Nursing Evidence-Based Practice Nursing CE Course

d apply this enhanced thought process to all aspects of patient care. This way of thinking cultivates a spirit of inquiry (step 0 of EBP) and leads to the formulation of clinical questions (ATI, n.d.).

Step 0: Cultivate a Spirit of Inquiry 

EBP begins with a spirit of inquiry, characterized by a desire to understand the skills and knowledge needed to provide high-quality care to patients and families. This spirit of inquiry is a foundation for developing best practices and inspires nurses to explore their problem-solving approaches. Nurses who use the spirit of inquiry may question current practices and apply the EBP process to revise them (ATI, n.d.; Melnyk & Fineout-Overholt, 2023).

Step 1: Clinical Question 

Asking a clinical question is Step 1 of the EBP process. Nurses can examine areas with insufficient evidence by asking “why” and “how.” The nurse should understand the rationale for their actions; if unable to identify it, they should examine the evidence supporting the interventions. Clinical questions can be formed in a subjective (qualitative) or objective (quantitative) manner. One common method of developing a high-quality clinical question is the PICOT method. The acronym PICOT helps clarify and refine a broad idea into a more specific, focused clinical question. A good research question must be specific enough to define the problem clearly but broad enough to allow for the collection of evidence. It helps break the question down into searchable keywords for use in academic databases (e.g., Cochrane, PubMed, Cumulative Index to Nursing and Allied Health Literature [CINAHL]) to find the best evidence. Clinical questions that are broad and nonspecific can lead to false assumptions, may not be answerable, or may be challenging to search for evidence (ATI, n.d.; Feldner & Dutka, 2024; Melnyk & Fineout-Overholt, 2023). The components of the PICOT technique are listed in Table 2, and an example of how to develop a research question using this method is provided in Table 3.

Table 2

Components PICOT Question

Acronym	Meaning	Definition
P	Population, problem, patient	A group of people experiencing the same problem. This may be the problem, population, or patient, including pertinent characteristics, demographics, or health issues.
I	Interventions, independent variables, indicators	The planned action or treatment aimed at solving the problem. This defines the intervention, independent variable, or indicator. Examples include medications, surgery, educational programs, or policy changes.
C	Comparison	This third component is an alternative intervention to address the problem. This may be no intervention (or placebo) or the current or customary 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.
O	Outcomes	Defines the outcome that is evaluated or the dependent variable.
T	Time	This optional component describes how long it will take to achieve the desired outcome.

(ATI, 2022; Feldner & Dutka, 2024)

Table 3

Using a Case Scenario and PICOT to Develop a Research Question

A wound care nurse working on a medical-surgical unit in a large hospital knows that pressure injuries are a significant cost to the health care system and detrimental to patient health. Hospital-acquired pressure injuries (HAPIs) cause pain, poor patient outcomes, increased health care costs, heightened risk for infection, and prolonged hospital stays. The nurse recognizes that the incidence/prevalence of pressure injuries is rising on their unit. After a chart review, the wound care nurse realizes that other nursing colleagues are not documenting pressure injuries 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 wound care nurse formulates a clinical question to address the inconsistencies in documentation, staging, and treatment of pressure injuries. A task force that includes the wound nurse, nurse manager, and nurse educator on the medical-surgical unit is created to investigate pressure injuries in their patient population. The task force reviews databases to find evidence-based literature and appraises the available research. They find a great deal of quality research indicating a lack of education on initial pressure injury staging and assessment, a common inhibitor of proper prevention and treatment. The wound nurse uses the current evidence to create an annual educational activity and corresponding competency based on the National Pressure Injury Advisory Panel’s prevention protocol. The nurses on the unit are required to take the training course and competency on an annual basis to confirm continued proficiency. The wound nurse chooses to compare the rate of pressure wounds after the intervention to the prior rates with the previous treatment. The expected outcome is a decrease in HAPIs. The nurses elect to continue with quarterly measurements of HAPI incidence.

Example of how to formulate the PICOT question

P: adult medical-surgical patients in an acute care setting

I: yearly competency for pressure injury assessment and staging

C: no yearly competency for pressure injury assessment and staging

O: HAPI rates

T: quarterly/every three months

Final research question:  Combining the preceding components 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 injury assessment and staging (C), compared to no yearly competency for pressure injury assessment and staging (O,) affect HAPI rates (T) within 3 months?”

Steps 2 and 3: Research and Appraisal

Finding information or evidence to answer the clinical question and appraising the evidence are steps two and three of the EBP process. This involves searching scholarly databases for the best available evidence and evaluating the findings by analyzing the evidence obtained. The nurse should ensure that the information obtained is reliable and valid. Reliability refers to the consistency of study findings when the intervention is repeated. External validity (generalizability) refers to whether study findings can be applied to different settings or populations. Internal validity examines the quality of the research and the accuracy of its conclusions, based on sound research methodology and the minimization of bias or confounding factors. The degree of bias in the research directly affects how plausible alternative explanations for the results are. Credible online sources include government agencies (.gov), peer-reviewed journals, national associations such as the American Heart Association (AHA), academic institutions (.edu), and published clinical practice guidelines. Many research articles can be identified through databases such as PubMed, MEDLINE, CINAHL, and the Cochrane Library. Some full-text articles are available free of charge through PubMed Central. Clinical practice guidelines can be accessed through professional organizations, government agencies, Guideline Central, and ECRI Guidelines Trust. Using scholarly databases and applying filters to narrow search results is the most efficient method of researching a topic. Each keyword from the research question is used in the search (ATI, n.d.; Berman et al., 2021; Center for Evidence-Based Management [CEBMa], n.d.; Evans & Mints, 2026; Venes, 2025).

There are common formats for journal articles. The most common is an original research article, which presents new data, draws conclusions, and raises questions for future research. Quantitative studies use data to answer their question, while qualitative studies explore real-world problems to offer insight by reporting subjects’ experiences, opinions, thoughts, and actions. The most valid of these in scientific research is the randomized control trial (RCT), which uses controls and randomization to enhance internal validity by reducing the chance of bias. A review article examines several original research articles. A literature review summarizes and synthesizes information, whereas a systematic review uses a reproducible, rigorous method to identify, appraise, and synthesize relevant evidence. A meta-analysis combines multiple studies to compare their results. Nonrandomized studies (i.e., quasi-experimental, observational, or correlational) have lower internal validity and a higher chance of bias than RCTs. A case report or case study seeks to describe a particular occurrence in detail, although it is not often representative of what is generally expected. Case studies and case reports are typically considered lower-level evidence. Observational studies and surveys are subject to selection and response bias. Finally, commentaries or letters may simply reflect the opinion of a single expert in a particular field (CEBMa, n.d.; Evans & Mints, 2026; Tenny et al., 2022).

In the research and literature review process, the quality and level of evidence are examined. Each article obtained from the literature search should be organized and analyzed. The researcher can organize their findings by creating a table of evidence (see Table 5). The quality of the evidence is based on how confident a researcher is that the information gained from a study is sufficient to help formulate a recommendation. The type of evidence determines the level of evidence, whether it is a study, literature review, clinical practice guideline, or expert panel opinion (Brunt & Morris, 2023; Melnyk & Fineout-Overholt, 2023). Several organizations have developed their own evidence levels, and a sample is outlined in Table 4.

Table 4

Levels of EBP

Level 1:	evidence gathered from systematic reviews (of homogeneous RCTs) or meta-analysis evidence-based clinical practice guidelines according to findings from a systematic review of RCTs the highest level of evidence that is the most reliable
Level 2:	evidence gathered from a well-designed RCT
Level 3:	evidence gathered from nonrandomized, well-designed controlled trials
Level 4:	evidence gathered from well-designed cohort or case-control studies
Level 5:	evidence gathered from a systematic review of qualitative and descriptive studies
Level 6	evidence gathered from a single, descriptive, or qualitative study
Level 7	evidence gathered from expert or authority opinions

(Brunt & Morris, 2023)

Table 5

Example of a Table of Evidence Tool 

Author(s)	Year	Title	Research Design	Findings	Recommendations
Alenezi, McAndrew, & Fallon	2019	Burning out physical and emotional fatigue: Evaluating the effects of a program aimed at reducing burnout among mental health nurses	Quasi-experimental pretest/posttest design to assess the efficacy of a burnout prevention program Sample: (N = 255) (Intervention group: N = 130; control group: N = 125)	Participants in the control and intervention groups had moderate levels of emotional exhaustion.	Recommend a burnout prevention program and repetitive interventions.

 (ATI, n.d.)

When researching a clinical question, the researcher must assess 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 evidence. Novice researchers should not hesitate to ask for help interpreting the information and statistical data from the collected studies. It is necessary to appraise the literature accurately to ensure scientific validity and applicability to the selected patient population. Some questions to ask when evaluating the literature include (Berman et al., 2021):

• 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?

The Critical Appraisal Skills Program (CASP) is recommended by Quality and Safety Education for Nurses (QSEN) to train people to conduct critical appraisals. CASP aims to help clinical decision makers understand scientific evidence worldwide by operationalizing the three questions outlined previously. CASP can be used by nurses who want to implement research evidence into their practice. The website offers appraisal tools, checklists for nurses reading research, and workshops to help nurses better understand research. Once each study has been appraised, the collected evidence is synthesized (CASP, n.d.; Melnyk & Fineout-Overhold, 2032).

 

Steps 4 and 5: Integrate the Intervention and Evaluating Results

Step four of the EBP process is integrating the best evidence from the literature with clinical expertise and patient preferences. Evidence-based nursing care integrates medical evidence with nursing experience, clinical decision-making, and patient preferences. For this reason, many nurses report feeling more comfortable with EBP as they gain years of practice. Over time, nursing experience provides a solid foundation for clinical decision-making and critical thinking. There may be times when the resources needed to implement treatments deemed best practice by EBP are unavailable. The nurse must find practical alternatives and, if necessary, restart the literature review to identify additional methods (Berman et al., 2021; Melnyk & Fineout-Overholt, 2023).

The nurse must thoroughly assess and educate the patient on the risks and benefits of the recommended intervention, allowing for ample time to discuss concerns and fears fully and clarify understanding. Sometimes, compelling evidence for specific treatments will conflict with a patient’s values or beliefs. Despite compelling evidence, the patient has the right to decide in these instances (Berman et al., 2021).

Once the EBP has been implemented in the nurse’s practice, the next step is to evaluate the outcomes and effectiveness of the change. Outcomes must be measured by their impact on health care quality and/or patient outcomes. Results do not always align with those reported in the literature; this may be due to differences in implementation or discrepancies in patient population characteristics or demographics (Berman et al., 2021). It is important to remember that not all variables can be controlled; patients may not mirror those included in research studies, and outcomes may differ. Outcome evaluation is important to assess how research translates into real-world use. Outcomes should be measured before, shortly after, and again within a reasonable time after implementation. Data from each of these points is important for fully evaluating the change. The EBP team should be part of collecting and assessing the outcomes data (Melnyk & Fineout-Overholt, 2023).

Implementing an EBP change across an organization is a more extensive undertaking. Typically, the organization will need to implement change in phases. Some organizations may develop an EBP implementation team to create new tools and processes to integrate the practice. This team can be multidisciplinary and include team members from all levels of management. Implementing EBP may change daily workflows and staff routines. Even highly motivated nurses may face challenges practicing in a continuously changing environment and may require support from their administration. Piloting minor changes and adjusting based on staff feedback can foster 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 gather feedback. Pilot testing in select patient care areas efficiently identifies and resolves problems before organization-wide implementation. The pilot areas can then be used as training sites for the rest of the organization when widespread use is initiated (Boswell & Cannon, 2023; Farrington et al., 2022; Melnyk & Fineout-Overholt, 2023).

In the previous case scenario (see Table 3), the study’s results indicated that HAPI rates declined rapidly after the initiation of annual competency and training. Six months after implementation, the HAPI rate for the medical-surgical unit fell from 4% to 0%. A simple explanation is that the initial assessment and accurate staging of pressure injuries helped staff identify them during the admission process. By implementing the EBP process, the wound nurse and task force can achieve a sustainable, substantial organizational change and improve patient outcomes.

 

Step 6: Dissemination of Knowledge

Once research is complete and the results of the evidence-based process are collected, it is important to share the knowledge with others. Other clinicians, facilities, and patients can benefit from an individual’s or team’s hard work, and additional research may be prompted. Knowledge dissemination aims to foster a culture of evidence-based decision-making and inquiry among nurses. Participation in EBP and dissemination activities can enhance nurses’ confidence, professional development, and engagement in evidence-based decision-making. Some facilities have EBP champions/teams or nurse mentors who educate staff about current evidence. Disseminating findings is the final step in the EBP process. Preparing and presenting a poster is an effective method of dissemination, as is publishing findings in a peer-reviewed journal. In the previous sample case scenario (see Table 3), the wound care nurse created a poster presentation that was presented at Samford University’s annual conference. The poster is also displayed at the local nursing school and on the medical-surgical unit where the study was completed (Berman et al., 2021; Melnyk & Fineout-Overholt, 2023).

Barriers to Evidence-Based Practice

There are many barriers to the use of EBP. Lack of EBP knowledge and skills is among the most consistently reported barriers to EBP implementation among nurses. This includes difficulties with literature searching, critical appraisal, and translating evidence into practice (ATI, n.d.; Mohamed et al., 2024). Frontline nurses may find EBP challenging due to limited clinical engagement in EBP, a lack of organizational support, inadequate mentoring, and workplace cultures that do not prioritize EBP. Undergraduate nursing students often value EBP but lack the competency and confidence to apply it without the necessary support and education. Undergraduate nurses should develop competency in EBP because it is essential to delivering high-quality direct patient care. The clinical learning environment, instructors, and the design of clinical experiences play a role in developing students’ knowledge, confidence, and skills in EBP. Clinical course activities should include foundational competencies that emphasize searching for and applying evidence for each patient in the clinical setting to overcome these barriers (ANA, 2023; Hooge et al., 2022; Melnyk & Fineout-Overholt, 2023; Mohamed et al., 2024).

Nurses also report a lack of resources needed to implement EBP. EBP must be prioritized at the institutional and governmental levels to ensure nurses have the resources and training they need. Nurses report that unsupportive organizational cultures and negative attitudes toward research can reduce confidence in implementing EBP. Another barrier to EBP is the time delay between collecting and applying research results. Nurses report that improved education, increased motivation, and employer acceptance of EBP increase its use (Melnyk & Fineout-Overholt, 2023; Mohamed et al., 2024).

Conclusion

EBP is essential to delivering high-quality health care, improving outcomes, and controlling care costs. EBP not only enhances patient care but can also increase nurses’ confidence in clinical decision-making, promote professional autonomy, and foster empowerment. Increasing EBP knowledge and skills among undergraduate and graduate nursing students can strengthen professional competencies and support the advancement of nursing practice. EBP is a systematic process that begins with a nurse using clinical expertise to question current practices. EBP combines the nurse’s experience, patient preferences, and the most compelling evidence to continuously improve health care and patient outcomes. Using the PICOT format to refine the clinical question will enable the nurse to identify pertinent research and current evidence. The outlined EBP process will allow 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 produce nurses more comfortable with the process. Practicing nurses can deepen their understanding of the EBP process by participating in continuing education units (CEUs) on EBP. Subscribing to nursing journals and discussing research literature are effective ways to consider and develop clinical questions. Forming task forces and formal teams, using mentors, journal clubs, and EBP rounds are also effective ways to instill the use of EBP within an organization. Forming an EBP team can help facilitate the process and implement change. Team members should be enthusiastic about EBP to build excitement within the organization and inspire staff to drive change (ANA, 2023; Hooge et al., 2022; McClinton, 2022; Mohamed et al., 2024).

References

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