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