Evidence -Based Practice

An Independent Study Short Course for Medical-Surgical Nurses

This module was developed by theClinical Practice Committee of the

Academy of Medical-Surgical Nurses,in accordance with

the 2010 strategic plan. (Revised February 2013)

Why is EBP relevant to 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

� Improved Patient Outcomes

� Decreased unnecessary procedures & complications

� Greater provider job satisfaction

� Third party reimbursement

� Effective nursing practice requires information , judgment, and skill

� EBP empowers nurses and expands their skills

The 2011 report by the Institute of Medicine (The Future of Nursing: Leading Change, Advancing Health) recommends that all health care professionals possess certain skills and competencies in order to enhance patient care quality and safety.

Competencies necessary for continuous improvement of the quality and safety of health care systems—patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.

- IOM, 2011

Purpose of Module• To provide an overview of evidence-based

practice (EBP), one of the five competencies that all health care professionals should possess (Institute of Medicine, 2011).– Where and how to find the best possible

sources of evidence for your practice.– How to formulate clear clinical questions.– How to search for relevant answers to the

questions.– Determine when and how to integrate these

new findings into practice.

Objectives

At the end of this module, you will be able to:

• Recognize evidence-based practice (EBP) as one of five core competencies all health professionals should possess regardless of their title or discipline.

• Define EBP.

Objectives

• Identify two characteristics differentiating research utilization and EBP in nursing.

• List three components of EBP.

• Describe the nurse’s role in EBP.• Describe the 5 steps of the EBP process.

Objectives

• Write a researchable clinical question.

• Identify resources for developing relevant answers to the question.

• Use clinical judgment and the 5-step process for determining when and how to integrate findings into practice.

Evidence -Based Practiceis

knowing that what we do is the best practice.

How do we know in nursing?

• Tradition• Authority• Borrowing• Trial and error• Personal experience• Role modeling and mentorship• Intuition and reasoning• Nursing research

Types of Nursing Research

• DescribeIdentify and understand phenomena, issues

• ExplainClarify relationships

• PredictEstimate the probability of outcome

• ControlManipulate the situation to get desired outcomes

Research -Practice Gap

Much of what is known from research has not been applied in practice.

This is known as

Research -Practice Gap

During the 1980s and 1990s, nursing emphasized bridging this research-practice gap through the development of research utilization (RU) projects.

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).

Research -Practice Gap

Even though guidelines and knowledge have been disseminated, the overall effect on clinical practice and patient outcomes is unclear.

Research -Practice Gap

• 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.

EBP is …• 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.

(Stevens, 2004)

EBP is …

� “ A problem-solving approach to clinical decision making within a health-care organization that integrates the best available scientific evidence with the best experiential (patient and practitioner) evidence.”

(Johns Hopkins Nursing Evidence-Based Practice Model and Guidelines, 2007)

Goals of EBP

• Provide practicing nurses with the best evidence-based data

• Resolve problems in the clinical setting• Achieve excellence in care delivery• Reduce variations in nursing care• Promote effective nursing interventions• Assist with efficient and effective decision-

making

Key Components of EBP

Decisions about care are based on:A. Research evidence.B. Clinical expertise, judicious use.C. Patient values and circumstances.

(Institute of Medicine, 2003)

A. Research Evidence

• Randomized controlled trials• Laboratory experiments• Clinical trials• Epidemiological research• Outcomes research• Qualitative research• Expert practice knowledge, inductive

reasoning

B. Clinical Expertise

• Knowledge gained from practice over time

• Inductive reasoning

C. Patient Values, Circumstances

• Unique preferences

• Concerns• Expectations

• Financial resources• Social supports

“In nursing, best research evidence refers to methodologically sound, clinically relevant research about the effectiveness and safety of nursing interventions, the accuracy and precision of nursing assessment measures, the power of prognostic markers, the strength of causal relationships, the cost-effectiveness of nursing interventions, and the meaning of illness or patient experiences.”

- Evidence-Based Nursing: A Guide to Clinical Practice, 2005

Nurse’s Role in EBPAmerican Nurses Association Standards of

Professional Nursing Practice� “The registered nurse participates, as

appropriate to education level and position, in the formulation of evidence-based practice through research.”

� “The registered nurse utilizes current evidence-based nursing knowledge, including research findings, to guide practice.”

American Nurses Association (2010). Nursing scope and standards of practice.

Nurse’s Role in EBP

AMSN Standards of Professional Performance

• “STANDARD VII. RESEARCH: Medical-surgical nurses use research findings in practice.”

Academy of Medical-Surgical Nurses (2012). Scope and Standards of Medical-Surgical Nursing Practice, 5th Edition.

Nurse’s Role in EBP

– Generate important questions– Know basis for nursing practice– Expect that evidence is the foundation of practice– Participate in EBP projects – Disseminate project findings in various forums– Collaborate with the healthcare team to provide

quality care

EBP Process

There are 5 steps in judging the evidence and determining the circumstances and patient values for guiding application.

EBP Process

1. Assess practice (formulate question)What isn’t working? What do you want to know about?

2. Decide (evidence review)What resources are available and are they any good? What has worked in other places? How can you change your practice?

3. Plan (develop a plan based on findings)Make a plan to change care based on relevant, applicable information. Let others help.

4. Intervene (take action to review process or change)Implement revised caregiving protocol in clinical unit.

5. Evaluate (care improved or modify and again intervene)How well is that working for you?

The EBP Process Steps are:

Additional Readings

Ackley, B.J., Swan, B.A., Ladwig, G.B., Tucker, S.J. (2007). Evidenced-Based Nursing Care Guidelines: Medical-Surgical Interventions, 1st ed.

Aherns, T. (2005). Evidence-based practice: Priorities and implementation strategies. AACN Clinical Issues. 16(1), 36-42.

Cullen, L., Greiner, J., Greiner, J., Bombei, C., & Comried, L. (2005). Excellence in evidence-based practice: Organizational and unit exemplars. Critical Care Nursing Clinics of North America, 17, 127-142.

Greiner, A., & Knebel, E., (Eds.). (2003). Health professions education: A bridge to quality. Washington, DC: The National Academies Press.

Stevens, K.R., & Staley, J.M. (2006). The Quality Chasm reports, evidence-based practice, and nursing’s response to improve healthcare. Nursing Outlook, 54(2), 94-101.

Titler, M., Kleiber, C., Steelman, V., Goode, C., Rakel, B., Barry-Wlker, J., et. al. (1994). Infusing research into practice to promote quality care. Nursing Research, 43, 307-313.

Titler, M., Kleiber, C., Steelman, V., Rakel, B., Budreau, G., Everett, L., et. al. (2001). The Iowa Model of evidence-based practice to promote quality care. Critical Care Nursing Clinics of North America, 13(4), 497-509.

ReferencesAcademy of Medical-Surgical Nurses.(2012).Scope and Standards of Medical-Surgical Nursing

Practice, 5th Edition. Ackley, B., Ladwig, G. (2008). Evidence-based Nursing Care Guidelines: Medical-Surgical

Interventions, 1st Ed. St Louis, MO, Mosby, Inc.American Nurses Association (2010). Nursing scope and standards of practice. Washington, DC:

author.DiCenso, A., Guyatt, G., & Ciliska, D. (2005). Evidence-Based Nursing: A Guide to Clinical Practice,

1st Ed. St Louis, MO., Mosby.Fineout-Overholt, E., Melnyk, B.M., & Schultz, A. (2005). Transforming health care from the inside

out: Advancing evidence-based practice in the 21st century. Journal of Professional Nursing, 21(6), 335-344.

Johns Hopkins Nursing Evidence-Based Practice Model and Guidelines, (2007), Newhouse, et al. Sigma Theta Tau International Honor Society of Nursing.

Institute of Medicine, (US)Greiner, A. & Knebel, E., (Eds.) (2003) Health Professions Education: A bridge to quality, The National Academies Press, 45-74

Institute of Medicine,(US) National Research Council (2011). The Future of Nursing: Leading Change, Advancing Health. The National Academies Press.

Melnyk, B. & Fineout-Overholt, E. (2005). Evidence-based practice in Nursing & Healthcare: A guide to best practice. Philadelphia: Lippincott Williams & Wilkins

National Patient Safety Goals. (2006). The Joint Commission (formerly JCAHO)Newhouse, R.P., Dearholt, S.L., Poe, S.S., Pugh, L.C., & White, K.M. (2007). Johns Hopkins Nursing

Evidence-Based Practice Model and Guidelines. Sigma Theta Tau International. Patient Safety & Quality—An Evidence-Based handbook for Nurses. AHRQ Publication No. 08-0043.

Retrieved from http://www.ahrq.gov/qual/nurseshdbk/

ReferencesStevens, K.R. (2005). Essential competencies for evidence-based practice in nursing (1st edition). San

Antonio, TX: Academic Center for Evidence-based Practice, The University of Texas Health Science Center at San Antonio

Stevens, K. R. (2004). ACE Star Model of EBP: Knowledge Transformation. Academic Center for Evidence-based Practice. The University of Texas Health Science Center at San Antonio. www.acestar.uthscsa.edu

Titler, M.G. (2008).The evidence for evidence-based practice implementation. In: Hughes, R. ed. Patient Safety & Quality—An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality. http://www.ahrq.gov/qual.nursehdbk/.