The purpose of this module is to provide an overview of the importance, process, and implementation of nursing evidence-based practice.
At the completion of this module, the learner will be able to:
- define evidence-based practice
- formulate a clinical question by using the PICOT format
- develop a PICOT question clinically relevant to your practicing environment
- discuss the importance of appraisal of literature
- discuss the importance of EBP in improving patient outcomes
Evidence-based practice: The integration of the best available scientific evidence with nursing experience and patient preference (Dang & Dearholt, 2018).
Appraisal of literature: The process of evaluating literature for its worth (i.e., validity, reliability, and applicability to clinical practice; Melnyk & Fineout-Overholt, 2015).
Levels of hierarchy of evidence: "A ranking of evidence by the type of design or research methodology that would answer the question with the least amount of error and provide the most reliable findings" (Melnyk & Fineout-Overholt, 2015, p. 607).
Quality of evidence: The confidence that the information gained from a study is adequate to support a specific recommendation (World Health Organization [WHO], 2013).
Quantity of evidence: The number of studies that have evaluated the specific clinical issue, the sample size among studies, the magnitude of the treatment effect, and the strength of the assessment of the interventions (Melnyk & Fineout-Overholt, 2015).
Consistency of evidence: Whether studies with similar and different designs report similar findings. This will require numerous studies to determine (Melnyk & Fineout-Overholt, 2015).
Dissemination of knowledge: The process of spreading or circulating knowledge (Melnyk & Fineout-Overholt, 2015).
Evidence-based practice (EBP) involves the use of published research in addition to one's clinical expertise and patient preferences (Horntvedt et al., 2018). EBP is a core component of clinical practice across all levels of nursing education. Nurses practicing across clinical settings are at the forefront of healthcare. These nurses serve a critical role in bridging the gap between practice and theory. The consistent application and integration of EBP into all levels of nursing practice leads to high-quality health care, improved patient outcomes, and healthcare cost savings. To increase the use of EBP, nurses must develop a strong foundation in the EBP process (Rudman et al., 2020). There are seven steps to EBP:
0) cultivate a spirit of inquiry,
1) ask a clinical question,
2) find information/evidence to answer the clinical question,
3) appraise the evidence,
4) combine evidence with clinical experience and patient preferences,
5) evaluate the results,
6) disseminate the results (Melnyk & Fineout-Overholt, 2015).
This module will review each step of the EBP process and provide a case scenario for a clinical example.
The Process of Evidence-Based Practice
Nurses and other members of the healthcare team often wonder why clinical practices are performed in a certain way or if those practices could be improved. Nurses are trained to think critically and apply this enhanced thought process to all aspects of patient care. This way of thinking often cultivates a spirit of inquiry, which is considered step 0 of EBP and leads to clinical questions (Melnyk & Fineout-Overholt, 2015).
Step 1: PICOT question
Developing a clinical question is the first step of the EBP process. Clinical questions must be formed in a subjectively and objectively measurable manner. One common method of developing a clinical question is the PICOT method. The acronym PICOT helps to clarify the clinical question, taking a broad idea and refining it into a more specific and narrow research question (Granger, 2020). Clinical questions that are broad and nonspecific can lead to false assumptions and may not be answerable or clearly define the problem. The components of a PICOT question are listed below:
P: Problem, population, or patient
I: Intervention, independent variable, or indicator
O: Outcome or dependent variable
T: Time frame
A good PICOT question must be specific enough to clearly define a problem, but broad enough to make finding evidence possible (Dang & Dearholt, 2018). The following case scenario is an example of how a PICOT question is developed in the clinical setting.
Case Scenario (Population)
A wound care nurse working on a medical-surgical unit in a large hospital knows that pressure ulcers are a significant cost to the healthcare system and detrimental to patient health. Hospital-acquired pressure ulcers (HAPU) cause pain, poor patient outcomes, increased healthcare costs, heightened risk for infection, and prolonged hospital stays. The nurse recognizes that the incidence of all types of pressure ulcers is increasing on her unit. After a chart review, she realizes that nurses are not documenting pressure ulcers that are present on admission, are not measuring and staging the wounds consistently, and are not formulating a proper treatment plan based on accurate staging. The nurse formulates a clinical question to address the inconsistencies in documentation, staging, and treatment of the pressure ulcers in (P) medical-surgical patients in an acute care setting. The (P) in the PICOT describes the problem, population, or patient, along with pertinent characteristics, demographics, or health issues. The rest of the PICOT question defines the intervention that will be implemented, how the outcome will be measured or compared, what outcome is expected, and the time frame needed to gather the necessary data.
The wound nurse, nurse manager, and nurse educator on the medical-surgical unit form a task force to investigate the pressure ulcer problem in their patient population. The task force reviews the evidence-based literature base and then performs an appraisal of the research available. They find a great deal of quality research that indicates a lack of education on pressure wound staging and assessment is a common inhibitor to proper prevention and treatment. Integrating the EBP research gathered, the wound nurse creates an annual educational activity and corresponding competency based on the National Pressure Ulcer Advisory Panel's prevention protocol. The nurses on the unit will be required to take the training course and competency on an annual basis to confirm continued proficiency. The nurses are able to formulate their intervention, (I) implementation of educational material, and a yearly competency for pressure wound assessment and staging using the information acquired from the literature appraisal. The (I) in the PICOT question defines intervention, independent variable, or indicator. Examples of these include medications, surgery, educational programs, or policy changes.
Comparison is the (C) component in the PICOT question. The (C) will often include no intervention or the current or common practice. This component can be difficult to determine at times, and there are instances where the C can be omitted, especially if the study does not have a control group, comparison group, or alternate treatment option to compare. In the example of the medical-surgical unit, there will not be a comparison or alternative intervention. The study would have to leave half of the nurses out of the competency for the specified amount of time to create a control group. The wound nurse chooses to compare the rate of pressure wounds after the intervention to the prior rates with the previous treatment. So, the PICOT would say (I) how does the implementation of a yearly competency for pressure wound assessment and staging (C) compare to no yearly competency for pressure wound assessment and staging?
Outcome and Time
In the scenario described above, the expected outcome for the medical-surgical unit is a decrease in the incidence of HAPU. The outcome for the PICOT question would state (O) affect HAPU rates. The nurses elect to continue with quarterly measurements of HAPU incidence. Since measurements are taken quarterly, the time will state (T) within 3 months.
Taking each unit of the PICOT question from the case scenario and combining each section results in the following question: "For (P) medical-surgical patients in an acute care setting (I) how does the implementation of a yearly competency for pressure wound assessment and staging (C) compare to no yearly competency for pressure wound assessment and staging (O) and affect HAPU rates (T) within 3 months?"
Step 2 and 3: Research and Appraisal
Finding research is step two of the EBP process. After a clinical question has been formed, and the population has been identified, research and literature reviews must be obtained from reliable sources and then appraised for validity and reliability (Horntvedt et al., 2018). Commonly used sources include journals, clinical practice guidelines, and textbooks. Using online sources and filters to narrow search results is the most efficient method of researching a topic. Each keyword from the PICOT question is used in the search. Many journals can be accessed for free via the National Institute of Health and the National Library of Medicine (PubMed.gov). Clinical practice guidelines can be accessed via the public resource website National Guideline Clearinghouse (Melnyk & Fineout-Overholt, 2015).
In the research and literature review process, the quality of the evidence is examined, as well as the level of evidence. The quality of the evidence is based on how confident a researcher is that the information gained from a study is adequate enough to help formulate a recommendation (WHO, 2013). The level of evidence is based on the type of source, whether it is a study, literature review, clinical practice guideline, or expert panel opinion. There are six levels of evidence, which are outlined below in Table 1. The levels of evidence range from Level I to Level VII, with Level I evidence being the strongest level of evidence.
When researching a clinical question, the researcher must determine the strength of the literature in terms of quality, quantity, and consistency (see definitions). It is often difficult for a new researcher to evaluate the level of research. Do not be afraid to ask for help in interpreting the information and statistical data in the research studies. It is necessary to correctly appraise the literature to ensure the scientific validity and applicability to the selected patient population (Umesh et al., 2016). Three core questions should be asked when evaluating literature.
- What are the actual results of the study?
- Are the results trustworthy and credible?
- Will the results help me in caring for my patient population? (Melnyk & Fineout-Overholt, 2015).
The Critical Appraisal Skills Program (CASP) is a program recommended by Quality and Safety Education for Nurses (QSEN) used to train people to perform critical appraisals. CASP's goal is to help clinical decision-makers understand scientific evidence around the world. CASP can be utilized by nurses who want to implement research evidence into their own practice. The website offers eight appraisal tools, includes checklists for nurses to use while reading the research, and offers workshops to help nurses better understand the research (Milner & Cosme, 2020).
Step 4 and 5: Combining Evidence and Evaluating Results
Step four of the EBP process integrates the best evidence found in the literature with clinical expertise and patient preferences. There will be times when compelling evidence for specific treatments will conflict with a patient's values or beliefs. In these instances, despite compelling evidence, the patient has the right to make the final decision. It is the nurse's responsibility to thoroughly assess and educate the patient on the risks and benefits, allowing ample time to fully discuss concerns, fears, and clarify understanding. There will also be times where healthcare resources may not be available to implement treatments deemed best practice by EBP. It is the nurse's responsibility to find practical alternatives and potentially begin the literature review process again in search of alternative methods (Melnyk & Fineout-Overholt, 2015). The premise of evidence-based nursing care is integrating medical evidence with nursing experience, clinical decision-making, and patient preferences. For this reason, many nurses report being more comfortable with EBP mid-career after 10 or more years of practice (Rudman et al., 2020). Nursing experience over time provides a solid foundation to support clinical decision-making and critical thinking.
Once the EBP has been implemented into the nurse's practice, the next step is to evaluate the outcomes and effectiveness of the change. Outcomes must be measured based on their impact on healthcare quality and/or patient outcomes. The results do not always reflect those found in research; this may be due to differences in the implementation of the intervention or due to discrepancies in the characteristics or demographics of the patient population (Melnyk & Fineout-Overholt, 2015).
Implementing an EBP change across an organization is a more extensive undertaking. Typically, the organization will need to start by enacting change incrementally. Some organizations may develop an EBP implementation team to generate new tools and processes needed to integrate the practice. This team can be multidisciplinary and involve team members from all levels of management. Implementing EBP may change the daily workflow and staff routines. Even motivated nurses can have difficulty practicing in a continuously changing environment and require support from their organization's administration. Piloting small changes and making adjustments based on staff feedback can ensure positive attitudes and successful adaptation to the new process. The results should be shared with all staff involved at the end of each pilot to ensure open communication, maintain motivation, and receive feedback. Pilot testing in selective patient care areas prior to organization-wide implementation is an efficient way to identify and remedy problems. The pilot areas can then be used as training sites for the rest of the organization when widespread use is initiated (Melnyk & Fineout-Overholt, 2015).
Once evidence-based changes have been made, clinical outcomes should be evaluated. It is important to remember that not all variables can be controlled, patients may not mirror those included in research studies, and the outcomes may be different than expected. Outcome evaluation is important to assess how research translates into real-world use. Outcomes should be measured before, shortly after, and then again within a reasonable length of time after implementation. Data from each of these points are important to fully evaluate the change. The EBP team should be a part of collecting and evaluating the outcomes data (Melnyk & Fineout-Overholt, 2015).
Case Scenario Outcome
In the case scenario, HAPU rates show a rapid decline after the initiation of the yearly competency and training. Six months after implementation, the HAPU rate on the medical-surgical unit decreases from 4% to 0%. A simple explanation is that the initial assessment and correct staging of pressure ulcers appropriately identify pressure ulcers in all stages on admission. Through the implementation of the EBP process, the wound nurse and task force are able to make a sustainable, substantial change in the organization and improve patient outcomes.
Step 6: Dissemination of Knowledge
Once research has been completed, and the results of the evidence-based process have been collected, it is important for the knowledge obtained to be shared with other clinicians. Other clinicians, facilities, and patients can benefit from one individual or team's hard work, and additional research may be prompted. This dissemination of knowledge also serves to inspire other nurses to form their own clinical questions and develop their own research. It inspires confidence and a feeling of autonomy in the nursing practice. The distribution of results is the final reward in the long EBP process. Preparing and presenting a poster is an effective and often preferred method of dissemination. Others may choose to submit findings for publication in a journal or discuss their findings locally in a case study presentation (Pashaeypoor et al., 2017). In the case scenario, the wound nurse creates a poster presentation, which is presented at Samford University's annual conference. The poster is also displayed at the local school of nursing and on the medical-surgical unit where the study was completed.
Barriers to Evidence-Based Practice
There are many barriers to the use of EBP. First, undergraduate nursing students report positive feelings about using EBP and research but are not well prepared to apply EBP. It is imperative that undergraduate nurses are comfortable with EBP because these are the nurses that spend the most time with patients providing direct patient care (Horntvedt et al., 2018). Nurses also report a lack of resources required to implement EBP. EBP must be prioritized at the institutional and governmental levels for nurses to have the resources and training needed (Duncombe, 2017). Some nurses report cultural disadvantages and negative attitudes about EBP, which leads to a lack of confidence in practicing EBP (Ryan, 2016). Another barrier to EBP is the time delay seen between the collection of research results and the application of those results. Nurses report that improved education, increased motivation, and acceptance of EBP by their employer increase the use of EBP (Pashaeypoor et al., 2017).
EBP is important to delivering high-quality healthcare and giving patients the best outcomes at the lowest cost. Not only does EBP improve healthcare for patients, but it also increases the nurse's autonomy and fosters a feeling of empowerment (Bissett et al., 2016). Improving understanding and increasing the use of EBP in undergraduate and graduate nurses will lead to growth throughout the entire nursing profession. EBP can be a long process that begins with a nurse using clinical expertise to question current practices. EBP combines the nurse's experience, patient preference, and the most compelling evidence available to continuously improve healthcare and patient outcomes. Using the PICOT format to refine the clinical question will enable the nurse to identify pertinent research and current evidence. Using the outlined EBP process will enable the nurse to complete the process and answer the clinical questions. There may be barriers to EBP at all levels. Increasing education on EBP in undergraduate nursing programs will help to produce nurses that are more comfortable with the process. Practicing nurses can improve their understanding of the EBP process by participating in workshops and completing CEU offerings related to EBP. Subscribing to nursing journals and discussing research literature is a great way to consider and develop clinical questions. Forming task forces and formal teams, using mentors, journal clubs, and EBP rounds are also good ways to instill the use of EBP into your organization. Forming an EBP team can help to facilitate the process and implement change. Team members should be passionate about EBP to build excitement within the organization and light a fire in the staff to drive change (Melnyk & Fineout-Overholt, 2015).
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