Implementing Evidence-Based Nursing Practice

Teri Britt Pipe; Kay E. Wellik; Vicki L. Buchda; Carol M. Hansen; Dana R. Martyn

Abstract and Introduction

A methodology for establishing and supporting evidence-based nursing practice is examined. Description of a clinical and
administrative scenario serves as an example of a systematic appraisal of the relevant literature that had implications for clinical
practice.

Abstract

Within the nursing profession, it is expected that new information in the form of research findings will be incorporated constantly
and knowledgeably into nursing practice. The staff nurse is a critical link in bringing research-based changes into clinical
practice. Depending on the environment, a health care organization may or may not have the resources to ensure critical, succinct,
reasonable evaluation and application of research findings as they relate to the point-of-care delivery. Health care organizations
are beginning to create mechanisms to facilitate the process of information translation from the literature to practice.

Introduction

The Purpose of this article is to describe a methodology for establishing and supporting evidence-based nursing practice (EBNP).
After establishing the background for this project, authors describe a clinical and administrative scenario in which an issue was
identified that warranted a systematic appraisal of the relevant literature to inform clinicians. An operational definition for EBNP
is presented, and a conceptual framework for translating evidence into practice is outlined. Next, a case study is presented to
describe the process of critically appraising the evidence and translating the findings into nursing practice, education, and
administration. The clinical and administrative outcomes are highlighted and the roles of EBNP team members explained.

The hospital described in this article has 205 licensed beds, 15 operating rooms, and a level II emergency department. Inpatient
specialty units include critical and intermediate care as well as several medical/surgical units serving various specialties
(orthopedics, neurology and neurosurgery, hematology and oncology, bone marrow transplant, solid organ transplant, cardiology,
and cardiac surgery). The environment is technology based, with an electronic medical record for all nursing documentation,
telemetry available to each inpatient bed, an epilepsy monitoring unit, electronic supply charging, filmless radiology, wireless
phones for each nurse, and a robotic surgical system. The hospital staff members are registered nurses assisted by patient care
assistants. Staff participation in nursing committees is encouraged. Support staff include unit-based educators and specialty-based
clinical nurse specialists (CNSs). Participation in nursing and other clinical research studies is encouraged.

In examining the issue of translating research-based evidence into practice, authors focused on collaboration, service, and
integration. Each of these components figures prominently in the work performed at the medical center. The approach selected to
use research in practice reflects the structure and mission of the organization, which is to provide the best care for the patient
using the three "shields" of practice, education, and research. The themes of collaboration, service, and integration were used to
weave together the expertise of library sciences and nursing services as well as collaboration among the nursing practice
subcommittee (NPS), the nursing education subcommittee (NES), and the nursing research subcommittee (NRS). This project is
an example of the integration of the work of these three subcommittees that was presented to the nursing staff in an attempt to
identify the best possible service for patients.
Evidence-based nursing

Evidence-Based Nursing or EBN is a type of evidence-based medicine. It involves identifying

solid research findings and implementing them in nursing practices, in order to
increase the quality of patient care. The goal of EBN is to provide the highest quality
and most cost-efficient nursing care possible. EBN is a process founded on the
collection, interpretation, and integration of valid, important, and applicable
research. Some define EBN tightly, considering only the application of the findings of
randomized clinical trials, while others also include the use of case reports and
expert opinions.[1] In order to practice evidence based nursing, practitioners must
understand the concept of research and know how to accurately evaluate this
research. These skills are taught in modern nursing education and also as part of
professional training. The 5 steps of EBN

1.Select a Topic

The first step is to select a topic. Ideas come from different sources but are categorized in two areas: Problem-focused triggers
and Knowledge focused triggers(see below). When selecting a topic, nurses should formulate questions that are likely to gain
support from people within the organization. An interdisciplinary medical team should work together to come up with an
agreement about the topic selection. The priority of the topic should be considered as well as the severity of the problem. Nurses
should consider whether the topic would apply to many or few clinical areas. Also, the availability of solid evidence should be
considered because providing proof of the research will increase staffs' willingness to implement into nursing practice.

2.Problem & Knowledge Focused Triggers

Problem focused triggers are identified by health care staff through quality improvement, risk surveillance, benchmarking data,
financial data, or recurrent clinical problems. Problem focused triggers could be clinical problems, or risk management issues.
Example: Increased incidence of deep vein thrombosis and pulmonary emboli in trauma and neurosurgical patients.

Deep Vein Thrombosis (DVT) is a blood clot in the deep venous system in the legs. Many things can contribute to a clot forming
in the legs such as impaired mobility and bed rest. A thrombosis in the leg is not a huge problem but becomes a very dangerous
situation when a piece of the clot breaks off and is free to travel in the bloodstream. In most situations, the thrombosis will travel
into the right heart and then into the pulmonary circulation and become wedged in the lungs. This creates a pulmonary embolism
which is a very serious situation.

Diagnosis and proper treatment of a DVT (Deep Vein Thrombosis) is a very important task for health care professionals and is
meant to prevent pulmonary embolism. This is an example of an important area that more research can be conducted to add into
Evidence Based Practice.

Knowledge focused triggers are created when health care staff read research, listen to scientific papers at research conferences
or encounter EBP guidelines published by federal agencies or organizations. Knowledge based triggers could be new research
findings that further enhance nursing, or new practice guidelines.
Example: Pain management, prevention of skin breakdown, assessing placement of nasogastric and nasointestinal tubes, and use
of saline to maintain patency of arterial lines.

It is important that individuals work closely together to reach the optimum outcome for the chosen topic. Some things that would
ensure collaboration are working in groups to review performance improvement data, brainstorming about ideas, and achieving
consensus about the final selection.

3.Form a Team

Some might become overwhelmed when they first learn about EBP and apply it for reasons other than improvement of patient
care. Forming a team increases the chance of EBP being adopted. A team becomes paramount in implementation, and evaluation
of the EBP. It is important to have representatives of the team from authority members of the organization and also grassroot
members. It is also important to consider interdiscipline involvement to decrease rejection, and for all to have an understanding
of the project. All these individuals have a great impact on the possibility of successful implementation. Other factors to put into
consideration include power figures in the organization who may directly or indirectly sabortage the efforts if they are not
consulted, and fully included in EBP implementation. The EBP team should have explanations that clearly define the types of
patients, setting, outcomes, interventions and exposures. This should be in simplified language that is comprehensible to a lay
person.

The role of the practitioners is remarkable in any meaningful gains, they are therefore inevitable and their role becomes pivotal.
The approach they adopt and their ability to educate the coworkers, answer their questions, and clarify any misconceptions
greatly improves the outcomes.

4.Evidence Retrieval

One of the most challenging issues in using EBP in the clinical setting is learning how to adequately frame a clinical question so
that an appropriate literature review can be performed. When forming a clinical question the following should be included: the
disorder or disease of the patient, the intervention or finding being reviewed, possibly a comparison intervention, and the
outcome. An acronym used to remember this is called the "PICO" model:

P = Who is the Patient Population?

I = What is the potential Intervention or area of Interest?

C = Is there a Comparison intervention or Control group?

O = What is the desired Outcome?

Once the topic is selected, the research relevant to the topic must be reviewed, in addition to other relevant literature. It is
important that clinical studies, integrative literature reviews, meta-analyses and well-known and reliable existing EBP guidelines
are accessed in the literature retrieval process. With the internet at one’s fingertips, a plethora of research is just a few clicks
away. However, just because you found it in a respectable journal does not signify high quality research. When reviewing any
article for evidence retrieval read it very closely. Articles can appear to be precise and factual on the surface but with further and
much closer examination, flaws can be found. The article can be loaded with opinionated and/or biased statements that would
clearly taint the findings, thus lowering the creditability and quality of the article. Use of rating systems to determine the quality
of the research is crucial to the development of EBP. There are several rating systems available online. The National Guideline
Clearinghouse is a database of published EBP guideline abstracts at (http://www.guideline.gov).

Time management is crucial to information retrieval. Nurses making their way through the vast amount of research available may
find it helpful to read research articles or critical reviews instead of clinical journals. To maintain high standards for EBP
implementation, education in research review is necessary to distinguish good research from poorly conducted research. Equally
important is that the materials being reviewed, consider if they are current.

Links to article sources

1. Cinahl Information Systems Home Page

2. British Medical Journal
3. Medline Industries, Inc
4. Pubmed

Once the literature is located, it is helpful to classify the articles as either conceptual (theory and clinical articles) or data-based
(systematic research reviews). Before reading and critiquing the research, it is useful to read theoretical and clinical articles to
have a broad view of the nature of the topic and related concepts, and to then review existing EBP guidelines.

5.Apply the Evidence

After determining the internal and external validity of the study , a decision is arrived at whether the information gathered does
apply to your initial question. Its important to address questions related to diagnosis, therapy, harm, and prognosis. The
information gathered should be interpreted according to many criteria and should always be shared with other nurses and/or
fellow researchers.
Qualitative Research Process

One method of research for Evidence based practice in nursing is Qualitative Research. "The word implies a oten baho bilat
entity and meanings that are not experimentally examined or measured in terms of quantity, amount, frequency, or intensity."
With qualitative research, researchers learn about patient experiences through discussions and interviews. The point of qualitative
research is to provide beneficial descriptions that allow insight into patient experiences. "Hierarchies if research evidence
traditionally categorize evidence from weakest to strongest, with an emphasis on support for the effectiveness of interventions.
That this perspective tends to dominate the evidence-based practice literature makes the merit of qualitative research unclear;" 1
Some people view qualitative research as less beneficial and effective, with its lack of numbers, the fact that it is "feeling-based"
research, makes the opponents associate it with bias. Nevertheless, the ability to empathetically understand an individual's
experience (whether it be with cancer, pressure ulcers, trauma, etc.), can benefit not only other patients, but the health care
workers providing care. For qualitative research to be reliable, the testing must be unbiased. To achieve this, researchers must
use random and non-random samples to obtain concise information about the topic being studied. If available, a control group
should be in use, if possible with the qualitative studies that are done. Evidence should be gathered from every available subject
within the sample to create balance and dissolve any bias. There should also be several researchers doing the interviewing to
obtain different perspectives about the subject. Researchers must also obtain negative information as well as the positive
information gathered to support the data. This will help to show the researchers were unbiased and were not trying to hide
negative results from readers, and actually makes it possible to objectively understand the phenomenon under investigation. The
inclusion of this negative information will strengthen the researchers initial study, and may actually work in favor to support the
hypothesis. Any data that has been gathered must be appropriately documented. If the data collected was obtained from
interviews or observation, it must all be included. Dates, times and gender of the sample may be needed, providing background
on subjects, such as breast cancer in women over thirty-five. Any pertinent information pertaining to the sample must be included
for the reader to judge the study as worthy.In addition, the current evidence-based practice (EBP) movement in healthcare
emphasizes that clinical decision making should be based on the "best evidence" available, preferably the findings of randomized
clinical trials. Within this context qualitative research findings are considered to have little value and the old debate in nursing
has been re-ignited related as to whether qualitative versus quantitative research findings provides the best empirical evidence for
nursing practice. In response to this crisis qualitative scholars have been called upon by leaders in the field to clarify for outsiders
what qualitative research is and to be more explicit in pointing out the utility of qualitative research findings. In addition,
attention to "quality" in qualitative research has been identified as an area worthy of renewed focus. Within this paper two key
problems related to addressing these issues are reviewed: disagreement not only among "outsiders" but also some nursing
scholars related to the definition of "qualitative research", and a lack of consensus related how to best address "rigor" in this type
of inquiry. Based on this review a set of standard requirements for qualitative research published in nursing journals is proposed
that reflects a uniform definition of qualitative research and an enlarged yet clearly articulated conceptualization of quality. The
approach suggested provides a framework for developing and evaluating qualitative research that would have both defensible
scholarly merit and heuristic value. This will help solidify the argument in favor of incorporating qualitative research findings as
part of the empirical "evidence" upon which evidence-based nursing is founded.

How to Critique a Research Article

The critiquing process is the building block and foundation for the multiple steps that are to follow in the successful
implementation of EBP. This is so because you must first ensure that the material and research that you are trying to convince
others to accept is reliable and accurate. By taking the time to thoroughly critique a study you can point out both the strengths and
weaknesses of the findings and weigh them accordingly. Successful completion of this vital step will help "weed out" the
material lacking the needed proof of effectiveness, therefore minimizing useless, or even harmful, implementation of new
practices in the healthcare field.

Critiquing criteria are the standards, evaluation guides, or questions used to judge (critique) an article. In analyzing a research
report, the reader must evaluate each step of the research process and ask questions about whether each step of the process meets
the criteria. Remember when you are doing a critique, you are pointing out strengths, as well as the weaknesses. To critique an
article you must have some knowledge on the subject matter. There is no replacement for reading the article many times. The
reader must search the article for contradictions, illogical statements, and faulty reasoning. It is important to evaluate every
section of the research article. Each section has different criteria to meet, in order to be considered a well-written addition to the
article.

Introduction, Purpose, and Hypothesis

Introductions need to at least include a literature review and a purpose statement, but they may also contain a theoretical
framework, a research question, and a hypothesis. The research question presents the idea that is to be examined in the study and
is the foundation of the research study. A well developed research question guides a focused search for scientific evidence about
assessing, diagnosing, treating, or assisting patients with understanding of their prognosis related to a specific health problem.
The hypothesis attempts to answer the research question. A hypothesis is a declarative statement about the relationship between
two or more variables that predicts an expected outcome. Characteristics of a hypothesis include a relationship statement,
implications regarding testability, and consistency with a defined theory base. They can be formed by either a directional or
nondirectional method. The literature review needs to explain the reason the study was conducted and why it was important for
the study to be conducted now. The theoretical framework and the literature review should also work together. The purpose
statement needs to explain what the study wants to accomplish. The purpose, aims, or objectives often provide the most
information about the intent of the research question and hypothesis and suggest the level of evidence to be obtained from the
findings of the study. The introduction should cover these topics, and should not throw in a lot of excess, useless knowledge. The
research question, hypothesis, and the study should all correlate together. You have to be careful when critiquing research articles
because sometimes researchers will try to cover up a poor study with lots of information that does not belong. It may look good
to the reader at first glance so it is always a good idea to reread the articles a few times to fully understand it and to see if there
are any discrepancies.

Methodology

The methodology section must start off by gathering a sample. There are a few definitions you must understand first.
'Population' is the group that you want you study findings to apply to. A 'sample frame' is the target population, in which the
study will affect. There are three different ways to select a population. The researchers can choose who they want in the study,
the participants can choose if they want to be in the study, or it can be a random selection in which neither the researcher or the
participant chooses. The study must either have external validity or internal validity. If the study has external validity then the
study's findings have different settings, procedures, and participants. External validity will also question what types of subjects
and conditions in which the same results can be expected to occur. If the study has internal validity then the findings are held
true within the sample. The researchers will rule out factors or threats as rival explanations of the relationship between the
variables that are present. Be careful with internal validity and external validity because there are a number of threats for both
that can affect the outcome of the study. These should be considered by the researchers who are planning the study and by
consumers before implementing the results into practice. Phenomenological method In qualitative research phenomenological
methods are used to learn and construct the meaning of the human experience through intensive dialogue with persons who are
living the experience. The researcher's goal is to explain the meaning of the experience to the participant. This is achieved
through a dialogic process, which is more than a simple interview.

Results and Discussion

The results section puts forth the findings of a study in a clear, logical, and unbiased manner. It presents the findings according
to the variables studied without extrapolating beyond what those variables yielded. Qualitative studies do not contain statistical
tests. Therefore, the themes, concepts, observational or print data are described in the "Methods" or "Data Collection" subtitles
and are reported in the "Results" or "Findings" section. A good results section should also make use of descriptive statistics.
Descriptive statistics are used to summarize, reduce, and organize the data and characteristics of the data into an easily
understood, manageable format. Finding data's mode, median, and mean are three techniques used to easily recognize central
tendency. Techniques such as range and standard deviation are used to measure variability and scatter plots are used to measure
correlation. After analyzing the data and finding central tendency, variability, and correlation, this information should be worked
into an easily understood format such as a frequency distribution table, chart, or graph. The reader should be able to easily
recognize and interpret the data. However, the reader must be on alert to recognize that this may yet be another opportunity for
the author of the study to make the results appear more grandiose than they are. Always look at what the actual numbers amount
to instead of just looking at how significant the graph or chart makes the data look. In a good results section, the author will not
try to make insignificant data look significant, but simply show the results. If the numerical data of a study does not show the
same claims that the researcher stated then this is a major flaw in the study and raises significant concerns about the study's
validity and reliability; therefore, a nurse and other healthcare providers should not only stay current on new research but should
be able to decipher the research in order to determine its true value to the medical practice.

The very last section of a research study is known as the discussion section. Here, the researchers draw all the pieces from the
study together to present the whole picture. The researchers review the literature and discuss how the results compare and
contrast previously completed studies. The researchers often present biased opinions in the discussion section but these should
always be supported by the research and not just the interpretation of the researchers. This overview of the study serves to make a
comparison with the background literature. The results and discussion sections can sometimes be combined into one by the
researcher, but normally, the researcher will report the findings into separate "results" and "discussion" sections. One way is not
better than the other when it comes to combining or dividing the findings into sections. Any new or unexpected results are
usually described in the discussion section as well.

Evaluating The Conclusion

A conclusion can be identified as paragraphs that state the main claims that came out of the findings that were read earlier in the
article. It should have a summary of the findings (strengths and weaknesses), status of the hypothesis, limitations, and
recommendations, implications, or applications. In each section the best and worst needs to brought forth. In a quality conclusion
section the author will only state what has been found, or not, without adding anything extra. The hypothesis will be proven true
or false and nothing in between. Limitations will be discussed such as the statistical framework or design errors made in the
beginning. The researcher should also present the limitations or weaknesses of the study. This presentation is important because it
effect's the studies generalizability. The generalizations or inferences about similar findings in other samples also are presented in
light of the findings. Recommendations will be few in quality research. If no loop holes or oversights are made at the beginning
then these will not have to be expressed at the end. When all of these come together in a simplified manner then a conclusion can
be considered strong.

A limitation is an admission of how certain aspects of the study, such as the sampling, were not as unbiased as they should have
been. This lets the reader know that improvements can be made from what was accomplished in the article.

The last thing the conclusion should do is give the reader a recommendation. This recommendation should be derived from the
results gathered earlier in the article. Based on the results, the reader will be able to judge whether the data and hypothesis should
be applied to nursing practice.[5]

Legal and Ethical Issues of Research

Both legal and ethical issues are important in considering patient-based research. The American Nurses Association (ANA) has
set up five basic rights for patient protection:

1. Right to self determination

2. Right to privacy and dignity
3. Right to anonymity and confidentiality
4. Right to fair treatment
5. Right to protection from discomfort and harm.

These rights apply to both researchers and participants. Informed consent is one area that nurses must be familiar with in order to
complete research. Informed consent is "the legal principle that governs the patients ability to accept or reject individual medical
interventions designed to diagnose or treat an illness". Informed consent can only be obtained before the procedure and after
potential risks have been explained to the participant. When dealing with the ethical portion of Evidence based practice, the
Institutional Review Boards (IRB) review research projects to assess that ethical standards are being followed. The institutional
review board is responsible for protecting subjects from risk and loss of personal rights and dignity. The IRB also come into play
when deciding on which populations can be included in research. Vulnerable groups such as children, pregnant women,
physically disabled or elderly maybe excluded from the process. Nurses must notify the IRB of any ethical or legal violations.

It is important to be up to date on all the appropriate state laws and regulations regarding vulnerable populations. This may mean
consulting with lawyers, clinicians, ethicists, as well as the affiliated IRB. It is imperative that researchers act as advocates for
these vulnerable persons that cannot do so for themselves.

Barriers to promoting Evidence Based Practice

The use of evidence based practice depends a great deal on the nursing student's proficiency at understanding and critiquing the
research articles and the associated literature that will be presented to them in the clinical setting. According to, Blythe Royal,
author of Promoting Research Utilization in nursing: The Role of the Individual, Organization, and Environment, a large amount
of the preparation requirements of nursing students consists of creating care plans for patients, covering in depth processes of
pathophysiology, and retaining the complex information of pharmacology. These are indeed very important for the future of
patient care, but their knowledge must consist of more when they begin to practice. Evidence based nursing in an attempt to
facilitate the management of the growing literature and technology accessible to healthcare providers that can potentially improve
patient care and their outcomes. Nancy Dickenson-Hazard states, "Nurses have the capacity to serve as caregivers and change
agents in creating and implementing community and population-focused health systems." There is also a need to overcome the
barriers to encourage the use of research by new graduates in an attempt to ensure familiarity with the process. This will help
nurses to feel more confident and be more willing to engage in evidence based nursing. A survey that was established by the
Honor Society of Nursing and completed by registered nurses proved that 69% have only a low to moderate knowledge of EBP
and only half of those that responded did not feel sure of the steps the process consists of. Many responded, "lack of time during
their shift is the primary challenge to researching and applying EBP." There is always and will always be a desire to improve the
care of our patients. The ever increasing cost of healthcare and the need for more accuracy in the field proves a cycle in need of
evidence based healthcare. The necessity to overcome the current issues is to gain knowledge from a variety of literature not just
the basics. There is a definite need for nurses, and all practitioners, to have an open mind when dealing with the modern
inventions of the future because these could potentially improve the health of patients.

There are many barriers to promoting evidence based practice. The first of which would be the practitioner's ability to critically
appraise research. This includes having a considerable amount of research evaluation skills, access to journals, and clinic/hospital
support to spend time on EPN. Time, workload pressures, and competing priorities can impede research and development. The
causes of these barriers include nurse's and other professional practitioners lack of knowledge of research methods, lack of
support from professional colleagues and organizations, and lack of confidence and authority in the research arena. Another
barrier is that the practice environment can be resistant to changing tried and true conventional methods of practice. This can be
caused because of reluctance to believe results of research study over safe, traditional practices, cost of adopting new practices, or
gaining momentum to rewrite existing protocols.. It is important to show nurses who may be resistant to changes in nursing
practice the benefits that nurses, their patients, and their institutions can reap from the implementation of evidence-based nursing
practice, which is to provide better nursing care. Values, resources and evidence are the three factors that influence decision-
making with regard to health care. All registered nurses and health care professionals should be taught to read and critically
interpret research and know where to find articles which relate to their field of care. In addition, nurses need to be more aware of
how to assess the information and determine its applicability to their practice.

Another barrier to implementing EBN into practice is lack of continuing education programs. Practices do not have the means to
provide workshops to teach new skills due to lack of funding, staff, and time; therefore, the research may be tossed dismissed. If
this occurs, valuable treatments may never be utilized in patient care. Not only will the patients suffer but the staff will not have
the opportunity to learn a new skill. Also, the practitioners may not be willing to implement change regardless of the benefits to
patient care.

Another barrier to introducing newly learned methods for improving treatments or patients' health is the fear of "stepping on
one's toes". New nurses might feel it is not their place to suggest or even tell a superior nurse that newer, more efficient methods
and/or practices are available.

The perceived threat to clinical freedom offered by evidence-based practice is neither logical nor surprising. Resistance to change
and to authority is part of human nature. When we make decisions based upon good quality information we are inconsistent and
biased. Human nature offers many challenges to evidence-based practice. Can we do a better job of promoting evidence-based
practice? And even if we find and use the evidence, will we make consistent unbiased decisions?

Even if clinicians do act consistently it is possible that their decisions are consistently biased. People put different values on gains
and losses. Tversky and Kahneman gave people the two identical problems (with the same probabilities of life and death
outcomes - see fig 1) but framed the outcome choices as either lives saved or as deaths.10 Most people wanted to avoid taking
risks with gains which could be safeguarded, but would take risks with losses which might be avoided; this is a framing effect. If
people are given identical options but different words are used to emphasize a gain rather than a loss, then a different response is
given by a large proportion of the population under study. Such a change in response appears to be inconsistent. (Health
Education Authority. Oral Health Effectiveness Review No 7. Effectiveness of oral health promotion. London: HEA, 1998).