EVIDENCE BASED PRACTICE
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. The best research evidence is usually found in clinically relevant research that has been
conducted using sound methodology.
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. Key
elements of a best practice culture are EBP mentors, partnerships between academic and clinical
settings, EBP champions, clearly written research, time and resources, and administrative support.
(Fineout-Overholt E, 2005).
Evidence based practice(EBP),alternatively known as empricially supported treatment(EST)
is the preferential use of mental and behavioural health interventions for which systematic empirical
research has provided evidence of specific problems ;EBP promotethe collection, interpretation and
intergration of valid, important and applicable patient reported, clinician observed, and research
derived evidence.
MEANING OF EVIDENCE BASED PRACTICE
Evidence-based practice (EBP) is an interdisciplinary approach to clinical practice that has been
gaining ground following its formal introduction in 1992. It started in medicine as evidence-based
medicine (EBM) and spread to other fields such as dentistry, nursing, psychology, education, library
and information science and other fields.
Its basic principles are that all practical decisions made should
1) be based on research studies and
2) that these research studies are selected and interpreted according to some specific norms
characteristic for EBP.
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”.
"Evidence-based decision-making is a continuous interactive process involving the explicit,
conscientious and judicious consideration of the best available evidence to provide care."- Position
Statement by Canadian Nurses Association. In increasing numbers, nurses as members of
interdisciplinary and transdisciplinary teams are implementing evidence-based practice (EBP)
changes. (Worral PS, 2009).
“Evidence-based practice is the conscientious ,explicit and judicious use of current best evidence in
making decisions about the care of individual patients.The practice of evidence-based medicine means
integrating individual clinical expertise with the best available external clinical evidence from
systematic research.(Sackett et al.,1996)
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.
PURPOSES AND OBJECTIVES
Evidence based practice seeks to replace practice as usual, with practice guided by rigorous outcome-
oriented research, ideally randomized controlled trials. It also seeks to make practice a less subjective
enterprise, and to raise it to a higher level of accountability. It is associated with efforts to identify best
practices in nursing and other disciplines. (Baumann SL, 2010)
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.
EBP is more focused on the science of nursing than on the art of nursing.
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.
RESEARCH-PRACTICE GAP
Steps of the process included:
Dissemination of knowledge.
Synthesis of findings.
Critique of studies
Application of findings.
Development of research-based practice guidelines (i.e., Agency for Health Care Policy and Research [AHCPR] practice guidelines; Conduct and Utilization of Research in Nursing [CURN] practice protocols).
The problems of importance to medical- surgical nursing (skin breakdown, pain, bowel function, treatment adherence, nausea) and related interventions are largely not collected in medical record databases.
Nursing research studies are predominately descriptive or qualitative in design, rather than what is considered more rigorous and quantitative.
Needed to help bridge the research- practice gap by:
– Strengthening the evidence base so that we know what works and what doesn’t work in providing
patients with the best outcomes.
– Standardizing evidence across fields to reach the best outcome for the patient.
– Housing evidence in online databases providing reviews of the evidence base.
– Translating and consolidating state of the science into clinical recommendations.
_Improve patient outcomes
_Decreased unnecessary procedures & complications
_Greater provider job satisfaction
_Third party reimbursement
_Effective nursing practice requires information, judgment, and skills.
EVIDENCE BASED MEDICINE
During the 1980s, the term “evidence-based-medicine” emerged to describe the approach
that used scientific evidence to determine the best practice. Later the term shifted to become “evidence
based practice” as clinicians other than physicians recognized the importance of scientific evidence in
clinical decision making. Various definitions of evidence based practice have emerged in the
literature, but the most commonly used definition is the conscientious, explicit, and judicious use of
current best evidence in making decisions about the care of individual patients.
Evidence-based medicine de-emphasizes intuition, unsystematic clinical experience, and
pathophysiologic rationale as sufficient grounds for clinical decision making and stresses the
examination of evidence from clinical research. Evidence-based medicine requires new skills of the
physician literature searching and the application of formal rules of evidence evaluating the clinical
literature. (Evidence-Based Working Group, 1992, p. 2420)
It is a problem solving approach to clinical practice that integrates-
A systematic search for and critical appraisal for the most relevant evidence to answer a burning
clinical question
One’s own clinical expertise
Patient’s preference and values
Evidence based treatment
Evidence-based treatment (EBT) is an approach that tries to specify the way in which
professionals or other decision-makers should make decisions by identifying such evidence that there
may be for a practice and rating it according to how scientifically sound it may be. Its goal is to
eliminate unsound or excessively risky practices in favor of those that have better outcomes.
EBT uses various methods (e.g., carefully summarizing research, putting out accessible
research summaries, educating professionals in how to understand and apply research findings) to
encourage, and in some instances to force, professionals and other decision-makers to pay more
attention to evidence that can inform their decision-making. Where EBT is applied, it encourages
professionals to use the best evidence possible, i.e., the most appropriate information available.
Research based evidence
Evidence-based design and development decisions are made after reviewing information
from repeated rigorous data gathering instead of relying on rules, single observations, or custom.
Evidence-based medicine and evidence-based nursing practice are the two largest fields employing
this approach. In psychiatry and community mental health, evidence-based practice guides have been
created by such organizations as the Substance Abuse and Mental Health Services Administration and
the Robert Wood Johnson Foundation, in conjunction with the National Alliance on Mental Illness.
Evidence-based practice has now spread into a diverse range of areas outside of health where the same
principles are known by names such as results-focused policy, managing for outcomes, evidence-
informed practice etc.
COMPONENTS OF EVIDENCE BASED PRACTICE
PROCESS OF EVIDENCE BASED PRACTICE
Clinical issue of interest
Formulate a researchable, answerable question
Streamlined, focused search
Rapid critical appraisal
Apply valid, relevant evidence Generate evidenceInternal:• Outcome management• Quality improvementExternal :• Research
STEPS OF EVIDENCE BASED PRACTICE
Evidence-Based Practice (EBP) is a thoughtful integration of the best available evidence, coupled with
clinical expertise. As such it enables health practitioners of all varieties to address healthcare questions
with an evaluative and qualitative approach. EBP allows the practitioner to assess current and past
research, clinical guidelines, and other information resources in order to identify relevant literature
while differentiating between high-quality and low-quality findings.
The practice of Evidence-Based Practice includes five fundamental steps:
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
the patients disorder or disease
Evaluate outcomes based on evidence
the intervention or finding under review
a comparison intervention
the question should be in PICOT or PICO format
PICOT
Patient, Population or Problemo What are the characteristics of the patient or population?
o What is the condition or disease you are interested in?( i.e. age, gender, ethnicity, with a certain disorder)
Intervention or exposureo What do you want to do with this patient (e.g. treat, diagnose, observe)?
(exposure to a disease, risk behavior, prognostic factor) Comparison
o 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 B )
Outcomeo What are the relevant outcomes (e.g. morbidity, death, complications, risk of disease,
accuracy of a diagnosis, rate of occurrence of adverse outcome) Time
o 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).
PPatient, Population, or Problem
How would I describe a group of patients similar to mine?
IIntervention, Prognostic Factor, or Exposure
Which main intervention, prognostic factor,or exposure am I considering?
CComparison or Intervention (if appropriate)
What is the main alternative to compare with the intervention?
OOutcome you would like to measure or achieve
What can I hope to accomplish, measure, improve, or affect?
TTime it takes to demonstrate an outcome
What time it takes for the intervention to achieve an outcome or how long participants are observed).
Examples of Evidence-Based PICOT Questions
Population: Bariatric adolescents considering or undergoing gastric bypass surgery.Intervention: The nurse’s role as a primary member of the multidisciplinary team regarding perioperative care of the bariatric adolescent patient.Comparison: The nurse's role as a secondary member of the multidisciplinary team without any specialized training and is only involved in perioperative care of the bariatric adolescent patient.Outcome: When the nurse is involved as one of the primary members in the multidisciplinary team approach, the bariatric adolescent patient has better continuity of care.Time: perioperative including the 6 weeks post recovery.
A preganant woman with type 2 diabetes is concerned about the effect her current treatment may have on her pregnancy and unborn child.
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
Population Intervention Comparison Outcome
Main keyword
Pregnant women and type 2 diabetes
Insulin pump therapy
Conventional insulin therapy
Improved managemnet of glucose levels
Synonym Pregnancy and diabetesInsulin infusion systems
Insulin injections Successful pregnancy
What is the ideal gestational age for a term twin pregnancy in a 35-year-old woman who wants to know whether a planned cesarean section or planned vaginal delivery is associated with improved outcomes, specifically, mortality?
PICO ElementP(atient) Term twin pregnancyI(ntervention) Planned cesarean sectionC(omparison) Planned vaginal deliveryO(utcome) Infant mortality
In adults, is binge drinking compared with nonbinge drinking associated with an increase in mortality?
PICO ElementP(atient) AdultsI(ntervention/exposure) Binge drinkingC(omparison) No binge drinkingO(utcome) Mortality
There are two types of clinical questions asked in PICO OR PICOT format.They are:
Background questions Foreground questions
Background questions ask for general knowledge about an illness, disease, condition, process or thing. These types of questions typically ask who, what, where, when, how & why about things like a disorder, test, or treatment, etc.Background questions are broader. Background questions usually concern conditions, and consist of two parts:
1. The root question (W5H) + verb, eg. what causes ...? [W5H = who, what, when, where, why, how]2. Problem, eg. influenza
For example
How overweight is a woman to be considered slightly obese? What are the clinical manifestations of menopause? What causes migraines? What is type 2 diabetes mellitus? Why does this patient have polyuria? Why does this patient have numbness and pain in his/her legs?
What treatment options are available?
Foreground questions ask for specific knowledge to inform clinical decisions. These questions typically concern a specific patient or particular population. Foreground questions tend to be more specific and complex compared to background questions. Quite often, foreground questions investigate comparisons, such as two drugs, two treatments, two diagnostic tests, etc. Foreground questions may be further categorized into one of 4 major types: treatment/therapy, diagnosis, prognosis, or etiology/harm. Foreground questions usually concern choices, are specific to decision-making, and are asked by more experienced clinicians who are able to use the specialised knowledge typical of experts in the subject field
For example
Is Crixivan effective in slowing the rate of functional impairment in a 45 year old male patient with Lou Gehrig's Disease?
In pediatric patients with Allergic Rhinitis, are Intranasal steroids more effective than antihistamines in the management of Allergic Rhinitis symptoms?
FRAMING GOOD QUESTIONS:
Framing the Research Question: PICO (T) Evidence-based models use a process for framing a question, locating, assessing, evaluating, and repeating as needed. PICO (T) elements include: Problem/Patient/Population, Intervention/Indicator, Comparison, Outcome, and (optional) Time element or Type of Study.
1. Frame the question: write out your information need in the form of a question, for example: Does hand washing among healthcare workers reduce hospital acquired infections?
The question above includes the PICO elements:
Example:
P (Problem or Patient or Population)
hospital acquired infection
I (intervention/indicator)
hand washing
C (comparison)no hand washing; other solution; masks
O (outcome of interest) reduced infection
2. Plan a search strategy by identifying the major elements of question, and translate natural language terms to subject descriptors, MeSH terms, or descriptors.
natural language term mapped to
database vocabulary
P (Problem/Patient/Population)=hospital acquired infection
cross infection [MeSH]
cross infection [CINAHL]
I (intervention/indicator)=hand washing
hand disinfection [MeSH]
handwashing [CINAHL] A simple database search strategy should begin with the P AND I:
cross infection AND (Handwashing OR Hand disinfection) Start with both CINAHL and Medline/PubMed as initial article databases for a scoping search for most
health sciences questions. If topic has a behavioral/mental health component, also try PsycINFO. 3. After viewing the initial search results may decide to narrow search with terms for the Comparison,
Outcome, Time factors or Type of study. Or may view results, abstracts, and full text of articles to view the comparison and outcome elements. Use database filters, explained in Filtering the Evidence.
SEARCH STRATEGIES--BACKGROUND INFORMATION Background information may be found in sources such as:
· reference book entries· textbooks, chapters, appendices· drug monographs, guides to diagnostic tests· the library’s Bobcat catalog· selected electronic Reference Tools for Background information in the health sciences
Sample Search Strategies for Background Questions:
Question Appropriate source type: Sample Strategy(ies):
1. What are the side effects of Lipitor?
Drug reference bookFrom the evidence pyramid, click on Background Information. One of the choices listed is:
StatRef (collection of reference tools, including drug references) Search on
drug name. Another choice is: Access
Medicine
3. Evidence of the relationship between dementia and caffeine consumption.
Article databases, both popular and scholarly
Proquest (Periodical Abstracts) (for recent popular newspaper article)
Medline/Pubmed (for scholarly biomedical research)
(A “Review” article in a journal may provide an up-to-date summary/overview of a broad topic. Search PubMed, limit to Article Type: "Review."
4. I need an overview of gestational diabetes.
Textbook, monograph, review article
From the evidence pyramid, click on Background Information. One of the choices listed is:
StatRef (collection of reference tools, including drug references)
Search on name of disease or condition.
Another choice is: Access Medicine
Use the Bobcat library catalog to search on gestational diabetes and retrieve:
Title: Management of high-risk pregnancy : an evidence-based approach/ Queenan, John T.,
2007.
5. The best evidence available about umbilical cord care.
Article databases, both popular and scholarly
Locating the "best evidence" might mean the most recent information that synthesizes the best research methodologies, such as a "Systematic Review" or a
"Randomized Controlled Trial."
CINAHLPlus: search Umbilical Cord, use Search Options to limit to Publication type: systematic review
Medline/Pubmed: search Umbilical Cord AND Sepsis, limited to Journal Subset: Systematic Reviews. OR use the Limits for Article Type: limit to randomized controlled trial. More about Limits here.
8. What are the personal experiences of medical students?
Memoir, biography, diaryA BobCat search medical students biography (as query words anywhere in the record) leads to titles with subject headings to explore for related results:
Students, Medical Personal Narratives
Or the more specific: Students, Medical United States Personal Narratives
SEARCH STRATEGIES--FOREGROUND QUESTIONS
Foreground questions seek evidence to answer a need for clinical information related to a specific patient, an intervention or therapy. Identifying the PICO (T) * elements helps to focus your question:
P = problem/patient/population I = intervention C = comparison intervention O = outcome (T)= time factor, type of study (optional)
Sample Search Strategies for Foreground Questions:
Question Natural Terms translated to Subject Sample PubMed Searches
language terms headings/MeSH terms/Descriptors [Database]
1. Does hand washing among healthcare workers reduce hospital acquired infections?
Hand washing
Hospital acquired infection
Hand disinfection [MeSH]
AND
Cross infection [MeSH]
Link to Handwashing AND hospital acquired infection
2. What is the effectiveness of continuous passive motion therapy (CPM therapy) following knee replacement in achieving optimal range of motion?
CPM therapy
Knee replacement
arthroplasty, replacement, knee [MeSH]
AND
motion therapy, continuous passive [MeSH]
Link to CPM Therapy AND knee replacement in sample PICO (T) searches
3. Is the incidence of ventilator-associated-pneumonia decreased by a higher nurse-patient ratio?
ventilator associated pneumonia
nurse-patient ratio
pneumonia, ventilator associated [MeSH]
(Nursing staff, hospital [MeSH]OR Personnel staffing and scheduling [MeSH])
Link to Ventilator-associated Pneumonia AND nurse-patient ratios in Sample PICO (T) searches
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:
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.
Filtered resourses- If you are trying to deside 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.
Unfiltered resources- If you don’t find an appropriate answer in the filtered resourses ,you will need
to search unfiltered resourses(the primary literature)to locate studies that answer your
question.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.
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), or 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.
EVALUATION AND REFLECTION
Reflection is now an established part of nursing practice. With regard to evidence based practice, some questions you could reflect on may be:
Stage 1. Asking the Question:
Was my question answerable? Was my question stated explicitly enough to help me in my search for the evidence?
Stage 2. Finding the evidence:
Did I search the right sources for the evidence or was there somewhere else I should have looked? Did I manage to find sound evidence quickly and efficiently?
Stage 3. Appraising and Interpreting the Evidence:
Did I appraise the evidence effectively? Do I need to improve my critical appraisal skills?
Stage 4. Acting on the Evidence:
Did I involve the patient (and appropriate others) in the decision to act on the evidence? Should I have attempted to answer my initial query a different way (eg. considered an alternative
treatment to the one evidence was sought for)?
By this stage you may be heaving a sigh of relief, feeling that you have successfully completed the five stages of evidence based practice. However, it is likely that answering (or failing to answer) your initial question has resulted in the generation of further questions.
Even if this is not the case, new information needs occur with every new challenge. Every patient is unique, and learning the skills necessary to engage in evidence based practice will help you deal with uncertainties in your practice as they arise.
Ask Questions Such As:
was the diagnosis and treatment successful?
is there new information /data in the literature?
how can I improve and/or update my clinical decisions?
All of these questions require thoughtful action and keeping up-to-date with the current literature.
THE STEPS IN THE EBP PROCESS:
Assess 1. Start with the patient – a clinical problem or question arises
from the care of the patient
ASK
the question
2. Construct a well built clinical question derived from the case
ACQUIRE
the evidence
3. Select the appropriate resource(s) and conduct a search
APPRAISE
the evidence
4. Appraise that evidence for its validity (closeness to the truth)
and applicability (usefulness in clinical practice)
APPLY: 5. Return to the patient -- integrate that evidence with clinical
talk with the
patient
expertise, patient preferences and apply it to practice
Self-
evaluation
6. Evaluate your performance with this patient
WAYS OF ACQUIRING KNOWLEDGE IN NURSING
Traditions
Borrowing
Trial & Error
Personal Experience
Role Modeling
Intuition
Reasoning
Research
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.
John Hopkins Model
Stelter Model
CURN
Iowa Model of Evidence Based Practice
• John Hopkins
A. 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:
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.
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.
Evaluation
In the final phase, the application is evaluated. Informal use of the innovation versus formal use would
lead to different evaluative strategies.
B. 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; and
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.
This model used a process of planned change . staff need to be empowered with ownership
of the change, as well as, with the knowledge and resources necessary to make this change.
This model supported the monitoring of patient outcomes by unit staff members for atleast
two consecutive quarters after implementation. These activities assisted in maintaining the practice
change and facilitating feedback to the staff. Outcome measurements are also focused on the effects of
change on the staff and fiscal parameters. Without thorough monitoring of all these areas an accurate
reflection of the cost/benefit relationship could not be realized.
THE EVIDENCE HIERARCHY:
The best evidence for interventions comes from systematic reviews and RCTs as we move
down this hierarchy in evidence, we usually have less good information available.
Systematic review
Randomized controlled trial
Cohort study
Case control study
Cross-section analytical study
Descriptive/narrative study
Limitations:
Resistant to changes in nursing practice.
Ability to critically appraise research findings.
Time, workload pressures, and competing priorities.
Lack of continuing education programs.
Fear of "stepping on one's toes"
Poor administrative support.
KEY COMPONENTS OF EBP
A. Research evidence.
B. Clinical expertise, judicious use.
C. Patient values and circumstances.
A. Research Evidence:
o Randomized controlled trials
o Laboratory experiments
o Clinical trials
o Epidemiological research
o Outcomes research
o Qualitative research
o Expert practice knowledge, inductive reasoning
B. Clinical Expertise
o Knowledge gained from practice over time
o Inductive reasoning
C. Patient Values, Circumstances
o Unique preferences
o Concerns
o Expectations
o Financial resources
o Social support
BARRIERS TO USING RESEARCH IN NURSING
RESEARCH RELATED BARRIERS
One impediment to using Research in practice is that for many nursing problems, a solid base
of valid and trustworthy study results has not been developed. Single studies rarely provide an
adequate basis for making changes in nursing practice. Therefore another constraint to using research
evidence is the dearth of published replications.
Research advise:
Some advices for researchers interested in promoting the use of research findings in clinical practice
are as follows:
Collaborate with clinicians. Practicing nurses will be more willing to use research findings if
researchers address clinical questions.
Do high quality research. The quality of nursing studies has improved dramatically in the past two
decades, but progress remains to be made to ensure valid and transferable findings.
Replicate use of research results can rarely be justified based on a single study, so researchers must
replicate studies and publish the results.
Communicate clearly A general aim should be to write research reports that are user-friendly with a
minimum of research jargon.
Suggest clinical implications if an implications section with suggestion for clinical practice became a
standard feature of research reports, then the burden of using research evidence would be lighter for
nurse clinicians.
Disseminate aggressively and broadly if researcher fails to communicate the results of a study to other
nurses it is obvious that the results will never be used by practicing nurses. The researcher should
report their results in journals especially nursing research journals, take steps to disseminate study
findings at conferences, workshops attended by nurse clinicians.
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: Every nurse can play a role in using research evidence. Here are some strategies:
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.
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.
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.
BARRIERS RELATING TO NURSING PROFESSION
There is a shortage of appropriate role models- nurses who can be emulated for their success in using
or promoting the use of research in clinical practice. The nurses feel that he or she didn’t have
“enough authority to change patient care procedures”
Advice: Educators could help to promote the use of research evidence through the following
strategies:
Incorporate research findings into curriculum. Research findings should be integrated throughout the
curriculum and when possible, the efficacy of specific procedures should be documented by referring
to relevant studies.
Encouraging research and research use. Either by acting as role models to students or by
demonstrating positive attitudes towards research and its use in nursing.
Place demands on researchers. Faculty review of research proposals should demand that researchers
demonstrate the proposed studies potential for clinical use; they can also demand that the researchers
include a specific plan for dissemination or utilization.
EBP RESOURCES
A. 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.
FPIN 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.
B. 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.
C. ELECTRONIC TEXTBOOKS AND LIBRARIES:
AccessMedicine: AccessMedicine 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.
D. 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.
NURSE ROLE IN EVIDENCE-BASED PRACTICE
1) In the leadership role: A nurse is a decision-maker and coordinator of care.
2) As a scientist: A nurse ensures his or her practice is evidence-based and that institution approved
protocols are utilized.
3) 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.
4) Manage resources and facilitate the success of unit-based EBP workgroups
5) Support EBP by communicating with unit staff the expectations for participation and available
resources
6) Encourage broad staff participation to promote collaborative teamwork
7) Become a primary vehicle for recognition of staff nurses' success
8) Encourage research and research uses.
9) Offer emotional and moral support to senior staffs for evidence based practice.
10) Foster a climate of intellectual curiosity.
11) Attend and encourage junior staffs to conference
12) The registered nurse participates, as appropriate to education level and position, in the formulation
evidence-based practice through research.”
13) The registered nurse utilizes current evidence- based nursing knowledge, including research findings,
to guide practice.
14) Know basis for nursing practice
15) – Expect that evidence is the foundation of practice
16) – Participate in EBP projects
17) – Disseminate project findings in various forums
18) –Collaborate with the healthcare team to provide quality care
References
1. Polit Denise F, Beck Cheryl Tatano. Nursing Research principles and
Methods: Utilizing Research: Putting Research Evidence Into Nursing Practice . 7 th
edition. Lippincott Williams and Wilkins 2008
2. Melnyk Bernadette Mazurek, Fineout Overhot Allen. Evidence Based
Practice In Nursing and Health Care. 1st edition. Lippincott Williams and Wilkins
2005 : 4,5,23-9
3.standfordhospital.org/clinicsmedservices/medicalservices/nursing/standford/
rolebasedpractice.html.
4.Shebeer .p. basher”A Concise Text Book Of Advanced Nursing
Practice”published by emmess,first edition
5.http://localhost/F:/
WillEvidenceBasedNursingPracticeMakePracticePerfectbyCaroleA.EstabrooksCJ
NR2030(4)
6.http://localhost/F:/
ImplementingEvidenceBasedNursingPractice_EvidenceBasedNursingPractice.mht.
7.http://localhost/F:/EvidenceBasedPractice.mht
8.www.currentnursing.com
9.www.wikipedia.com