TOPIC- EVIDENCE BASED NURSING PRACTICE AND

BEST PRACTICES
UNIT- BIO-PSYCHO SOCIAL PATHOLOGY
SUBJECT- ADVANCE NURSING PRACTICE

DATE OF SUBMISSION: -
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 EVIDENCE BASED NURSING PRACTICE
INTRODUCTION-

- During 1980s the term “evidence-based medicine” emerged to describe the approach
that used scientific evidence to determine the best practice. Evidence based practice
movement started in England in the early 1990s.
- Evidence-based medicine (EBM) or evidence-based practice (EBP), is the judicious
use of the best current evidence in making decisions about the care of the individual
patient.
- Evidence-based practice represents both an ideology and a method. The ideology
springs from the ethical principle that clients deserve to be provided with the most
effective interventions possible. The method of EBP is the way we go about finding
and then implementing those interventions.
- Today evidence based practice is becoming a goal of all health care institutions and an
expectation of professional nurses who are expected to use current evidence when
caring for patients.

DEFINITIONS-

1. Evidence- it is something that furnishes proof or testimony or something legally

submitted to ascertain in the truth of matter.
2. Evidence based practice- Evidence based practice is a problem solving approach to
clinical practice that integrates the conscientious use of best evidence in combination
with a clinical’s expertise and patient preferences and value in making decision about
patient care.(2)
It is systemic interconnecting of scientifically generated evidence with the tacit
knowledge of the expert practitioner to achieve a change in a particular practice for
the benefit of a well-defined client /patient group (French 1999).
3. Evidence based nursing- it is a process by which nurses make clinical decisions
using the best available research evidence, their clinical expertise and patient
preferences (mulhall,1998).
4. Evidence based medicine or practice- the conscientious, explicit and judicious use
of current best evidence in making decision about the care of individual patient. (Dr.
David Sackett, Rosenberg, 1996)
 5. Evidence based practice in nursing- it is a way of providing nursing care that is
guided by the integration of the best available scientific knowledge with nursing
expertise. This approach requires nurses to clinically assess relevant scientific data or
research evidence and to implement high quality interventions for their nursing
practice. (NLM Pubmed)

NEED FOR EBP

- For making sure that each client get the best possible services.
- Update knowledge and is essential for lifelong learning.
- Provide clinical judgment.
- Improvement care provided and save lives.

GOAL OF EBP-

- Provide practicing nurse the evidence based data to deliver effective care.
- Resolve problem in clinical setting.
- Achieve excellence in care delivery.
- Reduce the variations in nursing care and assist with efficient and effective decision
making.(3)

STEPS IN EVIDENCE-BASED PRACTICE

EBP is a systematic approach to rational decision making that facilitates achievement of best
practices. A step by step approach ensures that you obtain the strongest available evidence to
apply in patient care. There are six steps of EBP –

1. Ask a clinical question.

2. Collect the most relevant and best evidence.
3. Critically appraise the evidence you gather
4. Integrate all evidence with one’s clinical expertise and patient preferences and values
in making a practice decision or change.
5. Evaluate the practice decision or change
6. Share the outcome of EBP changes with others.

1. Ask a clinical question- question what does not make sense to you and what need to
be clarified. Think about a problem or area of interest that time consuming, costly or
not logical. Use problem and knowledge focused triggers to think critically about
clinical and operational nursing unit’s issues.
A problem – focused trigger is one you face while caring for a patient or a trend you
see on a nursing unit.
A knowledge- focused trigger is a question regarding new information available on a
topic.
Ask clinical questions in PICOT format. Inquiries in this format take into account
patient population of interest (P), intervention or area of interest (I), comparison
intervention or group (C), outcome (O) and time (T).
 The PICOT format provides an efficient framework for searching electronic
databases, one designed to retrieve only those articles relevant to the clinical
questions. Using the case scenario on rapid response team as an example, the way to
frame a question about whether use of such teams would result in positive outcomes
would be: “In acute care hospitals (patient population), how does having a rapid
response team(intervention) compared with not having a response team(comparison)
affect the number of cardiac arrest (outcome) during a three period (time)?” (1)

2. Search for the best evidence- the search for evidence to inform clinical practice is
tremendously streamlined when questions are asked in PICOT format. If the nurse in
the rapid response scenario had simply typed “what is the impact of having a rapid
response team?” into the search field of the data-base, the result would have been
hundreds of abstracts, most of them irrelevant. Using the PICOT format helps to
identify key words or phrases that, when entered successively and then combined,
Expedite the location of relevant articles in massive research database such as
MEDLINE or CINHAL. For the PICOT question on raid response teams, the first key
phrase to be entered into the database would be acute care hospitals, a common
subject that will most likely result in thousands of citations and abstracts. The second
term to be searched would be rapid response team, followed by cardiac arrests and
the remaining terms in the PICOT question. The last step of the search is to combine
the result of searches for each of the terms. This method narrows the results to
articles pertinent to the clinical question, often resulting in fewer than 20. It also
helps to set limits on the final search, such as “human subjects” or “English”, to
eliminate animal studies or articles in foreign languages.

3. Critically appraise the evidence- once articles are selected for review, they must be
rapidly appraised to determine which are most relevant, valid, reliable and applicable
to the clinical question. These studies are the “keeper studies.” One reason clinicians
worry that they don’t have time to implement EBP is that many have been taught a
laborious critiquing process, including the use of numerous questions designed to
reveal every element of a study. Rapid critical appraisal uses three important
questions to evaluate a study’s worth.
 Are the results of the study valid? This question of study validity
centers on whether the research methods are rigorous enough to render
findings as close to the truth as possible. For example, did the
researchers randomly assign subjects to treatment or control groups
ensure that they shared key characteristics prior to treatment? Were
valid and reliable instruments used to measure key outcome?
 What are the results and are they important? For intervention
studies, this question of study reliability addresses whether the
intervention worked, its impact on outcomes, and the likelihood of
obtaining similar results in the clinicians own practice settings. For
qualitative studies, this includes assessing whether the research
 approach fits the purpose of the study, along with evaluating other
aspects of the research such as whether the result can be confirmed.
 Will the results help me care for my patients? This question of study
applicability covers clinical considerations such as whether subjects in
the study are similar to one’s own patients, whether benefits outweigh
risks, feasibility and cost-effectiveness and patient values and
preferences.
After appraising each study the next step is to synthesize the
studies to determine if they come to similar conclusions, thus
supporting an EBP decision or change.

4. Integrate the evidence with clinical expertise and patient preferences and values-
research evidence alone is not sufficient to justify a change in practice. Clinical
expertise based on patient assessment, laboratory data and data from outcomes
management programs, as well as patient’s preferences and values are important
component of EBP. There is no magic formula for how to weigh each of these
elements, implementations of EBP is highly influenced by institutional and clinical
variables. for example, say there is a strong body Of evidence showing reduced
incidence of depression in burn patients if they receive eight sessions of cognitive
behavioral therapy prior to hospital discharge. You want your patients to have this
therapy and so do they. but budget constraints at your hospital prevent hiring
therapist to offer the treatment. this resource deficit hinders implementation of EBP.

5. Evaluate the outcomes of the practice decisions or changes based on evidence-

after implementing EBP, it is important to monitor and evaluate any changes in
outcomes so that positive effects can be supported and negative ones remedied. just
because an intervention was effective in a rigorously controlled trial does not mean it
will work exactly the same way in the clinical setting. monitoring the effect of an
EBP change on Healthcare quality and outcomes can help clinicians spot flaws in
implementation and identify more precisely which patients are most likely to benefit.
When results differ from those reported in the research literature monitoring can help
determine why.

6. Disseminate EBP results- clinicians can achieve wonderful outcomes for their
patients through EBP but they often to share their experiences with colleagues and
their own or other Healthcare organization. this leads to needless duplication of
effort and perpetuates clinical approaches that are not evidence based. Among ways
to disseminate successful initiative are EBP In your institution, presentations at
local, regional and national conferences and reports in Peer reviewed journals
professional newsletters and Publication for general audiences .
SOURCES OF EVIDENCE
- research evidence has assumed priority over other sources of evidence in the delivery of
evidence based healthcare.
- it includes
1. Filtered Resources- clinical expert and subject specialist pose a question and then
synthesis evidence to States conclusion based on available research. these sources are
helpful because the literature has been searched and result evaluated to provide an
answer to clinical question.
2. Unfiltered Resources (Primary Literature)- it provides most recent information
examples MEDLINE CINHAL etc provide primary and secondary literature for
medicine.
3. Clinical Experiences- knowledge professional practice and life experiences makes
up the second part in the evidence based person, centered care.
4. Knowledge From Patients- delivered from patients knowledge of themselves their
bodies and social lives.
5. Knowledge From Local Context-
-Audit and performance data
-Patient stories and narrative
-knowledge about the culture of the organization and individuals within it
-social and professional network
-information from feedback
-local and national policy

HIERARCHY OF EVIDENCE
MODELS OF EBP-
1. John Hopkins Nursing EBP Model- used as a framework to guide the synthesis
and translation of evidence into practice.
There are three phases of the JHNEBP model-
i. The identification of an answerable question.
ii. A systematic review and synthesis of both research and non research
evidence.
iii. Translation include implantation of the practice change as a pilot study,
measurement of outcomes and dissemination of findings.

2. IOWA model- the IOWA model focuses on organization and collaboration

Incorporating conduct and use of research along with other types of
evidence. It was originated in 1994.
The star point in the model can either be-
- A knowledge focused triggered (that emerges from awareness of innovative
research findings).
- A problem focused trigger (that has its root in a clinical or organizational
problem)
3. The Stetler Model- this model examines how to use evidence to create formal
change within organizations, as well how individual practitioners can use research on
an informal basis as part of critical thinking and reflective practice.
The Stetler model of evidence-based practice based on following-
- Use may be instrumental, conceptual and symbolic.
- Other type of evidence and non-research related information are likely to be
combined with research findings to facilitate decision making or problem
solving.
- Internal or external factors can influence an individual’s or group’s review
and use of evidence.
- Research and evaluation provide probabilistic information not absolutes.
- Lack of knowledge and skills pertaining to research use and evidence-
informed practice can inhibit appropriate and effective use.
This model consist of five phases. Each phase is designed to-
- Facilitate critical thinking about the practical application of research
findings
- Result in the use evidence in the context of daily practice
- Mitigate some of the human errors made in decision making
BARRIERS IN EBP-
- Lack of value for research in practice
- Difficulty in bringing changes
- Lack of administrative support
- Lack of knowledge mentors
- Lack of time for research
- Lack of knowledge about research
- Research reports not easily available
- Complexity of research reports
- Lack of knowledge about EBP (3)
ADVANTAGES OF EBP-
- Provide better information to practitioner
- Enable consistency of care
- Better patient outcome
- Provide client focused care
- Structured process
- Increase confidence in decision making
- Generalize information
- Contribute to science of nursing
- Provide guidelines for further research
- Helps nurses to provide high quality patient care
DISADVANTAGES OF EBP-
- Not enough evidence for EBP
- Time consuming
- Reduced client choice
- Reduced professional judgment/ autonomy
- Suppress legal proceedings
- Publication bias
ROLE OF NURSE IN EBP-
- Generate important questions
- Know basis for nursing practice
- Expect that evidence is the foundation of practice
- Participate in projects
- Disseminate project findings in various forums
- Collaborate with the healthcare team to provide quality care
American nurses association standards of professional nursing practice
- The registered nurse participates as appropriate to education level and position, in the
formulation of evidence based practice through research.
- The registered nurse practitioner utilizes current evidence based nursing knowledge
including research findings to guide practice.
- Medical surgical nurse uses research findings in practice.
 BEST PRACTICES
INTRODUCTION-
Best practice is defined as the conscientious and judicious use of current best evidence in
making decisions about the care of individual patient.
Perieth et al said that ‘Best Practice’ in health care broadly refers to a systematic process
involving the identification, collection, evaluation, dissemination and the monitoring of
outcomes of health care interventions for population groups and defined indications or
conditions.
Best practice in nursing-Best practice in nursing refers to nursing practices that are based
on the ‘best evidence’ available from nursing research. The goal of ‘best practice’ is to apply
the most recent, relevant and helpful nursing interventions, based on research, in real life
practice.

PRINCIPLES OF BEST NURSING PRACTICE-

1. Principle A- Nurses treat everyone in their care with dignity and humanity. They
understand their individual needs, show compassion and sensitivity, and provide care
in a way that respects all people equally.
2. Principle B- Nurses take responsibility for the care they provide and answer for their
own judgements and actions. They carry out these actions in a way that is agreed with
their patients, and the families and in a way that meets the requirements of their
professional bodies and the law.
3. Principle C- Nurses manage risk are vigilant about risk and help to keep everyone
safe in the places they receive health care.
4. Principle D- Nurse provide and promote care that puts people care at the centre,
involves patients, services users, their families and their caregivers in decision and
help them make informed choices about their treatment and care.
5. Principle E- Nurses are at the heart of the communication process: they assess, record
and report on treatment and care, handle information sensitively and confidentially,
deal with complaints effectively and are conscientious in reporting the things they are
concerned about.
6. Principle F- Nurses have up-to-date knowledge and skills, and use these with
intelligence, insight and understanding in line with the needs of each individual in
their care.
7. Principle G-Nurses work closely with their own team and with other professionals,
making sure patient’s care and treatment is co-ordinate, is of a high standard and has
the best possible outcome.
8. Principle H- Nurses lead by example, develop themselves and other staff and
influence the way care is given in a manner that is open and responds to individual
needs.(4)
EXAMPLES OF BEST NURSING PRACTICES-
1. Best practice for nurse-to-nurse shift change- the most important element in
nursing best practices is communication especially during a shift change. During a
shift change nurses record and transfer important patient information, and it is
imperative that the information is accurate and complete.
There is greater risk of patient care mistakes during a nurse-to-nurse shift change. P
Problems exist due to the complex nature of specialized health systems.
Incomprehensive handoffs can result in gap in patient care- incorrect medications,
 surgery mistakes and even fatalities. Improper handoffs happen because of a
breakdown in communication and the omission of crucial patient information on sign
out sheets.
A successful handoff happens without interruption to a patient’s care. Regulatory
agencies such as the agency for healthcare research & quality, the joint commission
and the national quality forum have established protocols for handoffs. Details of a
patient’s care should not have any omissions regarding medication regimen or
treatments, and the new attending nurse should know about any patient restrictions or
physical needs. During a shift change, there should be full staff coverage so nurses are
free from distractions. The shift change handoff should include the submission of
accurate and up-to-date patient documentation and the opportunity to ask questions.
The on-duty nurse should verify patient information by reading it back to the end-of-
shift nurse.

2. Nursing best practices for evidence-based infection control- according to an

article in critical care nurse, hospital patients contract an infection at a rate of 4.5 out
of 1,000. A patient who develops an infection is at risk for a prolonged hospital stay,
serious illness or death. The transmission of bacteria in hospitals can cause infections
at the surgical site, in the urinary tract or other sites as well. Bacteria can also cause
central catheter bloodstream infections. One of the concerns about infections is due
to the prevalence of multidrug-resistant organisms like staphylococcus aureus,
vancomycin-resistant enterococcus and gram-negative bacilli.
The joint commission’s national patient safety goals, the world health organization
and the centers for disease control and prevention provide guidelines for the
prevention of infections. The evidence-based practice for combating the spread of
infection consists of these standard care procedures:

o Hand hygiene.
o Barrier protection.
o Decontamination
o Antibiotic prophylaxis

A nurse should conduct hand hygiene after every interaction with a patient and when
entering and exiting a patient’s room. Barrier protection includes wearing gloves,
gowns, masks and goggles. Decontamination of the room and equipment is necessary
in reducing and preventing the spread of infection. Antibiotic stewardship is critical to
stopping the overuse of the treatment. Antibiotics should only be used when other
methods fail and the therapy should be closely monitored. In extreme cases, patients
with an active infection may have to be isolated.

3. Care rounding and care calls to improve patient satisfaction-Hospitals are

implementing best practices for patient care follow-up and discharge instruction.
Care rounding is used to reduce the need for the patient’s call light. Typically,
patients push the call button to notify nurses that they need urgent care. Nurses who
institute a care-rounding schedule are more accessible to patients. This procedure
reduces the number of times patients use the call light to summon a nurse for a non-
emergency reason.
When patients are ready for discharge, they are often impatient and unable to retain a
nurse’s instructions about medications or home care. Care calls allow nurses to check
up on discharged patients and answer any questions. Generally, a nurse will make a
 care call 48 to 72 hours after a patient is discharged. Care calls build relationships
between nurses and patients and improve patients’ satisfaction regarding their
healthcare experience.
Some hospitals are including both care rounding and care calls as part of their best
practices. By adding technology, nurses can streamline the discharge process. They
can upload instructions to a patient’s phone or computer and send patients the
following items:
 Links to healthcare resources.
 Insurance information.
 Reminders about healthcare instructions(5)

RESEARCH FINDINGS-
1. Translating research into practice: case study of a community based
dementia care giver intervention.(Mittleman MS, BartlelsSJ)
Evidence from the randomized clinical trials has demonstrated the effectiveness of
providing psychosocial interventions for caregivers to lesson their burden. this
case study describes outcomes of the implementation of an evidence based
intervention in a multisite program in Minnesota. Consistent with the original
randomized clinical trial of the intervention, assessment of this program showed
decreased depression and distress among caregivers. Some of the challenges in the
community setting included having caregivers complete the full six counseling
sessions and acquiring complete outcome data. Given the challenges faced in the
community setting, web-based training for providers may be a cost-effective way
to realize the maximum benefits of the intervention for vulnerable adults with
dementia and their families.(6)

2. Promoting Evidence-Based Practice Through a Research Training Program

for Point-of-Care Clinicians(Agnes T. Black,Lynda G. Balneaves, Candy
Garossino et al)
OBJECTIVES: The purpose of this study was to evaluate the effect of a research
training program on clinicians’ knowledge, attitudes, and practices related to
research and evidence-based practice (EBP).
METHODS: Mixed-methods design was used to evaluate a research training
intervention with point-of-care clinicians in a Canadian urban health organization.
Participants completed the Knowledge, Attitudes, and Practice Survey over 3 time
points. Focus groups and interviews were also conducted.
RESULTS: Statistically significant improvement in research knowledge and ability
was demonstrated. Participants and administrators identified benefits of the
training program, including the impact on EBP.
CONCLUSIONS: Providing research training opportunities to point-of-care
clinicians is a promising strategy for healthcare organizations seeking to promote
EBP, empower clinicians, and showcase excellence in clinical research.(7)
SUMMARY- we have discussed about the evidence based practice- its goals, needs, steps of
Evidence based practice, sources of evidences, models of EBP, its advantages and
disadvantages, and role of nurse in EBP. We have also discussed about the best nursing
practices, principles of best nursing practice and examples of best nursing practice.

CONCLUSION- evidence-based nursing care is a lifelong approach to clinical decision

making and excellence in practice. Evidence- based nursing care is informed by research
findings, clinical expertise and patient’s value and its use can improve patient’s outcomes.
Use of research evidence in clinical practice is an expected standard of practice for nurses
and health care organizations but numerous barriers exist that create a gap between new
knowledge and implementation of that knowledge to improve patient care. Using the levels of
evidence nurses can determine the strength of research studies, assess the findings and
evaluate the evidence for potentiate implementation into best practice.
BIBLIOGRAPHY-
1. Potter and Perry’s. Fundamental of nursing. South asian edition.2013;97.
2. Brunner and Suddarth. Textbook of medical surgical nursing. 13th edition. Volume
New Delhi: Wolteus Kluwer;2015;4.
3. Suresh K. Sharma. Nursing research and statistics.2nd edition. New
Delhi:Elsevier;2014;29.
4. Principles of nursing practice. Royal college of nursing.2018. Available from-
http://www.rcn.org.uk/professional-development/principles-of-nursing-practice
5. 3 examples of nursing best practices. University of Rhode Iceland[internet]. 2017
June 27. Available from-
https://online.uri.edu/articles/examples-of-nursing-best-practices.aspx
6. Mary S. Mittleman and Stephen J. Bartels.Translating research into practice: case
study of a community based dementia care giver intervention. Health affairs.[serial
online].2014;33(4). Available from-
https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2013.1334
7. Agnes T. Black, Lynda G. Balneaves, Candy Garossino, Joseph H. Puyat, Hong
Qian. Promoting evidence-based practice through a research training program for
point-of-care clinicians. JONA[serial online]. 2014;45(1). DOI:
10.1097/NNA.0000000000000151. Available from-
https://www.researchgate.net/publication/268232352_Promoting_Evidence-
Based_Practice_Through_a_Research_Training_Program_for_Point-of-
Care_Clinicians