Evidence-based practice is an important approach to provide the best quality care to patients and their families. Melnyk and Fineout-Overholt purport that practice based on evidence can help decrease uncertainty commonly experienced by both patients and healthcare professionals in today’s complex healthcare system.1 Further, evidence-based practice improves patient outcomes as compared to traditional practice. Research has shown patients who receive care based on evidence from well-designed studies experience nearly 30 percent better outcomes.2
When defining evidence-based practice in nursing, it is important to distinguish between research utilization, evidence-based practice and research conduct. Research utilization is defined as “the use of research knowledge, often based on a single study in clinical practice.” Although the term “research utilization” often is used interchangeably with evidence-based practice, research utilization is but a part of evidence-based practice.
Evidence-based practice is defined as “a problem-solving approach to practice that involves the conscientious use of current best evidence in making decisions about patient care.”1 Evidence-based practice involves a systematic search for the most relevant evidence, as well as critical appraisal of this evidence to answer a clinical question. Evidence-based practice also considers the clinician’s expertise and patient values and preferences.
Research conduct, or the research process, is the “systematic, logical and empirical inquiry into the possible relationships among particular phenomena to produce verifiable knowledge.”3 It is not uncommon for nurses to confuse the terms “research” and “evidence-based practice.” One perspective is to think of basing one’s practice on existing evidence, or research that has been conducted – that is, utilizing existing literature or evidence on which to base one’s practice. For example, to make a practice change based on the best evidence, one would conduct a literature search and critically appraise the literature.
Once best practices are determined, the practice change can occur. However, in the event that evidence does not exist or is severely limited, a systematic research study is warranted. Conducting research can provide the necessary evidence on which to base nursing practice.
History of Evidence-Based Practice
Archie Cochrane, a British epidemiologist, founded the evidence-based practice movement in which his influence and dedication were key in helping individuals make well-informed decisions about healthcare. Cochrane’s work is most evident in the Cochrane Database of Systematic Reviews, published several years after his death in 1988.4 The database contains highly structured and systematic reviews on a multitude of priority healthcare topics.
In addition, Sigma Theta Tau International provides systematic reviews, entitled Worldviews on Evidence-Based Nursing, to guide nursing practice across many priority topics.5 Tutorials that teach the five steps of evidence-based practice can be found through the Teaching/Learning Resources for Evidence-Based Practice at Middlesex University in London.6 Tutorials on evidence-based practice also can be found through the University of Rochester Medical Center.7
The five key steps in the evidence-based practice process include:
1. formulation of a clinical question;
2. gathering the best evidence to answer the clinical question;
3. critical appraisal of the best evidence;
4. integration of the evidence with the clinician’s own expertise, assessment of the patient’s condition, available healthcare resources, and the patient’s preferences and values to implement a clinical decision; and
5. evaluation of the practice change as a result of implementing the evidence.
While all five steps are critical, the fifth step is one of the most neglected. It is not uncommon for practitioners to implement a practice change based on evidence, but fail to evaluate the effectiveness of the change. Evaluation of the practice change is paramount, as it is imperative nurses and other healthcare professionals know how a particular treatment worked or the effectiveness of clinical decisions.1
Melnyk and Fineout-Overholt advocate asking clinical questions in the PICO format, defined as follows:1
P-Patient Population: A clear description of the patient population and setting is necessary to retrieve the most relevant evidence.
I-Intervention of Interest: The intervention of interest may include, but is not limited to, any treatment, patient perception, exposure or diagnostic test. The more defined the intervention, the more focused the search for evidence will be.
C-Comparison Intervention: The comparison intervention usually is the standard of care compared to a new treatment or procedure. The comparison also can be a true control, such as a placebo.
O-Outcome: Specific identification of the outcome variable facilitates the search for evidence that has investigated the same outcome.
The authors maintain that asking the questions in this format will yield the most relevant and best evidence.1
Barriers to Implementation
Several barriers to implementing evidence-based practice have been identified and are associated with demanding patient loads, in addition to a high volume of journal articles related to various areas of clinical practice.
These barriers include lack of knowledge regarding evidence-based practice strategies; uncertainty or skepticism that evidence-based practice will result in better patient outcomes than traditional care; lack of time and resources to search for and appraise evidence; organizational constraints, such as lack of administrative support; and peer pressure to continue practices because “they have always been done this way.”
In an effort to overcome barriers, Melnyk and Fineout-Overholt have identified facilitators to evidence-based practice: administrative support and time to critically appraise literature for relevant and best evidence, as well as to implement and evaluate findings.1 Mentorship also is a key component in facilitating evidence-based practice.
In addition to these strategies, it is imperative federal agencies, healthcare organizations, health insurers, policy makers and regulatory bodies advocate for and require the use of evidence-based practice. Further, translational research must be established as a high priority by funding agencies.1
The American Nurses Credentialing Center has identified key characteristics of Magnet-recognized hospitals, including incorporation of evidence-based practice throughout the organization. The Magnet Recognition Program, developed by the center, recognizes healthcare organizations that provide the best in nursing care and uphold the tradition of professional nursing practice. The program also provides a mechanism for disseminating successful practices and strategies among nursing systems.
Based on quality indicators and standards of nursing practice as defined in the American Nurses Association’s Scope and Standards for Nurse Administrators, the Magnet designation process includes the appraisal of both qualitative and quantitative factors in nursing.8 Recognizing quality patient care and nursing excellence, the Magnet program provides consumers with a benchmark to measure the quality of care they can expect to receive.
A key characteristic of Magnet-recognized organizations is not only adaptation to regulatory considerations related to the model-of-care delivery, but the incorporation of evidence-based practice throughout the organization. To date, there are 225 Magnet-recognized organizations.9
Creating a Culture
New nurses are expected to implement evidence-based practice. However, this poses a challenge in that new nurses often are focusing on their transition to professional nursing practice and learning various policies and procedures. It is not uncommon for new nurses to focus more on tasks and organizational skills than specific patient needs.10 New nurses frequently experience stress and lack of confidence. Once confidence is gained, new nurses are better able to focus on patient needs, thereby facilitating implementation of evidence-based practice.
Nurse administrators are key leaders in facilitating an evidence-based practice culture within a healthcare facility. They are in the best position to support new nurses in their transition and in evidence-based practice.10
There are many strategies for disseminating evidence: oral presentations, posters, hospital/organization-based and professional committee meetings, journal clubs and publishing.
The first step in preparing for an oral presentation should involve knowledge about the target audience. Issues to consider include educational level and current knowledge level of topic, as well as logistical issues such as number of participants, length of presentation and availability of audiovisual equipment.11
Poster presentations differ in that they allow more time for interaction with colleagues. Posters should be innovative and designed to capture the audience’s attention. Evidence-based practice poster presentations should follow a format, including a statement of the problem, a clinical question, search for evidence, presentation of evidence and clinical practice implications.
When presenting evidence-based practice information at a professional committee meeting, prepare by knowing the target audience and how much time is allotted to share the information. Melnyk and Fineout-Overholt suggest beginning the presentation with an overview of the topic’s relevance to the group.1 The format will ideally follow that of a journal article, starting with the clinical question, search for evidence, critical appraisal of the evidence, implications for practice and evaluation of the practice change.
Journal clubs are steadily evolving and can serve as a vehicle for sharing and learning about best evidence on site. Articles reviewed by journal club participants should generally be studies or evidence reviews that are current, use valid and reliable instrumentation, have appropriate study designs and are appropriate to the clinical practice for the staff.
When publishing an evidence-based practice article in a peer-reviewed journal, follow the instructions specific to the journal. The general format, however, begins with identification of the clinical problem and the clinical question, followed by the search for evidence, presentation of the evidence, critical appraisal of the evidence with implications for future research, application to practice and evaluation of the practice change.
No Longer an Option
Evidence-based practice, a problem-solving approach to using best evidence in making decisions about patient care, is no longer an option for staff nurses. Patient care must be based on evidence for optimal outcomes. Equally important as utilizing evidence as the foundation of quality patient care is the conduct of research to fill the gaps in existing nursing literature.
While nurses can be taught how to implement evidence-based practice at the bedside, ongoing support is necessary from nursing administration. This support is critical in facilitating an evidence-based practice culture within the healthcare facility.
1. Melnyk, B., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare. Philadelphia: Lippincott, Williams and Wilkins.
2. Heater, B., Becker, A., & Olson, R. (1988). Nursing interventions and patient outcomes: A meta-analysis of studies. Nursing Research, 37(5), 303-307.
3. LoBiondo-Wood, G., & Haber, J. (2006). Nursing research: Methods and critical appraisal for evidence-based practice. St. Louis: Mosby Elsevier.
4. The Cochrane Collaboration. The Cochrane Database of Systematic Reviews. Retrieved Nov. 10, 2006 from the World Wide Web: www.cochrane.org
5. Sigma Theta Tau International. Worldviews on evidence-based nursing. Retrieved Nov. 10, 2006 from the World Wide Web: www.nursingsociety.org
6. Research Centre for Transcultural Studies in Health. Teaching/learning resources for evidence-based practice. Retrieved Nov. 10, 2006 from the World Wide Web: www.mdx.ac.uk/www/rctsh/ebp/main.htm
7. University of Rochester Medical Center. Evidence based clinical practice tutorial. Retrieved Dec. 7, 2006 from the World Wide Web: www.urmc.rochester.edu/hslt/miner/resources/evidence_based/EBHC_tutorial1.cfm
8. American Nurses Association. (2003). Scope and standards for nurse administrators. Silver Spring, MD: Author.
9. American Nurses Credentialing Center. Organizational self-assessment for Magnet readiness. Retrieved Nov. 11, 2006 from the World Wide Web: www.nursingworld.org/ancc/magnet/index.html
10. Ferguson, L., & Day, R. (2004). Supporting new nurses in evidence-based practice. Journal of Nursing Administration, 34(11), 490-492.
11. Betz, C., et al. (2005). Evidence-based practice in nursing and healthcare. Philadelphia: Lippincott, Williams and Wilkins.
Solberg, L., et al. (2000). Lessons from experienced guidelines implementers: Attend to many factors and use multiple strategies. Joint Commission Journal on Quality Improvement, 26(4), 171-188.
Crystal Bennett is director of research, outcomes and regulations at Childrens Hospital Los Angeles.