Evidence based practice in nursing

Introduction

Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care

that integrates the best evidence from studies and patient care data with clinician expertise
and patient preferences and values. (Fineout-Overholt E, 2010). 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.

Definition

Evidence Based Nursing: “An integration of the best evidence available, nursing expertise,
and the values and preferences of the individuals, families, and communities who are served.

Key components of evidence based practice

Health care that is evidence-based and conducted in a caring context leads to better clinical
decisions and patient outcomes. Gaining knowledge and skills in the EBP process provides
nurses and other clinicians the tools needed to take ownership of their practices and transform
health care.
The key components of ebp are:-

 Research evidence:
o Randomized controlled trials
o Laboratory experiments
o Clinical trials
o Epidemiological research
o Outcome’s research
o Qualitative research
o Expert practice knowledge, inductive reasoning

 Clinical expertise, judicious use:

o Expert practice knowledge
o inductive reasoning

 Patient values and circumstances.

o Unique preferences
o Concerns
o Expectations
o Financial resources
o Social support
Aims of evidence based practice

 To provide the high quality and most cost-efficient nursing care possible.
 To advance quality of care provided by nurses.
 To increase satisfaction among patients.
 To focus on nursing practice away from habits and tradition to evidence and research.
 It results in better patient outcomes.
 It contributes to the science of nursing.
 It keeps practices current and relevant.
 It increases confidence in decision-making.

Features of ebp
 Problem based and within the scope of the practitioners experience.
 It brings together the best available evidence and current practice by combining
research with knowledge and theory. So it narrows the research practice gap. It
facilitates application of research into practice by including both primary and
secondary research findings.
 It concerned with quality of service and is therefore a Quality assurance activity.
 EBP projects are team projects and therefore require team support and collaborative
action.
 It support research projects and outcomes that are cost effective EBP de- emphasizes
ritual, isolated and unsystematic clinical experiences ungrounded opinions and
tradition as a basis of practice. It stresses the use of research findings.

Why is ebp relevant to the nursing practice?

 There is a gap between what we know and what we do.
 Nursing practice can and must be changed from tradition-based to science-based
 Research-practice gap: Much of what is known from research has not been applied in
practice. This is known as Research-Practice Gap.

Steps of evidence based practice

 Step 1: formulating a well built question

 Step 2: collecting the most relevant and best evidence to answer the clinical question
including searching for systematic reviews/identifying articles
 Step 3: Critically appraising the evidence that has been collected for its validity,
relevance and applicability.
 Step 4: integrating the evidence with ones clinical expertise, assessment of patient’s
condition and available health care resources along with the patients preferences and
values to implement the evidence.
 Step 5: Evaluating the change resulting from application of evidence in practice.
Determine the areas for improvement.

Step1: FORMULATING THE QUESTION

 With clinical areas ,there is often a barrage of details to digest.

 A well built question includes the following components :
 a. the patients disorder or disease
b. the intervention or finding under review
c. a comparison intervention
d. the question should be in PICOT or PICO format

PICOT FORMAT
 Patient, Population or Problem
 What are the characteristics of the patient or population?
 What is the condition or disease you are interested in? ( i.e. Age, gender, ethnicity,
with a certain disorder)

 Intervention or exposure
 What do you want to do with this patient (e.g. Treat, diagnose, observe)?
 (exposure to a disease, risk behavior, prognostic factor)

 Comparison
 What is the alternative to the intervention (e.g. Placebo, different drug, surgery)?
 (could be a placebo or "business as usual" as in no disease, absence of risk factor,
Prognostic factor )

 Outcome
 What are the relevant outcomes (e.g. Morbidity, death, complications, risk of disease,
accuracy of a diagnosis, rate of occurrence of adverse outcome)

 Time
 What time it takes to demonstrate an outcome (e.g. The time it takes for the
intervention to achieve an outcome or how long participants are observed).

Example

Are insulin pumps more effective than conventional therapies in managing type 2 diabetes in
pregnant women?
 Patient/Population - Pregnant women with type 2 diabetes
 Intervention - Insulin pump therapy
 Comparison - Conventional insulin therapy
 Outcome - Improved management of glucose levels

Step 2. DATABASE /RESOURCE SEARCHING

Once a clinical practice question has been selected, the next step is to search and assemble
research evidence on the topic. In doing a literature review as a background for a new study,
the central goal is to discover where the gap are and how best to advance knowledge.

The resourses falls into 3 categories

1. General information/background resourses- to collect the past information of a

particular disease.
  E.g: measles has been nearly eradicated, but there has been a fairly recent outbreak. If
you need to refresh your knowledge of the clinical presentation, diagnosis etc of
measles, a background resource would be the best place to start.
2. Filtered resourses- If you are trying to decide on a course of action for a patient
(diagnosis, treatment etc)and want to base your decision on the best available
evidence, consult a filtered resource. Clinical experts and subject specialists pose a
question and then synthesize evidence to state conclusions based on the available
research. Because of this pre evaluation, the clinician does not have to do the
literature searching and evaluate each study that comes up, saving time and ensuring a
level of completeness.
3. Unfiltered resourses- provide the most recent information ,but its upto to the
clinician to evaluate each study found to determine its validity and applicability to the
patient. Effectvely searching and evaluating the studies found in unfiltered resources
takes more time and skill, which is why filtered resources are the first choice of
answering clinical questions.
Step3. CRITICALLY APPRAISING THE ARTICLE

 The assessment of evidence by systematically reviewing its relevance, validity and

results of specific situations.
 In determining the implementation potential of an innovation in a particular setting,
several issues should be considered, particularly the transferability of the innovation,
the feasibility of implementing it and its cost benefit ratio.
 For example, the traditional method for verifying the placement of a nasogastric tube
was air insufflation. However, according to current nursing research, the accurate
method for verifying placement is radiologic examination (Metheny & Titler, 2001).
 If the implementation assessment suggests that there might be problems in testing the
innovation in that particular practice setting, then the team can either identify a new
problem and begin the process anew or consider adopting the plan to improve the
implementation potential (e.g. Seeking external resources if cost were the inhibiting
factors)

Step 4. APPLYING THE EVIDENCE/INTEGRATING EVIDENCE WITH ONES

CLINICAL  EXPERTISE

 If the implementation criteria are met the team can design and plot the innovation.
 To reach your conclusion you may consult questions related to diagnosis ,therapy,
harm and prognosis keep in mind that you must interpret the information based on a
number of criteria and depending on your skill and experience ,you may need to
confer with a peer. Example- Sample evidence practice
 e.g. Consider a nine year old girl present in the ER with abdominal pain and you
suspect appendicitis. Which imaging modality is best for making the diagnosis CT or
ultrasound.

Step 5. EVALUATING THE CHANGE

 The fifth step of the process, outcome evaluation, attempts to interpret the results and
evaluate the outcomes of the applied evidence (intervention).
 Outcome measures may be
 psychosocial (quality of life, improved patient perception of care, reduction in
depressive and anxiety symptoms)
 physiologic (improved health, reduced complications),
  functional improvement. Evaluation of the process and the results may occur through
peer assessment, audit, or even self reflection.
 Depending on the type of outcomes achieved, it may be possible to compare the
outcomes of a study with similar outcomes on a local, regional, national, or
international level.

EBP RESOURCES

 PRE-APPRAISED RESOURCES:
 Filtered resource have been reviewed for quality and relevance to clinical care- ACP
Journal Club. This Web site comprises a 10- year archive of the cumulative electronic
contents of "ACP Journal Club", with recurrent weeding of out-of- date articles. The
content is carefully selected from over 100 clinical journals through reliable
application of explicit criteria for scientific merit, followed by assessment of
relevance to medical practice by clinical specialists.
 Clinical Evidence-Clinical Evidence describes the best available evidence from
systematic reviews, rcts, and observational studies when appropriate for assessing the
benefits and harms of treatments.  Dynamed. Dynamed is a point-of-care reference
resource designed to provide clinicians with current, evidence-based information to
support clinical decision-making.  Essential Evidence. Essential Evidence is a one-
stop reference that includes evidence-based answers to clinical questions concerning
symptoms, diseases, and treatment.
 Clinical Inquiries- Clinical Inquiries provides answers to clinical questions by using a
structured search, critical appraisal, clinical perspective, and rigorous peer review.
FPIN Clinical Inquiries deliver evidence for point of care use.
 UpToDate-UpToDate is an evidence-based, peer reviewed information resource
available via the Web, desktop/laptop computer, and PDA/mobile device.

 DATABASES:
 PubMed- PubMed comprises more than 22 million citations for biomedical articles
from MEDLINE and life science journals. Citations may include links to full-text
articles from PubMed Central or publisher web sites.
 Cochrane Library- The Cochrane Library contains high- quality, independent
evidence to inform healthcare decision-making. It includes reliable evidence from
Cochrane systematic reviews and a registry of published clinical trials. The
methodology used to create the Cochrane reviews is recognized as the gold standard
for developing systematic reviews.  Center for Reviews and Dissemination (DARE).
The databases DARE, NHS, EED and HTA assist decision- makers by identifying and
describing systematic reviews and economic evaluations, appraising their quality, and
highlighting their relative strengths and weaknesses.

 ELECTRONIC TEXTBOOKS AND LIBRARIES:

 Access medicine: Access Medicine is an online resource that provides students,
residents, clinicians, researchers, and other health professionals with access to
"Harrisons Online". Scientific American Medicine. Formerly known as ACP
Medicine, Scientific American Medicine includes science, medicine, health and
technology information. It is also available from Stat!Ref. ACP Smart Medicine.
Formerly known as ACP PIER, ACP Smart Medicine is an online clinical tool that
provides evidence-based clinical guidance to improve clinical care. It is free to ACP
 members or can be purchased as a subscription. Stat!Ref. STAT!Ref is a collection of
online electronic textbooks for healthcare professionals.

 META-SEARCH ENGINES:
 Trip-The TRIP Database searches across multiple internet sites for evidence-
based content. It covers key medical journals, Cochrane Systematic reviews,
clinical quidelines, and other highly relevant websites to help health
professionals find high quality clinical evidence for clinical practice

Models for evidence based nursing practice

The models offer guidelines for designing and implementing a utilization project in a practice
setting. The two models stelter model and Iowa model incorporate evidence practice
processes rather than research utilization alone.

Model of Evidence Based Practice:

 THE STELTER MODEL: The stelter model was designed with the assumption that
Research Utilization could be undertaken not only by organizations but by individual
clinicians and managers.
 It was a model designed to promote and facilititate critical thinking about the
application of research findings in practice.
 The current model presented graphically involves five sequential phases:
a. Preparation- In this phase, the nurses define the underlying purpose and outcomes of
the project, search, sort and select sources of research evidence. She considers
external factors that can influence potential application and internal factors that can
diminish objectivity and affirm the priority of perceived problem.
b. Validation-This phase involves a utilization of focused critique of each source of
evidence, focusing in particular on whether it is sufficiently sound for potential
application in practice. Comparative evaluation and decision- making - This phase
involves a synthesis of findings and application of criteria that taken together are used
to determine the desirability and feasibility of applying findings from validated source
to nursing practice. The end result of the comparative evaluation is to make a decision
about using the study findings. Translation/application - This phase involves activities
to conform how the findings will be used (e.g. Formally or informally) and spell out
the operational details of the application and implement them.
c. Evaluation - In the final phase, the application is evaluated. Informal use of the
innovation versus formal use would lead to different evaluative strategies

 IOWA MODEL: Efforts to use research evidence to improve nursing practice are
often addressed by group of nurses interested in the same practice issues.
 This model, like the stelter model, was revised recently an renamed the Iowa Model
of evidence Based Practice to promote quality of care.
  The current version of Iowa Model acknowledges that formal RU/EB Project begins
with a trigger an impetus to explore possible changes to practice. The start point can
be either knowledge focused trigger that emerges from awareness of innovative
research findings.
The model outlines a series of activities with three clinical decision points.
I. Deciding whether the problem is a sufficient priority for the organization exploring
possible changes; if yes, a team is formed to proceed with the project: if No, a new
trigger would be sought.
II. Deciding whether there is sufficient Research base; if Yes, the innovation is piloted
in the practice setting. If No, the team would either search for other sources of
evidence or conduct its own research.
III. Deciding whether the change is appropriate for adoption in practice; if yes, a change
would be instituted and monitored. If No; the team would continue to evaluate
quality of care and search for new knowledge.
The points of entry to this model were problem and knowledge focused triggers.
 Problem focused triggers encompassed frequently encountered clinical problems, risk
management and quality improvement data and total quality management programs/
in contrast,
 Knowledge focused triggers include new information that resulted from such sources
as the Agency for Health care policy and Research, specialty organizations and
research publications.
 When a trigger was identified the next step included assembling, critiquing, and
evaluating the applicability of relevant research literature.
 After the research base was evaluated and critiqued, a decision was made regarding
whether or not a change in practice was warranted. If, however, a sufficient and
appropriate research base was found that supported modification of current practice,
changes were initiated that were congruent with those suggested by the research
results. If research base had insufficiencies, further research was conducted, experts
were consulted and applications of scientific principles were considered.
To translate research findings into practice several steps were necessary:
1) Expected outcomes of the change and baseline or current status were documented.
2) Nursing/ multidisciplinary interventions were designed
3) Practice changes were implemented on a pilot unit.
4) Process and outcomes were evaluated.
5) The interventions were modified as necessary
The next critical decision point involved determination of whether practice changes should
be made for all patient populations affected by the research based interventions.
Considerations included cost of implementations, overall impact on quality of care, staff
competency and support of administration.

BARRIERS TO USING RESEARCH IN NURSING RESEARCH

RELATED BARRIERS

NURSE RELATED BARRIERS

 Many Nurses have not received any formal instruction in research and they lack skill
to judge the merits of a study.
 Nurses attitude toward research and their motivation to engage in EBP have been
identified a potential barrier.
  People are often resistant to change. Change requires effort, retraining and
restructuring of work habits. Thus there is likely to be some opposition to introducing
innovations in practice setting.

Advice
 Read widely and critically.
 Professionally accountable nurses should read journals relating to their specialty,
including research reports in them.
 Attend professional conference. Conference attending give opportunities to meet
researchers and to explore practice implications.
 Learn to expect evidence that a procedure is effective. Nurses need to develop
expectations that the decisions they make in their clinical practice are based on sound
rationales.
 Become involved in a journal club. Many organizations that employ nurses sponsor
journal clubs that meet to review research articles that have potential relevance to
practice.
 Pursue and participate in EBP projects. Nurses who are involved in research related
activities develop more positive attitudes toward research and better research skills

ORGANIZATIONAL BARRIERS
 Many of the major impediments to using research in practice stem from the
organizations that train and employ nurses.
 Organizations have failed to motivate or reward nurses to seek ways to implement
appropriate findings in their practice. In several studies of barriers to RU, one of the
greatest reported Barrier was “insufficient time on the job to implement new ideas”.
 Organizations may be reluctant to expand resources for RU, EBP activities or for
changing organizational policy.

Advice:
To promote the use of research evidence, administrators can adopt the following strategies:
 Foster a climate of intellectual curiosity. Open communication is important in
persuading staff nurses that their experiences and problem are important and that the
administration is willing to consider innovative solutions.
 Reward efforts for using research. RU should not be the primary criterion for
evaluating nurses performance but its inclusion is an important criteria to affect their
behavior.  · Seek opportunities for institutional RU/EBP projects. Organizational
efforts and commitment are essential for the type of projects.
 Offer emotional or moral support. Administrators need to make their support visible
by informing staff by establishing EBP committees, by helping to develop journal
clubs and by serving as role models for staff nurses.
 Offer financial or research support for utilization.

NURSE ROLE IN EVIDENCE-BASED PRACTICE

 A nurse can be a decision-maker and coordinator of care.

 As a scientist: A nurse ensures his or her practice is evidence-based and that
institution approved protocols are utilized.
 As a transferor of knowledge: This important role is invoked when discussing the plan
of care with patients, their loved ones, and with other members of the healthcare team.
 Manage resources and facilitate the success of unit-based EBP workgroups
 Support EBP by communicating with unit staff the expectations for participation and
available resources Encourage broad staff participation to promote collaborative
teamwork
 Become a primary vehicle for recognition of staff nurses' success
 Encourage research and research uses.
 Offer emotional and moral support to senior staffs for evidence based practice.
 Foster a climate of intellectual curiosity.
 Attend and encourage junior staffs to conference
 The registered nurse participates, as appropriate to education level and position, in the
formulation evidence-based practice through research.”
 The registered nurse utilizes current evidence- based nursing knowledge, including
research findings, to guide practice.
 Know basis for nursing practice
 Expect that evidence is the foundation of practice
 Participate in EBP projects
 Disseminate project findings in various forums
 Collaborate with the healthcare team to provide quality care