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This offering expires in 2 years: February 4, 2010
The goal of this continuing education offering is to provide nurses with current information on evidence-based practice and best practice in nursing. After reading this article, you will be able to:
1. Define evidence-based practice and best practice.
2. Discuss the current status of evidence-based practice in the U.S. and Canada.
3. Actively support the importance of future collaboration between the U.S. and other countries.
You can earn 1 contact hour of continuing education credit in three ways: 1) For im-mediate results and certificate, go to www.advanceweb.com/nurses. Grade and certificate are available immediately after taking the online test. 2) Send this answer sheet (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.
Merion Publications Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 008-0-07), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).
Nurses in all clinical settings are being called upon to identify and incorporate evidence-based practice (EBP) into their clinical practice sites. But what do the terms EBP and best practice mean, and how should the information be used to improve patient outcomes? Are best-practice standards limited to the U.S. or are they based on evidence practiced in other countries?
The interchange of terms can be confusing to the practitioner who is seeking to understand and practice using evidence as a basis for decision-making or to apply this information to nursing interventions.
Holleman, et al. say a number of definitions of EBP exist with many having a similar core. In the article, the authors state, "EBP combines information about the results of well-designed research, clinical expertise, patient concerns and patient preferences."1
Best practice is a term often used interchangeably with EBP, but actually is a subset of EBP. It is the process of shaping clinical practice based on scientific inquiry.2
EBP is part of a larger national and international interdisciplinary movement that seeks to improve patient care and patient outcomes. In the early 1990s, evidence-based medicine (EBM) was introduced as a framework for research and practice as a way to enable physicians to effectively access clinical research. EBM eventually evolved into EBP as more related specialties such as physical therapy, nursing and occupational therapy embraced this concept. While this concept of basing practice on evidence is widespread among the other health professions, each is at a different place in developing and implementing the model within their specific disciplines.
EBP combines information about the results of well-designed research, clinical expertise, patient concerns and patient preferences. EBP serves as the foundation in the form of a set of values, sources and criteria upon which to gain access to, select and critique knowledge for nursing practice.
For nurse clinicians and nurse administrators, best practice is more often the term used to describe the organizational use of evidence to improve practice. Within the clinical setting, best practice is associated with the use of clinical guidelines and disease management.
Best practice also serves as a way of targeting interventions to reach desired patient outcomes, while controlling or even decreasing resource consumption. Although the philosophy and framework underlying best practice has a broader basis, evidence is key to accomplishing the goals desired in implementing best practices.
Many nurses appreciate and value the corpus of evidence needed to care for clients from diverse backgrounds and in a variety of settings, and the information necessary to improve health outcomes and clinical practice. They are familiar with the importance of synthesizing knowledge from research; pathophysiology; data analyzed from the medical records; quality improvement and risk data; international, national and local practice standards; cost-effectiveness analysis; benchmarking; patient preferences; and clinical expertise.
Nurses are able to embrace the next step to using evidence to enhance clinical practice with organizational support and education.
The process involved in developing evidence-based strategies is critically important in today's clinical settings because of their potential to save both nursing time and healthcare dollars. Therefore, if evidence is to be meaningful and successfully translated into practice by individuals and practitioners, best practice must be considered on an organizational level and through ongoing quality monitoring to promote continual improvement.
From this, we see best practice is not a specific practice; rather, it is a level of agreement about research-based knowledge and an integrative process of embedding this knowledge into the organization and delivery of healthcare. It is important to remember nursing is a part of the EBP movement and not separate from other health professionals, as it uses information from a variety of settings.
Commitment to Evidence
The commitment to using evidence as a basis for healthcare practice is both national and international. The U.S. commitment to EBP can be found in the establishment of the Agency for Healthcare Research and Quality (AHRQ), formerly the Agency for Health Care Policy and Research (AHCPR), an agency within the Department of Health and Human Services.
AHRQ sponsors and conducts research that provides evidence-based information on healthcare outcomes; quality; and cost, use and access. The information helps healthcare decision-makers - patients and clinicians, health system leaders, purchasers and policymakers - make more informed decisions and improve the quality of healthcare services.
In 1997, AHCPR, now known as the AHRQ, launched its initiative to promote EBP in everyday care throughthe establishment of 12 EBP centers. These centers develop evidence reports and technology assessments on topics relevant to clinical, social science/behavioral, economic, and other healthcare organization and delivery issues.
hrough this program, AHRQ became a "science partner" with private and public organizations in their efforts to improve the quality, effectiveness and appropriateness of healthcare by synthesizing the evidence and facilitating the translation of evidence-based research findings.
Another example of the U.S. government's commitment to this effort is the International Journal for Quality in Health Care, sponsored by the AHRQ, which is devoted to the Health Care Quality Indicators Project. The U.S. Preventive Services Task Force compiled guidelines for evidence quality (see Table 1).3
In Canada, a Canadian Best Practices System has been developed by the Centre for Chronic Disease Prevention and Control within the Public Health Agency of Canada. Developmental work with stakeholders, beginning in July 2001, identified the need to invest in building capacity among those working in the area of chronic disease prevention by providing relevant and easily accessed best practice information.
This national system has evolved to address three purposes:
facilitate knowledge exchange about best practice among decision-makers in research, policy development and practice;
build consensus about best-practice approaches; and
provide a centralized access point for these approaches and coordinate activities to increase the uptake and utilization of best-practice approaches.
The long-term goal of the Canadian Best Practices System, found within the Canadian government's Observatory of Best Practices is "to improve health, reduce the burden of chronic disease and reduce costs to the healthcare system." Canadians are building on these efforts by developing other projects in collaboration with other community partners that support the application of best practice.
The above descriptions serve to show how important this concept is within the U.S. and Canadian governments. This focus on using evidence beyond "borders" supports the important evolutionary and collaborative process necessary to broaden our understanding and integration of information developed by others.
Looking for Evidence
A good foundation for improving patient health outcomes within the hospital setting is the established process of identifying the information, practice strategies and desired patient outcomes. Using evidence to inform practice strategies also can serve to advance the development of nursing practice autonomy and professionalism.
Nurses will want to apply all sources of "evidence" related to their practice area to develop, implement and evaluate nursing practice strategies. Where can nurses look for this evidence? Can information be used from nursing colleagues in other countries? Is all evidence the same?
There are different categories of evidence that shape practice, such as randomized clinical trials, research, expert knowledge, theory and consumer preferences. The nurse will want to understand the basis of the evidence used to support outcomes or recommendations. Also, the nurse needs to be aware of current issues that shape the definitions of evidence both nationally and internationally.
Kronenfeld, in his review article for librarians, noted the EBP movement in nursing is more advanced in Australia, Canada and Britain.4 He makes this statement based on the number of centers for evidence-based nursing and EBP resources produced there. This article points out the reason for the difference is because the roots of EBM are in these countries and have been nourished by the centralization and support of national health services.
It is important for professional nursing organizations in the U.S. to use the same terminology on their Web sites or in their journals to make it easier for nurses to identify and use current information related to EBP.
On the other hand, information on best practice can be found in a variety of places. For example, the Joanna Briggs Institute provides extensive, free-access information about evidence-based healthcare on its Web site. Other sources include the electronic professional journals accessed through Ovid, PubMed or CINAHL; your professional nursing organization; and private and government-generated information and databases. For a list of resources, see Table 2.
When examining the development and application of EBP in nursing, future trends will call for extending what we do and know beyond the borders of North America. Transcontinental nursing partnerships will help our profession become more astute and responsive to the unique dimensions of our practice given the commonalities in health concerns across the globe.
Much can be learned as we share knowledge, skills and research that transcend geographic boundaries and include diverse cultural groups. It is important to examine beliefs, values and cultural practices of people of other countries to understand how these beliefs may affect their health. This approach can facilitate the development of culturally sensitive nursing interventions that will contribute to the health and well-being of people throughout the world.
The concept of best practice is ever-evolving, given the state of advances in information technology and communications, as well as international travel. Partnerships between nurses around the globe would benefit from sharing assessment techniques, intervention strategies and care outcomes that could promote evidence-based nursing practice.
Moreover, nurses in different contexts need to conduct comparative research. Findings from these studies can further validate the effectiveness of interventions cross-culturally, particularly when using community development approaches and sociocultural perspectives.
Equally important is to recognize the numerous areas in which evidence does not exist to support current nursing practices. International collaborations can unite to design and conduct studies to answer high-priority, compelling clinical questions that can improve decision-making and interventions in nursing practice.
Who knows where the future will take us? We may not be able to predict it; however, we can influence it and create animpact on our profession. To not learn from experiences beyond our borders would thwart our ability to bring new ideas and thinking to our own country while sharing our own thinking and observations withother nations. Looking beyond our own backyard will help shape how we ride the waves of change of best practice in our profession.
1. Holleman, G., et al. (2006). Promotion of evidence-based practice by professional nursing associations: Literature review. Journal of Advanced Nursing, 53(6), 702-709.
2. Holmes, D., Perron, A., & O'Byrne, P. (2006). Evidence, virulence and the disappearance of nursing knowledge: A critique of the evidence-based dogma. Worldviews on Evidence-Based Nursing, 3(3), 95-102.
3. U.S. Preventive Services Task Force. (2007). Guide to clinical preventive services, 2007. Retrieved Jan. 5, 2008 from the World Wide Web: www.ahrq.gov/clinic/pocketgd.htm
4. Kronenfeld, M., et al. (2007). Review for librarians of evidence based practice in nursing and the allied health professions in the United States. Journal of the Medical Library Association, 95(4), 394-407.
Public Health Agency of Canada. The Canadian Best Practices System. Retrieved Jan. 27, 2008 from the World Wide Web: www.cbpp-pcpe.phac-aspc.gc.ca/system/index_e.cfm
Public Health Agency of Canada. Centre for Chronic Disease Prevention and Control. Retrieved Jan. 27, 2008 from the World Wide Web: www.phac-aspc.gc.ca/ccdpc-cpcmc/index_e.html
Robinson, J.G. (2007). Utilizing best practice in dementia care. Canadian Nursing Home, 18(1), 22.
Roberta Waite is an assistant professor at Drexel University College of Nursing and Health Professions, Philadelphia, and Priscilla Killian is an assistant professor at MCP Hahnemann University, College of Nursing and Health Professions, Philadelphia.