From Research Evidence to “Evidence by Proxy”? Organizational Enactment of Evidence‐Based Health Care in Four High‐Income Countries

Published date01 September 2019
Date01 September 2019
Abstract: Drawing on multiple qualitative case studies of evidence-based health care conducted in Sweden, Canada,
Australia, and the United Kingdom, the authors systematically explore the composition, circulation, and role of
codified knowledge deployed in the organizational enactment of evidence-based practice. The article describes the
“chain of codified knowledge,” which reflects the institutionalization of evidence-based practice as organizational
business as usual, and shows that it is dominated by performance standards, policies and procedures, and locally
collected (improvement and audit) data. These interconnected forms of “evidence by proxy,” which are informed
by research partly or indirectly, enable simplification, selective reinforcement, and contextualization of scientific
knowledge. The analysis reveals the dual effects of this codification dynamic on evidence-based practice and highlights
the influence of macro-level ideological, historical, and technological factors on the composition and circulation of
codified knowledge in the organizational enactment of evidence-based health care in different countries.
Evidence for Practice
The evidence-based policy and practice movement encourages the incorporation of evidence from research
into decision making.
Its implementation at the organizational level involves an increasing role for “evidence by proxy,” such as
performance standards, organizational policies, and local data.
Different forms of evidence by proxy are interconnected, simplifying scientific knowledge, reinforcing some
of its elements, and making it applicable to the local context.
Frontline practitioners tend to rely on evidence by proxy, which is created, circulated, and analyzed by
The composition and circulation of different forms of evidence by proxy differ across countries.
The evidence-based policy and practice
movement encourages decision makers at
different levels to be concerned with “what
works,” on the assumption that increased use of
research evidence will lead to better outcomes in terms
of effectiveness, accountability, and sustainability
(Hall and Van Ryzin 2018; Head 2016; Newman,
Cherney, and Head 2016; Nutley, Walter, and Davies
2007). In the context of health care, this paradigm-
shifting doctrine is based on the premise that clinical
practice should integrate professional experience
with the best available scientific evidence about
the effectiveness of the interventions used (Ferlie et
al. 2009; Rousseau and Gunia 2016; Sackett et al.
1996). Research directly informs clinical guidelines,
providing actionable recommendations for practice
that are developed using rigorous, systematic,
and transparent processes to summarize the best
available evidence (Harrison 1998; Knaapen 2013;
Timmermans and Kolker 2004).
Research has shown, however, that the uptake of
clinical guidelines by health-care practitioners
remains low as codified “know-what” research
evidence has to compete with multiple forms of
tacit “know-how” knowledge and skills (Gabbay
and le May 2011; McCaughan et al. 2005). At
the same time, we know from organization and
management theory that the institutionalization
of new approaches in day-to-day organizational
practices always involves a complex interplay of tacit
and codified knowledge (Kislov et al. 2014; Tsoukas
and Vladimirou 2001). As evidence-based practice
has been widely embraced by health care systems and
organizations (Dopson et al. 2003), this study aims
to look beyond guidelines, exploring the role of other
forms of codified knowledge—that is, knowledge
that is formal, systematic, and expressible in text or
numbers, making it easy to store, transfer, and use
across space and time (Turner et al. 2014)—in the
enactment of evidence-based practice.
Roman Kislov
Paul Wilson
University of Manchester
Greta Cummings
University of Alberta
Anna Ehrenberg
Dalarna University
Wendy Gifford
University of Ottawa
Janet Kelly
University of Adelaide
Alison Kitson
Flinders University
From Research Evidence to “Evidence by Proxy”?
Organizational Enactment of Evidence-Based Health Care in
Four High-Income Countries
Lena Pettersson
Dalarna University
Lars Wallin
Dalarna University, Karolinska
Institute, and Sahlgrenska Academy
Gill Harvey
University of Adelaide
Anna Ehrenberg is professor of
nursing and head of research in health and
welfare in the School of Education, Health
and Social Studies, Dalarna University,
Sweden. Her research is in the area of
implementation of evidence-based practice,
patient safety, and nursing informatics to
support nursing knowledge in assessments
of patient care needs and clinical decision
Greta Cummings is dean of the
Faculty of Nursing, University of Alberta,
Canada. She leads the CLEAR (Connecting
Leadership Education and Research)
Outcomes Research Program, focusing on
leadership practices of health-care decision
makers to achieve better health outcomes
in the health-care system and for providers
and patients. She has published more than
200 papers and was a 2014 Highly Cited
Researcher in Social Sciences (Thomson
Reuters) for papers arising from her
leadership research.
Paul Wilson is senior research fellow
in the Alliance Manchester Business
School, University of Manchester, United
Kingdom. His research interests are focused
on evidence-informed decision making
in health policy and practice and the
development and evaluation of methods
to increase the uptake of research-based
knowledge in health systems. He is the
co-editor-in-chief of
Research Article
Roman Kislov is senior research fellow
in the Alliance Manchester Business School,
University of Manchester, United Kingdom.
He conducts qualitative research on the
processes and practices of knowledge
mobilization, with a particular interest
in communities of practice, intermediary
roles, organizational learning, and
implementation of change. Before joining
academia, he worked as a doctor for a gold
mining company in Central Asia, combining
clinical work with a managerial post.
Public Administration Review,
Vol. 79, Iss. 5, pp. 684–698. © 2019 The
Authors. Public Administration Review
published by Wiley Periodicals, Inc. on behalf of
The American Society for Public Administration.
DOI: 10.1111/puar.13056.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited
and is not used for commercial purposes.

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