5944966.ppt

American Association of Colleges of Nursing. © 2009 - All Rights Reserved.
This program generously funded by the Robert Wood Johnson Foundation
Evidence-Based Practice
Jane H. Barnsteiner, PhD, RN, FAAN

Evidence-Based Practice:
As Used in this Module
Integrating best current evidence
with clinical expertise and
patient/family preferences and
values for delivery of optimal
health care.

Key Message
The key message of this module is:
Safe, effective delivery of patient care requires the use
of nursing practices consistent with the best available
knowledge. This includes use of clinical expertise and
patient preferences and values in addition to current
best research evidence.

Learner Objectives
By the end of this module, the learner will be
able to:
1. Define Evidence-Based Practice and
Translation Research.
2. Describe activities in research synthesis.
3. Describe how to evaluate merit and
usability of existing research.
4. Describe the process from research
generation, dissemination, implementation
and evaluation.
5. Analyze personal and patient
preferences/values implementing research
findings.

Introduction
We are living in a fast-moving world where our
understanding of what can be achieved in health care is
constantly being reframed by advances in science and
technology. A major challenge in health care is valuing
the continual discovery of new knowledge, assessing it
for appropriateness for inclusion in care delivery and
putting into practice the knowledge that exists.

Introduction
It is said that it takes 10 to 20 years for scientific findings
to be integrated into practice and that only 20% or less
of health care is based on research. The challenge we
face is how to increase the rate of adoption and continue
the movement from a profession based on ritual and
tradition to using a wide range of evidence.

Introduction
Evidence-based practice (EBP),
integrating best current evidence
with clinical expertise and
patient/family preferences and
values for delivery of optimal health
care, provides the direction for the
way to think about clinical practice
and lead practice change.

The Role of Evidence
Students need an appreciation and
understanding of the role of evidence,
which includes how to select an
evidence-based practice, and how
clinical expertise and patient values and
preferences should form the basis for
nursing intervention.
It incorporates the development of skills
in locating knowledge, critical thinking
and clinical discernment.

History of EBP in Nursing
Evidence-based practice was first systematically introduced in
nursing with the Conduct and Utilization of Research in
Nursing (CURN) project in the late 1970’s. They reviewed the
research on 10 common nursing procedures including
Structured Preoperative Teaching, Preventing Decubitus
Ulcers, and Reducing Diarrhea in Tube-fed Patients. The
project developed research-based clinical protocols,
systematically implemented them into practice, and measured
the outcomes. Applying the framework of Everett Rogers,
they developed a guide that described, from an organizational
perspective, how to advance nursing practice via use of
research findings.

History of EBP in Nursing
The CURN project demonstrated that synthesized
research put into clinical protocols would be used by
clinicians with beneficial results to patients.
Today we have progressed from research utilization to
EBP and translational research. Faculty and students
need an understanding of the process of getting to EBP
and the potential for positive impact on patient care.

Synonymous Terms with EBP
A variety of terms are used interchangeably with EBP.
These include:
 research utilization
 research implementation science
 dissemination
 diffusion
 research use
 knowledge transfer
 uptake
 knowledge to action
 translational research.

Research conduct is the systematic investigation of clinical
phenomenon or the generating of new knowledge.
Research Utilization (RU) was a term used in the 1980’s and 90’s
to describe a 2 step process of dissemination and implementation.
Dissemination is the systematic efforts to make research available
and implementation is the systematic implementation of scientifically
sound, research-based innovation.
EBP as is noted above builds on RU and integrates clinical
expertise and patient/family preferences and values.

• Translational research is the testing of the effect of
interventions aimed at promoting the rate and extent of
adoption of EBP by healthcare providers.
 Translational research further subdivided to describe
both T1, which is moving research findings from "bench
to bedside" and T2, the translation of results from
clinical studies into everyday clinical practice and health
decision making.
• The work in this competency is directed to T2.

Models and Steps to EBP
Numerous models have been published to guide nurses
in moving to EBP. Commonly used nursing models
include the Iowa, STAR, Hopkins and University of
Arizona.
They share a common foundation in that they use a
Planned Action theoretical approach but do not
necessarily cover all 16 elements in moving knowledge
to practice.

Models and Steps to EBP
1. Identify problem and
formulate a specific
question
2. Identify need for change
3. Identify change agents
4. Identify target audience
5. Identify stakeholders
6. Locate the body of
knowledge, synthesize and
extract the clinical meaning
7. Adapt the
knowledge/design the
innovation to the local
users
8. Assess the barriers to
using the knowledge
9. Develop the dissemination
plan
10.Develop evaluation plan
11.Pilot test the EB practice
12.Evaluate the process
13.Implement the practice
change
14.Evaluate the outcome
15.Maintain the change
16.Disseminate the results of
the practice change

1. Identify Problem and Formulate
a Specific Question
The PICO model is often used to
define a problem and formulate a
specific question:
 Population
 Intervention
 Comparison
 Outcome

1. Identify Problem and Formulate
a Specific Question
An example of the PICO is as follows:
In hospitalized patients over 60 years of age, how
effective is a falls-prevention program in
comparison to the normal standard of care in
decreasing falls and falls injury rates by 50%?
The question guides the search for evidence so the
more explicit the question the easier it is to develop the
search strategies.

2. Identify Need for Change
It is important to identify where the need for change has
arisen. It may be related to new knowledge that needs to
be examined for implementation into the clinical setting
while there has not been any concern with current
practice noted; or it may be related to a clinical problem
which has been identified by clinicians and existing
knowledge is being sought to provide solutions or
improvements to the clinical problem.

3. Identify Change Agents
The earlier that participants who will be instrumental in
bringing about the change are identified and included in
the process, the more likely the change is to be
successful.

4. Identify Target Audience
In this step, those who will be affected by the change are
identified so the practice change can be tailored to fit the
audience.

5. Identify Stakeholders
Knowing the individuals or groups who have a vested
interest in the project and anticipating their acceptance,
support, or resistance is critical to the success of the
project.

6. Locate the Body of Knowledge, Synthesize
and Extract the Clinical Meaning
Searching for evidence in the healthcare literature is
difficult and complex. Numerous templates are used for
conducting systematic reviews. Detailed search
strategies are necessary to locate and compile the
studies to address the question, and appraisal methods
need to be chosen to summarize the state of the
knowledge. Information is gathered from several sources
including locating systematic reviews, clinical practice
guidelines, and searching journal publications for
pertinent research articles.

It includes using multiple search engines such as
Medline and CINAHL and databases such as the
Cochrane collection, clearly identifying search terms and
inclusion and exclusion criteria, developing a Table of
Evidence to lay out the findings, grading the research for
strength of evidence, searching for bias, determining the
benefit versus the risk and burdens of the
treatment/care, and extracting the implications for
practice.

• There are numerous approaches to locating the body of
knowledge to answer a question.
• Clinical practice guidelines, which are systematically
developed statements gleaned from summaries of best
available evidence, may have been developed to assist
clinicians to make decisions about specific clinical
circumstances. Examples include pain management, falls
prevention, congestive heart failure management, and
others. These may be found on the AHRQ National
Guidelines Clearing House Web site.

High quality systematic
reviews provide the
foundation for knowledge
synthesis and they are
indexed in both large,
CINAHL and MEDLINE, and
small databases such as the
Cochrane and Campbell
Collaborations.

There are instances where quality summaries of
evidence or EB guidelines or systematic reviews are not
available and databases are used to locate individual
journal articles for review and synthesis. Knowledge
synthesis is the analysis and interpretation of the results
of individual studies. A librarian is very helpful in
assisting with the search for evidence. Once the studies
are located they must be critically appraised to
determine if the quality of the study is sufficiently sound
to use the results and if the findings are applicable in a
particular setting.

Hierarchy of Evidence / Strength of Evidence
Much has been written about the importance of grading
evidence. A hierarchy of evidence model developed for
questions regarding the effectiveness of an intervention or
therapy has been widely applied to all questions related to
health care (AHRQ, 2002). Numerous hierarchical models for
rating strength, quality and consistency of research evidence
have been disseminated. The models, which use anywhere
from four to eight levels for rating strength of evidence, have
largely originated from medicine. This hierarchy posits the
randomized clinical trial (RCT) as the strongest evidence for
EBP questions.

The Center for Evidence Based Medicine uses Level
and grade: Level 1 (a,b,c), Level 2, (a, b, c), Level 3 (a &
b) and Level 4, and Level 5.
The American Heart Association uses Level A, B, C for
the estimate of certainty of the treatment effect and then
adds Class I, IIa, IIb and III for the size of the treatment
effect .

The ACCP describes the grading recommendations on
the strength of recommendation (Grade I=strong and
Grade 2=weak) and then further classifies the quality of
the methodology as A (RCT), B (downgraded RCTs or
upgraded observational studies) and C (Observational
studies or RCTs with major limitations)
The US Preventive Task Force uses a consistent set of
criteria in assessing strength of evidence

When grading strength of evidence in nursing what needs
to be kept in mind is that different questions have different
hierarchies and the RCT is not necessarily the gold
standard to be applied across all of healthcare. For each
type of question there is an appropriate research design.

The wiki Evidence-Based Medicine Librarian is a
community of librarians involved in teaching and
supporting EBP. On this site are listed numerous
tutorials and resources for grading evidence for various
clinical questions. Toolkits are available to guide
clinicians in the critical appraisal of studies to determine
if study results are valid, interpreting the results in the
context of the patient population and determining if the
results apply to the clinical setting.

7. Adapt the Knowledge / Design the
Innovation to the Local Users.
• This is often referred to as academic tailoring and is
the adapting of the protocol or message to fit the
audience. It includes identifying any processes that
may be peripheral to the clinicians who will implement
the EBP change and should be developed in
consideration of any barriers for change. In nursing
this may include pharmacy, information technology,
and other professional disciplines.

8. Assess the Barriers to Using
the Knowledge
Consideration of barriers that may be
encountered and resolving them prior to
dissemination will help to ensure the
success of the EBP.
This includes identifying resources that
may be necessary and plans to garner
them.

9. Develop the Dissemination Plan
A comprehensive and detailed plan including
communication of the change to all those affected,
training requirements, development of detailed
protocols, and notifying other departments and
individuals who may be affected by the change is
included in the dissemination plan. Active interventions
such as self-study, learning labs, reminders, and
decision supports are more likely to induce change than
passive education.

10. Develop Evaluation Plan
Identifying the predictors of
success and developing a plan
for collecting and analyzing
data are components of the
evaluation plan. This includes
identifying who will be
responsible for collecting,
analyzing, and reporting the
data and at what intervals.

11. Pilot Test the EB Practice
• Pilot test the EB practice. It is always preferable to
pilot test a practice change. Research is conducted
under controlled conditions and it is uncertain how the
intervention will work when applied to real world
conditions.
• Doing small tests of change allows for identification of
challenges and refining of the protocol.

12. Evaluate the Process.
Determine how the practice change is used. Audit and
feedback demonstrates the gap between actual and
desired results and address questions such as did the
clinicians receive the information about a practice
change and did they adhere to the practice change.
How difficult or smooth was it to use the new way?

13. Implement the Practice Change
When the practice change has been modified sufficiently
so that it is working as expected, it is ready to be
implemented in other areas.
A dissemination plan similar to the steps outlined above
is needed to ensure a smooth implementation process.
This includes planning for communication, training, and
obtaining sufficient resources.

14. Evaluate the Outcome
Quality of Care has assumed increasing importance.
The public, government, and third-party payers want to
know the outcomes of our interventions and the
outcomes of care being delivered.
Does it make a difference in the patient’s health, the
provider components of care, and is it cost effective?
Increasingly, nursing is being held accountable for the
quality of nursing care delivered.

15. Maintain the Change
A plan for continued monitoring with
feedback to clinicians promotes
sustainability of the EBP change over
time and allows for assessment of
achievement of desired results.

16. Disseminate the Results of the
Practice Change
Inform clinicians and all stakeholders
of the results of the practice change
including financial and clinical
improvements.

Tailoring the EBP to Users
EBP may be about an individual having a clinical
question or discovering knowledge that may improve
one’s own practice or it may be related to widespread
implementation and organization system change.
When tailoring the EBP to users and developing the
implementation plan, Rogers identifies five steps that
need to be considered.

Tailoring the EBP to Users
• Relative advantage—whether the new EBP is viewed as being better
than the previous practice. This includes economic considerations and
making a business case
• Compatibility—how the EBP is perceived as consistent with the needs
of the adopters or with past practice.
• Complexity—how difficult the EBP is to use and understand.
• Triability—degree to which the EBP may be "tried out" to solve any
glitches in the process.
• Observability—how visible the EBP is to others. The more visible a
change the more likely clinicians are to take up a new practice.

Barriers to EBP
Much has been written describing barriers to EBP and
little has changed in nurses responses over the past 15
years, regarding why nurses do not use evidence in their
practice.

Barriers to EBP
Barriers identified include:
 Lack of time to locate and synthesize knowledge
 Negative attitudes towards research and EBP
 Lack of skill to search the literature and to interpret
evidence
 Access to the internet and computerized resources
 The perception of lack of authority to change practice
These barriers need to be kept in mind even as one
moves through the steps in the process.

Knowledge Explosion
Lifelong learning is an important value in EBP. Keeping
up with the latest evidence, however, is an increasingly
difficult task. It is estimated that more than 6,000 pages
are published daily and with internet resources
expanding the numbers only increase.
A search for synthesized knowledge should be
completed prior to embarking on collecting studies for
synthesis.

Sources of Synthesized Knowledge
Sources of synthesized knowledge include:
 National Guidelines Clearing House
 Sigma Theta Tau International
 Evidence-Based Nursing
 Worldviews on Evidence-Based Nursing
 The Johanna Briggs Institute
 Cochrane Collaborative
 Health Information Resources

Clinical Practice Guidelines
EB clinical practice guidelines are systematically
developed statements that help clinicians and patients
make decisions about health care for specific clinical
circumstances. They often are developed by a
multidisciplinary group, followed by external review prior
to publication.
The National Guidelines Clearinghouse has guidelines
developed in the US as well as internationally.

EB Summaries of Systematic Reviews
Evidence summaries or
systematic reviews provide a
foundation for EBP activities.
Clinicians often do not have the
time to summarize the total
evidence for a question.
Systematic reviews may be
published and indexed in large
databases such as Medline and
CINAHL.

Clinical Expertise and Patient
Values in the Equation

Clinical Expertise and Patient Values
in the Equation
Little has been written regarding patient/family
preferences and values related to EBP as well as the
role of clinical expertise. Generally EBP has focused on
the translation of research into practice. One of the
complaints of EBP is that it is cookbook health care.
However, research evidence alone is not sufficient to
ensure sound clinical decisions necessary for effective
health care.

Clinical Expertise
There are times when evidence is not available to guide practice or
it is equivocal and no clear direction is obvious. Clinical decision
making is a complex process and requires more than research to
guide practice. Clinical expertise is the proficiency and judgment
that individual clinicians acquire through clinical experience and
clinical practice. Increased expertise is reflected in numerous ways,
but especially in more effective and efficient assessments and
diagnoses and thoughtful identification and compassionate use of
individual patients' predicaments, rights, and preferences in making
clinical decisions about their care. Experienced clinicians use both
individual clinical expertise and the best available external evidence.

Incorporating Patient / Family Preferences
One of IOM’s 10 rules for health care calls for the
patient to be at the center of decision making. As such,
incorporating patient/family preferences and values
includes asking patients about their preferred role in
decision making, clarifying
their values, and asking
about support or undue
pressure.

Incorporating Patient / Family Preferences
Question prompts for patients, and coaching to develop
skills in questioning clinicians and deliberating about
options improve patient/family member decision-making
abilities. Kleinman’s questions for ascertaining patients’
beliefs and values may serve as a useful reference.
Some make the case that patient-centered care may at
times conflict with evidence-driven care and that patient
preferences have priority over evidence-based
recommendations.

Ethical Dimensions to EBP
There are certainly ethical dimensions
to EBP.
Some examples of ethical dilemmas
include: priority setting in deciding which
innovations to support or promote; when
is it safe to translate new knowledge into
practice; and what processes should be
subject to ethics oversight and the
mechanisms for this.

Trevor-Deutsch and colleagues (2009) propose two ethical
principles—utility and justice—as the basis for a bioethics
framework.
From a utility perspective, maximization of benefits and
minimization of risk should guide implementation of EBPs.
Considerations should include beneficial outcomes, achieving
greatest benefit for greatest numbers when there are
competing innovations, and consideration of potential benefit
when allocating resources to EBP. Justice mandates the fair
distribution of benefits among beneficiaries.

Questions often arise regarding ethical aspects of
implementing and studying the outcomes of EBP.
Issues such as:
 privacy concerns
 protection of participants' physical well-being
 the data being collected and analyzed
 and any potential conflicts of interest
determine if Institutional Review Board approval is
needed for an EBP practice project.

Evidence-Based Culture
• An EBP culture is one in which all clinicians value—
and are committed to—each of the stages of the EBP
process. The organization is a knowledge-driven
system with strong leadership and a clear strategic
vision and data that form the basis of information. In
teaching students how to deliver safe, effective patient
care, knowledge and skill development needs to
incorporate how to question evidence substantiating
practice as well as how to evaluate existing research.

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