https://en.wikipedia.org/wiki/Evidence-based_nursing
Evidence-based nursing (EBN) is an approach to making quality decisions and providing nursing care based upon personal clinical expertise in combination with the most current, relevant research available on the topic. This approach is using evidence-based practice (EBP) as a foundation. EBN implements the most up to date methods of providing care, which have been proven through appraisal of high quality studies and statistically significant research findings. The goal of EBN is to improve the health and safety of patients while also providing care in a cost-effective manner to improve the outcomes for both the patient and the healthcare system. EBN is a process founded on the collection, interpretation, appraisal, and integration of valid, clinically significant, and applicable research. The evidence used to change practice or make a clinical decision can be separated into seven levels of evidence that differ in type of study and level of quality. To properly implement EBN, the knowledge of the nurse, the patient's preferences, and multiple studies of evidence must all be collaborated and utilized in order to produce an appropriate solution to the task at hand. These skills are taught in modern nursing education and also as a part of professional training.
Evidence-based nursing (EBN) is an approach to making quality decisions and providing nursing care based upon personal clinical expertise in combination with the most current, relevant research available on the topic. This approach is using evidence-based practice (EBP) as a foundation. EBN implements the most up to date methods of providing care, which have been proven through appraisal of high quality studies and statistically significant research findings. The goal of EBN is to improve the health and safety of patients while also providing care in a cost-effective manner to improve the outcomes for both the patient and the healthcare system. EBN is a process founded on the collection, interpretation, appraisal, and integration of valid, clinically significant, and applicable research. The evidence used to change practice or make a clinical decision can be separated into seven levels of evidence that differ in type of study and level of quality. To properly implement EBN, the knowledge of the nurse, the patient's preferences, and multiple studies of evidence must all be collaborated and utilized in order to produce an appropriate solution to the task at hand. These skills are taught in modern nursing education and also as a part of professional training.
The 7 Steps of EBP
Cultivate Spirit of Inquiry
A
spirit of inquiry refers to an attitude in which questions are
encouraged to be asked about existing practices. Cultivating a spirit of
inquiry allows healthcare providers to feel comfortable with
questioning current methods of practice and challenging these practices
to create improvements and change. A culture that fosters this should
have a philosophy that incorporates EBP, access to tools that can
enhance EBP, and administrative support and leadership that values EBP.
Key Elements to Foster EBP
- Always question current practices as nursing professional.
- Integrate EBP as higher standard/mission/philosophy and include competencies for EBP.
- EBP mentors for skills and knowledge availability to others to provide and help.
- Tools to enhance EBP (e.g. meetings, educational/classroom time, access to, etc.).
- Higher level support and ability for leaders to model valued EBP skills.
- Recognition of use of EBP often
Ask Clinical Question (PICOT)
PICOT
formatted questions address the patient population (P), issue of
interest or intervention (I), comparison group (C), outcome (O), and
time frame (T). Asking questions in this format assists in generating a
search that produces the most relevant, quality information related to a
topic, while also decreasing the amount of time needed to produce these
search results.
- An example of an intervention focused PICOT question would be: In total knee arthroplasty patients (Population), what is the effect of nerve blocks (Intervention) compared to opioid pain medication (Comparison) in controlling post-operative pain (Outcome) within the first 24 hours after surgery (Time)?
- An example of an issue of interest focused PICOT question would be: How do post-rehab chronic obstructive pulmonary disease (COPD) patients (Population) with stage 3 (Issue of Interest) perceive their ability to perform activities of daily living (Outcome) after first month (Time) of rehabilitation? [No comparison group].
Search for and Collect Relevant Evidence
To
begin the search for evidence, use each keyword from the PICOT question
that was formed. Once results have been found on the intervention or
treatment, the research can be rated to determine which provides the
strongest level of evidence. There are seven levels of evidence, with a
level I being of the strongest quality and a level VII being of the
weakest quality:
- Level I: Evidence from systematic reviews or meta-analysis of randomized control trials
- Level II: Evidence from well-designed randomized control trials
- Level III: Evidence from well-designed control trials that are not randomized
- Level IV: Evidence from case-control or cohort studies
- Level V: Evidence from systematic reviews of descriptive or qualitative studies
- Level VI: Evidence from a single descriptive or qualitative study
- Level VII: Evidence from expert opinions
The strongest levels of evidence, systematic reviews and
meta-analyses, summarize evidence related to a specific topic by finding
and assessing studies that specifically relate to the question being
asked. Meta-analyses are systematic reviews that also use quantitative
measures such as statistics to summarize the results of the studies
analyzed.
Pyramid framework. Thinking of the information
resources used to obtain evidence as a pyramid can help determine what
the most valid and least biased evidence is. The top of the pyramid is
just that. This is where decision support can be found, which is found
within the medical record. The middle of the pyramid is the reviews of
the evidence. This includes systematic reviews, practice guidelines,
topic summaries, and article synopses. The bottom of the pyramid is the
original studies. The bottom is also considered the foundation of the
pyramid and where evidence begins. This includes research articles.
Those who look for evidence here need special knowledge and skills to
not only find the evidence itself but how to evaluate its worthiness.
Critically Appraise the Evidence
To
begin the critical appraisal process, three questions need to asked to
determine the relevance of evidence and if evidence applies to
population being cared for. The three questions are:
- Are the results of the study valid?
- What are the results?
- Will the results be applicable in caring for patients?
- Question 1 measures the validity. In order to be valid, the results of the study must be as close to the truth as possible. Also, the study must be conducted using best available research methods.
- Question 2 measures the reliability of the study. If it is an intervention study, reliability consists of: whether the intervention worked, how large the effect was, and whether a clinician could repeat the study with similar results. If it is a qualitative study, reliability would be measured by determining if the research accomplished the purpose of the study.
- Question 3 measures the applicability. The study may be used in practice when caring for patients if the subjects are similar to the patients being cared for, the benefit outweighs the harm, the study is feasible, and the patient desires the treatment.
After asking these three questions, evidence appraisal continues by
creating an evidence synthesis. This synthesis compares multiple studies
to see if they are in agreement with each other.
Integrate the Evidence
After
appraising the evidence, it is necessary to integrate it with the
provider's expertise and patient's preferences. The patient is
encouraged to practice autonomy and participate in the decision-making
process. Therefore, even if the study had successful outcomes, the
patient may refuse to receive a treatment. Assessment findings and
patient history may reveal further contraindications to a certain
evidence-based treatment. Lastly, availability of healthcare resources
may limit the implementation of a treatment even if it is found to be
effective in a study.
Evaluate Outcomes
The
next step in the evidence-based practice process is to evaluate whether
the treatment was effective in terms of patient outcomes. It is
important to evaluate the outcomes in a real-world clinical setting to
determine the impact of the evidence-based change on healthcare quality.
Disseminate Outcomes
The
last step is to share the information especially if positive outcomes
are achieved. By sharing the results of evidence-based practice process,
others may benefit. Some methods to disseminate the information include
presentations at conferences, rounds within one's own institution, and
journal publications.
Qualitative research process
One
method of research for evidence-based practice in nursing is
'qualitative research': "The word implies a 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.
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:
- Right to self-determination
- Right to privacy and dignity
- Right to anonymity and confidentiality
- Right to fair treatment
- 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
patient's 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
half of those that responded did not feel sure of the steps in the
process. 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 EBN. Time, workload pressures, and competing
priorities can impede research and development. The causes of these
barriers include nurses' 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.
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.
Implementation and sustainability
The
Iowa Model is used to promote quality of care. It is a guideline for
nurses in their decision making process. The decision making can include
clinical and administration practices. These practices affect patient
outcomes. The model is based on problem-solving steps at are a part of
the scientific process. Recognition for applicability and ease of use.
Key components of using the Iowa Model:
- Identify "triggers"
- Clinical applications
- Organizational priorities
- Forming a team
- Piloting a practice change
- Evaluating the pilot
- Evaluate change and share results
- First, identify "triggers", which can be either problem focused or knowledge focused. These can be the important questions that arise from current practices. With knowledge focus, nurses can question a current practice due to shared scientific knowledge. This knowledge can be in the form of research or national guidelines for example. With problem focus, nurses can find room for improvement from already existing facts.
- Second, clinical application is how nurses figure out the importance of the question identified and the relevance by using the EBP process.
- Third, organizational priorities is ranking the question by the priorities of the organization. High priority given to areas that focus on high-volume/risk/cost, organization’s plan, or motivated by other forces. Knowing where a question lies in priorities can be a determination factor of getting the necessities needed to do an EBP projection for that organization.
- Fourth, forming a team is possible once agreeance occurs. The team is assembled to create, do, and evaluate the change. It is a multi-disciplinary functioning team with various skill sets and networks.
- Fifth, the piloting of a practice change is the essential step to this process. Having a selected area of the organization to pilot the practice change can help identify any issues that arise from implementation of the change before the change is spread throughout the organization. This is a multiple step process.
- Sixth, the evaluation of the pilot is the decision making process that evaluates if the pilot is accomplishing the goals of implementation, which is the quality of care provided improving, due to this pilot or not. It can involve either problem solving of the issues being had, dropping the implementation completely/postponing, or going ahead and implementing.
- Lastly, the EBP changes continued to be monitored with reports of quality and performance improvements being noted. Sharing the results with the rest of the organization is key for learning. It also promotes the EBP culture.