The purpose of this module is to provide an overview pertaining to the process and implementation of nursing evidence-based practice (EBP).
At the completion of this module, you will be able to:
- Define evidence-based practice.
- Recall the PICOT question format to following evidence-based practice process.
- Apply a PICOT to a clinical question relevant to your practicing environment.
- Identify the levels of evidence for literature appraisal.
- Discuss the purpose of EBP is to improve patient outcomes with peers and leadership colleagues.
Evidence-based practice (EPB) is a topic relevant to all registered nurses, practitioners, and nursing leaders as well as a multitude of interprofessional disciplines within the healthcare system. The goal of EBP is to provide the highest quality of healthcare to improve the populations’ health outcome while reducing unnecessary costs. Nursing has been evolving from a traditional practice to a scientific, research-based practice. However, struggles continue to exist within healthcare to address the knowledge gap to implement EBP (Munn, Lockwood, & Moola, 2015).
Evidence-based Practice Process
Implementing an EBP project within a healthcare organization requires a team approach and collaboration with other disciplines. When nursing practice changes, it may affect other disciplines or other processes as well. It is important to note that communication between nursing leadership, clinical nurses, and any other key stakeholders will aid in the success of the project. The following sections will outline the step-by-step process.
The common and acceptable format to frame a clinical question for an EBP project is PICOT. This is a systematic process to standardize and guide the process with intent to develop credible evidence.
Population of interest
Intervention or issue of interest
Comparison of interest
Time for the intervention to achieve the outcome
The Clinical Question
Practicing clinical nurses and leaders are experts in their field. The frequent interactions with patients, equipment, technology, and processes lend the opportunity to be inquisitive and evaluate what might need improving. A clinical question can be identified during an epiphany after multiple direct observations or during a team brain storming exercise. Melnke and Fineout-Overholt (2015) formulated that there are five categories of questions:
- What intervention is most effective in a positive outcome?
- What predictors are most associated with a risk for an outcome?
- What mechanism (test or assessment) most accurately diagnosis an outcome?
- What extent a factor, process, or condition is highly associated with an outcome (etiology question, usually a negative outcome)?
- How an experience influences an outcome?
Case Scenario (clinical question)
An oncology nurse understand that mucositis is a significant problem among the oncology patients. Oral mucositis (OM) causes significant pain and discomfort, anorexia, increase risk of infection, and prolongs hospital admissions. The oncology nurse noticed that the nurses on her unit documented mucositis inconsistently and without an evidence-based mucositis grading scale, thus resulting in delayed recognition and treatment. A clinical question formulated to address the inconsistent mucositis staging documentation; (P) oncology patients in an acute care setting.
Once a clinical question and population have been identified, a literature review is performed to evaluate and appraise the existing and recent body of evidence to support the EBP project. This step requires access to sources of evidence such as journals, textbooks, and, guidelines. Electronic databases are the most efficient method to search for relevant topics using key search terms. There are a few free resources such as (1) MEDLINE® via PubMed®, (2) National Guideline Clearinghouse, and (3) National Institute for Health and Care Excellence. To search efficiently takes practice, using limitations (filters) to narrow your search will reduce the burden of reviewing thousands of articles.
Appraisal of Literature
According to Melnke and Fineout-Overholt (2015), “The purpose of rapid critical appraisal is to determine whether the literature identified in the search is relevant, valid, reliable, and applicable to the clinical question” (p. 71). The critical appraisal process includes evaluating the quality and the hierarchy of evidence (also known as the level of evidence). The six levels are defined below. Not all research is created equal and therefore the reader must determine the strength of the literature using three domains: (1) quality, (2) quantity, and (3) consistency (see definitions). To simplify, when reviewing a quantitative study, you want to ask a few questions:
- Why was the study done?
- What is the sample size?
- How did they measure what was studied (i.e. scales or lab values)?
- If a scale was used, has it been used before to establish validity and reliability?
- How was the data analyzed?
- How does the results of the study compare to other studies? Is there consistency in the finds or are the results still controversial?
- How do the findings relate to your clinical practice?
Critical appraisal is a skill that takes time to develop. When evaluating an article, pull out the section that you understand and discuss with others as well as seek advice to learn how to interpret the sections that are unclear. It is common to experience a challenge when interpreting the statistical analysis but with persistence your knowledge will develop.
Case Scenario (outcome of appraisal)
The oncology committee worked on the literature and appraisal of evidence as a team. The committee determined, based on the relevant oncology literature, to select the World Health Organization (WHO) grading of OM and collaborated with the information technology (IT) department to build the OM grading assessment in the electronic health record (EHR). Prior to implementation of a new EHR assessment, the oncology nurses were educated on the OM and how to use WHO’s grading scale; (I) Implementation of a OM grading scale for daily assessment into the EHR.
Comparison of intervention
The (C) component of the PICOT format is not as intuitive as the others. Depending on the design and clinical question ‘the comparison’ can be omitted. In the oncology department case scenario, they rolled out the intervention to the entire unit and did not have a comparison group or control group. However, if the oncology unit decided to implement the WHO OM grading assessment to half the unit for three months, this would create a control group for comparison and the PICOT format would state (I) how does a daily assessment of OM using WHO grading scale (C) compare to those who are not using the WHO grading scale.
Case scenario (outcome and time)
The expected outcome of using an evidence-based oral mucositis grading scale in the EHR is that nurses will identity all stages of OM daily and intervene appropriately to improve the patient experience by reducing pain and discomfort; (O) consistent OM assessment leads to early intervention to improve patient experience. To observe the outcome for reduction of hospital length of stay, this will take time; (T) reduction of length of stay within six months.
Case scenario (dissemination of knowledge)
The oncology nurses created a poster presentation and presented at the organization’s research day. They also presented at the local oncology nurses society chapter. The poster then hung in the nurses’ lounge. It is important to share your work within your work environment (internally) and outside your work environment (externally) such as journals or organizations. Why? Sharing EPB helps others learn and gives nurses the opportunity to adopt the new knowledge into their practice. Additionally, sharing knowledge creates a spirit of inquiry and will encourage others to think of their own clinical questions. It motivates others to overcome a lack of confidence and empowers other to follow. Dissemination of knowledge is extremely powerful. It is also the opportunity to celebrate and reward the success of generating practice change.
Evidence-based practice. Defined by Melnke and Fineout-Overholt (2015), EBP is a paradigm and lifelong problem-solving approach to clinical decision making that involves the conscientious use of the best available evidence (including a systemic search for and critical appraisal of the most relevant evidence to answer a clinical question) with one’s own clinical expertise and patient values and preference to improve outcomes for individuals, groups, communities, and systems. (p. 064)
Hierarchy of evidence. A mechanism for determine which study designs have the most power to predict cause and effect. The highest level of evidence is systematic reviews of randomized controlled trials, and the lowest level of evidence is expert opinion and consensus statements (2015).
Levels of evidence. Defined by Melnke and Fineout-Overholt (2015), a ranking of evidence by the type of design or research methodology that would answer the question with the lease amount of error and provide the most reliable findings.
Level I evidence. Evidence that is generated from systemic reviews or meta-analysis of all relevant randomized control trials (RCTs) or evidence-based clinical practice guideline based on systematic reviews of RCTs (2015).
Level II evidence. Evidence generated from at least one well-designed randomized clinical trial (2015).
Level III evidence. Evidence obtained from well-designed controlled trials without randomization (2015).
Level IV evidence. Evidence from well-designed case-control and cohort studies (2015).
Level V evidence. Evidence from systematic reviews of descriptive and qualitative studies (2015).
Level VI evidence. Evidence from a single descriptive or qualitative study (2015).
Level VIII evidence. Evidence from the opinion of authorities or reports of expert committees (2015).
Quality. The extent to which a study’s design, conduct, and analysis have minimized selection, measure, and confounding bias (2015, p. 79).
Quantity. The number of studies that have evaluated the clinical issue, overall sample size across all studies, magnitude of the treatment effect, and strength from causality assessment for interventions such as relative risk or odds ratio (2015, p. 80).
Consistency. Whether investigation with both similar and different study designs report similar findings (2015, p. 80)
Barriers to Evidence-based practice
When tackling EPB projects it is important to know the barriers identified in the literature. As stated previously, the implementation of EPB can be challenging. One barrier is overcoming the idea of practice change. Multiple studies have shown that nurses can be resistant to practice change (Johnston et al., 2016; Munn, Lockwood, & Moola, 2015; Ramos-Morcillo, Fernandez-Salazar, Ruzafa-Martinez, & Del-Pino-Casado, 2015). A lack of time is another barrier identified by the literature (Munn et al., 2015). A viable solution to this barrier is team work; by collaborating and delegating tasks the workload can be divided equitably. Critical appraisal of research reports can be challenging as this is a skill set that takes time and practice to learn. A barrier identified in the literature was a lack of EBP knowledge and skill (Ramos-Morcillo et al., 2015). A strategy to overcome this is to solicit help from someone within the organization who has experience with research. Essentially, the guidance of a EPB mentor is an optimal solution. If your organization does not have an EBP committee one could advocate to form this group. Selecting a committee chair, with EPB experience, to lead the group would be ideal because the chair can then teach and mentor the committee. Working in real time with a mentor is an exciting way to the practical application of EBP.
Embarking on the EPB journey is a rewarding way to improve nurses’ autonomy. The nurse is the clinical expert; by using EBP to guide practice change your voice will be stronger. Organizational decisions are often determined by what the literature supports. Starting a journal club is a great way to start discussing the concepts of EBP by reviewing new information and discussing among your peers. There are other creative ways to share research literature if schedules are not amendable to group journal club meetings. There are several books and courses to continue to enrich your knowledge of EBP; however, seeking a EBP mentor is an ideal strategy to facilitate the navigation of a project within your organization. Posing your clinical questions using the PICOT format will allow you to systematically identify the clinical issue. The PICOT format drives a focused question. Following the subsequent EBP process supported by evidence will guide the project to answering the question.
Johnston, B., Coole, C. Narayanasmy, M., Feakes, R., Whitworth, G., Tyrrell, T., & Hardy, B. (2016). Exploring the barriers to and facilitators of implementing research into practice. British Journal of Community Nursing, 21(8), 392-398.
Melnky, B., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing and healthcare: a guide to best practice (3rd ed.)
Munn, Z., Lockwood, C., & Moola, S. (2015). The development and use of evidence summaries for point of care information systems: a streamlined rapid review approach. World on Evidence-Based Nursing, 12(3), 131-138.
Ramos-Morcillo, A., Fernandez-Salazar, S., Ruzafa-Martinez, M., & Del-Pino-Casado, R. (2015). Effectiveness of a brief, basic, evidence-based practice course for clinical nurse. Worldviews on Evidence-Based Nursing, 12(4), 199-207.