdated too.

Thirdly, an element of EBP is the patient’s values and decisions. Some patients may choose to search for evidence themselves. They face the same issues that healthcare practitioners have with access, but they also potentially could be faced with another problem. Should the practitioner have access to more recent research than the patient, the patient maybe conflicted with what information to use. However, should all evidence be open access, patients and practitioners will have access to the same information and therefore patients will have more confidence in the evidence (as they can find it themselves should they wish).

However, publishing an open access article does not guarantee the reader will have addressed the availability issues completely. JISC highlights two types of open access publishing: Gold and Green open access³.

Gold access allows the fully published article to be immediately available without the requirement of a fee or subscription by the viewer. This allows the latest research to be made available immediately, but there is an article processing fee (APC) instead that the researcher must pay which can be expensive and therefore a potential barrier.

Green open access involves fully published articles being made available under a subscription based model, but also allows accepted manuscripts to be uploaded or self-archived in a repository. This can involve an embargo, that once expired allows the fully published article to be made freely available. This has the advantage of not involving an APC. The disadvantage it has is that repositories can be less discoverable, and therefore if an embargo is in place, it limits the availability of the article until the embargo has ended. This means that as healthcare professionals, it is important that we are equipped with the digital literacy skills to find these studies on resources such as Google Scholar, and as educators we provide our students with the required skills.

The BMJ also identifies another model – “Diamond” or “Platinum”¹⁰. This involves fully published articles being made immediately available without a direct publishing fee. This would allow the most recent evidence to be most freely available and therefore has the potential to be most useful to EBP.

Another factor to consider with open access and EBP, is what else can be done with the research, other than provide clinical evidence as soon as possible to all. JISC identifies the importance of allowing the research to be re-used³. Open access has the potential to accelerate research, provide stronger evidence in the form of systematic reviews, provide more enhance and up to date clinical management guidelines and highlight more quickly further areas of research⁵. The move to open access can therefore promote EBP and better research, which therefore promotes open access, thus acting in a self-propelled mechanism.

What can be done to promote the benefits of open access to EBP?

Academic promotion has traditionally had requirements that include the publication in high impact journals which can often non-open access⁶. I find it ironic that as a healthcare educator in the UK who promotes and teaches EBP, a facet that we judged on does not promote EBP.

Researchers will often consider impact factor and the quality of peer review before publishing¹¹, and it was often perceived that open access journals lack impact factor which would affect academic promotion¹². This provides a dilemma to researchers in that should they publish for promotion or publish to allow their research to be more readily available, and therefore contribute further towards EBP. However, it is also important that we realise that some open access journals now have an impact factor¹³.

One of the influences on the impact factor (amongst many others) are the number of citations. The evidence of the effect that open access has on citations is often contested, with some suggesting it has very little impact¹², whilst others indicating that it has a positive impact^11,14. However, they all indicate the publishing in open access does not reduce the number of citations, and therefore would not reduce the impact of the article. It is therefore fundamental that academic institutions continue to realise that academic promotion should not be negatively affected by publishing in open access.

In recent years, The National Institute for Health and Care Research (NIHR) and a group of national research organisations in Europe have implemented policies that require studies to be published on open access platforms or journals^15,16. This is a significant policy that will improve the access to the latest research so it directly promotes EBP, but will also cause more research institutions to rethink their own policies on promotion.

How will this impact my future practice?

When I consider how open access will affect my work with evidence based practice, I need to split it into two elements, as a lecturer and as an optometrist working in primary care.

As a lecturer, I teach students how they can use EBP very generically at the start of their degree, but also more specifically to individual fields later on. In the early stages, I look at promoting the reason of EBP and situations where it is useful, and teach the use of research databases, but I must confess that I never considered access what I teach. As highlighted earlier, I and students have the privilege of institutional access, but I now feel the need to prioritise how to search for open access research instead, so that this becomes the normal way for to find the information they need, even in their normal life.

It also led me to look at the resources I use in my teaching when discussing individual topics, as well as the sources of information I promote the use. Resources such as the Cochrane Library allow free access to everyone in the UK and many other countries (including low income countries)¹⁷, are particularly useful. The College of Optometrist Clinical Management Guidelines¹⁸ are also useful. Although the articles they use are not always open access, the evidence based detailed information that they provide on each eye condition is, and again will be a resource I will promote. This is something I think students will benefit from as they may not always find the information they need openly, and should therefore be able to use tools that are a “compromise”.

It is vital that all healthcare educators take this approach. Newly graduated professionals often take the habits of what they are taught, so if more are taught to use and search in open access resources, they will pass these practices on too.

As a practitioner, open access will also influence the speed at which I find clinical information. My first thought will be to search for open access articles as I know I will not be faced with the potential of pay or subscription walls. This will lead to patients being given more accurate information sooner, which for some could lead to faster diagnosis and treatment, which can give a better prognosis.

On publishing of this work, I have decided that it is important to provide it with a Creative Commons license, specifically CC-BY (attribution). In order for the importance of open practice to EBP to be fully realised by as many practitioners or academics as possible, I think it is extremely valuable for this work to be shared and developed upon as much as possible by all, regardless if they are affiliated with a commercial entity or not. Although ideally I would like future work to be used as openly and freely as this one, I have chosen not include the Share-Alike licence as this may restrict how this work can be combined with work with other licences¹⁹, reducing the span as to who can build upon it.

References

1. Dawes M, Summerskill W, Glasziou P et al., 2005. Sicily statement on evidence-based practice BMC Medical Education 5(1) 1-7
2. Paci, M., Faedda, G., Ugolini, A. and Pellicciari, L., 2021. Barriers to evidence-based practice implementation in physiotherapy: a systematic review and meta-analysis. International Journal for Quality in Health Care, 33(2), p.mzab093.
3. An Introduction to Open Access. https://www.jisc.ac.uk/guides/an-introduction-to-open-access [Accessed: 04/01/2024]
4. Kundart, J. Open access publishing: opportunities and challenges. Optometric Education, Volume 38, Number 3/ Summer 2013, p 89-91
5. Nick, J. (2011). Open Access Part I: The Movement, The Issues, and The Benefits. OJIN: The Online Journal of Issues in Nursing, 17(1). https://doi.org/10.3912/ojin.vol17no01ppt02.
6. Lawton, A. and Flynn, E., 2015. The Value of Open Access Publishing to Health and Social Care Professionals in Ireland. Available from: http://www.ariadne.ac.uk/issue/73/lawton-flynn/
7. Tennant, J. P., Waldner, F., Jacques, D. C., Masuzzo, P., Collister, L. B., & Hartgerink, Chris. H. J. (2016). The academic, economic and societal impacts of Open Access: an evidence-based review. F1000Research, 5, 632. https://doi.org/10.12688/f1000research.8460.3
8. What Is “Open Access”? – Open Society Foundations. https://www.opensocietyfoundations.org/explainers/what-open-access [Accessed: 04/01/2024]
9. Davis, P.M., Lewenstein, B.V., Simon, D.H., Booth, J.G. and Connolly, M.J., 2008. Open access publishing, article downloads, and citations: randomised controlled trial. BMj, 337.
10. Frequently asked questions on open access. BMJ https://www.bmj.com/company/openaccess/open-access-faq/ [Accessed: 04/01/2024]
11. Nagaraj, M.N. and Bhandi, M.K., 2017. Physics Researchers’ Perception of Advantages and Disadvantages of Open Access Journals: A study.
12. Forrester, A., 2015. Barriers to open access publishing: Views from the library literature. Publications, 3(3), pp.190-210.
13. Björk, B.C., 2013. Open access—Are the barriers to change receding?. Publications, 1(1), pp.5-15.
14. Huang, C.-K. (Karl) et al., 2024. Open access works – 420 million citations show OA outputs are cited by more researchers from more places, Impact of Social Sciences. Available from: https://blogs.lse.ac.uk/impactofsocialsciences/2024/01/30/open-access-works-420-million-citations-show-oa-outputs-are-cited-by-more-researchers-from-more-places/ [Accessed: 19/01/2024]
15. New Open Access policy for NIHR funded researchers – National Institute for Health and Care Research. https://www.nihr.ac.uk/news/new-open-access-policy-for-nihr-funded-researchers/29244 [Accessed: 19/01/2024]
16. What is cOALITION S? – Plan S. https://www.coalition-s.org/about/ [Accessed: 19/01/2024]
17. Access options for the Cochrane Library – the Cochrane Library online. https://www.cochranelibrary.com/help/access [Accessed: 19/01/2024]
18. How to use the clinical management guidelines – The College of Optometrist. Available from: https://www.college-optometrists.org/clinical-guidance/clinical-management-guidelines/how-to-use-the-clinical-management-guidelines [Accessed: 19/01/2024]
19. Redhead C, 2015, Why CC-BY? Available from https://oaspa.org/why-cc-by/ [Accessed 19/01/2024]