The following categories emerged from the content analysis carried out on the material gathered during the interviews: understanding evidence; learning how to use evidence; transferring evidence; adjusting to the context; and observing the advantages of evidence-based practice. Extracurricular activities were perceived as an opportunity to understand what evidence is and observe in loco the advantages of health care for clients, teams, and services. During the project, the participants developed cross-sectional competencies and envisaged changes to their professional activity as a result of changes in their attitude regarding evidence and its use. We concluded that the opportunity to develop evidence-related activities allows for the development of skills and influences the attitude towards evidence-based practice and knowledge use.The increase in health research brings challenges to the production, synthesis, and use of research findings in clinical practice. In the case of undergraduate training in nursing, it is necessary to think about the curricular contents and create opportunities to develop skills for learning evidence-based practice. The objective of this study was to analyze nurses’ perspectives regarding the effects of their participation in a project of translation of knowledge into clinical practice during undergraduate nursing education, specifically involving knowledge, attitudes, and competencies related to the use of evidence. This is a qualitative case study grounded in the knowledge-to-action theoretical framework. The participants were 13 nurses who were involved in a project about the translation of knowledge into clinical practice during the last term of their undergraduate course. The data were collected by applying interviews between December 2020 and April 2021. Content analysis was carried out by using the qualitative data analysis software tool webQDA There is a consensus that nurses must carry out evidence-based practice (EBP) in their professional activities and take leadership roles, in collaboration with other health professionals, to support reforms in health care that include, among other factors, the introduction of research results in practice contexts so that the health care offered to the population can be improved ,2,3. TheOther barriers to implementing EBP include difficulties related to the time and resources necessary for training in this area, a lack or insufficiency of academic programs on the subject, inconsistencies between learning and practice environments chosen by students, logistic challenges related to introducing the development of competencies in a system traditionally based on learning a specific set of knowledge , and a lThe content about EBP is integrated into the syllabuses of health programs in undergraduate and graduate nursing courses and continuing education initiatives ,6. HowevThe interest in this phenomenon has been increasing over the past decade with recommendations that future health professionals be involved in this type of activity in order to support a culture and spirit of research ,9. This Health care is becoming increasingly complex and now requires more scientific competencies , but a lIn Portugal, the nursing degree has about 50% of the contact hours for clinical training in different settings so that students can develop clinical skills for the provision of quality nursing care that ensure people’s safety. So, this type of teaching assumes a vital importance mainly because of the associated learning opportunities and the theoretical-practical integration of knowledge , creatinFaced with the above our research question emerged: does the participation of nursing students in knowledge translation activities during clinical teaching enable the acquisition of knowledge and the development of attitudes and skills for the use of evidence in clinical practice?The objective of the present study was to analyze the perspectives of nurses regarding the effects of their participation in a project of translation of knowledge into clinical practice during their undergraduate nursing course, specifically involving knowledge, attitudes, and competencies related to the use of evidence.The study was a qualitative case study  groundedThe participants in the present study were nurses who participated in a research project to get their degree; it was entitled “Safe Transition,” and took place during the last term of their undergraduate nursing course. This project involved three institutions that developed activities in partnership: a nursing school, a hospital, and a set of primary healthcare institutions in Lisbon and the Tejo Valley region, Portugal. The specific purpose of the project was translating knowledge into clinical practice. The nurses participated in the project during their clinical clerkship, which was carried out in the last term of the course and aimed to integrate them into professional life, as an extracurricular activity. Participation in the project was simultaneous with the clerkship, for which there were predefined activities and schedules. The participation of the undergraduates was voluntary and followed their signature of free and informed consent forms. The activities in which the students would participate under the guidance and supervision of professors and clinical supervisors were previously defined by the nursing school and the service institutions.The choice of participants was intentional, as we intended to study how participation in this activity led to knowledge, attitudes, and competencies related to the use of evidence. The inclusion criteria for the participants were: having participated in the project “Safe Transition” during the last term of their undergraduate nursing course; being involved in knowledge creation and/or knowledge application activities; having over 12 months of professional experience; and not working at the institution where they did their clinical clerkship. The exclusion criteria were: having less than 12 months of professional experience and working at the institution where they did their clinical clerkship. Thirteen out of 15 nurses who were eligible to be included in the sample of the present study agreed to participate in it.The number of interviews made theoretical saturation possible, the sample size of qualitative studies being debatable, as well as the possibility of saturation, in the case of this research, from the 10th interview no new categories emerged.“Safe Transition” is an intervention project. The choice of a qualitative study, which is used to understand people’s beliefs, experiences, attitudes, behaviors, and interactions , was basThe data were collected by applying semi-structured interviews between December 2020 and April 2021. The interview script was designed according to the knowledge-to-action model .The stimulus questions for the interview were: 1. Do you consider that the involvement in the project allowed you to develop knowledge about EBP practice? 2. Do you consider that the participation in the project changed your attitudes towards the use of evidence in clinical practice? 3. Tell me a little about the skills that you have developed through your participation in the project; and 4. Which of the acquired skills have been the most mobilized/useful during the first years of professional practice?The interview was conducted by a senior researcher from the team, who knows the context and the safe transition project, but was not involved in the clinical projects that the participants were part of.® platform, were recorded and transcribed by the researcher who conducted them. Subsequently, they were independently analyzed by two researchers, according to the content analysis technique , it is a bit similar to what they say in nursing school, but when we do our clinical clerkship we focus on reproducing what our supervisors do. Therefore, during the project, it was clear that evidence is in papers, in scientific databases, and it is not always put into practice, […], it is hard to make it get to services, because people are not always studying and looking for it” (N01). Regarding integration between practice and theory of knowledge about evidence, one participant said that he “had had contact with and discussed the expression Evidence Based Practice during theoretical classes, but it was during the course of the project that it was possible to understand its true meaning and develop competencies to support practice with evidence” (N07).Regarding the first category, the participants emphasized the importance of their participation in the project for their understanding of what EBP is, because, as expressed by one participant, “When we start working or doing our clerkship, there is a bit of a tendency, […], not to guide ourselves by evidence, and we do things based on what the supervisor nurse does or says or what you hear other nurses say. From really simple things, such as application of ointment on the skin, dilution of antibiotics, or preparation for patient discharge, simple stuff, to shift organization regarding records, lots of things, really lots of things!” (N11).The participants also mentioned that clinical clerkships do not always provide the opportunity to compare the ways to do what is recommended by research results. One participant said it was because “Even because the experience was enriching in terms of helping us avoid automatic practice, that is, helping us, as undergraduates, think about what we do, how we do it, and based on what rather than encouraging us to carry out practice by imitation, always doing the same, without thinking if there are already other solutions. It is necessary to raise awareness, for instance, of the main automatic and standardized practices, and promote reflective practice. But it is also necessary to allow professionals and students to have access to the most reliable databases. We need to invest in training of who has the power of defining strategies, developing actions, and inspiring future care providers” (N13). “It even influenced me to realize that we often use evidence poorly, not really use it poorly, we do not use it at all, we say that we do everything based on knowledge… which may even be true, but it is not the most recent knowledge” (N04).The importance of thinking about EBP for a change of attitude as undergraduates when faced with evidence presented in scientific publications emerged, together with the perception of the EBP concept: “Understanding what EBP is and analyzing its advantages, but also reflecting on the way nurses work, make decisions, and are influenced by culture and shaping in clinical contexts are fundamental steps for professionals to adjust their practice so that it is aligned with knowledge and critically analyze their performance as a way to develop professionally.During the undergraduate course, when we are students, we neither know how these activities are carried out nor have the chance to carry them out, which is why the clerkship is a great opportunity to learn how to formulate projects and develop activities that change practices” (N03). Another pointed out that the project was important “because there are gains regarding knowledge”, and that when information about EBP was acquired, it also allowed nurses to develop “important competencies for searching for and identifying needs and problems” (N02). More specifically, one participant said that this included “identifying needs and problems; formulating questions; planning, implementing, and evaluating interventions; identifying the best available evidence; and developing synthesis/summarization, critical thinking, and decision-making skills” (N13).The category learning how to use evidence was the one with the highest relevance regarding the record units. One nurse declared that “We force ourselves to search about the subject, see things that are already being done, to be able to better justify our practice; The research part also helps, because it improves our language a little, that is, it makes us use more scientific language, not just scientific, but also technical-scientific terms; in other words, helps us to truly understand what a clinical trial or validation is, and when we use the terms we know exactly what they are about […]. I have a better notion of what data collection is, of how to consult databases, and of data analysis, and I have a very clear idea of how they are related” (N06).Learning about evidence is a process that occurs at different levels by means of research activities, critical reading of studies, evidence synthesis, and opportunities to carry out research activities in ongoing research processes, as reported by one of the participants: “Learning about evidence is achieved by integrating theoretical knowledge into practice. However, extracurricular activities allow students to obtain new knowledge by means of participation in activities that offer the possibility of identifying clinical areas that are a priority for the introduction of evidence, continuing to use knowledge, evaluating results, and monitoring the use of this knowledge.Evidence Based Practice also allowed us to perceive how things are changed” (N09). Aspects related to the process of the introduction of research results and barriers to it emerged in the interviews.Regarding the category transferring evidence, one participant said that “I found myself talking to the articles and thinking ‘so this intervention is for solving the problem straightaway, so this is the path I want to take; how am I going to prioritize it? I have my shift ahead; is it possible to do something different already?’” (N02). Another participant mentioned that “We knew, in theory, that we would be able to improve the outcomes of the patients if the knowledge were transferred into practice. Then, once we got to the practice part and evaluated everything, […], we ended up realizing that sticking to studies really makes sense. I mean, putting them into practice and producing more studies, which is what we ended up doing after coming across evidence and seeing how to put it into place so it could provide results, because we saw all this in the project. Therefore, learning this theoretical framework, applying it, and evaluating it ended up helping me realize the importance of Evidence Based Practice” (N10).One of the nurses declared: “the confirmation of what people say about the difficulties of using the results of scientific research” (N04). The identified barriers were related to personal, temporal, and organizational factors. According to the participants, “Obstacles are inevitable. Personal and professional experience and routine procedures are the greatest barriers in my opinion, but there is also the issue of constant updating in the health area, with the need for massive personal investment that often takes a heavy toll. This leads to large gaps between currently recommended practice and care that is actually delivered” (N13). “Another thing we say a lot, I and my colleagues, those who were with me, is that it is a long process and it is not easy to introduce this information into services, because each person has their own ideas, their own way to do things and, even with training, which not everybody attends, it is not possible to change things quickly” (N01).In contrast, the experience even allowed “Transferring knowledge into clinical practice was achieved by resorting to different strategies, and an analysis of the barriers allowed the implementation of measures to control them and make changes possible. Negotiation in the teams and the definition of strategies between the people involved in the project (including the students) promoted collaborative work, problem solving, and the introduction of evidence into clinical practice.I remember that the professor raised the question of this difficulty when we first got involved and she warned us that, sometimes, it is necessary to adjust knowledge to the reality of a given context, because studies can be carried out in other countries. Then we are sort of importing results into our reality, which may be different, even because of how our care procedures are organized” (N01). “We did not have the necessary resources that other places would have and we gradually adapted, with the help of the professor and the nurse who were there. We identified what we could do with the materials, team, and physical space we had and, after reading the systematic literature review and getting to know the project that also existed, […], we ended up realizing that we had some limitations and would have to adapt because of them and work with what was possible” (N10).The methodology used allowed the participants to learn how to adjust evidence to the context, which was illustrated by the following accounts: “The truth is that we already had knowledge about what a cerebrovascular accident is and care that should be delivered, but we were there, so we had to be good at care delivery. Consequently, I had to have this knowledge, and being able to verify whether to do something or not in the context itself really makes sense. That is, it makes sense that work is in loco and oriented toward the needs of the context. Being in loco is a fully feasible strategy because I was doing that search […], I was looking for evidence to guarantee that care would be guided by the improvement of the patient, which makes total sense to me. I was, so to speak, like a means to empower that person, and that motivated me, because I knew that my search process would result in gains. Gains for the patient, and this motivated me more to read, and search, and identify what was necessary” (N11).Adapting to the context is necessary because of the available material and human resources, but also because of the characteristics of the service, organization of care procedures, and dialogue between what exists in clinical practice and what is recommended by evidence. “The analysis of the context showed that the opportunity to adjust evidence to the context at issue was positively regarded by the participants, not just because of the lesson of how to do something, but also because the comparison between evidence and what is actually carried out allows them to think about practices and advantages of using evidence, which feeds back into the process that leads to a transfer of knowledge into practice, so its applicability is guaranteed.The project also ended up hugely raising awareness of that and about what is necessary, the conditions of the patient at hospital discharge, what they need regarding nursing care. That is because most of the time the patient is discharged but is not trained to carry out activities of daily living, is dependent regarding self-care, cannot manage medications yet, and cannot manage post-discharge everyday life, and there was no time to inform them, provide education about health, train them to do what they have to at home” (N05). “It was also important to realize that people recognized the importance of our work and how it would improve the preparation for hospital discharge for patients and relatives, and it would even impact their return home, because people became more independent” (N03).In the category observing the advantages of EBP, there were accounts about the results obtained in the project and the recognition of how it helped improve care quality: “We had already carried out searches for other college projects, but not for implementation with users, in the service, and improving care delivered to patients, not for implementing things and seeing our project being developed and bearing fruit. We realized that it was really important” (N07).The participants stressed the importance of verifying these advantages for their own motivation: “In fact, the project had indicators that were measured every six months, which allowed an assessment of its results and the use of EBP. The improvement in the indicators related to care delivery encouraged professionals to keep using EBP and monitor its results.The views of the 13 nurses who participated in the present qualitative study corroborated the results of other studies that have reported that education in EBP does not occur in schools ,17. InstGaps in knowledge and competencies are some of the factors that lead clinical nurses to apply a range of decision-making processes during their practice that are not always supported by evidence ,11,19. CThe findings of the present study reinforced the results of an integrative literature review on the attitude of undergraduate nursing students regarding research. It showed that taking a research-related subject, having interest in a specific research field in nursing, and having the possibility to apply research knowledge and previous research experiences  allowed for marked improvement in the attitudes of the students regarding research and its use . The accStudies on the subject have shown the advantages of EBP but have not conclusively addressed the impact of these experiences once they are completed and what strategies should be adopted to effectively use EBP at the beginning of a career. A program oriented toward initiating students in research suggested that active and early participation of nursing undergraduates in research activities encourages new graduates to incorporate evidence into care delivery and seek a graduate degree . In anotA study on the use of EBP reinforced the gains in knowledge and motivation . In addiThe results also identified difficulties and barriers in the implementation of knowledge in clinical settings, which corroborates the results of other studies whose conclusion was that, despite the individual efforts of nurses, it is difficult to create an organizational culture that can support EBP and make it feasible. Some studies have recommended that leaders try to minimize expected barriers and base institutional policies on evidence ,24,25,26Therefore, it is necessary to design more studies on the challenges of transferring knowledge to final consumers  and beneficiaries (care users) and the way it is carried out, which would bridge the conceptual and pragmatic gap between what is produced and what is used to actually improve health. The creation of communication and collaboration networks involving researchers, professionals, and citizenships would be useful in this process .In view of the results, we recommend that clinical teaching students have the opportunity to use research results and learn to transfer them to clinical settings because we believe that this will be a core competence for the health professionals of the future, with an impact on improving care and the sustainability of health systems. The international nursing movement should discuss the need to include in curricula and clinical learning contents and activities related to evidence synthesis and its transfer to clinical settings.This study had limitations regarding its method, data collection technique, and data analysis. The intentional choice of participants and the concrete experience of having participated in the safe transition project limited the results to the context. The interaction between researcher and participant may have influenced the response to what is socially accepted.Despite the limitations, the results provided new knowledge about the contribution of the participation of students in knowledge transfer projects during the last clinical clerkship in undergraduate nursing courses. This step presumably would integrate students into professional life, for their acquisition of knowledge and development of competencies to be applied to EBP.The 13 nurses who participated in the present qualitative study, which was grounded in the theoretical framework of the knowledge-to-action model cycle, participated in a project oriented toward transferring knowledge into clinical practice during the last clinical clerkship of their undergraduate course. The following categories emerged in the content analysis: understanding evidence, learning how to use evidence, transferring evidence, adjusting to the context, and observing advantages of evidence-based practice.The findings showed the effect of this participation on the understanding of what EBP is, decision-making based on knowledge, and critical analysis of their professional performance. Education about evidence was achieved by integrating theoretical knowledge into clinical practice, which allowed for the verification, in a clinical context, of the advantages of this learning process. It also involved gains for users and improvement of indicators established for evaluating the project. The opportunity to verify gains in loco helped support the use of knowledge and encouraged this practice.Future studies could explore the results of other educational programs addressing evidence, in coordination with clinical services, and examine the relationship between attitudes and competencies acquired by students during their academic trajectory, and the adoption of actual EBP during their professional activities.


Decision making often entails evidence accumulation, a process that is represented by neural activities in a network of multiple brain areas. Yet, it has not been identified where exactly the accumulation originates. We reason that a candidate brain area should both represent evidence accumulation and information that is used to compute evidence. Therefore, we designed a two-stage probabilistic reasoning task in which the evidence for accumulation had to be first determined from sensory signals orthogonal to decisions. With a linear encoding model, we decomposed the responses of posterior parietal neurons to each stimulus into an early and a late component that represented two dissociable stages of decision making. The former reflected the transformation from sensory inputs to accumulable evidence, and the latter reflected the accumulation of evidence and the formation of decisions. The presence of both computational stages indicates that evidence accumulation signal in the parietal cortex is computed locally. The source of the evidence accumulation signal widely observed in the brain during decision making is unknown. Here, the authors used a two-stage decision task to show that the accumulation signal in the posterior parietal cortex arises locally. Since then, similar evidence-dependent ramping activities have been demonstrated in many other brain structures, including the prefrontal cortex5, the striatum6, and the superior colliculus9. These results, although by themselves not against LIP’s role in decision making, raised the question of whether evidence accumulation signals in LIP only reflect the computation carried out somewhere else in the brain. This question cannot be examined with lesions experiments, which have been used to provide clues on whether LIP activities causally contribute to behavior12. Whether LIP plays a causal role in decision-making or not does not exclude the possibility that LIP sits downstream of where decisions are computed and inherits the evidence accumulation signal from there.Ramping activities associated with evidence accumulation during decision making are considered as a signature of brain areas involved in decision making. The lateral intraparietal area (LIP) was among the first where neurons were demonstrated to exhibit such an activity pattern and therefore proposed as a critical decision-making area where neurons accumulate evidence for decisions14. Yet, in other tasks where evidence is conferred via arbitrary stimulus-evidence associations, extra steps are necessary to compute evidence from the sensory information17. In these cases, we distinguish the evidence that can be readily accumulated based on its neural representation from the raw sensory information that requires additional preprocessing. Although it has been shown that LIP activities represent evidence accumulation in these tasks16, it is unclear where the extra steps take place locally or in a different brain structure. Representations of the sensory-to-evidence transformation in LIP, if demonstrated, would argue strongly for the hypothesis that evidence accumulation is computed in LIP.Here, we approached the question from a different angle. We reason that if LIP inherits evidence accumulation signal from somewhere else, we are unlikely to observe computation stages that happen before the accumulation. In particular, the transformation from sensory inputs to accumulable evidence, which has not been well studied in the field, is a necessary computation stage in certain types of decision making. This computation may be trivial in some perceptual decision-making tasks, including the classic random dot motion discrimination task, as the evidence is approximately linearly encoded by the firing rate of the sensory neurons and can be directly accumulated16. Just as in the original task, the monkeys were required to accumulate evidence from a series of visual stimuli to form eye movement decisions between a green and a red peripheral target. However, in the new task, each stimulus could be either red or green, and its shape provided information only on the reward probability of the target that had the same color. Therefore, the evidence associated with each shape had to be determined from both the shape and the color of the stimulus before it was accumulated. We observed that the LIP neuronal activity could be decomposed into an early and a late component. The early component encoded the shape weights and additional computation signals, which were independent of the eye movement decisions and represented the sensory-evidence transformation. The late component, in the familiar form of ramping activity, reflected the accumulation of evidence and the formation of decisions. By showing that both the sensory-to-evidence transformation process and the evidence accumulation process are represented in LIP, we conclude that the evidence accumulation signal in LIP arises locally.To this end, we adapted a probabilistic reasoning task that was previously used to investigate evidence accumulation in the LIPn and m are the numbers of red and green shapes displayed in a trial (n + m = 6), We trained two monkeys with a probabilistic reasoning task Fig. . The monThe monkeys had to maintain fixation when viewing the stimuli and choose the better target by saccading toward it when the fixation point was turned off. The reward was delivered based on the reward probability of the chosen target for Monkey M. For monkey H, we delivered a juice reward only when the target with a higher reward probability was chosen to encourage a better performance. Regardless of the different reward schemes in the two monkeys, decision making in this task required both monkeys to evaluate evidence associated with each shape based on its shape and color and accumulate evidence accordingly.The task required the monkeys to accumulate evidence based on both the shape and the color of the stimuli. A shape in green with a positive weight supports the green choice, but a green shape with a negative weight supports the red choice. Likely, a shape in red may support either the green or the red target depending on the sign of its assigned weight. The choice should depend on the difference between the total weight of the red shapes . All stimuli in the sequence exerted significant influence on the monkeys’ choices, suggesting that they were integrated to form choices Fig. .Tin) of the neuron being recorded, and the other target was in the opposite visual hemifield (Tout). The color of Tin and Tout was random trial-by-trial.After the monkeys learned the task, we recorded single-unit activities from LIP. Only well-isolated neurons with persistent activity and spatial selectivity during the delay period in a memory saccade task were used for the analyses. We collected data from 207 neurons from two monkeys . We identified the neurons’ receptive field location with the memory saccade task. During the recording, one of the targets was located in the receptive field . The average latency of the shape weight encoding across neurons was significantly shorter than that of the evidence encoding . The evidence is the shape weight if their colors match, and the minus shape weight if they do not . The results were different between the two monkeys. For monkey M, color consistency, but not color evidence, was represented in its LIP Fig. . 47 out nce Fig.  and evidnce Fig. , suggestnce Fig. . The resMonkey H, however, showed a distinct pattern. Color consistency was encoded in monkey H’s LIP, but only by a small number of neurons Fig. . On the Although the LIP activity patterns in the two monkeys suggested that they computed evidence in two different routes, via color consistency in monkey M and via color evidence in monkey H, the results from both monkeys consistently showed that the early component of LIP responses reflected the intermediate variables in the transformation from the sensory inputs to the evidence for eye movement decisions. These variables are orthogonal to eye movements but encoded by the same neurons that accumulate evidence for eye movement decisions.Tin’s and Tout’s color, respectively. Therefore, we investigated whether LIP activity reflects a decision process based on the competition between the evidence accumulated separately for the two targets or on the accumulation of each shape’s evidence favoring one target versus the other.One final scenario that has not been discussed so far is that the LIP neurons might only accumulate a shape’s evidence when the shape’s color matches its response field target’s, and the final decision might be based on the comparison between two populations of neurons, each accumulates evidence for Tin’s  was also found to accumulate evidence for eye movements, it only weakly encoded stimuli’s color weights, which were quantities comparable to shape weight in the current study, and a correlation between the encoding of color weight and evidence at individual neuron level was absent. Even though DLPFC neurons are well known for their heterogeneity26, their responses did not fully capture the transformation from sensory inputs to accumulated evidence. In addition, the signal for accumulated evidence in the DLPFC had a later onset than what was found in LIP in the current study. Therefore, the accumulated evidence signal in LIP is unlikely to come from the DLPFC. Between the two areas, LIP is a more likely candidate where evidence accumulation occurs.The representation of both the evidence accumulation and the computation before accumulation has not been demonstrated in any other brain areas. In particular, our results provide an interesting contrast against the findings from the prefrontal cortex. In a recent study, Lin et al. used a similar but simpler task to study evidence accumulation in the prefrontal cortex28.Although we interpret the early component of LIP responses as sensory, it is relative to the later accumulated evidence and eye movement signals. Shape weight represented in LIP is already an intermediate variable between raw sensory inputs and the following computations. The shape weight signals may arise from the orbitofrontal cortex (OFC). Shape weight is a quantity tied to value, and the OFC has been shown to encode value associated with visual stimuli30, suggesting that the weight encoding cannot be explained by choice reward. The negative encoding also cannot be explained by salience31, which may be quantified as the absolute value of shape weight in our experiment. The weight encoding in LIP was signed: positive weights induced suppression of LIP responses, and negative weights increased the neurons’ responses. We suspect that the negative encoding reflected the nature of the inputs from the brain area where LIP receives this information. Depending on where information comes from and how information is encoded in the source brain area, we may observe different encoding patterns of sensory inputs in LIP. The encoding may be consistent with, orthogonal to, or even opposite to the eye movement signals in LIP. In a recent study, LIP neurons were found to encode evidence negatively in a face discrimination task, providing another example where the encoding of sensory inputs was seemingly contradictory to evidence accumulation17.The current literature cannot explain why the early LIP responses negatively encoded the shapes’ weight regardless of their color. Because shape weight is related to targets’ reward probability, the results mean that stimuli that led to larger reward probabilities suppressed LIP neurons’ responses. This is opposite to the studies that showed that the LIP activities were positively correlated with choice reward32. This explanation is not supported by our data, because the weight encoding that we observed had a short latency and preceded the encoding of evidence. In addition, the dip occurred after each stimulus in the trial sequence  were used in the study (M and H). They weighted on average 10–11 kg during the experiments. All experimental procedures were approved by the Animal Care Committee of Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences .During training and recording sessions, the monkeys were seated in a primate chair. Visual stimuli were presented on a 23.6-inch video monitor, which was placed at a 60 cm distance from the monkey. The behavioral paradigm was controlled through custom code with the MatLab-based MonkeyLogic Version 1. The eye movements were tracked with a high-speed infrared camera at a sampling rate of 500 Hz . Juice or water reward was provided as rewards based on the monkeys’ preference. The liquid delivery was controlled by a computer-controlled solenoid. The monkeys drank ~200–350 ml per experimental session.Monkeys started each trial by fixating on a central fixation point (FP) (0.3° in diameter). After 567 ms, a red and a green target (0.2° in diameter) were displayed on the left and right sides of the FP, equidistant from the FP. During the recording sessions, one of the targets was in the response field of the neuron being recorded, and its color varied trial by trial. After 533 ms, six visual stimuli were shown at the center of the screen sequentially. Each was displayed for 333 ms and followed by a 133 ms delay. After the last shape disappeared, there was a variable delay (randomly selected from 433/533/633 ms). Afterward, the FP was turned off, instructing the monkey to report its choice by making a saccade to one of two targets and fixating on the target for 283 ms. The reward was delivered based on the chosen target’s reward probability.The stimuli were randomly sampled with replacement from a pool of six shapes. Each shape was assigned a unique weight. The stimulus color was randomly chosen between red and green. The color indicated the target that the stimulus carried information about. Each target yields either a large reward or a small reward, and the probability was determined by the total weight of the shapes with the same color that appeared in the trial Eqs.  and 2. F−1, i.m.) and anesthetized with isoflurane gas . Their body temperature, heart rate, blood pressure, and CO2 were monitored during the surgeries.The monkeys received a chronic implant of a titanium headpost with standard procedures before the training. After their performance reached a satisfactory level, we performed a second surgery to implant an acrylic recording chamber over the intraparietal sulcus, which allowed electrophysiological recording from LIP. The inner diameter of the cylindrical chamber was 19 mm. All surgery procedures were done under aseptic conditions. The monkeys were sedated with ketamine hydrochloride (5–15 mg kgA plastic grid (1 mm spacing) was placed inside the chamber to precisely locate the targeted brain areas. Single tungsten electrodes (Alpha Omega) were used for recordings, and electrodes were accurately placed with a microdrive . The neural responses were collected with an AlphaLab SnR System 2.0.4.5 (Alpha Omega).In each session, one or two single electrodes were placed in the ventral division of LIP (LIPv), which was located based on structural magnetic resonance imaging and transitions of white and gray matter during penetrations. Action potential waveforms were isolated online using a window discriminator or sorted offline (Offline Sorter Application Version 4.5.0). Only units with well-isolated waveforms were recorded and used for analysis.Units with persistent activity and spatial selectivity in a memory-guide saccade task were used for further analysis. In the memory-guide saccade task, a target appeared shortly (200 ms) in the periphery while the monkey fixated the central fixation point. After a variable delay period (uniformly selected from 533/633/733 ms), the fixation point disappeared, instructing the monkey to make a saccade toward the target. The receptive field was defined as the target position where the unit showed the maximal responses during the delay period. During the probabilistic reasoning task, one of two targets was placed in the receptive field, and the other was in the opposite visual hemifield. We collected data from 207 neurons .Q, provided by the presented stimuli:i appeared in a trial in red and in green, respectively (i = 1…6). Logistic regression was applied to determine how each shape affected the choice. The probability of choosing the red target is a function of the sum of leverages, i. i is not red, and We performed logistic regression to assess whether the stimuli in all epochs affected monkeys’ choice as follows,We performed all electrophysiological analyses separately for two monkeys.34. The model assumes the spikes follow a Poisson distribution with a time-varying spike rate ith variable, ∆ is the time bin size (10 ms), and T is the number of time bins in each trial. fminunc. The model’s predicted responses generated from the 5th and the 6th stimulus extend beyond the end of a trial, but only the part before the end of the trial was considered during the fitting. We did not use any regularization or penalize high-valued kernel weights for us to determine the significance of the kernel weights more easily. The fitting results were validated with five-fold cross-validation . We calculated the longest duration of the time window during which the kernel weights were significantly different from 0. This procedure was repeated 100 times to obtain the 95th percentile of the longest encoding duration. A neuron was considered to encode a certain variable significantly only if its kernel’s longest encoding duration was above this 95th percentile. In addition, a neuron’s encoding was considered positive if the average kernel weight during the first significant encoding duration was positive. Negative encoding neurons were similarly defined. The neuron’s encoding latency was defined as the beginning of the first significant encoding duration.To quantify the encoding significance, we shuffled the external variables across trials and performed the GLM on the shuffled data sets. The significance of the kernel weight at each time point was determined with a two-tailed t test , color evidence, target onset, and target configuration .In the GLM in Figs. In Fig. For fair comparisons, all comparisons of average latency, kernel weight, and CPD were based on results from the same GLM.i and neuron j was calculated as follows:i shuffled. This procedure was repeated 100 times, and the CPD plotted in Fig. The CPD analyses in Fig. Further information on research design is available in the Supplementary InformationPeer Review FileReporting Summary


Clinical significance can be very different to statistical significance. There is also a growing concern over the way in which an approach supposedly based on evidence medicine is being applied to treatment recommendations. This is in danger of creating unhelpful biases that can undermine the delivery of personalized care which is at the heart of clinical animal behaviour practice. In order to address this, increased open access and data-sharing is to be encouraged. Evidence from scientific studies needs to be combined with critical reflection of its relevance on a case by case basis by clinicians. Accordingly it is imperative that they have a high level of scientific literacy.Effective and ethical management of problem animal behaviour requires the translation of scientific research into practice. However, to do this we must appreciate different scientific perspectives and their limitations. There are serious limitations to the application of population level effects to the care of the individual. Factors such as Both the public and clinicians are interested in the application of scientific knowledge concerning problem animal behaviour and its treatment. However, in order to do this effectively it is essential that individuals have not only scientific literacy but also an appreciation of philosophical concepts underpinning a particular approach and their practical implications on the knowledge generated as a result. This paper highlights several common misunderstandings and biases associated with different scientific perspectives relevant to clinical animal behaviour and their consequences for how we determine what may be a useful treatment for a given patient. In addition to more reflective evaluation of results, there is a need for researchers to report more information of value to clinicians; such as relevant treatment outcomes, effect sizes, population characteristics. Clinicians must also appreciate the limitations of population level study results to a given case. These challenges can however be overcome with the careful critical reflection using the scientific principles and caveats described. Clinical animal behaviour is the management of problem animal behaviour, and emerged as a specific scientific discipline about 50 years ago . As an aGreater engagement with scientific research literature by clinicians has led to many benefits from a more evidence-based approach over the last 30 years . LikewisThe nature of clinical animal behaviour and especially the complex nature of many interventions, mean that important philosophical underpinnings  and assuScientific disagreement is common, but based on rational argument and should never be personal. It is not about winning the argument, but rather getting to the truth. This is one of the reasons why scientists place more weight on peer-reviewed publications than what is on the wider internet, for evidence. Reliable scientific enquiry requires an appreciation of the assumptions underpinning the nature of what is being studied (ontology), and distinction between opinion and justified belief as sources of knowledge (epistemology). This demands that we give consideration to what might be accepted as factual from a scientific perspective and the methods used to generate scientific knowledge. A key feature of the scientific method is its reproducibility, and it can be argued that insufficient value has been placed on this by some scientific publishers [An essential feature of the scientific revolution which developed out of the Age of Enlightenment, is the questioning of our assumptions and beliefs within the context of current knowledge and rational argument . Scientiblishers ,17, althblishers . From anblishers  but thisblishers   is not mandated by the scientific methods as defined above. For example, the scientific study of the psychological capacities of non-human animals, has a long history of rejection of ideas by the scientific establishment . In relathe medical model tends to view problem behaviour as a pathological state, akin to a physical disease and is grounded in a physical positivist reductionism, with the source of the problem being, for example, in a chemical brain imbalance.the behavioral model emphasizes the importance of environmental contingencies in shaping behaviour. This is grounded in the behaviorism of experimental psychology, but also has a physical positivist focus that is outside the animal—on the observable events in the environment.The two (non-exclusive) approaches that have historically dominated our thinking and practice of clinical animal behaviour are described below and will be readily recognized by those working in the field :the medi3.sensu Anderson & Adolphs [the “psychobiological” perspective draws on developments in affective neuroscience, behavioural biology and evolutionary biology. This also has a different ontological perspective, by emphasizing the importance of referencing a range of psychological constructs, such as motivational and emotional state, as useful variables for predicting individual behavioural responses. In this context, motivation refers to the psychobiological processes controlling actions for which there is a single explicit goal that is being pursued at a given time. The associated biological processes include the neuro-endocrinological states and responses underpinning the action; while the psychological processes include any representation of the importance and goal of the behaviour as well as the choices made. Identification of reinforcement effects  helps in the formulation of hypotheses about the goal of the behaviour. By contrast the term emotion is used to describe a multicomponent psychobiological response arising from the perception and appraisal of the significance and importance of elements of the environment at a given time to a particular individual, in line with the component process theory described by Scherer . The res Adolphs ) and ari Adolphs . While a Adolphs  presentsIn the last 25 years an effort has been made to develop a third eclectic and systematic approach ,30, thisIt is important to be aware of these philosophically different perspectives as they result in practical biases. For example, a medical approach to problem behaviour will tend to emphasize the importance of, and need for, chemical intervention  to augment appropriate psychological states. This is because it views problem behaviour largely in terms of the output of discrete disorders or pathologies which require correction . The idExperience from the human field has shown that both the medical and behavioral approaches can be morally problematic, and there is perhaps insufficient debate of these moral concerns within the equivalent veterinary behaviour field. For example, the medicalization of human thoughts into diseased states has been used to justify the removal of patient autonomy or opinion in the selection of treatment, resulting in enforced institutionalization and sedation or the use of dubious forms of aversion therapy including electroshock . This prThe scientific method is justifiably respected for the quality of the process, but it is important to appreciate that there are potentially both intrinsic biases  and methodological biases (in terms of the judgements made within the process), which can go unrecognized. Greater awareness of these biases allows a more honest discussion of the meaning of research results and increases scientific progress. This mandates an appreciation of the probabilistic nature of scientific knowledge.The uncertainty that is inherent within all scientific knowledge described above, is often overlooked; this can result in a failure to appreciate other approaches to gaining knowledge, especially with regard to non-physical phenomena. Within science, epistemology concerns the difference between justified belief and opinion. The facts of science change as our knowledge of a subject grows, accordingly scientists change their opinion in light of new evidence that contradicts previous knowledge. Science is concerned with truth, but it is not the absolute truth of facts that is its focus, it is the truthfulness of the process that has been used to evidence the beliefs that is important. Conclusions should be based on a scientific evaluation of the evidence of all reasonable explanations: a distinction that is not always appreciated in public debates concerning the quality of evidence for a particular position. Given the inherent uncertainty of science, it is not surprising that many scientists are cautious about their conclusions, even when they feel they are scientifically justified. However, the cautiousness of the scientists may be no match for the passion or zeal of those with firmly held personal beliefs, when it comes to convincing a wider audience who may be more interested in the nature of the debate than the truth of the arguments  of the statistical test used in the analysis of related data. This is traditionally set at an arbitrary value of p < 0.05 or less than a 1 in 20 chance either that the results obtained came from a situation where there was no real difference or of obtaining a more extreme value  and type 2  statistical errors, within results is perhaps less often expressed [It is well recognised by researchers that many design factors (not least sample size) affect the meaningfulness of a xpressed . I specuIt is useful to distinguish between two different types of study which both involve statistical testing of hypotheses, but which reduce scientific uncertainty to different degrees because of their methodological rigor . In a rep-values, so should there be greater concern over the use or not of statistical corrections of this value, when multiple tests are undertaken. The argument in favor of correction is that the more tests we do, the greater is the global risk of a Type I error, since there are several hypotheses being tested at the same time. If enough people, roll 8 dice, someone will eventually get the improbable result of 8 sixes on their first throw, but this is not good evidence that the dice are loaded. Statistical correction should be carefully evaluated as the trade-off between reducing the chances of a Type I error and increasing the chances of a Type II error—the equivalent of failing to reject loaded dice. The relative importance of one type of error over another is a matter of some judgment, and again depends on careful scientific reflection on a case-by-case basis. A key point to consider is how definitive the research aims or claims to be [Just as there should be concern over the unthinking use of ms to be , and we n = 15). This study used a within subjects counterbalanced design to reduce the effects of random differences in the measures taken in the two conditions which increases the risk of a Type II error in small populations . A further concern relating to this risk was a recognition that animals can express the same emotion in different ways. Accordingly, they argued that measures of inferred emotional state (if they could be shown to be reliable) may be more sensitive than behaviour for detecting an effect of this product. These states were chosen based on the proposed ability of the pheromonal mixture to increase the perceived safety of a physical environment. No correction was made for multiple testing (three measures of emotion and three of behaviour were considered) given the small sample size and thus increased risk of Type II error if such a correction was made. In summary, the measures of inferred emotion were found to be more reliable to record than the measures of behaviour, and amongst other measures the dogs were consistently found to be more relaxed when exposed to DAP. There were no significant differences in the specific behaviour measures. These results are consistent with the predictions made a priori, and precautions taken in the design and analysis as a result. Indeed, if statistical corrections had been applied some of the results concerning emotional state would still have been significant. Does this study support the use of DAP in the clinic? Yes. Does it provide definitive evidence that DAP increases relaxation in this setting? No—further studies are required, and while we showed that the measures of relaxation were reliable, we have no further evidence that this is how they felt , beyond anecdotal reports of those present at the time. From a clinical perspective, should we now recommend DAP to improve the welfare of dogs visiting the vet’s clinic? Yes, especially given the relatively low financial investment required and consistent evidence that visiting the vets is stressful for many dogs and the suffering that would be caused if we rejected the evidence from this study. The clinical decision depends on a careful judgement of both the quality of the evidence and a cost–benefit analysis of potentially rejecting this, including its impact on animal welfare.The following example illustrates some of the points made so far, and the value of explaining the decisions made, in order to reduce the risk of misrepresentation or misunderstanding of the results. Mills et al.  describeAt this point it is worth highlighting the ease with which a study design can return a null  result and the associated problems when this finding is not critically appraised. Caution is always required in the evaluation of such studies, if a type II error is to be avoided. Just as it is important to look for potential confounds with an intervention when a positive result is found, so it is important to look at experimental design when a negative result is found. As mentioned above, scientific progress is incremental and it is important to build on the insights gained from previous studies when designing a new one, to reduce the risk of inaccurate conclusions. For example, the study described previously involving DAP in the clinic , also nothe application of a DAP diffuser did not markedly influence the behavior” is not supported by the study, given the methodological flaws—it was simply not designed adequately to draw a specific conclusion about lack of effect. The failure to find significant effects does not provide good scientific evidence one way or the other as to whether DAP is effective in this context, since it could plausibly be argued that multiple aspects of the design increased the risk of a Type II statistical error. Given the design limitations, only the finding that there was an effect would have added much scientifically, i.e., despite these risks there was still an effect found. In other words, multiple negative results from poorly designed studies do not provide good evidence that an intervention is not effective; they simply do not increase scientific knowledge. It is for this reason that such poorly designed studies should be rejected from any quantitative synthesis of results from multiple studies, such as a meta-analysis. There is growing interest in the value of such syntheses, as they are considered to potentially offer a high level of evidence about the true effects of an intervention, but as we will see in the next section, this is not necessarily the case and there are many issues with evidence-based medicine which do not appear to be widely appreciated yet by this field.No study is perfect, and any study can be criticized, however scientific critique considers the likelihood that any flaws have a meaningful impact on the conclusions drawn and how definitive they might be. In the latter case, they clearly do; the conclusion drawn by the authors that “p-value [There is also a tenuous link between statistical significance and clinical significance, which is not always understood in the applied sciences. From a practical clinical perspective, as discussed below it may be more valuable to have an estimate of the effect size of an intervention (and our confidence in this) than its p-value . In othep-value .p-values by some scientists discussed in the previous section, I will argue in this section that some practitioners and researchers of EBM are making unsound epistemological claims about scientific knowledge.While the increased use of scientific evidence to inform clinical practice has undoubtedly brought enormous benefits, this is not the same as practicing Evidence Based Medicine (EBM). Somewhat like the importance placed on Within the medical field there are various forms of hierarchy used within “evidence based medicine”  and so cannot randomly draw on participants. This means that the error of any method could be even greater than is supposed by the analytical method used. In a non-random sample, e.g., with volunteers, there is no guarantee that the sample profile actually represents the target population profile. This point is important to appreciate, as any reasoning that aims to control for a type error I at a level of 5%, including any kind of corrections, is also affected by potential error in the sampling method.These limitations to the generalization of findings need to be acknowledged and critically evaluated to progress beyond a position of personal opinion to the development of scientifically justifiable beliefs about best practice based on the wider scientific research available.2.Bias towards single/general interventions: EBM is biased towards what can be readily measured, and so favors relatively simple interventions that can be incorporated into the “gold standard” double-blinded randomized controlled trial. This aligns EBM closely to a medical model and interventions that conform to this philosophy, but also the problems inherent within this approach when it comes to clinical animal behaviour, which were discussed above. This means EBM is well suited for, but also biased towards, interventions such as drug therapies with simple measurable outcomes. Complex, multimodal interventions or heterogenous personalized care programmes are perhaps the norm in clinical behaviour management, as both the patient and its carer typically need to engage in some form of behaviour change [r change ,73. Hower change   and so r change . Indeed r change , but seer change  for a us3.Exclusion of clinical skills from medical practice: EBM through its requirements for standardization finds it difficult to accommodate professional clinical judgment, or “the art” of clinical practice. As mentioned above, each patient is unique and subjects are generally believed to perform better with a bespoke behaviour modification programme, e.g., Blackwell et al. [l et al. . It is dl et al.  highligh4.Production of formulaic guidelines: a corollary of the above is the tendency of EBM to result in the production of clinical guidelines, which while useful can become proscriptive, limiting clinical autonomy and client choice as a result. As mentioned above, within clinical animal behaviour, protocols are usually bespoke, and this has been found to be of greater benefit to patients [patients .5.Failure to consider client views: What can be shown to work in clinical trials may not be what clients prefer. The four core ethical principles of clinical practice refer to autonomy, beneficence, non-maleficence and justice [ justice . EBM pri justice .6.Difficulties in translating evidence into practice: Even when EBM produces strong evidence of best practice, then there can be issues with EBM being adopted by practitioners. Indeed, within the veterinary field there does not seem to be a relationship between the quality of research as determined by EBM and its uptake [s uptake . AlthougSomewhat ironically, but also possibly most damningly, Lambert  highlighstudies in which the owner of the company that produces the commercially available canine and feline pheromones was a coauthor were excluded”. There is no scientific justification for this; although it might be argued that this exclusion avoids any risk of bias from someone with a vested interest in the results, this should be detectable from the scientific report, unless the authors believe that these authors are dishonest. This would be a very serious accusation that would have to be taken seriously . If we follow the logic of these authors, then we should exclude the data from any study published by the license holder of any pharmaceutical product. This line of thinking would totally undermine the evidence-based approach, as not surprisingly those with an interest in a product are most likely to invest in the higher quality research studies which lead to the evidence required for licensing. Unfortunately, Frank et al. [While the hierarchy purports to illustrate increasing quality of evidence from the associate types of study, this is not necessarily the case, especially when the study does not adopt appropriate standards. Systematic reviews are generally placed at the top of this hierarchy, but that does not mean their conclusions are necessarily accurate since they might be biased. The reporting of the systematic element of the review process should allow detection of errors including systematic biases and consideration by future readers, even if it is not recognized by the original authors. Unfortunately, subsequent critical evaluation of such publications for important errors does not seem to be happening in the veterinary behaviour literature, with the consequence that poor conclusions are potentially being perpetuated. For example, Frank et al.  in theirk et al.  did not k et al. ,86 and sAnother way to eliminate potential bias, which was unfortunately not adopted in this particular systematic review  would beAs with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute”. Yeh et al. [The appeal to the authority of evidence that characterizes evidence-based practices does not increase objectivity but rather obscures the subjective elements that inescapably enter all forms of human inquiry”. As noted already, from the veterinary behavioural medicine perspective, available evidence might suggest that greater treatment success is often associated with the inclusion of ideographic knowledge of the patient that allows the development of an individualized programme [A further entertaining illustration of the practical problems with an uncritical approach to EBM has been highlighted by Smith and Pell . They unh et al.  took thih et al. . From 92h et al.  argues trogramme . Accordirogramme ,103. ThiSome current dimensions of applied behavior analysis” Baer et al. [reversibility, i.e., the consistent return to the base state once an intervention which brings about a meaningful change is withdrawn; andthe use of multiple baselines, in which baseline levels of response are established across a variety of contexts and the intervention introduced in one of these. A relevant change should change the baseline of the behaviour only within the context that it has been introduced. The process can then be extended to other contexts and similar changes should occur. This negates the need to withdraw treatment which could be practically and ethically problematic.By contrast, within Applied Behavior Analysis, the uniqueness of the individual is very much at the centre of treatment and so scientific methods for establishing efficacy have focused on addressing the challenge of statistical confidence when n = 1. In their classic paper “r et al.  emphasizWith sufficient repetition, these results can be made more robust through appropriate statistical analysis. This approach has been adopted in a number of recent reports concerning the application of functional analysis within the field of clinical animal behaviour , it could be argued that the quality of the latter two studies is better, due to the content of the results presented. Further consideration of the issues raised here, will hopefully continue to improve the reporting of scientific results in veterinary behavioural medicine. Unfortunately, as we have already seen, few of the potential interventions for problem behaviour management have such a strong scientific basis. Therefore, in the final section of this manuscript a framework is provided to assist with clinical decision making, drawing on the points discussed so far relating to the effective use of available scientific information.In order to make best use of available scientific information it is important to appreciate and accept the uncertainty inherent within all such information. Nothing is absolute, but that does not mean all information is equal or scientific information is no better than personal opinion. Scientific literacy means being able to recognize what can be taken from a publication to help reduce our ignorance and what cannot be logically deduced. Critique requires a judgment on the likely impact of flaws within a design (since no study is perfect) on the conclusions that can be drawn, and should be distinguished from simple criticism, which seeks to point out the flaws. Evaluating the quality of a study does not just come from the design but also how it is executed and so it is important to evaluate the methods carefully and ensure valuable information is available. To this end, the growth of open access publication and open research agreements aimed at encouraging data sharing  are potThose reading publications should not assume that their definition of a problem behaviour/client complaint  is necessarily the same as that of the author. We should look carefully for the definition used by authors (who likewise should ensure they carefully define such terminology). Depending on the nature of the research definition might be done in several ways, for example through the description of inclusion and exclusion criteria or by reference to a diagnosis which ideally makes reference to the context of the behaviour, and associated motivational and emotional states. The process used to make inferences about these latter two states should also be outlined, as appropriate. Critically it is important that any consideration or discussion of results in relation to the wider scientific literature, remains mindful of the potential that the populations being studied may be quite different, even if they have the same label. This will prevent the misrepresentation and overgeneralization of the findings.Broadreach Nature Relaxing Moments calming room spray for dogs”TM describes itself as “a special blend of fragrance extracts to simulate canine pheromones” but closer inspection of composition reveals only Valerian Root Extract, Chamomile Extract, Rosemary Oil, Clove Oil which are herbals and not pheromonal with no logical reason as to why these should be considered to simulate pheromones [… it seems likely that a placebo effect accounts for the perceived effectiveness of those products where the success rates were 35% or less in the present study, which was the case for pheromone products…” is unsound, especially in light of more direct evidence to the contrary, e.g., Landsberg et al. [Uncertainty within the scientific method: the place of justified beliefs versus opinions and the meaningfulness of p-values” it is worth emphasizing from a clinical perspective only a positive result would be of interest. A negative result does not help to reduce uncertainty given the flaw described.Likewise, it is important to recognize how treatments are defined and the limitations of this. Some studies, e.g., Riemer  in a sureromones . Unfortug et al. . To refeIt is obviously important that any proposed intervention has a rational scientific basis, but by the same measure the method used to evaluate it needs to be rational. As discussed above, simple dependence on the hierarchy within EBM as a measure of quality can lead to unhelpful conclusions. The rationale for a particular methodology will be affected by pragmatic factors like, how much we already know about an intervention based on both research and both clinical experience. Randomized controlled trials are an essential requirement for the registration of medications and are expensive. They also imply a medical perspective on treatment and associated limitations, as described above. Not least, in the case of clinical animal behaviour these sorts of trial often refer to the effect seen in a population that has been very loosely defined on the basis of superficial behavioural characteristics , and so the likelihood of failing to show a significant difference was very high. The risk of a false negative is further increased, when it is realized that nearly half the subjects (18/39) were not considered treatment successes. This not only reduces the power even further of being able to detect a difference in those cases where the intervention seemed appropriate, but also questions the validity of the diagnostic instrument used  to define anxiety disorders, given its poor sensitivity in predicting the effect of therapeutic intervention. Using such a poor diagnostic instrument to define the target population only further increases the chance of a false negative result in a comparative study. Accordingly, I would suggest that these flaws mean a more appropriate conclusion would be along the lines of: “based on the sample used and considering all limitation of this study we did not find significant difference between the two groups and cannot evaluate if they have any degree of equivalence”. However, because the data are well reported we can take home some useful insights, regarding the poor quality of the EDED scale as a tool for predicting treatment success when either agent is used. The data on individual subpopulations might also be useful pilot data for future hypothesis testing, if they could be examined further to identify the potential differences between responders and non-responders in each group.Having established that the experimental design and metrics used are of clinical relevance, it is useful to then consider the size of effect. In this regard, a et al.  reportedp-values. However, this should not be taken to mean that p-values are not of use. The presentation of both provide the richest information for discussion of clinical significance. Even if a study does not reach the statistical threshold for significance, it may still show a large effect size, especially if the sample was small; which might provide valuable preliminary insight into the potential value of an intervention; especially in a field like clinical animal behaviour where there are so few high-powered studies. It is perhaps unrealistic to expect this situation to change much, with no regulatory requirement for the demonstration of efficacy of interventions within clinical animal behaviour.In general, metrics of effect sizes, such as Cohen’s d, Hedges g or simply odds ratios with confidence intervals e.g., Engel et al.  are ofteNeither assessing evidence quality nor applying this assessment to real world clinical situations in a meaningful way lends itself well to simply formulaic solutions. As mentioned already, scientific advance is about reducing uncertainty and it is important to keep this in mind when considering the information we have available to assist clinical decision making. At both a pragmatic and scientific level, we can still make rational use of poorer quality information, so long as we engage with the essential scientific skill of critical reflection. This means we must carefully consider the importance of identifiable flaws in line with the principles described in this paper. Another important principle is to be open to revising our conclusions as new information comes to light. This information may come from new insights into existing evidence or new evidence. We might then be able to rationally justify one intervention over another, even when evidence is far from ideal. I suggest from both a practical and scientific perspective this is preferable to simply dismissing poor quality evidence so long as it is not fatally flawed.I describe below a “logic” hierarchy to aid the selection of the best adjuncts to behaviour modification exercises given this imperfect reality. It is assumed that the behaviour modification exercise is effective but would benefit from augmentation. Level 1 represents proximity to the ideal, with higher numbers indicating less desirable options; at each stage the significance of imperfections has to be considered in relation to the patient under consideration, so that treatment can remain personalized. Through critical reflection of published data (rather than simple acceptance of author conclusions), we can make best use of the available evidence to reduce our uncertainty about the value, or potential value, of one intervention over another on a rational basis. Imperfect evidence is still preferable to no evidence, so long as the costs of it being wrong are less than the costs of ignoring it if it is right. An essential practical point concerning the use of this hierarchy is careful reflection on the impact of our decision about the evidence being wrong. This reflection is important up to and including the point, when we decide to prefer one intervention over another, in order to avoid the literally fatal flaws associated with the evidence concerning parachutes described earlier.Level 1. An adjunct with strong evidence of meaningful efficacy in relevant diagnostic contexts (including representative populations) from diverse well-designed trials, ideally supported by additional insight relating to the specific characteristics of the patient under consideration, to allow confidence in the personalized treatment plan.Ideally the diagnostic context should include a rational defense concerning inferences about the motivational and emotional state underlying the behaviours of concern.The specific risks, e.g., health risks associated with any intervention need to be considered and can result in contra-indication.Level 2. An adjunct with consistent evidence of meaningful efficacy from multiple appropriate studies (beware the poorly designed study which shows a negative result), which may have flaws  in relevant diagnostic contextsLevel 3. An adjunct with some evidence or potential efficacy from a relevant study, including a case series or the documented clinical experience of multiple independent clinicians, giving due consideration to the relevance of the evidence to the current case. In the case of multiple potential adjuncts being considered then a rational argument should be made concerning the relative importance of one set of flaws and knowledge gaps over another, for each intervention under consideration.Level 4. An adjunct whose efficacy is based on personal experience (own or others).This proposed hierarchy provides a guide to the relative weight that should be given to the available evidence, which recognizes perhaps a greater diversity of sources, through its emphasis on critical reflection of both the quality of evidence and its relevance. In reality the scale exists on a continuum; many adjuncts will sit between levels and the merits of one over another depend on an assessment of the evidence in relation to the case being considered. This approach maintains an individualized treatment perspective. The key question to keep asking when reviewing evidence is: to what extent does this information help to reduce scientific uncertainty in my clinical decision making?The scientific method remains the most powerful tool for determining knowledge, however it is incumbent upon anyone claiming to use this process to apply it honestly and to the best of their ability. This obligation is especially important when one seeks to take responsibility for translating research into practice. When undertaking such knowledge translation, it is imperative that individuals do not simply apply formulaic processes, but that they actively engage in scientific thinking throughout the process. This includes a balanced consideration of both the limitations of knowledge and its inherent uncertainty. The generation of knowledge is an iterative process and so individuals need to be careful about simply referring to original work, whose conclusions may need refining since their original publication. The advent of electronic publications, makes it much easier to track citations, including criticism, which can prove invaluable in this regard.This article has provided a point of reference for future discussion of more effective methods for evaluating interventions within the field of clinical animal behaviour. To assist the debate, it has sought to highlight the differing philosophical underpinnings to the discipline, which are rarely articulated and often go unrecognized. It is hoped that increased awareness of the issues raised here will help fuel more informed debate, so that the undoubted value of a scientific approach can be more fully realized to the benefit of our patients.