A,E. C. S.

MAARUTI COLLEGE OF NURSING

BANGALORE

ANP SEMINAR ON,

EVIDENCE BASED PRACTICE

SUBMITTED TO,
Mrs. RADHA DEVI
LECTURER

SUBMITTED BY,
Mrs.RAJI
VARGHESE
1 YR M.Sc
NURSING

ROLE OF EVIDENCE BASED NURSING PRACTICE - BEST PRACTICE

Introduction

Nursing practice based on scientific evidence posses a unique challenge for today’s nurse. It is
rather recent phenomenon. During the 1970s, research utilization becomes an important issue
and focus to translate research findings into practice. Whereas the term evidence based practice
(EBP) applied to nursing to facilitate the highest quantity of care and the best client outcomes
was from 1988 since the journal Evidence based nursing established to advanced EBNP.

The term evidence based practice originated in the field of medicine. Most people credit the
beginning of the movement toward evidence based practice to “ ARCHIE COCHRANE” (1909-
1988), a British Medical researcher and epidemiologist. Cochrane suggested that because health
care resources would always be limited, resources that are available should be used to provide
the health care shown to be most effective. He stressed the importance of using evidence from
randomized controlled trials also called the randomized clinical trials.

In India, the term evidence based nursing practice or health care is a relatively new term. It may
means different meaning to different people. Evidence based practice is a goal for the nursing
profession and for each practicing nurse. Currently many nursing intervention are evidenced
based, or supported by research knowledge generated from several quality studies. EBP of
nursing and medicine has expanded extensively over the last five years. Research knowledge is
generated everyday that needs that needs to be critiqued and synthesis to determine the best
evidence used.

WHAT IS EVIDENCE?

The concept of incorporating research evidence into decisions seems simple, but complexities
arise as soon as we start to consider what is meant by “research evidence”. Evidence refers to
“judicious use of current best judgments in practice.

Evidence Based Practice

Evidence-based practice (EBP) is an approach to health care wherein health professionals use the
best evidence possible, i.e. the most appropriate information available, to make clinical decisions
for individual patients.

Definition of evidence based practice

1. Evidence-based practice integrates the providers’ clinical expertise with the best external
clinical evidence” (Sackett et al 2000)

2. Evidence based practice as “ an approach to professional nursing practice that bases relevant
decisions and practice strategies on best available, evidence, including research findings and
as appropriate , other credible verifiable facts and information.” (Stetler, 2001)
3. The evidence used in making clinical decision may include the best available research,
consensus of clinical experts, clinical expertise of the health care providers and the patient
values and expectation. (Sheldon et al,1998)

Evidence-based nursing practice

1. A process of finding, appraising and applying scientific evidence to the treatment and
management of health care.
2. Evidenced based nursing practice represents a systematic search for the knowledge needed
to provide high quality care. It is one of the requirements for professionalism and supplies a
foundation for accountability.

Types of Practice

1. Research-based Practice
2. Best Practice
3. Knowledge-based Practice
4. Evidence-based Practice

1. Research-based Practice

Application of findings from a study(s) that:

• is well-designed
• is of acceptable quality
• has meaningful results
• has findings that are generalizable
• can or has been replicated

2. Best Practice
• Practice defined by regulatory, accreditation agencies, and professional standards
• Practice that may not have compelling evidence or research to support it
• Practice that has tradition and an extensive documentation of proven effectiveness
• Practice based on sound rationales and“good clinical sense”
Examples:
• assess pain regularly
• inform patients of their rights to adequate pain control

3. Knowledge-based Practice
Derived from information from:
• Textbooks
• Educators
• Educational programs
• Experience

4. Evidence-Based Practice
 Involves life-long, self-directed, problem-based learning
 Involves exploring the relationship between clinical reasoning and research
evidence
 Involves practice

GOALS OF EBP

 Provide practicing nurses with evidence-based data.

 Resolve problems in the clinical setting.
 Achieve excellence in care delivery.
 Introduce innovation.
 Reduce variations in nursing care.
 Assists with efficient and effective decision-making.

 Using best evidence to implement the regulation of nurses.

 Resolve regulatory problems.
 Achieve excellence in regulation.
 Introduce regulatory innovation.

Hierarchy of evidence based practice:

In nursing ,Stetler et al(1998)have suggested a heirarchy of level evidence for use in practice:

1. The first level is meta analysis studies that provide evidence from multiple studies.
2. The second level is the single experimental studies.
3. The third level of evidence is quasi experimental studies, such as cohort studies and time-
series studies.
4. The fourth level of evidence Non-experimental studies such as comparative and
correlation studies.
5. Program evaluation research and quality improvement projects provide the fifth level of
evidence.
6. Finally, opinions of authorities or experts is the sixth level of evidence.

The Hierarchy of Evidence

Evidence comes in many forms and varies in quality. Within research, there is a recognised
hierarchy of reliability which can be used as a guide when considering the effectiveness of
evidence. This is outlined in the table below:

Level Description Example

 Strong evidence from at least
one systematic review of well Meta-analyses
One
designed randomized controlled The Cochrane Collaboration
trials (RCTS)

Evidence from at least one properly designed RCT Articles published in peer-
Two
of appropriate size reviewed journals

Evidence from well designed trials without

Articles published in peer-
Three randomization: cohort, time series or matched
reviewed journals
case controlled studies

Evidence from well designed non-experimental

Articles published in peer-
Four studies from more than one centre or research
reviewed journals
group

Opinions from respected authorities, based on NICE guidelines

Five clinical evidence, descriptive studies or reports Evidence-based local
from committees procedures and care pathways

Nursing colleagues or members

Six Views of colleagues/peers
of the multidisciplinary team

Models for evidence based practice

A number of different of evidence based practice and research utilisation have developed. These
models offer frameworks for understanding the EBP process for desingning and implementing an
EBP project in a practice setting. Some models focus on the use of research from the perspective
of individual clinicians(e.g., the Stetler Model), whereas some focus on institutional EBP
efforts(e.g., the Iowa Model).

Steler model applied to evidence based practice:

Preparation Validation Comparative Translation / Evaluation

evaluation application
This phase requires Utilization – This involved This phase Evaluation of the
that there be clarity focused synthesis from focuses on how application is
of purpose and critique is multiple studies. to implement the done. There is a
potential used. The The nurse synthesized deliberate,
significance. The findings are identifies, findings. This systematic, and
nurse is reminded to appraised organized, and may include continuous
consider external rather than integrates development of evaluation
factors that the study information plans for formal process with the
influence itself. Critical across multiple organization feedback to users
application and to thinking is studies. The change. It will and refinement in
consider internal applied. utilization include evidence the
factors (personal) decision will be based strategies implementation.
that may influence to use, to for dissemination
objectivity. Relevant consider use, or of translated
information should to not use. The findings and
be identified decision to facilitation of
consider use behavioral
might result in changes in the
modification. users.
The Iowa Model of
Evidence Based Practice to Promote Quality Care

Problem Focused Triggers Knowledge Focused

1. Risk Management Data Triggers
2. Process Improvement 1. New Research or Other
Data Literature
3. Internal/External 2. National Agencies or
Benchmarking Data Organizational
4. Financial Data Standards & Guidelines
5. Identification of Clinical 3. Philosophies of Care
Conside Is this Topic
Problem No 4. Questions from
r a Priority
Institutional
Other For the
Standards Committee
Triggers Organization?
Y = a decision Point
Form a esTeam

Assemble Relevant Research & Related Literature

Critique & Synthesize Research for Use in Practice

Is there a sufficient
research based?
yes No
 Pilot the Change in Practice Base Practice on Other
1. Select Outcomes to be Achieved Types of Evidence
2. Collect Baseline Data 1. Case Reports
3. Design Evidence-Based 2. Expert Opinion
Practice (EBP) Guideline(s) 3. Scientific Principles
4. Implement EBP on Pilot Units 4. Theory
5. Evaluate Process & Outcomes
6. Modify the Practice Guideline Conduct
Research

Is change appropriate
for adoption in
practice?
Continue to evaluate
Institute the
quality of care and
change in
new knowledge
practice

Monitor & analyze structure,

process, &outcomes data:
environment, staff, cost, patient
Disseminate
& family.
results

Use of evidence in nursing practice:

There is an always limited health care resource. Those available limited resources should be used
to provide the most effective results.

 Krugman (2005) has asserted that EBNP is for ensuring optional patient outcomes.
 Evidence based practice is important in nursing to expand the scientific body of
knowledge, to maintain specific accountability to the public, to document nursing
 contribution to health care delivery , and to provide the bases for sound clinical decision
making in client care.
 The role of research findings in improving quality of patient care also could be
considered as a part of need for evidence based nursing practice.
 Diers (1979) identifies the role of nursing research as
 Nursing research to improve client care.
 To develop theory and the body of scientific knowledge. It is one of the
requirements for professionalism and supplies a foundation for accountability.
 A research problem becomes a nursing problem when nurses have access to and
control over the phenomena being studied.
 The information revolution that is transforming the present and shaping the future
has made reading, understanding, and using nursing research as fundamental to
professional practice as the knowledge of asepsis, application of the nursing
process and communication skills.

STEPS OF EVIDENCE BASED PRACTICE

The 5 steps of EBN

Step 1: Select a Topic

The first step is to select a topic. Ideas come from different sources but are categorized in two
areas:
1. Problem-focused triggers and
2. Knowledge focused trigger.
1. 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.
2. 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.
Step 2: Form a Team

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 grassroots members. It is also important to
consider interdisciplinary 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. 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.

Step 3: 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.

Step 4: 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 initial question. It’s 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.

Step 5: Decision to Change the Practice

When the studies are completed, and the EBP outcomes are evaluated, a decision is reached on
whether to use this in practice. Several factors are put into consideration. First the relevance of
evidence for practice and second the consistency in findings across studies and/or guidelines; a
significant number of studies and/or EBP guidelines with sample characteristics similar to those
to which the findings will be used; consistency among evidence from research and other
nonresearch evidence; feasibility for use in practice; the risk/benefit ratio risk (risk of
harm;potential benefit for the patient). Putting together results from other studies may end up
supporting what is currently in practice rather than changing practice. Using a focus group is a
great way to provide discussion about the EBP standard and to point out key areas that may
cause problems during the implementation phase.

Difference between Research based practice (RBP) and evidence based practice(EBP)
RBP & EBP are often used interchangeably, but they are not synonymous.EBP is a more general
term encompassing evidence broader than research findings and thus includes RBP.EBP includes
the preferences and values of the patient & family in the process.

Research based practice is a term that refers to the systematic application of research
findings into practice. This may involve the utilization of findings from individual
research studies and or multiple studies. The patient values and expectation are generally
not considered unless there are focus of a particular study. EBP has a broader focus than
research utilization and is an essential requirement of health care agencies. Evidence
based practice guidelines from meta analysis, integrative reviews of research and
extensive clinical trials; supported by consensus from recognized national experts; and
affirmed by outcomes obtained by clinician
A new concept in the area of EBP is “care bundle”.care bundles groups togethers
several evidenced- based practices. The belief behind care bundle is that when several
practices or interventions are used in combination or as a cluster, they have a greater
effect on outcomes than if just one intervention was used.

Example : Crudel et al evaluated the impact of the four protocols in the ventilator care
bundle: Prophylaxis against peptic ulceration , prophylaxis against deep vein thrombosis,
daily cessation of sedation , and elevation of the patient’s head and chest to at least 30
degreees.mens length of stay was reduced and ventilator days were reduced.

Limitations of Evidence based practice/inhibitor of research utilization.

 Nurses deal with the psychological, social, cultural and spiritual aspects of their
patients/clients. Often these issues do not land themselves to randomized clinical trials.
 Nurses may be feel threatened when long established practices are questioned.
 Nurses use of point of care, online evidenced system remain unanswered.
 Lack of the necessary skills to identify the latest evidence .
 The nurses perceived lack of authority to change client care procedures
 Insufficient time to implement new ideas
 Lack of support and cooperation from physicians, administrators and other staff.
 Inadequate facilities for implementation
 Lack of time to read.
  Other inhibitors are characteristic of the research reports;these reports are perceived as
difficult to read and understand, particularly when statistical information is reported.often
nurses are not aware of research that has been done.

Facilitators of research ulitilization

The factors facilitating research utilization are those that provide nurse with information about
research development to be able to integrate research as a part of day today practice, nurses must
work to overcome the inhibitors and perpetuate the facilitator of research utilization.

Key strategies for success follows:

 Nurses must develop a positive attitude toward research utilization, viewing it as a

tool to attain clinical excellence.
 Nursing administrations need to provide time, facilities, equipment, and support
personnel needed for research utilization activities.
 Administration of hospitals that is conducive to research based innovation.
 Haller ,Reynolds, and Horsley formulate criteria for utilization of research in nursing
practice. These criteria are:
o Replication: the criteria for of replication require that the results of a study be
replicated a number of times before its findings are accepted as credible and
applicable to practice.
o Scientific merit: the scientific merit of a study is probably the single most
important criterion in judging its readiness for application in practice.
o Risk: the degree of risk involved in using the findings of a study is another
criterion to be considered. Nursing interventions that have been found effective
through research may be readily implemented if they carry little risk.
o Clinical merit: the criterion of clinical merit evaluates the degree to which
research findings have the potential to solve an existing problem in the clinical
setting.
o Clinical control: clinical control refers to the degree to which nurses are in
control of the circumstances related to the implementation and evaluation of the
research based innovation.
o Feasibility: the criterion of feasibility is defined as the degree to which resources
time, personnel, expertise, equipment are available to implement the innovation.
for example , the introduction of a new intervention may require the ordering and
purchasing of equipment or supplies and in-service training for nursing staff.
o Cost: cost is always a vital consideration. Cost is closely related to feasibility. A
cost benefit analysis would be important in order to weigh the costs against the
benefits of implementing a new intervention.
 o Potential for clinical evaluation: potential for clinical evaluation pertains to the
degree to which the variables in the original research base can be evaluated by
nurse in the clinical setting.

ISSUE PRESENT WITHIN THE PRACTICE SETTINGS:

Clinical nursing issues that must be addressed by nurse educators include time factors, access to
information and resources, nurses’ research knowledge and skills, and the current nursing
culture.
1. Time Factors
One of the major issues present in clinical practice settings is time constraints. Nurses
feel they are too busy to take part in evidence-based nursing activities. Nursing’s
worth continues to be measured in tasks rather than the critical thinking being done
by nurses.
2. Access to Information and Resources
Another issue present within clinical settings is that registered nurses may not have the
appropriate access to current information and the resources to support the search for new
knowledge An evidence-based nursing approach can become a reality only if registered
nurses have access to libraries near clinical settings, current research journals and research
resources, and the Internet for use in clinical practice .

3. Nurses’ Research Knowledge, Skills, and Learning Opportunities

Clinical registered nurses may also require additional knowledge and skills to
critically appraise the findings from research and its affect on their practice. The
literature provides examples where additional learning such as increased knowledge
about available evidence, the skills to search for and critique research, the ability to
read, interpret, and translate research into practice, and the skills to evaluate the
strength of the evidence is necessary
4. Current Nursing Culture

In many clinical practice settings, information-seeking behaviors and use of current

evidence is neither valued nor supported as part of nursing culture. This includes the
lack of collegial and organizational support from physicians and fellow registered
nurses at the time evidence-based changes to nursing practice are suggested or imple-
mented. This nursing culture is probably the most significant issue present within
clinical practice settings that has an effect on overall patient outcomes.

Responsibility for evidence based nursing practice:

Professionals association, regulatory bodies for nurses specialty groups for nurses individual
nurse schools of nursing, organization employing nurses , accreditation councils, government,
health information agencies and nurse researcher share the responsibility of facilitating evidence
based decision making and evidence based practice . These responsibility extend to identifying
the factors and barriers and enhancing the factors within organization structures that promotes
and facilitate evidence based practice.

Independent nurse:

 Position themselves to provide optimal care by acquiring competencies, for evidence

based nursing practice.
 Generate researchable question and communicate them to the researcher; and
 Evaluate, use and promote evidence based nursing practice.

Professional, regulatory and nursing specialty association

 Use the best available evidence as a basis for standards and guidelines; and
 Lobby government for funding to support nursing research and information system
nursing data.

Researcher

 Identify knowledge gaps and use them to established research priorities in conjunction
with nursing practitioner ;
 Generate high quality evidence through research;
 Engage in effective knowledge transfer ,translation and exchange to communicate
relevant findings of the result of research to those who require the information; and
 Develop and carry out ongoing research to explore the concepts, of evidence
dissemination and utilization in nursing practice.

Educators and educational institution:

 Ensure that those graduating from basic and continuing nursing education programs
acquire competencies to provide evidence based nursing.
 Use and develop evidence based curricula.; and
 Promote a spirit of inquiry, critical thinking and a philosophy of lifelong learning.

Government:

 Support development of health information system that support evidence based nursing
practice.
 Support health information institution; and
 Provide adequate funding to support nursing research in all its phases.

Roles of nurse in evidence based practice:

 The responsibility for assuming various activities and roles is related to level of
education. The development and utilization evidence based depends upon the interaction
between researcher and clinician.
  Nurses in clinical practice identify the problems in need of investigation and collaborate
with nurse researchers, who design studies to address the problems identified and analyze
the data.
 Nurse in the clinician determine the appropriate application of those findings to practice.
 Nurses support the research protocol and uphold the scientific rigor of the study by
carefully maintaining the research protocol. At the same time, it is the right of the nurse
to be informed of the purpose of the study and to understand the protocol.

 Clinical nurse educators play an influential role in the development of orientation

programs for new nursing staff and have the opportunity to promote best evidence-based
nursing practices.

 Clinical nurse educators can provide support by setting up computer links to local library
databases, providing relevant systematic reviews that summarize findings, circulating
valid and reliable research literature within clinical settings, and introducing nurses to the
Cochrane Library and the journal Evidence-Based Nursing encouraged an inquiring,
reflective approach to nursing practice by taking time to ask questions about the validity
of current practices and possible alternatives.
 Clinical nurse educators have access to programs that can assist nurses in analyzing
current evidence. Professional development courses on evidence-based nursing and
research inquiry courses can assist nurses in critically examining evidence directly related
to current clinical issues also strongly supports journal clubs as a way to facilitate inquiry
and educate nurses in determining what evidence meets the criteria for practice.
 Clinical nurse educators have the opportunity to become facilitative change towards
evidence based nursing practice. Facilitators of evidence-based nursing are expected to
enable individuals and teams to review their habits and ways of thinking and to work
together toward positive change

Conclusion

There is signs that evidenced based practice movement is beginning to develop a more
comprehensive view of evidence and there are research initiatives attempting to construct
approaches to assess and synthesis the result of interpretive and critical research so that these
form of evidence can become an integral parts of systemic review and thus forms practice . such
an approach to evidence will help us , as practitioner , to performs well in our practice, using our
professional judgment ,and appropriate evidence.
Bibliography

1. Blais Kathleen Koernig, et al, “Professional nursing practice- concept and perspectives ,
5th edition, Pearson Education, New Delhi,2007
2. Baler Majorie, et al, “ The practice of nursing Research,conduct , critique, and
utilization”,Elsevier,New Delhi, 2007.
3. Paramonczyk, A. (2005). Barriers to implementing research in clinical practice.
Canadian Nurse, 101(3), 12-15.
4. Pravikoff, D. S., Pierce, S., & Tanner, A. (2003). Are nurses ready for evidence-based
practice? American Journal of Nursing, 103(5), 95-96.
5. Process to Practice Bracken Health Sciences Library (adapted from a presentation of
Dr. Norma MacIntyreSchool of Rehabilitation Therapy, Queen’s University)
6. Journal : Nightingale nursing times, vol, 4, No 12, march 2009.