Evidence-Based

Practice:
AN INTRODUCTION

Adopted
Adopted from
from the
the Presentation
Presentation of:
of:
Suzanne
Suzanne Prevost,
Prevost, RN,
RN, PhD
PhD
Associate
Associate Dean
Dean for
for Practice
Practice
University
University of
of Kentucky
Kentucky College
College of
of Nursing
Nursing
President-Elect
President-Elect –– Sigma
Sigma Theta
Theta Tau
Tau International
International
The Evolution of
Evidence-Based Practice
 What is - Evidence?

Anything that provides material or

information on which a conclusion or proof
may be based; used to arrive at the truth,
used to prove or disprove the point at issue.
(Webster)
 Evidence-Based Practice

• Evidence-Based Practice – Conscientious, explicit and judicious

use of current best evidence with clinical expertise, and patient
values to make decisions about the care of patients. (Sackett, 2000)

• Evidence-based nursing practice is the process of shared decision-

making between practitioner, patient and significant others, based
on research evidence, the patient’s experiences and preferences,
clinical expertise, and other robust sources of information.
(STTI , 2007)
• EBP is both a process and a product…
requiring that the evidence which is produced –
is also applied to practice.
(D. Rutledge, 2002)
 Evidence based practice is ‘the
process by which nurses make
clinical decisions using the best
available research evidence, their
clinical expertise and patient
preferences, in the context of
available resources’ (DiCenso et al, 1998)
 Evidence-based Practice
Process by which clinical decisions are
made using:

• Best available research evidence

• Clinical expertise

• Patient preference
 Perspectives on Evidence

Research
Evidence
Nursing Action

Clinical Patient /
expertise User
perspectives

Nursing Outcomes

Practice Context
Variation in practice leads to:

• Variable quality of care

• Higher cost of care

• Potential for errors that may cause harm

DOES TURNING CRITICALLY
ILL PATIENTS MANUALLY
EVERY 2 HOURS ENOUGH
TO PROMOTE PULMONARY
GAS EXCHANG?
INSTILLING NSS BEFORE
ET SUCTIONING:
HELPFUL OR HARMFUL?
MASSAGING OVER
BONY PROMINENCE
IS IT HELPFUL?
ASKING THE PATIENT
TO SPEAK OR HUM TO
DETERMINE NG TUBE
PLACEMENT?
 Table 1

Bedside Assessment of Enteral Tube P

lacement: Aligning Practice with Evide
nce
Simons, Shellie Robin; Abdallah, Lisa M.
AJN The American Journal of
Nursing112(2):40-46, February 2012.
doi:
10.1097/01.NAJ.0000411178.07179.68

Policies for Assessing Placement of

Enteral Feeding Tubes at 28 New
England Hospitals

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. 14

 AIMS OF EVIDENCE
BASED PRACTICE
 To provide the high quality and most cost- nursing
efficient 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.
 Evolution of EBP

• 1991 – Evidence-based medicine -first described in the

American College of Physicians Journal Club.
• 1992 – the Evidence-based Medicine Working Group
described it as a “paradigm shift” in JAMA

– Clinical observations and experience, principles of

pathophysiology, knowledge gained from authoritative figures,
and common sense -- are no longer a sufficient guide for
clinical practice, decision-making, or the development of
practice guidelines
 Evolution of EBP
• Early 1990’s – US Prev. Services TF – began developing EB
Guidelines for Screening and Prevention

• 1992 – AHCPR (now AHRQ) – started publishing systematic

reviews and consensus statements in the form of Clinical
Practice Guidelines, starting with the guideline for Acute
Pain, 19 guidelines were produced from ’92-’96

• 1993 - the first annual Cochrane Colloquia was held at the

New York Academy of Sciences

• 1993 – Online Journal of Knowledge Synthesis for Nursing

Evolution of EBP

1997 – Jan 2011 – 198 Evidence

Reports published by the EBP centers

– May, 2005 – Episiotomy Use

– “…no health benefits from episiotomy…
routine use is harmful …”
 Nurse Staffing and Quality of
Patient Care
• Objectives: To assess how nurse to patient ratios and
nurse work hours were associated with patient outcomes
in acute care hospitals

• Results: Higher RN staffing was associated with less

mortality, failure to rescue, cardiac arrest, hospital
acquired pneumonia, and other adverse events. Limited
evidence suggests that the higher proportion of RNs with
BSN degrees was associated with lower mortality and
failure to rescue. More overtime hours were associated
with an increase in hospital related mortality, nosocomial
infections, shock, and bloodstream infections.
Within one decade, the concept of
evidence-based practice has
evolved and been embraced by
nurses in nearly every clinical
specialty, across a variety of roles
and positions, and in locations
around the globe.

EBP – means many things to many

people
 Factors Contributing to Emphasis on
Evidence-Based Nursing Practice

• Scientific knowledge expansion

– Knowledge expands exponentially q 2 yrs
– 12 yrs. from now – 128 x as much knowledge

• Knowledge availability -- The Internet

• Highly educated nurses in clinical settings

– APNs – focusing on evidence-based clinical problem-solving
– Clinical Nurse Researchers
– DNP Movement
Factors Contributing to Emphasis on
Evidence-Based Nursing Practice

• Aggressive pursuit of cost-effectiveness

• Focus on quality of care, Risk & error
reduction
• Highly educated consumers
• JCAHO/Accreditation expectations
• Increased attention to institutional image
– Magnet hospital movement
What is the 1st step toward EBP for the
practicing nurse?

• Asking good clinical questions

• Nurses must be empowered to ask

critical questions in the spirit of
looking for opportunities to improve
nursing care and patient outcomes

• Risk-taking environment
Nursing vs. Medical Questions

• Often more exploratory

• Less frequently focused on intervention selection
• Less evidence to support many nursing
interventions
• Most nursing interventions have less capacity for
harm
• Many nursing challenges often go beyond
individual clinical interventions
(e.g. nurse staffing, education, recruitment)
Clinical Nursing Questions

• In postoperative patients, does prn or

ATC analgesic administration yield better
pain relief?

• Among critically ill patients, is controlled

or open visitation more effective in
reducing patient anxiety?
What kind of questions might the
Nurse Manager ask?

• On medical-surgical units, do 12 hour or 8

hour shifts result in more medication
errors?
Key Questions to Ask When
Considering EBP

• Why have we always done “it” this way?

• Do we have evidence-based rationale?
• Or, is this practice merely based on tradition?
• Is there a better (more effective, faster, safer,
less expensive, more comfortable) method?
• What approach does the patient (or the target
group) prefer?
• What do experts in this specialty recommend?
Key Questions to Ask When
Considering EBP

• What methods are used by leading/benchmark,

organizations?
• Do the findings of recent research suggest an
alternative method?
• Are organizational barriers inhibiting the
application of best practices in this situation?
• Is there a review of the research on this topic?
• Are there nationally recognized standards of care,
practice guidelines, or protocols that apply?
 Steps in the EBP Process
• Developing a well-built question
• Finding evidence-based resources to
answer the question
• Evaluating the strength and applicability of
the evidence
• Applying the evidence to practice
• Evaluating the effects
• Once we agree upon the question that
poses an opportunity for improvement, then
we must find the evidence

• Where should we look?

• Are all forms of evidence equivalent in

quality?
 Strength of Evidence

• Level I - meta-analysis of multiple studies

• Level II - experimental studies, RCTs
• Level III - quasiexperimental studies
• Level IV - nonexperiemental studies
• Level V - case reports, clinical examples
AHCPR/AHRQ

• At what level is most nursing evidence?

 AACN Levels of Evidence
(Armola, et al. , C C Nurse, 2009)

• Level A • Meta-analysis or metasynthesis of multiple

controlled studies, supporting a specific action
• Level B
• Controlled, randomized, or nonrandomized studies,
• Level C supporting a specific action
• Qualitative, descriptive or correlational studies or
• Level D systematic reviews with consistent results
• Peer-reviewed prof. organ. standards with studies to
• Level E
support them
• Level M • Theory-based evidence from expert opinion or case
studies
• Manufacturer’s recommendations only
What constitutes the “Evidence” in
Evidence-Based Practice?

“Evidence-based practice has been defined

as the use of the best clinical evidence from
systematic research (referring to meta-
analysis, integrated reviews, & RCTs – as
the gold standard). …Others (often nurses)
believe that experimental studies,
observational studies, and correlational
studies are also suitable evidence.”
C. Goode, Applied Nursing Research, 2000
A major dilemma for the
practicing nurse:
Finding the time, access, and research expertise that are
needed to search and analyze the evidence to find
answers to their clinical questions.

For those of you who are already pursuing EBP, which of

these issues pose the greatest challenges for you?
AHRQ – Agency for Healthcare
Research and Quality
 Cochrane Collaboration

• “an international, independent, not-for-profit organization of over 27,000

contributors from more than 100 countries, dedicated to making up-to-
date, accurate information about the effects of health care readily available
worldwide.

• Contributors produce systematic assessments of healthcare interventions,

known as Cochrane Reviews, which are published online in
The Cochrane Library.

• Rely heavily on RCTs

• Primarily focused on effectiveness of interventions, more
medical and pharmaceutical than nursing
Cochrane Collaboration
http://www.cochrane.org
 Moving Toward our Destiny

Evidence-based practice is every nurses’

responsibility

What can you do to make this goal a reality?

 Educator’s Role

– EB Education for EB Practice

– Base educational content on evidence
– Seek the most current forms of
evidence, e.g. journals & online
sources vs. texts
– Encourage students to question and
challenge
– Teach research content in a manner
that is interesting and useful
 Manager/Administrator’s Role
Manager/Administrator’s Role

– Encourage inquisitive minds

– Promote risk-taking and flexibility in the clinical
environment
– Incorporate EBP activities into performance
evals
– Provide time & resources – unit internet
access
– Provide support personnel
– Empower staff to make EB practice changes
– Acknowledge and reward EB improvements
 Researcher’s Role

– Remain clinically in touch

– Conduct clinically useful studies
– Support clinicians in accessing and
synthesizing the evidence
– Collaborate with clinicians and patients
– Disseminate findings that are
understandable and accessible
– Emphasize clinical implications
Nurse Clinician’s Role

– “Worry and Wonder”

– Be the Inquiring Mind
– Question clinical traditions
– Stay abreast of the literature - guidelines
– Find your niche – and become the expert
– Collaborate with APNs & researchers
– Be an advocate for evidence-based changes
– LISTEN to your PATIENTS – to guard patient &
family preferences
…IN CONCLUSION

 We must commit to take action on

recommendations from IOM report
 Affirm that this is about access to
access to patient-centered care and
health care reform
 Essential that nurses mobilize 49