CRITICAL THINKING

INTRODUCTION
To become a professional nurse requires that you learn to think like a nurse. What makes the thinking
of a nurse different from a doctor, a dentist or an engineer? It is how we view the client and the type of
problems we deal with in practice when we engage in client care. To think like a nurse requires that we
learn the content of nursing; the ideas, concepts and theories of nursing and develop our intellectual
capacities and skills so that we become disciplined, self-directed, critical thinkers.

Critical thinking is the disciplined, intellectual process of applying skillful reasoning as a guide to
belief or action (Paul, Ennis & Norris). In nursing, critical thinking for clinical decision-making is the
ability to think in a systematic and logical manner with openness to question and reflect on the
reasoning process used to ensure safe nursing practice and quality care (Heaslip).

Elements of Reasoned Thinking

Reasoning in nursing involves eight elements of thought. Critical thinking involves trying to figure out
something; a problem, an issue, the views of another person, a theory or an idea. To figure things out
we need to enter into the thinking of the other person and then to comprehend as best we can the
structure of their thinking. This also applies to our own thinking as well.

The Elements of Thought

All thinking, if it is purposeful, includes the following elements of thought (Paul, 1990).
1. The problem, question, concern or issue being discussed or thought about by the thinker. What
the thinker is attempting to figure out.
2. The purpose or goal of the thinking. Why we are attempting to figure something out and to
what end. What do we hope to accomplish.
3. The frame of reference, points of view or even world view that we hold about the issue or
problem.
4. The assumptions that we hold to be true about the issue upon which we base our claims or
beliefs.
5. The central concepts, ideas, principles and theories that we use in reasoning about the problem.
6. The evidence, data or information provided to support the claims we make about the issue or
problem.
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 7. The interpretations, inferences, reasoning, and lines of formulated thought that lead to our
conclusions.
8. The implications and consequences that follow from the positions we hold on the issue or
problem.

Knowing how one thinks helps the nurse work collaboratively with other health care providers.
Critical thinkers are people who know how to think. They possess intellectual autonomy, in that they
refuse to accept conclusions without evaluating the evidence (facts and reasons) for themselves.
Critical thinkers have the ability to think beyond the obvious and make connections between ideas.

Components of Critical Thinking

Critical thinking is composed of three primary components: mental operations, knowledge, and
attitudes.
Mental Operations
Mental operations include activities such as decision making and reasoning that are used to find or
create meaning. Nurses engage in such activities when they search for solutions based on sound
rationale and develop outcomes accordingly. The result of these mental operations is creative and
appropriate problem solving.

Knowledge
Critical thinking calls for a knowledge base that includes declarative knowledge, (specific facts or
information) and operative knowledge (an understanding of the nature of that knowledge). Nursing
education assist the student in learning specific facts about nursing and the delivery of quality care.
Students are taught how to examine the beliefs underlying the facts in order to analyze and interpret
those facts. In words, students are not expected to merely repeat that have been memorized (learned
by rote) but instead to understand the reasoning behind the knowledge. Finding meaning in what the
learner is learning is the core of \
Critical thinking.

Attitudes
Certain attitudes enhance a person’s ability to think critically. One of the most important attitudes
needed by a critical thinker is a sense of curiosity that allows the person to question assumptions
upon which decisions are based. Analysis of basic assumptions allows the learner to plan and act in a
rational manner rather than out of habit or routine.
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 Attitudes of critical thinker:
 Tolerance, open-mindedness, nonjudgmental mind-set
 Curiosity
 Persistence, intellectual courage; proactive instead of reactive
 Respect for others‟ perspectives; flexible
 Comfort dealing with ambiguity, uncertainty
 Intellectual humility (knowing that one does not have all the answers)
 Self-confidence (belief in own ability to think things through and make
appropriate decisions) From Ruben Feld & Schaeffer [1999]. In Delude &
Ladner, 2002)

Phases of critical thinking

 Trigger event: A problem that is reframed as an opportunity for improvement;
 Appraisal of the situation: Self-examination of one’s underlying assumptions;
 Exploration: Searching for new ideas, solutions, and approaches;
 Integration: Incorporating new information and new way of thinking.

Development of Critical thinking skills

 Identify goals;
 Determine what knowledge is required;
 Assess the margin for error;
 Determine the amount of time available for decision making;
 Identify available resources.
 Recognize factors (i.e., biases, fatigue) that may influence decision making (Alfaro-Lefebvre,
1998 in Delude & Ladner, 2002).

Critical Thinking Skills and Abilities

Critical thinkers in nursing are skillful in applying intellectual skills for sound reasoning.
Critical Thinking Skills

Analysis: Examine ideas, identify and analyze arguments;

Influence: Query evidence, conjecture alternatives, draw conclusions;
Explanation: State results, justify procedures, present arguments;
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 Evaluation: Assess claims, assess arguments;
Self-regulation Self-examination, self-correction (if necessary).
(From Pesut, D. J., & Herman, J. [1999]. Clinical reasoning: The art and science of critical
and creative thinking. Albany, NY: Delmar.)
Creative nurses think in new ways when searching for innovative solutions to problems. The process
of creative problem solving is goal- directed thinking that leads to achievement by using new ideas
or methods. The challenges presented by the current health care environment demand that nurses be
creative thinkers. Creative thinking is the foundation for individualizing client care, in that the nurse
identifies unique needs of each client and develops interventions specific to those needs. Without
creative thinking, nursing care would become routine, that is, the same for every client.

There is a strong link between critical and creative thinking. In order to develop creative solutions to
problems, the nurse needs to use critical intellect. Also, to be an excellent critical thinker, the nurse
needs to exercise creative thinking.
Critical thinking in nursing practice is a discipline specific, reflective reasoning process that guides a
nurse in generating, implementing, and evaluating approaches for dealing with client care and
professional concerns” (National League for Nursing 2000, p. 2).
Critical thinking is essential to safe, competent, skillful nursing practice. The amount of knowledge
that nurses must use and the continuing rapid growth of this knowledge will prevent the nurses from
being effective practitioners if they attempt to function with only the information acquired in school
or outlined in books.
Decisions that nurses must make about client care and about the distribution of limited resources
force them to think and act in areas where there are neither clear answers nor standard procedure and
where conflicting forces turn decision making into a complex process. Nurses therefore need to
embrace the attitudes that promote critical thinking and master critical-thinking skills to process and
evaluate both previously learned and new information. (Kozier & al, 2008)

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 Ten top reasons to improve thinking
10. Things aren’t what they used to be or what they will be.
9. Patients are sicker, with multiple problems.
8. More consumer involvement (patients and families).
7. Nurses must be able to move from one setting to another.
6. Rapid change and information explosion requires us to develop new learning and
workplace skills.
5. Consumers and payers demand to see evidence of benefits, efficiency, and results.
4. Today’s progress often creates new problems that can’t be solved by old ways of
thinking.
3. Redesigning care delivery and nursing curricula is useless if students and nurses
don‟t have the thinking skills required to deal with today‟s world.
2. It can be done—it doesn‟t have to be that difficult.
1. Your ability to focus your thinking to get the results you need can make the
difference between whether you succeed or fail in this fast-paced world.
From R. Alfaro-Letevre, 2004 Critical Thinking in Nursing: A Practical Approach 3rd ed.,
Elsevier.

Critical thinking, as suggested by Meleis, combines both logical and creative thinking. Critical
thinking is a professional skill that combines framework thinking and flexible viewing. Professional
nurses use critical thinking in both clinical decision-making and professional leadership. Leadership
by nurses is needed for both nursing and health care. Nurses believe that they know many ways to
lead their clients to better health, and many ways to guide the health care industry toward improved
health care delivery. The skills of critical thinking and leadership are not developed miraculously,
nor are they developed without considerable effort on the part of learners and teachers.

 REFLECTION QUESTIONS

1. Using the criteria for professions given above, and your critical thinking abilities, how do you rate
nursing on each criterion in comparison with other professions?

2. How might modern technology enhance or threaten nursing’s:

a. Development as a profession?
b. Traditional values?
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3. Discuss the ways in which nursing differs from medicine.

NURSING PROCESS
Define the term Nursing Process
 Describe seven characteristics of the nursing process
 List five steps in the nursing process
 Identify four sources of assessment data
 Differentiate between data base, focus, and functional assessment

Learning objectives

 List three parts of a nursing diagnostic statement

 Describe the rationale for setting priorities
 Discuss appropriate circumstances for short term and long term goals.
 Identify four ways to document a plan of care
 Describe the information that is documented in a plan of care
 Discuss three outcomes that results from an evaluation
 Describe the process of concept mapping as an alternative learning strategy for student clinical
experiences.

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WHAT IS NURSING PROCESS

The nursing process is the systematic, problem-solving approach to providing nursing care to
individuals, families, and communities
The nursing process is also a series of scientific knowledge to diagnose the strengths and nursing
care needs of persons and to implement therapeutic actions for the purpose of attaining, maintaining
and promoting biopsychosocial functioning.

 It is an organized sequence of problem solving steps

 It is a process used to identify and manage the health problems of clients
 It is a framework for nursing care
 It allows clients to receive quality care with maximum efficiency
The Nursing Process has seven distinct Characteristics
1. Within the legal scope of nursing- means practicing nursing independently to problem-solve,
involving diagnosing and treatment of potential health problems.
2. Based on knowledge- means using critical thinking skills to identify and resolve problems, by
using evidence based nursing interventions.
3. Planned- this leads to organized, orderly and systematic care
4. Client-centered- the process helps nurses to plan care centered on that particular patient,
allowing them to actively participate in their care.
5. Goal directed- The nurse is able to work with the client and develop goals and outcomes.
6. Prioritized-Focusing on more serious health /risk factors for a resolution
7. Dynamic- Constant changes in health status requires evaluations, data collection and
revaluation
STEPS
There are SIX Steps in the Nursing Process
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
6. Documentation
Assessment is the First step in the nursing process, involving nurse/client contact

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It involves collection of data from the client, such as abnormal findings, things that causes health
problems.

KEMU department of Nursing uses Marjory Gordon ELEVEN Functional Health Patterns to collect
data from the client.

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Types of Data
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Data can be Objective, or signs of a disorder which are observable or measurable. OR it can be
 Examples of Objective Data (see)
 Weight
 Temperature
 Skin color
 Blood cell count
 Vomiting
 Bleeding
Subjective or symptoms that the client feels and can describe Examples of Subjective Data (what the
client feels)

 Pain
 Nausea
 Depression
 Fatigue
 Anxiety
 Loneliness
Sources of data:
 Primary source– The client
 Secondary sources– The client’s family, reports, test results past medical history or
discussion with other health care professionals
 Tertiary sources are the client’s record and other health care providers, such as other
nurse’s physicians, and dietitians.
Types of assessment

1. Data Base Assessment

 Is obtained on admission
 Consists of predetermined questions and systematic head-to toe examination
 Performed once
 Suggests possible problems
 Findings documented on an admission assessment form
 Time-consuming -1hr or more
 Supplies a broad, volume of data
 Provides breadth for future comparisons
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  Reflects the clients condition on entering the health care system

2. Focus Assessment
 Compiled throughout subsequent care
 Consists of unstructured questions and a collection of physical assessments
 Repeated each shift or more often
 Rules out or confirms problems
 Findings are documented on checklist or progress notes
 Completed about 15 mins.
 Collects limited data
 Adds depth to the initial database
 Provides comparative trends for evaluating the clients response to treatment

3. Functional Assessment
 Completed within the first 14 days of admission
 Can follow various assessment tools is reviewed every 3 months, and identifies physical ,
psychological, and social factors that affect self-care of the patient
 May involve a multidisciplinary team with final completion and signed by an RN.

Comprehensive evaluation for strength or decline are done and the data is compared /used as facility
quality report
The next step is Diagnosis
 This is the second step in the nursing process
 The nurse identifies health related problems, analyzing data for abnormal findings that results
in a diagnosis.
 Nursing Diagnosis : Is a health issue that can be prevented reduced, or enhanced through
independent nursing measures
Components of Nursing Diagnosis

a) Strengths

Strengths represent inner health that promotes greater wellness. Without assessing client’s strengths,
the nurse is second guessing what would be a therapeutic approach to care for the client’s problems.
Consider the following strengths:
 Support systems for the client such as family, friends and so forth;
 financial resources: income
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 Education: level, training or occupational experience
 Environmental resources such as recreation, transport, so forth.

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 b) Needs/Problems
Another element of nursing diagnosis is the problem or need category.
Problems can be classified into four areas: (1) actual problems, (2) potential problems, (3)
possible problems, and (4) Wellness diagnosis.

Actual problems/diagnoses or needs are those that currently exists that can be identified from
the current data, Examples include:

 Decreased endurance
 Respiratory distress with minimal exertion
 Anxiety related to forthcoming surgery
 Chronic nausea
 Ineffective Breathing Pattern and Anxiety

Potential problems/diagnoses a problem the client is uniquely at risk for developing those that
the person is at high risk to develop, given his or her particular situation. The presence of risk
factors indicates that a problem is likely to develop unless nurses intervene. Examples include:
 Skin breakdown related to decreased mobility
 Increased respiratory secretions related to postoperative state
 Diminished self-esteem related to alteration in usual functioning.

Possible problems/diagnoses or needs are those for which the nurse has obtained enough data
to suggest a hunch, but not enough to identify an actual problem. An example might be
possible financial problems. The client may indicate that he or she is not worried about
finances, yet the nurse notes that the client twists his or her hands when questions of finances
arise.

A wellness diagnosis “describes human responses to levels of wellness in an individual,

family or community that have a readiness for enhancement” (NANDA International, 2005, p.
277). Examples of wellness diagnoses would be Readiness for Enhanced Spiritual Well-Being
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 or Readiness for Enhanced Family Coping.

The Nursing Diagnostic statement has 3 parts

1. The problem or health-related issue:- (NANDA)The client has a disturbed sleep pattern
2. Etiology or cause:- The disturbed sleep is related to excessive intake of coffee
3. Signs and Symptoms:- As manifested by difficulty in falling asleep.
 Feels tired during the day
 Irritability during the day with others.

Planning: - The third step in the nursing process.

1. It is the process of prioritizing nursing diagnosis and collaborative problems
2. It identifies measurable goals and outcomes
3. Helps to selects appropriate interventions
4. Helps to document the plan of care.
To plan there are priorities that have to be set.
 First we have to determine which problems require immediate or less attention. ( in other
words the most serious).
 Ways to determine priorities of needs .These priorities can change as new problems arise
or are resolved.
 A method used is Maslow’s Hierarchy of human needs
Establishing Goals-----What are goals?
 Goals are expected or desired outcomes. Goals help the nurse to determine if the nursing
care done is appropriate for the nursing diagnosis.
 They can be short-term or long term
 An example of a goal-

Goal- The client will be well hydrated by 10/23

 An example of an outcome ( more specific)

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 The client will have adequate hydration as evidenced by an oral intake 2-3,000 mls/24 hrs

Short-Term Goals are used mostly by nurses in an acute care setting, (few days- 1 week) and
have the following characteristics: (box 2-7 example)

1. Are developed from the problem portion of the diagnostic statement

2. Are client centered/ what they can accomplish

3. Measurable, identifies evidence of goals achieved

4. Realistic, avoid attainable goals

5. Accompanied by a target date for accomplishment

Long-Term Goals, outcomes takes a few weeks or months to accomplish:

 Usually done for clients with chronic health problems requiring extended care in nursing
home, or community health or home health service. E.g. stroke/ partial function.
 Goals for Collaborative Problems
 Focus on what the nurse will monitor/ record /report/ or do to promote early detection.

Implementation: is the fourth step in the Nursing Process

 The nurse implements medical orders as well as nursing orders.
 Implementing the plan involves clients, members of the health team.
 Medical record has evidence of care both quantity and quality of the client’s response.
 Maintaining open lines of communication, ensures the client’s continuing progress,
complies with accreditation standards and helps ensure reimbursement from government
or private insurance.
Nursing interventions, nursing actions, or nursing measures are the steps taken to help the client
attain the stated goals or outcomes, and are directed toward promoting or maintaining health.
They are planned using the person’s strengths and are implemented to mobilize those strengths
toward self-care capabilities.

Types of interventions

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Diagnostic interventions are nursing actions that help the nurse and the client better determine
the needs and the course of events in a given situation. Examples of diagnostic interventions
include the following:

• Observe—consider such aspects as nonverbal behavior, skin-color changes, progress in

ambulation, and response to medication.
• Inspect—examine a wound for signs of infection.
• Monitor—Check vital signs on a regular schedule, test blood glucose level four times a
day, weigh the client daily.
• Listen—Obtain data to detect changes in voice tones, either for cues to respond in a
specific way or for clues to a person’s
• Needs, concerns, or wishes; osculate (listen with a stethoscope) to determine changes in
condition.
Therapeutic interventions are nursing actions planned to maintain strengths and treat
problems. Examples of therapeutic interventions include the following:

• Listen—Provide opportunities for the person to verbalize; sit with and talk to the person;
use touch and acknowledge strengths.
• Support physiologic needs such as assist clients with activities of daily living (ADL)
• Educate such as health education information;
• Refer the client and so forth.
• Effective interventions require the use of a framework on which to base interventions.
Evaluation: is the fifth and final step in the nursing process
 It helps the nurse to determine if the client has reached his or her goals and how effective
the nursing care was.
Can be done with the client and or family or at the nursing team conference

Documenting the Plan of care

 Plans of care can be written, or printed forms, or can be computer generated.
 It is a requirement.
 Can be written by hand, computer generated
 Nursing Orders are signed and provide specific instructions for all health team members
to follow and provide care.

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 Communicating the Plan of Care

 Nursing shares the plan of care with nursing team, family members and the client, who
signs the care plan. The care plan is kept per facility policy, followed and revised daily
according to changes in client’s condition.

 REFLECTION QUESTION
Case Study

 Kanana Tabu, a 28-year-old female was admitted to the KNH with an elevated
 Temperature, a productive cough, and rapid, labored respirations. In taking a nursing
history, you RN, finds that Kanana has had a “chest cold” for two weeks, and has been
experiencing shortness of breath upon exertion. Yesterday she developed an elevated
temperature and began to experience “pain” in her “lungs.”
 Apply all the Nursing Process steps in the care of Kanana from admission to her
discharge from the hospital. Establish a database, interpret and analyze the data, set
priorities and goals, select nursing strategies/interventions, perform planned nursing
intervention using health pattern, document and evaluate the nursing care.

STANDARDS OF CARE IN NURSING

Standards of care or standards of practice in nursing are general guidelines that provide a
foundation as to how a nurse should act and what he or she should and should not do in his or her
professional capacity. Deviating from this standard can result in certain legal implications.
Background of Standards
A standard is the established practice that is accepted as correct within that particular industry.
Organizations that provide oversight often develop standards of practice in order to define the
type of quality that should be provided. In nursing, these standards change as new methods and
technology change. They are based on the most recent scientific data available. Regarding
nursing, standards have been developed through the contribution of administrative, academic and
clinical experts.
Standards of Care in Nursing
Standards of care in nursing are important because they recognize the trusted role that a nurse
plays. These standards are considered the baseline for quality care. They must be developed

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while assessing the state and federal rules, regulations and laws that govern the practice of
nursing. Other agencies and organizations may also assist in the development of these standards.
Standards of care apply equally to nurses in various settings. They govern the nurse’s practice at
every level of practice.
Often, standards of care are established at the national level so that care will be the same
regardless of the venue. However, states and local areas may also establish their own set of
standards of care.
Importance of Standards
nursing standards of care are important for a number of reasons.
 They outline professional expectations of nurses.
 They guide nurses on proper protocol and give them an objective standard to evaluate
other nurses with.
 They provide consistency throughout the profession so that patients receive quality care.
 Ultimately, standards give nurses the necessary information that they need to know the
quality of care that they must provide to patients and establish measures in which to
evaluate the care provided.
Generally, nurses are expected to be in compliance with these standards and to ensure that their
own underlings are in compliance. It is critical that they comply with these standards in order to
protect the public whom they treat.
Types
A. internal standards of care
1. Job description
2. Education
3. Expertise
4. Institutional policies and procedures
B. external standards of care
1. Nurse practice acts
2. Professional organizations
3. Nursing specialty practice organizations
4. Federal organizations and federal guidelines

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Legal Implications
If a nurse does not meet the accepted standards of practice, he or she may be found negligent if
his or her negligence caused a patient harm. In most litigation, a nurse is accused of violating a
standard of care in a negligence lawsuit. In the medical profession, this is often referred to as
malpractice.
Nurses may be held liable in malpractice cases if they inappropriately administer medication, fail
to monitor equipment, fail to warn patients about known harms or fail to protect patients from
known dangers. Nurses are required to completely and accurately report the assessment and
observations that they make regarding each patient in a timely manner. If they do not monitor the
patient’s condition or be alerted to changes in the patient’s condition, they may be found
negligent. Nurses have a duty to communicate changes to the attending doctor to avoid harm to
the patient. Additionally, not complying with state rules regulating the nursing practice regarding
the delegation of certain tasks to unlicensed individuals or mishandling patient identification can
also cause legal liability to arise.
Special Knowledge or Skill
If a nurse has a special knowledge or skill, the standard that the nurse is judged against is this
special knowledge and skill. This means that rather than comparing what another nurse would
have done in the same situation, the question is how a nurse with the same special knowledge or
skill would have acted in the same or similar circumstances.
Legal Assistance
when a nurse does not follow the standards of care, he or she better insulates the nurse to legal
liability or a finding of an ethical violation. Nurses that realize the importance of complying with
nursing standards and who do actually comply with these standards are less likely to be held
legally accountable if a patient is harmed and brings a personal injury lawsuit. By not complying
with these standards, a nurse is more likely to be the first person penalized for his or her actions.

TOOLS FOR MEASURING STANDARDS

INTRODUCTION
 Standard = Quality

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  Quality refers to excellence of products or service, including its attractiveness, lack of
defects, reliability and long term durability
 Quality assurance provide for the mechanism to effectively monitor patient care provided
by healthcare professionals using cost-effective resources.
 Quality assurance motivates nurses to strive for excellence in delivery of quality patient
care
 Quality assurance are concerned with the quantitative assessment of nursing care as
measured by proven practice
2 major categories of approach exist in quality assurance:

 General
 specific
1. General Approach:

Involves large governing of official body’s evaluation of a person or institution to meet

established criteria or standards at any given time

These include:
 CREDENTIALING:
 Formal recognition of professional or technical competence & attainment of minimum
standards by a person or institution Example: NCK , ICN

Credentialing has 4 functional components:

 Produce a quality product
 Confer a unique identity
 Protect provider & public
 Control the profession
 LICENSURE :
 Individual
 Institution
 ACCREDITATION
 Quality audits by certification bodies e.g.:
 ISO
 Kenya Bureau of standards (KEBS)

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  Joint Commission International (JCI)
2. Specific approach
 AUDITS :
 Nursing audits:
 Process of collecting information from nursing reports & other documented evidence
about patient care & assessing the quality of nursing care given. This could be:
i. Concurrent –performed during ongoing nursing care
ii. Retrospective- performed after the patient has been discharged from the facility, using
client’s records
 Clinical audits:
 A powerful way of measuring and improving service performance by reflecting on a
particular aspect of the service.
 Provides a means to identify and promote good practice, try out service developments
and systematically measure the results also offers opportunities for the training and
development of staff, and for joint working between staff and service users across
different disciplines
 Framework for clinical audit
 It can also be multi-disciplinary
• The main stages of the clinical audit process are:
 Selecting a topic.
 Agreeing standards of best practice (audit criteria).
 Collecting data.
 Analyzing data against standards.
 Feeding back results.
 Discussing possible changes.
 Implementing agreed changes.
 Allowing time for changes to embed before re-auditing.
 Collecting a second set of data.
 Analyzing the re-audit data.
 Feeding back the re-audit results.
 Discussing whether practice has improved.

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  Medical audits

Systematic, critical analysis of the quality of medical care including the procedure of diagnosis
& treatment, use of resources,& resulting outcome and quality of life for the patient.
 SURVEYS :
 Customer satisfaction surveys
 Peer reviews
 Health professional evaluating the quality of individual performance
 CLINICAL OUTCOMES REVIEW:
 Morbidity &Mortality review boards
 Number of medico-legal cases/ incidences
 Others
 Standard operating procedures (SOP)
 Clinical manuals
 Clinical assessments

The following methods can be applied when collecting data for analysis & discussion
 Questionnaires
 Checklists
 Interviews
 Photos ( before & after)
 Observations

 REFLECTIVE TASK
1. Discuss where you can find the various sources of standards of care for your area of practice in
your institution.

2. Develop standards of care for a nursing treatment and a risk management issue.

3. Develop policies and procedures for an area of nursing practice that you see as a problem in your
area of practice/ institution.

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 EVIDENCE BASED NURSING

DEFINITION
This is the conscientious, explicit and judicious use of current best evidence in making nursing
decisions about the care of individual patients.
It means integrating individual clinical expertise with the best available external, clinical
evidence from systematic research (Sackett et al, 1996)
It is also systematic search for, and appraisal of, best evidence in order to make clinical
decisions that might require changes in current practice, while taking into account the individual
needs of the patient’ (Carnwell,2001)
‘Best evidence might be defined as that which is valid and relevant to the patient.’
Evidence-based medicine (EBM) is an approach to health care that promotes the collection,
interpretation, and integration of valid, important and applicable patient-reported, clinician
observed and research-derived evidence. The best available evidence moderated by patient
circumstances and preference, is applied to improve the quality of clinical judgments (McKibbon
et al, 1995)
EBP based practice involves the incorporation of 3 Components to improve outcomes & quality
of life:
1. External evidence –systematic reviews, randomized control trials, best practice and clinical
guidelines that support a change in clinical practice
2. Internal evidence- includes health institution based quality improvement programs/projects,
outcome management initiative & clinical expertise
3. Accounting for the patient preference and values .Evidence-based practice looks at research
findings, quality improvement data and other forms of evaluation data, and expert opinion to
identify methods of improvement
Evidence-based practice is used to close the gap between the research being conducted and the
practice
It challenges nurses to look at the "why" behind existing methods and processes in the search for
improvement
Impact of evidence based practice

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The impact of evidence-based practice (EBP) has echoed across nursing practice, education, and
science. The call for evidence-based quality improvement and healthcare transformation
underscores the need for redesigning care that is effective, safe, and efficient
Why use evidence based practice?
This include:
1. To provide effective care
2. Up-to-date evidence
3. To fulfill your role and meet your job criteria
The Six Steps of Evidence-B Practice
1. Ask clinical questions/Assessment
Evidence-based practice questions may concern:
Etiology/cause, diagnosis/assessment, prognosis/outcome, economics/costs,
treatment/intervention methods, preventative interventions, mode of delivery/organization.
4 components to evidence-based practice questions:
i. the patient or the problem
ii. the intervention
iii. contrasting or comparative action
iv. an outcome which can be evaluated
2. Find the Evidence
3. Analyze the Evidence
4. Combine the Evidence with Your Understanding of the Client and Situation
5. Application to Practice
6. Monitor and Evaluate Results
Is evidence based practice the way to go?
Advantages
PATIENTS
 Reduces the amount of time wasted on inappropriate care options
 Increased consistency as all patients receive the same level of care
 Increased confidence in practitioners as their knowledge of options is transparent
 Increased value for money
 Reduced variation of services

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  Evidence can be used to support the need for additional resources
PRACTIONERS
 Professional empowerment through enhanced knowledge
 Increased personal and professional confidence in problem solving as practitioners adopt
a critical approach
 Increased quality of care through patient satisfaction and positive healthcare outcomes
 Protection against litigation through rationales for action
 Ability to scientifically support actions
 Appraise options and interventions
ORGANISATIONS
 Enhance quality of service delivery as practitioners can draw upon a variety of options
 Enhanced confidence in the workforce as decision making is reflected in enhanced care
outcomes
 Reduction in complaints and litigation
 Observable commitment to clinical governance
 Increased cost effectiveness and value for money
 Evidence for the allocation of resources
Barriers to using evidence based practice
 limits professional autonomy
 Over reliance on randomized controlled trials
 limited use of qualitative research
 limited inclusion of consumer choice
 lack of multi-disciplinary research agenda on work practice change
 Limited experimental research in Industrial and Organizational
 Expensive.
 time consuming

 REFLECTION QUESTIONS
1. Why is EBP important in nursing?
2. There are many examples of EBP in the daily practice of nursing .Discuss any eight at
your work place

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