SUBJECT: ADVANCED NURSING PRACTICETOPIC: EVIDENCE BASED NURSING PRACTICE

EVIDENCE BASED PRACTICEEBP is simply the integration of the best possible research to evidence with clinical expertise and with patients needs.patient need here refers to the expectations, concerns, and requirements that patient brings to their clinical experience.evidence indicates that patients who receive care based on the best and latest evidence from well designed studies experiences 28% better outcomes(heater,becker & olson,1988).Although the amount and quality of clinical research has increased, and more research content has threaded throughout educational programs, awareness and use of research by practicing health care providers remains poor(camiah, 1997; jolley, 2002). The gap between the publication of research evidence and its translation into practice to improve patient care is a cause of concern in healthcare.

HISTORICAL OVERVIEW : Much of the original work on evidence-based practice (EBP) focuses on EBP in medicine. Although the term “evidence-based medicine” (EBM) reportedly was first used in the 1980s, the practice gained wide recognition in 1992 when the Journal of the American Medical Association published an article by the evidence-based medicine working group on its role in medical education. According to Montori and Guyatt (2008), that article brought both the term and the concept to the attention of a wider medical community. The working group published a series of 25 articles between 1993 and 2000 that outline criteria to evaluate current evidence to support clinical decisions. This body of work forms the basis of most of the critical appraisal tools used today (Guyatt & Rennie, 2002). 

DEFINITION:The EBP process is a method that allows the practitioner to assess research, clinical guidelines, and other information resources based on high quality findings and apply the results to practice.

EBP is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” (Sackett D, 1996)

EBP is the integration of clinical expertise, patient values, and the best research evidence into the decision making process for patient care. Clinical expertise refers to the clinician’s cumulated experience, education and clinical skills. The patient brings to the encounter his or her own personal preferences and unique concerns, expectations, and values. The best research evidence is usually found in clinically relevant research that has been conducted using sound methodology. (Sackett D, 2002)

Evidence based practice (EBP) is the conscientious use of current best evidence in making decisions

about patient care (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000).

EVIDENCE BASED NURSING PRACTICEEvidence-based nursing and evidence-informed decision-making began with Florence Nightingale in the 1850s during the Crimean War. She noted a connection between poor sanitary conditions in the hospital and rising death rates among wounded soldiers. “It is Nightingale who developed the coxcomb, a visual display to demonstrate how military deaths could be prevented” (Morin, 2010). Her subsequent efforts to sanitize hospitals to save soldiers led to dramatic drops in patient mortality.

DEFINITION:Scott & McSherry's extensive literature review looked at commonalities between EBN definitions and synthesized them to come up with the following definition: "An ongoing process by which evidence, nursing theory and the practitioners’ clinical expertise are critically evaluated and considered, in conjunction with patient involvement, to provide delivery of optimum nursing care for the individual."GOALS:The goal of EBP is the integration of:

(a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver perspectives to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve.

TYPES OF EVIDENCE : Various systems have been developed to rank evidence. Here are two examples.The Canadian Institutes for Health Research (2009) created a hierarchy of quantitative evidence:systematic reviews of randomized controlled trials;randomized controlled trials;systematic reviews of non randomized or cohort studies;cohort studies;case control studies;case series;case report;ideas, editorials, opinions;animal research; and in-vitro (test tube) research.

Brian Haynes (2007) developed the 5S Pyramid for finding the best evidence with the least amount of time and effort: Studies are individual studies related to a particular focused question. There are several searchable

databases that would help you find individual studies. The most used in Canada include Medline, PubMed and CINAHL, but there are many other specialized databases.

Syntheses include systematic reviews of all studies that could be found on a particular focused question. These include The Cochrane Library, Worldviews on Evidence-Based Nursing, the Agency for HealthCare Research and Quality(AHRQ) Evidence-based Practice Centre Reviews. Both groups have similar, rigorous methods for review. Another source for systematic reviews and summaries about interventions related to public health in Canada is theEffective Public Health Practice Project. Further, Health-Evidence.ca rates reviews that are relevant to public health in Canada, summarizes them and provides recommendations for practice and policy that arise from the reviews.

Synopses are brief reports (1-2 pages) of pre-appraised individual studies or systematic reviews that give key methodological details and results, along with an expert commentary, on issues of applying the results in practice. Examples of synopses are found in 23 evidence-based journals that cover topics such as medicine, nursing, dentistry and health policy (e.g., Evidence-Based Nursing ).

Summaries are usually text-based and are related to a specific disease or condition (e.g., Clinical Evidence).

Systems are electronic systems that can be linked to patient records and prompt practitioners with guidelines for care (e.g., what tests to order, what interventions to provide). For example, for a patient with type 2 diabetes, it would prompt the caregiver that blood work, eye exam, foot exam and diet review need to be done.

SKILLS NECESSARY FOR EBP: Critical thinking skills - it is defined as the rational examination of ideas,

inferences,assumptions,principles, arguments, conclusions, issues, statements, beliefs and actions.(bradman & bradman,1995)

Critical examination skills - to examine scientific evidences Information technology knowledge and skills - it is the use of information systems at the clinical sites Information literacy - it means that a nurse is able to recognize when information is needed to plan and

provide nursing care, and has the ability to find, evaluate, and effectively use the information(American library association,2001).

Communication skills - graduate nurses should be an effective and skilled communicators.

THE STEPS IN THE EBP PROCESS:

The five key steps in the evidence-based practice process include:

1. formulation of a clinical question

2. gathering the best evidence to answer the clinical question

3. critical appraisal of the best evidence

4. integration of the evidence with the clinician's own expertise, assessment of the patient's condition, available healthcare resources, and the patient's preferences and values to implement a clinical decision; and

5. evaluation of the practice change as a result of implementing the evidence.

While all five steps are critical, the fifth step is one of the most neglected. It is not uncommon for practitioners to implement a practice change based on evidence, but fail to evaluate the effectiveness of the change. Evaluation of the practice change is paramount, as it is imperative for nurses and other healthcare professionals to know how a particular treatment worked or the effectiveness of clinical decisions.

Melnyk and Fineout-Overholt advocate asking clinical questions in the PICO format, defined as follows:

P-Patient Population: A clear description of the patient population and setting is necessary to retrieve the most relevant evidence.

I-Intervention of Interest: The intervention of interest may include, but is not limited to, any treatment, patient perception, exposure or diagnostic test. The more defined the intervention, the more focused the search for evidence will be.

C-Comparison Intervention: The comparison intervention usually is the standard of care compared to a new treatment or procedure. The comparison also can be a true control, such as a placebo.

O-Outcome: Specific identification of the outcome variable facilitates the search for evidence that has investigated the same outcome.

KEY STEPS :

ASSESSthe patient

1. Start with the patient -- a clinical problem or question arises from the care of the patient

ASKthe question

2. Construct a well built clinical question derived from the case 

ACQUIREthe evidence

3. Select the appropriate resource(s) and conduct a search

APPRAISEthe evidence

4. Appraise that evidence for its validity (closeness to the truth) and applicability (usefulness in clinical practice)

APPLYtalk with the patient

5. Return to the patient -- integrate that evidence with clinical expertise, patient preferences and apply it to practice

Self-evaluation6. Evaluate your performance with this patient

STRATEGIES TO PROMOTE EBN: Strategies to promote evidence-based practice / evidence-informed decision-making by nursesStrategies include, but are not limited to: provide nurses with “access to a rich library with nursing and medical journals” (Eizenberg, 2011) provide nurses with “opportunities for working with a computer and for searching the Internet in the

workplace” (Eizenberg, 2011) “system support for searching and reading professional literature” (Eizenberg, 2011) implementation of a virtual journal club (Lehna, Berger,Truman, Goldman & Topp, 2010) “provide nurses with access to evidence-based practice resources via mobile information technologies”

(Doran et al, 2010) implement an EBP mentorship programme with EBP mentors who are “skilled in both EBP and

organizational culture and change” (Wallen et al, 2010) support nurses to acquire the skills needed to read, evaluate and critically appraise evidence (Eizenberg,

2011) establish leadership, a coherent change strategy, and relationships between point of care providers and

managers (Baeza, Fitzgerald & McGivern, 2008) nurse managers act as role models (Van Patter Gale & Schaffer, 2009) nurse managers provide the resources and the support for the work and celebrate success with

recognition of unit staff (Van Patter Gale & Schaffer, 2009) designate a champion who is “accessible to the nurses, along with other leaders and innovators who can

answer questions and reinforce the practice change “(Van Patter Gale & Schaffer, 2009) involve the “clinical educator as a part of the support system of the EBP change” (Van Patter Gale &

Schaffer, 2009)

IMPORTANCE OF EBN: Evidence-based nursing is one approach that may enable nurses to manage the explosion of new

literature and technology and ultimately may result in improved patient outcomes. Nursing students spend a great deal of preclinical preparation time designing care plans, reviewing

pathophysiology, and memorizing pharmacologic interactions. Although these activities are useful, they cannot be the only methods of preparing students for nursing practice.

Sole reliance on textbooks and expert faculty knowledge does not promote the critical thinking skills that nurses must have to survive in the current fast paced clinical settings. Students must learn to develop independent, evidence-based methods of clinical decision making.

Evidence based practice (EBP) "involves an ability to access, summarize, and apply information from the literature to day-to-day clinical problems".

Evidence based practice "requires an emphasis on systematic observation and experience and a reliance

on the research literature to substantiate nursing decisions." Evidence based practice allows practitioners to meet a daily need for valid information about clinical

situations. Evidence based practice allows nurses to enrich their clinical training and experience with up to date

research. With the large amount of research and information that exists in nursing, learning the skills of evidence based practice allows nurses to search for, assess, and apply the literature to their clinical situations.

BARRIERS TO EVIDENCE-BASED NURSING : Repeatedly, lack of time is identified one of the most crucial barriers to implementing evidence-based practice in the workplace (Bradshaw, 2010). Other documented barriers include: Nurse characteristics:

lack of the knowledge needed to interpret statistical analyses lack of interest lack of confidence in critical appraisal skills lack of knowledge and skills to confidently conduct computer based literature searches and utilize

the research process nurses’ perceptions that they lack the authority and cooperation to change patient care procedures negative beliefs, attitudes and values educational preparation.

Organizational characteristics: limited or lack of time heavy patient workloads inadequate staffing limited access to resources lack of support from nurse managers different goals for practice between administrators and staff nurses (Van Patter Gale & Schaffer,

2009) lack of evidence-based practice mentors in health-care systems (Bertulis, 2008).

Nature of research information: “Research is seen as too complicated, too scholarly, excessively statistical, ambiguous, and having

limited or no relevance to practice” (Van Patter Gale & Schaffer, 2009) “Research reports lack clear practice implications and generalizability” (Wells, Free & Adam,

2007). Health-care environment:

“Multiple barriers have contributed to the slow uptake of EBP across healthcare systems…traditional approaches to teaching healthcare students the rigorous process of how to do research rather than how to use research to guide best practice” (Wallen et al, 2010).

It takes as long as 17 yrs to translate research findings into practice(balas & boren,2000)

Cabana and colleagues(1999) used a review of 5,658 articles about EBP guidelines, from which they selected 76 studies to formulate their own framework of barriers that affect practitioner adherence to guidelines. Three categories were identified through this review, including: Lack of Knowledge and awareness( lack of accessibility and familiarity with guidelines) Attitudes (lack of confidence, motivation and self efficacy) Behaviors (inability to incorporate patient preferences into clinical decision making process).

OVERCOMING BARRIERS TO EBN:

For EBP to become gold standard of practice, EBP barriers must be overcome. Federal agencies, healthcare organizations and systems, policy makers, and regulatory bodies must advocate for and require its use. The following must be given high priority: Promoting acceptance Correcting misconceptions Questioning clinical practices Developing guidelines

FACILITATORS OF EBN:a) Support and encouragement from administrationb) Clearly written research reportsc) Organizational capacity for changed) Infrastructure implementation( time and resources)e) Healthcare team( their vision and mission)f) Credibility and utilization of guidelines

MAXIMI Z ING THE POTENTIAL OF EVIDENCE-BASED NURSING : Evidence-based care concerns the incorporation of evidence from research, clinical expertise, and patient preferences into decisions about the health care of individual patients. Most professionals seek to ensure that their care is effective, compassionate, and meets the needs of their patients. Therefore sound research evidence which tells us what does and does not work, and with whom and where it works best, is good news. Maximum use must be made of scientific and economic evidence, and the products of initiatives such as the Cochrane Collaboration. However, nurses and consumers of health care clearly need other evidence, arising from questions which cannot be framed in scientific or economic terms. Nursing could spark some insightful debate concerning the nature and contribution of other types of knowledge, such as clinical intuition, which are so important to practitioners.In summary, in embracing evidence-based nursing we must heed these considerations:

Nursing must discard its suspicion of scientific, quantitative evidence, gather the skills to critique it, and design imaginative trials which will assist in improving many aspects of nursing

We must promulgate naturalistic/interpretist studies by indicating their usefulness and confirming/explaining their rigor in investigating the social world of health care

More research is needed into the reality and consequences of adopting evidence-based practice. Can practitioners act on the evidence, or are they being made responsible for activities beyond their control?

It must be emphasized that those concerns which are easily measured or articulated are not the only ones of importance in health care.

CONCLUSION:Evidence-based practice involves the incorporation of three components to improve outcomes and quality of life. External evidence includes systematic reviews, randomized control trials, best practice, and clinical practice guidelines that support a change in clinical practice. Internal evidence includes health care institution based quality improvement projects, outcome management initiatives, and clinical expertise. Accounting for patient preferences and values is the third component of this critical equation. 

Research + Clinical Expertise + Patient Preference = EBP

If evidence based practice is to work and be sustained, it requires commitment at every level of healthcare system. From government to private and corporate sector, from administrators to providers as well as patient and communities, each will be required to participate in a fundamental change in the foundations of health care delivery. Evidence based practice provides a format and means for creating effective change in the way healthcare is delivered and in the subsequent higher value obtained from the health service providers.

REFERENCE: Melnyk,fieout-overholt:evidence based practice in nursing and healthcare.lippincott williams & wilkins Malloch.k,porter.t:introduction to evidence based practice in nursing and healthcare.jones and bartlett

publishers Canadian Institutes for Health Research. (2009). Introduction to evidence-informed decision making.

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307.7 KB]. [Position statement]. Ottawa: Author