Evidence-based Practice

Background, Definitions & Responsibilities

The utilization of evidence-based decision-making by registered nurses is an important element of quality nursing practice.

Definitions:

Sackett (1996) Evidence Based Medicine

  • "Integrating clinical expertise and the best available evidence from systematic research"

Stetler (1998) Evidence Based Nursing

  • "De-emphasizes ritual and isolated unsystematic clinical experience, ungrounded opinions and traditions."
  • "Emphasizes research, findings from QI data and other operational and evaluation data, consensus of experts, affirmed experiences.

Background

Nursing practice is based on values, theories and evidence. Although evidence is an important element in decision-making in nursing, decisions are also influenced by individual values, client choice, clinical judgement, experiential knowledge, ethics, legislation, as well as the pressures and working conditions within given organizations and work environments. The term 'evidence-based practice' has emerged in the 1990's to incorporate efforts to build practice patterns and protocols on the best evidence available, including but not limited to research. This movement results from international efforts over the past two decades to synthesize research into guidelines for practice. In actuality, evidence-based practice includes research-based practice and the two are equivalent in general process and the focus on use of research findings to guide practice. The terms are not consistently differentiated in the literature. Evidence-based practice, as noted in the Iowa Model, is a broader concept, including best available' evidence in the absence of adequate research.

Responsibility for Evidence-Based Practice

The medical center, professional associations, and nursing educators share the responsibility for developing and funding strategies that facilitate evidence-based decision-making and evidence-based practice. These responsibilities extend to identifying the barriers and enhancing the factors within organizational structures that facilitate and promote evidence-based practice.

  • Individual nurses have the primary responsibility for evaluating and promoting evidence in the context of their practice to ensure that nursing practice maximizes health and quality of life from the client's perspective.
  • Professional and regulatory nursing associations have the responsibility to encourage and support evidence-based practice.
  • Nursing educators and educational institutions have the responsibility to assist nurses in developing the skills and abilities to assess, interpret and incorporate evidence into their practice on a continuing basis; to ensure that researchers communicate their findings in language that is familiar to practitioners; and to ensure that nursing curricula are evidence-based.
  • The medical center has the responsibility to provide: an environment supportive of evidence-based practice, the tools necessary to implement evidence into practice, and continuing education to assist nurses in developing the skills and abilities to assess and incorporate evidence into practice.
Competencies for the Use of Evidence in Practice
  • Competencies in evidence-based decision-making must be developed through basic and continuing nursing education programs, should be applied through critical analysis, and must be reinforced within practice environments.

evidence chart

 

evidence chart

Evidence Base Nursing

What's Evidence Based Nursing (EBN)?

Evidence Based Nursing is the process by which nurses make clinical decisions using the best available research evidence, their clinical expertise and patient preferences. Three areas of research competence are: interpreting and using research, evaluating practice, and conducting research. These three competencies are important to EBN.

    • To carry out EBN the following factors must be considered:
      • sufficient research must have been published on the specific topic
      • the nurse must have skill in accessing and critically analyzing research
      • the nurse's practice must allow her/him to implement changes based on EBN
Definitions

Evidence-based Nursing Practice: solves problems encountered by nurses by carrying out four steps:

    1. Clearly identify the issue or problem based on accurate analysis of current nursing knowledge and practice
    2. Search the literature for relevant research
    3. Evaluate the research evidence using established criteria regarding scientific merit
    4. Choose interventions and justify the selection with the most valid evidence
  • Research Use
    Transfers research findings to nursing practice: Carried out by individual nurses, groups of nurses working together to solve problems, by interdisciplinary teams, and by institutions and organizations seeking to make system-wide improvements in care outcomes
    • Literature review
      Scholarly analysis of a body of research about a specific issue or topic[1]
    • Integrative literature review
      Integration of a body of research findings (including theory, statistics) which concludes by addressing issues for future research[1]
    • Systematic literature review
      Comprehensive, unbiased analysis of research findings on a specific topic which uses a strict scientific design to select and assess various related scientific studies[1]
      Meta-analysis
      Merged statistical results from a number of related studies which combines various research studies with the goal of discovering consistencies and differences between studies[1]
      Clinical Decision-making
      drawing conclusions based on EBN, clinical expertise, patient preference, and other factors such as cost-benefit analysis, availability of alternatives, etc.
      Reference: 1.Stevens & Cassidy (199) Evidence-based teaching: Current Research in Nursing Education, 11.
History
  • Nursing research began to focus on clinical issues in the mid 80's (Stevens & Cassidy, 1999).
  • The National Institute for Nursing Research (NINR) (http://www.nih.gov/ninr/) was formed in 1986, greatly increasing the visibility and funding opportunities for nursing research.
  • Many new journals emphasize nursing research
  • In recent years the International Society for Nursing Research, Sigma Theta Tau, has greatly increased its capacity to support and disseminate nursing scholarships (http://www.nursingsociety.org/)
  • McMaster University in Ontario, Canada has developed extensive resources in teaching and implementing evidence-based practice in nursing and other disciplines (http://www.fhs.mcmaster.ca/ceb/acts/ebcp.htm)
Models

Three models for research utilization in nursing serve as a foundation to understand evidence-based nursing practice.

  1. The Conduct and Utilization of Research in Nursing (CURN) project.[1, 2, 3]
    The CURN Project was designed to develop and test a model for using research-based knowledge in clinical practice settings. Research utilization is viewed as an organizational process. Planned change is integrated throughout the research utilization process. Systems change is essential to establishing research-based practice on a large scale.
  2. The Stetler Model of Research Utilization[4,5,6,7]
    The Stetler Model of Research Utilization applies research findings at the individual practitioner level. The model has six phases: (1) preparation, (2) validation, (3) comparative evaluation, (4) decision making, (5) translation and application, and (6) evaluation. Critical thinking and decision making are emphasized.
  3. Iowa Model for Research in Practice [8]
    The Iowa Model of Research in Practice infuses research into practice to improve the quality of care [8], and is an outgrowth of the Quality Assurance Model Using Research (QAMUR)[9] . Research utilization is seen as an organizational process. Planned change principles are used to integrate research and practice. The model integrates evidence-based healthcare acknowledges and uses a multidisciplinary team approach.[10]

Reference:

1. Haller, K. B., Reynolds, M. A., & Horsley, J.A. (1979). Developing research-based innovation protocols: Process, criteria and issues. Research in Nursing and Health 2, 45-51;
2. Horsley, J.A., Crane, J., & Bingle, J. D. (1978). Research utilization as an organizational process. Journal of Nursing Administration, July, 4-6;
3. Horsley, J. A., Crane J., , Crabtree, M. K., & Wood, D. J. (1983). Using research to improve practice. Orlando, FL:Grune & Stratton.
4. Stetler, C. B. (1983):Nurses and research responsibility and involvement. National Intravenous Therapy Associations, Inc. 6(May/June), 207-212,
5. Stetler, C. B. (1985). Research utilization: Defining the concept. Image: The Journal of Nursing Scholarship XVII (2), 40-44
6. Stetler, C. B. (1994). Refinement of the Stelter /Marram model for application of research findings to practice. Nursing Outlook, January/February, 15-25;
7. Stetler, C. B., & Marram, G. (1976). Evaluating research findings for applicability in practice. Nursing Outlook 24(9), 559-563.
8.Titler, M. G., Kleiber, C., Steelman, V., Goode, C., Rakel, B., Barry-Walker, J., Small, S., & Buckwalter, K. (1994) Infusing research into practice to promote quality care. Nursing Research 43(5), 307-313
9.Watson, C. A., Bulecheck, G. M., & McCloskey, J. C. (1987). QAMUR: A quality assurance model using nursing research. Journal of Nursing Quality Assurance 2(1), 21-27.
10.Kleiber, C., & Titler, M. G., (1998). Evidence based practice and the revised Iowa Model. Fifth national research utilization conference (April 23-24). Iowa City, IA: University of Iowa hospitals and Clinics.
11. Carroll, D. L., Greenwood, R., Lynch, K. E., Sullivan, J. K., Ready, C. H., & Fitzmaurice, J. B. (1997). Barriers and facilitators

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