EVEDENCE
BASED
PRACTICE
PRESENTED BY
PANKAJ SINGH RANA
NURSE PRACTITIONER IN
CRITICAL CARE

INTRODUCTION
Evidence-based practice (EBP) is a problem-solving approach to the
delivery of health care that integrates the best evidence from
studies and patient care data with clinician expertise and patient
preferences and values. (Fineout-Overholt E, 2010).
EBP is the integration of clinical expertise, patient values, and the
best research evidence into the decision making process for
patient care.
Clinical expertise refers to the clinician’s cumulated experience,
education and clinical skills.
The patient brings to the encounter his or her own personal
preferences and unique concerns, expectations, and values.

Health care that is evidence-based and conducted in a
caring context leads to better clinical decisions and
patient outcomes. Gaining knowledge and skills in the
EBP process provides nurses and other clinicians the tools
needed to take ownership of their practices and
transform health care.

WAYS OF ACQUIRING
KNOWLEDGE IN NURSING
 Traditions
 Borrowing
 Trial & Error
 Personal Experience
 Role Modeling
 Intuition
 Reasoning
 Research

KEY COMPONENTS OF
EBP
A. Research evidence.
B. Clinical expertise, judicious use.
C. Patient values and circumstances.

KEY COMPONENTS OF EBP
Research
Evidence
Clinical
Expertise
Patient Values,
Circumstances
Randomized controlled
trials
Laboratory experiments
Clinical trials
Epidemiological research
Outcomes research
Qualitative research
Expert practice
knowledge, inductive
reasoning
Knowledge gained
from practice over time
Inductive reasoning
Unique preferences
Concerns
Expectations
Financial resources
Social support

EBP NURSING
Evidence Based Nursing: “An integration of the
best evidence available, nursing expertise, and the
values and preferences of the individuals, families,
and communities who are served.

AIMS OF EVIDENCE
BASED PRACTICE
 To provide the high quality and most cost-efficient nursing
care possible.
 To advance quality of care provided by nurses.
 To increase satisfaction among patients.
 To focus on nursing practice away from habits and tradition to
evidence and research.
 It results in better patient outcomes.
 It contributes to the science of nursing.
 It keeps practices current and relevant.
 It increases confidence in decision-making.

FEATURES of EBP
 Problem based and within the scope of the practitioners experience.
 It brings together the best available evidence and current practice by
combining research with knowledge and theory. So it narrows the research
practice gap. It facilitates application of research into practice by including
both primary and secondary research findings.
 It concerned with quality of service and is therefore a Quality assurance
activity.
 EBP projects are team projects and therefore require team support and
collaborative action.
 It support research projects and outcomes that are cost effective EBP de-
emphasizes ritual, isolated and unsystematic clinical experiences
ungrounded opinions and tradition as a basis of practice. It stresses the use
of research findings.

WHY IS EBP RELEVANT
TO THE NURSING
PRACTICE?
 There is a gap between what we know and what we do. Nursing
practice can and must be changed from tradition-based to
science-based:
 Research-practice gap: Much of what is known from research has
not been applied in practice. This is known as Research-Practice
Gap.

STEPS OF EBP

STEPS OF EVIDENCE BASED
PRACTICE
Step 1: formulating a well built question
Step 2: collecting the most relevant and best
evidence to answer the clinical question
including searching for systematic
reviews/identifying articles
Step 3: Critically appraising the evidence that has
been collected for its validity, relevance and
applicability.

Step 4: integrating the evidence with ones
clinical expertise, assessment of patient’s
condition and available health care
resources along with the patients
preferences and values to implement the
evidence.
Step 5: Evaluating the change resulting from
application of evidence in practice.
Determine the areas for improvement.

Step1: FORMULATING THE
QUESTION
 With clinical areas ,there is often a barrage of
details to digest. a well built question includes
the following components
 the patients disorder or disease
 the intervention or finding under review
 a comparison intervention
 the question should be in PICOT or PICO
format

PICOT FORMAT
Patient, Population or Problem
 What are the characteristics of the patient or population?
 What is the condition or disease you are interested in?
( i.e. age, gender, ethnicity, with a certain disorder)
Intervention or exposure
 What do you want to do with this patient (e.g. treat, diagnose, observe)?
(exposure to a disease, risk behavior, prognostic factor)
Comparison
 What is the alternative to the intervention (e.g. placebo, different drug,
surgery)?
(could be a placebo or "business as usual" as in no disease, absence of
risk factor, Prognostic factor B )

Outcome
 What are the relevant outcomes (e.g. morbidity, death,
complications, risk of disease, accuracy of a diagnosis, rate of
occurrence of adverse outcome)
Time
 What time it takes to demonstrate an outcome (e.g. the time it
takes for the intervention to achieve an outcome or how long
participants are observed).

Are insulin pumps more effective than
conventional therapies in managing type 2
diabetes in pregnant women?
 Patient/Population - Pregnant women with
type 2 diabetes
 Intervention - Insulin pump therapy
 Comparison - Conventional insulin therapy
 Outcome - Improved management of glucose
levels

SEARCH STRATEGIES BACKGROUND
INFORMATION
 Background information may be found in
sources such as:
 reference book entries
 textbooks, chapters, appendices
 drug monographs, guides to diagnostic tests
 the library’s Bobcat catalog
 selected electronic Reference Tools for
Background information in the health science.

Step 2. DATABASE /RESOURCE
SEARCHING
 Once a clinical practice question has been selected,
the next step is to search and assemble research
evidence on the topic. In doing a literature review as a
background for a new study, the central goal is to
discover where the gap are and how best to advance
knowledge. The resourses falls into 3 categories:

General information/background resourses-
to collect the past information of a particular disease. e.g measles
has been nearly eradicated, but there has been a fairly recent
outbreak. If you need to refresh your knowledge of the clinical
presentation, diagnosis etc of measles, a background resource
would be the best place to start.
Filtered resourses-
If you are trying to decide on a course of action for a patient
(diagnosis, treatment etc)and want to base your decision on the
best available evidence, consult a filtered resource. clinical experts
and subject specialists pose a question and then synthesize
evidence to state conclusions based on the available research.
because of this pre evaluation, the clinician does not have to do the
literature searching and evaluate each study that comes up, saving
time and ensuring a level of completeness.

 · Unfiltered resources-
If you don’t find an appropriate answer in the
filtered resourses ,you will need to search
unfiltered resourses (the primary literature) to locate
studies that answer your question. unfiltered
resourses provide the most recent information ,but
its upto to the clinician to evaluate each study found
to determine its validity and applicability to the
patient.
Effectvely searching and evaluating the studies
found in unfiltered resources takes more time and
skill, which is why filtered resources are the first
choice of answering clinical questions.

EBP RESOURCES
A. PRE-APPRAISED RESOURCES: Filtered resource
have been reviewed for quality and relevance to
clinical care.
 ACP Journal Club. This Web site comprises a 10-
year archive of the cumulative electronic contents of
"ACP Journal Club", with recurrent weeding of out-of-
date articles. The content is carefully selected from over
100 clinical journals through reliable application of
explicit criteria for scientific merit, followed by
assessment of relevance to medical practice by clinical
specialists.

 Clinical Evidence.
Clinical Evidence describes the best available evidence from
systematic reviews, RCTs, and observational studies when
appropriate for assessing the benefits and harms of
treatments.
 Dynamed.
Dynamed is a point-of-care reference resource designed to
provide clinicians with current, evidence-based information to
support clinical decision-making.
 Essential Evidence.
Essential Evidence is a one-stop reference that includes
evidence-based answers to clinical questions concerning
symptoms, diseases, and treatment.

 FPIN Clinical Inquiries.
Clinical Inquiries provides answers to clinical
questions by using a structured search,
critical appraisal, clinical perspective, and
rigorous peer review. FPIN Clinical Inquiries
deliver evidence for point of care use.
 UpToDate.
UpToDate is an evidence-based, peer
reviewed information resource available via
the Web, desktop/laptop computer, and
PDA/mobile device.

 DATABASES:
PubMed. PubMed comprises more than 22 million
citations for biomedical articles from MEDLINE and life
science journals. Citations may include links to full-text
articles from PubMed Central or publisher web sites.
 Cochrane Library. The Cochrane Library contains high-
quality, independent evidence to inform healthcare
decision-making. It includes reliable evidence from
Cochrane systematic reviews and a registry of published
clinical trials. The methodology used to create the Cochrane
reviews is recognized as the gold standard for developing
systematic reviews.
 Center for Reviews and Dissemination (DARE). The
databases DARE, NHS, EED and HTA assist decision-
makers by identifying and describing systematic reviews
and economic evaluations, appraising their quality, and
highlighting their relative strengths and weaknesses.

ELECTRONIC TEXTBOOKS AND LIBRARIES:
 AccessMedicine: Access Medicine is an online resource
that provides students, residents, clinicians, researchers, and
other health professionals with access to "Harrisons Online".
 Scientific American Medicine. Formerly known as ACP
Medicine, Scientific American Medicine includes science,
medicine, health and technology information. It is also
available from Stat!Ref.
 ACP Smart Medicine. Formerly known as ACP PIER, ACP
Smart Medicine is an online clinical tool that provides
evidence-based clinical guidance to improve clinical care. It is
free to ACP members or can be purchased as a subscription.
 Stat!Ref. STAT!Ref is a collection of online electronic
textbooks for healthcare professionals.

META-SEARCH ENGINES:
 Trip. The TRIP Database searches across
multiple internet sites for evidence-based
content. It covers key medical journals,
Cochrane Systematic reviews, clinical
quidelines, and other highly relevant websites
to help health professionals find high quality
clinical evidence for clinical practice.

Step3. CRITICALLY APPRAISING THE
ARTICLE
 The assessment of evidence by systematically reviewing its
relevance, validity and results of specific situations.
 In determining the implementation potential of an innovation in a
particular setting, several issues should be considered, particularly
the transferability of the innovation, the feasibility of implementing it
and its cost benefit ratio. For example, the traditional method for
verifying the placement of a nasogastric tube was air insufflation.
However, according to current nursing research, the accurate
method for verifying placement is radiologic examination (Metheny
& Titler, 2001).

 If the implementation assessment suggests that there might
be problems in testing the innovation in that particular
practice setting, then the team can either identify a new
problem and begin the process anew or consider adopting
the plan to improve the implementation potential (e.g.
seeking external resources if cost were the inhibiting factors)

Step 4. APPLYING THE EVIDENCE/INTEGRATING EVIDENCE
WITH ONES CLINICAL
 EXPERTISE
 If the implementation criteria are met the team can design and plot
the innovation. To reach your conclusion you may consult
questions related to diagnosis ,therapy, harm and prognosis keep
in mind that you must interpret the information based on a number
of criteria and depending on your skill and experience ,you may
need to confer with a peer.
example- Sample evidence practice e.g. consider a nine year
old girl present in the ER with abdominal pain and you
suspect appendicitis. which imaging modality is best for
making the diagnosis CT or ultrasound.

Step 5. EVALUATING THE CHANGE
 The fifth step of the process, outcome evaluation, attempts to
interpret the results and evaluate the outcomes of the applied
evidence (intervention). Outcome measures may be
psychosocial (quality of life, improved patient perception of
care, reduction in depressive and anxiety symptoms),
physiologic
 (improved health, reduced complications), or functional
improvement. Evaluation of the process and the results may
occur through peer assessment, audit, or even self reflection.
Depending on the type of outcomes achieved, it may be
possible to compare the outcomes of a study with similar
outcomes on a local, regional, national, or international level.

MODELS FOR EVIDENCE
BASED NURSING
PRACTICE The models offer guidelines for designing and
implementing a utilization project in a practice setting.
The two models stelter model and Iowa model
incorporate evidence practice processes rather than
research utilization alone.
 John Hopkins Model
 Stelter Model
 CURN
 Iowa Model of Evidence Based Practice

A. THE STELTER MODEL
 The stelter model was designed with the assumption
that Research Utilization could be undertaken
 not only by organizations but by individual clinicians
and managers. It was a model designed to promote and
facilititate critical thinking about the application of
research findings in practice.
 The current model presented graphically involves five
sequential phases:

Preparation
 In this phase, the nurses define the underlying purpose and outcomes
of the project, search, sort and select sources of research evidence.
She considers external factors that can influence potential application
and internal factors that can diminish objectivity and affirm the
priority of perceived problem.
Validation
 This phase involves a utilization of focused critique of each source of
evidence, focusing in particular on whether it is sufficiently sound for
potential application in practice.
Comparative evaluation and decision- making
 This phase involves a synthesis of findings and application of criteria
that taken together are used to determine the desirability and
feasibility of applying findings from validated source to nursing
practice. The end result of the comparative evaluation is to make a
decision about using the study findings.

Translation/application
 This phase involves activities to conform how the
findings will be used (e.g. formally or informally) and
spell out the operational details of the application and
implement them.
Evaluation
 In the final phase, the application is evaluated.
Informal use of the innovation versus formal use
would lead to different evaluative strategies.

IOWA Model
 Efforts to use research evidence to improve nursing
practice are often addressed by group of nurses interested
in the same practice issues.
 This model, like the stelter model, was revised recently an
renamed the Iowa Model of evidence Based Practice to
promote quality of care.
 The current version of Iowa Model acknowledges that
formal RU/EB Project begins with a trigger an impetus to
explore possible changes to practice. The start point can be
either knowledge focused trigger that emerges from
awareness of innovative research findings.

 The model outlines a series of activities with three
clinical decision points.
 I. Deciding whether the problem is a sufficient priority
for the organization exploring possible changes; if yes,
a team is formed to proceed with the project: if No, a
new trigger would be sought.
 II. Deciding whether there is sufficient Research base; if
Yes, the innovation is piloted in the practice setting. If
No, the team would either search for other sources of
evidence or conduct its own research.
 III. Deciding whether the change is appropriate for
adoption in practice; if yes, a change would be
instituted and monitored. If No; the team would
continue to evaluate quality of care and search for new
knowledge.

 The points of entry to this model were problem and knowledge
focused triggers.
 Problem focused triggers encompassed frequently encountered
clinical problems, risk management and quality improvement
data and total quality management programs/ in contrast,
 Knowledge focused triggers include new information that
resulted from such sources as the Agency for Health care policy
and Research, specialty organizations and research
publications.
 When a trigger was identified the next step included assembling,
critiquing, and evaluating the applicability of relevant research
literature.
 After the research base was evaluated and critiqued, a decision
was made regarding whether or not a change in practice was
warranted. If, however, a sufficient and appropriate research
base was found that supported modification of current practice,
changes were initiated that were congruent with those
suggested by the research results. If research base had
insufficiencies, further research was conducted, experts were
consulted and applications of scientific principles were
considered.

To translate research findings into practice several steps
were necessary:
 1) Expected outcomes of the change and baseline or
current status were documented.
 2) Nursing/ multidisciplinary interventions were designed
 3) Practice changes were implemented on a pilot unit.
 4) Process and outcomes were evaluated; and
 5) The interventions were modified as necessary
The next critical decision point involved determination of
whether practice changes should be made for all patient
populations affected by the research based interventions.
Considerations included cost of implementations, overall
impact on quality of care, staff competency and support of
administration.

 This model used a process of planned change . staff need to be
empowered with ownership of the change, as well as, with the
knowledge and resources necessary to make this change.
 This model supported the monitoring of patient outcomes by unit
staff members for atleast two consecutive quarters after
implementation. These activities assisted in maintaining the
practice change and facilitating feedback to the staff. Outcome
measurements are also focused on the effects of change on the
staff and fiscal parameters. Without thorough monitoring of all these
areas an accurate reflection of the cost/benefit relationship could
not be realized.

THE EVIDENCE
HIERARCHY:
 The best evidence for interventions comes from
systematic reviews and RCTs as we move down this
hierarchy in evidence, we usually have less good
information available.
 Systematic review
 Randomized controlled trial
 Cohort study
 Case control study
 Cross-section analytical study
 Descriptive/narrative study

THE EVIDENCE HIERARCHY

Limitations
 Resistant to changes in nursing practice.
 Ability to critically appraise research
findings.
 Time, workload pressures, and competing
priorities.
 Lack of continuing education programs.
 Fear of "stepping on one's toes“
 Poor administrative support.

BARRIERS TO USING RESEARCH IN
NURSING RESEARCH RELATED
BARRIERS

NURSE RELATED BARRIERS
 Many Nurses have not received any formal instruction in
research and they lack skill to judge the merits of a study.
 Nurses attitude toward research and their motivation to
engage in EBP have been identified a potential barrier. People
are often resistant to change. Change requires effort,
retraining and restructuring of work habits. Thus there is likely
to be some opposition to introducing innovations in practice
setting.
ADVICE
 Read widely and critically. Professionally accountable nurses
should read journals relating to their specialty, including
research reports in them.

 Attend professional conference. Conference attending give
opportunities to meet researchers and to explore practice
implications.
 Learn to expect evidence that a procedure is effective.
Nurses need to develop expectations that the decisions they
make in their clinical practice are based on sound rationales.
 Become involved in a journal club. Many organizations that
employ nurses sponsor journal clubs that meet to review
research articles that have potential relevance to practice.
 Pursue and participate in EBP projects. Nurses who are
involved in research related activities develop more positive
attitudes toward research and better research skills.

ORGANIZATIONAL
BARRIERS
 Many of the major impediments to using research in practice stem from the
organizations that train and employ nurses. Organizations have failed to
motivate or reward nurses to seek ways to implement appropriate findings
in their practice. In several studies of barriers to RU, one of the greatest
reported Barrier was “insufficient time on the job to implement new ideas”.
Organizations may be reluctant to expand resources for RU, EBP activities or
for changing organizational policy.
 ADVICE: To promote the use of research evidence, administrators can
adopt the following strategies:
 · Foster a climate of intellectual curiosity. Open communication is important
in persuading staff nurses that their experiences and problem are important
and that the administration is willing to consider innovative solutions.

 Reward efforts for using research. RU should not be the
primary criterion for evaluating nurses
 performance but its inclusion is an important criteria to
affect their behavior.
 · Seek opportunities for institutional RU/EBP projects.
Organizational efforts and commitment are essential for
the type of projects. ·
 Offer emotional or moral support. Administrators need to
make their support visible by informing staff by
establishing EBP committees, by helping to develop
journal clubs and by serving as role models for staff
nurses.
 Offer financial or research support for utilization.

BARRIERS RELATING TO
NURSING PROFESSION
 There is a shortage of appropriate role models- nurses
who can be emulated for their success in using or
promoting the use of research in clinical practice. The
nurses feel that he or she didn’t have “enough
authority to change patient care procedures”
ADVICE:
 Educators could help to promote the use of research
evidence through the following strategies:

 Incorporate research findings into curriculum.
Research findings should be integrated throughout
the curriculum and when possible, the efficacy of
specific procedures should be documented by
referring to relevant studies.
 Encouraging research and research use. Either by
acting as role models to students or by demonstrating
positive attitudes towards research and its use in
nursing.
 Place demands on researchers. Faculty review of
research proposals should demand that researchers
demonstrate the proposed studies potential for
clinical use; they can also demand that the
researchers include a specific plan for dissemination
or utilization.

NURSE ROLE IN
EVIDENCE-BASED
PRACTICE1. A nurse can be a decision-maker and coordinator of care.
2) As a scientist: A nurse ensures his or her practice is evidence-based
and that institution approved protocols are utilized.
3) As a transferor of knowledge: This important role is invoked when
discussing the plan of care with patients, their loved ones, and with
other members of the healthcare team.
4) Manage resources and facilitate the success of unit-based EBP
workgroups
5) Support EBP by communicating with unit staff the expectations for
participation and available resources Encourage broad staff
participation to promote collaborative teamwork

7) Become a primary vehicle for recognition of
staff nurses' success
8) Encourage research and research uses.
9) Offer emotional and moral support to senior
staffs for evidence based practice.
10) Foster a climate of intellectual curiosity.
11)Attend and encourage junior staffs to
conference
12) The registered nurse participates, as
appropriate to education level and position, in
the formulation evidence-based practice
through research.”

13) The registered nurse utilizes current
evidence- based nursing knowledge, including
research findings, to guide practice.
14) Know basis for nursing practice
15) Expect that evidence is the foundation of
practice
16) Participate in EBP projects
17) Disseminate project findings in various
forums
18) Collaborate with the healthcare team to
provide quality care

Thank
you