-Evidence-based Practice in Nursing -Steps of Evidence-Based Practice -Hierarchy of Evidence | Quantitative Questions -Elements of Evidence-Based Practice -Nursing Research -Types of Research -Rights of Human Subject -Comparison of Nursing Process with Research Process Table -Performance Improvement in Nursing -Examples of Performance Improvement Models -Relationship between Evidence-Based Practice, Research, and Performance Improvement -Similarities and Differences among Evidence-Based Practice, Research, and Performance Improvement

1. REFERENCE: Fundamentals of Nursing 10TH EDITION, 2021
(Hall, Amy M. Perry, Anne Griffin Potter etc.)
THE NEED FOR EVIDENCE-BASED PRACTICE
Evidence-based practice (EBP) is a problem-solving approach to clinical care that combines the purposeful
and systematic application of best evidence with a clinician's skills, patient preferences and values, and
accessible health care resources when making patient care decisions.
Implementing new knowledge into practice requires a systematic approach that incorporates evidence-
based practices to enhance clinical educational and administrative practice.
SOURCES OF EVIDENCE
 A textbook incorporates evidence into the information, practice guidelines, and procedures it
includes.
 Articles from nursing and health care literature are available on almost any topic involving nursing
practice in either journals or on the Internet.
The challenge is to obtain the very best, most relevant, current, and accurate information when you
need it for patient care
The best scientific evidence comes from well-designed studies published in peer-reviewed journals. After
a study is completed, researchers can typically determine if a new treatment or technique works.
Application of evidence and outcomes vary depending on your patients' values, health, preferences, worries,
and/or expectations. Evidence-based practice requires ethical and accountable professional nursing
practice. As a nurse, you utilize critical thinking to decide which evidence is relevant to your patients'
situations.
STEPS OF EVIDENCE-BASED PRACTICE
Evidence-based practice is a methodical, problem-solving approach that enables the implementation of best
practices. Adhering to a step-by-step process consistently guarantees that you receive the strongest available
evidence for use in patient care.
1. Cultivate a spirit of inquiry within an EBP culture and environment.
2. Ask a clinical question in PICOT format.
3. Search for the most relevant and best evidence.
4. Critically appraise the evidence you gather.
5. Integrate the best evidence with your clinical expertise and patient preferences and values to make
the best clinical decision.
6. Evaluate the outcomes of practice changes based on evidence.
7. Communicate the outcomes of EBP decision or changes.
Always keep your practice in mind when caring for patients. What does not make sense to you and what
requires clarification? Consider a time-consuming, costly, or irrational problem or area of interest. These
reflections are part of a continuing quest for best practices.
To formulate questions in Evidence Based Practice, use the PICOT format.
PICOT stands for:
Population/ Patient Problem: Who is your patient? (Disease or Health status, age, race, sex)
Intervention: What do you plan to do for the patient? (Specific tests, therapies, medications)

2. LEVEL 1
LEVEL 2
LEVEL 3
LEVEL 4
LEVEL 5
LEVEL 6
LEVEL 7
Comparison: What is the alternative to your plan? (ie. No treatment, different type of treatment,
etc.)
Outcome: What outcome do you seek? (Less symptoms, no symptoms, full health, etc.)
Time: How long does it take for an intervention to accomplish a result (e.g., how long does it take
to modify a patient's quality of life or behavior)?
Your PICOT question will fall under one of these types:
 Therapy/Prevention
 Diagnosis
 Etiology
 Prognosis
Once you have a PICOT question, you can start looking for evidence. Evidence for your question can be
found in agency policy and procedure manuals, quality improvement statistics, existing clinical practice
recommendations, and journal papers. Ask for help finding relevant evidence. Nurse educators, risk
managers, and infection control nurses are key resources.
RATING SYSTEM FOR THE HIERARCHY OF EVIDENCE: QUANTITATIVE QUESTIONS
Level I: Evidence from a systematic review of all relevant randomized controlled trials (RCT's), or
evidence-based clinical practice guidelines based on systematic reviews of RCT's
Level II: Evidence obtained from at least one well-designed Randomized Controlled Trial (RCT)
Level III: Evidence obtained from well-designed controlled trials without randomization, quasi-
experimental
Level IV: Evidence from well-designed case-control and cohort studies
Level V: Evidence from systematic reviews of descriptive and qualitative studies
Level VI: Evidence from a single descriptive or qualitative study
Level VII: Evidence from the opinion of authorities and/or reports of expert committees
ELEMENTS OF EVIDENCE-BASED ARTICLES

3. 1. ABSTRACT. An abstract rapidly tells you if the article is scientific or clinical. An abstract outlines the
article's goal.
2. INTRODUCTION. The introduction explains the article's aim. There is generally a brief explanation
of the topic's importance. The abstract and introduction combined help you decide whether to read
the whole article.
3. LITERATURE REVIEW OR BACKGROUND. A good author provides a full background of the topic's
scientific or clinical facts. The literature review explains why the author chose to examine or report
on a clinical subject.
4. MANUSCRIPT NARRATIVE. The article's "middle section," or narrative, varies according on the
sort of evidence-based article.
Example: A clinical article explains a patient population, the nature of an illness or health change,
how patients are affected, and the necessary nursing therapies.
5. PURPOSE STATEMENT: Describes a study's purpose. Predictions concerning the relationship or
differences among study variables (concepts, qualities, or characteristics that vary among subjects)
are called research questions.
6. METHODS OR DESIGNS: This section outlines the steps taken to address the research question or
test the hypothesis. This section describes the study's design and the number of participants.
Patients, family members, and health care workers are common research subjects.
7. ANALYSIS: This section outlines how a study's data is analyzed. If the study collects quantitative
data such as physical measures or survey ratings, the results are discussed.
8. RESULTS OR CONCLUSIONS: An article's summary section. In a clinical paper, the author discusses
the topic's clinical consequences. A research article describes the findings of a study and how a
hypothesis or research question is answered. In this part, an author should also highlight study
limitations. The limits information might help you determine whether to utilize the evidence with
your patients. Ask a professor or a nurse to assist you comprehend statistical data.
9. CLINICAL IMPLICATIONS: A research paper contains a section describing if the study's findings
have clinical relevance. The researcher discusses the generalizability of the findings or how to use
them in practice for the sort of subjects researched.
INTEGRATE THE EVIDENCE
Once you have determined that the evidence is reliable and pertinent to your patients and clinical
setting, you may begin determining how to incorporate it into practice. The first step is to incorporate
the study into your patient's plan of care. Utilize the evidence you discover to justify an intervention
you intend to try.
When you work on a hospital committee or task force, EBP changes can be significant. Engaging all
stakeholders (individuals who have an interest or concern in the practice change) requires explaining
the importance of evidence-based treatments.
Consider the setting in which the evidence will be used and inquire if stakeholders support the change.
To incorporate evidence into practice, all stakeholders must be educated. This includes educational
seminars, informative newsletters, and periodic staff meetings.
Integrating evidence into practice is frequently accomplished by incorporating new evidence into
policies and processes (P&Ps). A critical aspect of an evidence-based practice environment is the
requirement that clinical practice policies and procedures be evidence-based.
EVALUATE THE OUTCOMES OF THE PRACTICE DECISION OR CHANGE
After using evidence in your practice, evaluate the results. How does it work? Is your patient or practice
setting the clinical decision? Sometimes evaluating an intervention is as simple as verifying whether the
intended outcomes are met.

4. COMMUNICATE THE OUTCOMES OF THE EVIDENCE-BASED PRACTICE DECISION
It's critical to communicate the results of EBP changes. If you use an evidence-based intervention on
one patient, you and the patient decide how effective it is. When a nursing unit changes a practice, the
clinical staff on that unit is often the first to discuss the outcomes. Huddles and visual management
tools like a Gemba board for process issues are useful ways to communicate EBP modifications.
Share the data with professional bodies such as the nursing practice council, EBP council, or research
council to support professional development and improved patient outcomes.
As a professional nurse, you must contribute to the developing body of nursing knowledge. Nurses
frequently report EBP changes during clinical grand rounds and professional conferences. Professional
organizations enable them to present EBP improvements in scientific abstracts, posters, or even podium
presentations.
SUSTAIN KNOWLEDGE USE
It's difficult to sustain EBP-induced changes in practice. Government and accrediting bodies, internal
administrative initiatives, and the continual pressures of providing safe and effective patient care
bombard health care organizations. It is critical to integrate new practice changes into an organization's
culture and practice environment. Institutions must adopt targeted measures to sustain EBP choices
and modifications. Major health care systems often recruit nurse researchers or scientists to run and
expand their EBP and nursing research programs.
NURSING RESEARCH
By conducting nursing research, you can discover out new information, improve nursing education, and
better utilize healthcare resources. To re-search or re-examine. It is a methodical procedure of asking
and answering questions. The knowledge supports nursing practice and validates nursing interventions.
Nursing research improves professional education and practice, and helps nurses use resources
efficiently (e.g., establishing the optimal nurse-assistant ratio on a nursing unit). Science in nursing
continues to expand, allowing nurses to deliver safe and effective patient care. There are many
professional and specialized nursing organizations with research goals for their members.
TRANSLATION RESEARCH
 Translation research aims to improve patient outcomes and population health by exploring
implementation methods.
 It is also called implementation science.
 Translation researchstudies aim to examine implementation tactics to see which ones performbest
to enhance EBP use.
 By performing translation research, nurses can enhance and sustain the use of the best available
evidence in clinical practice, with the aim of enhancing patient care, population health, and health
outcomes.
5 PHASES OF TRANSLATION RESEARCH
Preclinical and animal studies—basic science research
Phase 1 clinical trials—testing safety and efficacy in a small group of human subjects
Phase 2 and 3 clinical trials—testing safety and efficacy in a larger group of human subjects and
testing for comparison to standard treatment
Phase 4 clinical trials and outcomes research—translation to practice
Phase 5 population-level outcomes research—translation to community

5. In translation research, a study evaluates the tactics used to implement and maintain EBP, whereas EBP
focuses on the utilization of the best available evidence in practice. Research into translation poses a
research topic and a hypothesis.

6. OUTCOMES RESEARCH
Outcomes research assists patients, health care professionals, and everyone involved in health care policy
in making evidence-based decisions. Typically, outcomes research examines the benefits, dangers, costs,
and overall effects of a treatment on patients.
Components of an outcome consist of the outcome itself, how it is observed (the indicator), its important
qualities (how it is assessed), and its spectrum of parameters.
SCIENTIFIC METHOD
The scientific method is the most dependable and impartial way to gather knowledge. This method is a
scientific way to learn. Incorporate research-based evidence into practice and do more research. When
completed correctly, you know that the study supports the validity, reliability, and generalizability of the
data.
CHARACTERISTICS OF SCIENTIFIC RESEARCH
1. The research identifies the problem or study area.
2. A research study is planned and executed in a systematic manner.
3. Researchers try to control variables that aren't being researched but can affect a link between
variables.
4. Researchers employ empirical data collected through observations and assessments to uncover
new information.
5. The goal is to apply study findings to a larger patient population.
NURSING AND THE SCIENTIFIC APPROACH
Nursing research addresses key nursing topics. Some of these concerns concern the profession itself, nurse
education, individual patient and family requirements, and issues within the health care delivery system.
After research is completed, it is critical to share the findings. Publication of discoveries in professional
publications is one form of dissemination. Clinical issues are studied in nursing research.
TYPES OF RESEARCH
1. Historical research designed to establish facts and links relating to the past
2. Exploratory research. Initial investigation aimed at developing or refining the dimensions of
phenomena (facts or happenings) or developing or refining a hypothesis regarding the links
between phenomena.
3. Evaluation research. Evaluation of the effectiveness of a program, practice, or policy.
4. Descriptive research. A study that examines the qualities of individuals, circumstances, or groups,
as well as the frequency of events or attributes.
5. Experimental research: The researcher controls the study variable and randomly assigns individuals
to various situations in order to test the variable.
6. Correlational research. Study that explores the interrelationships among variables of interest
without any active intervention by the researcher.
TYPES OF RESEARCH APPROACH
1. Quantitative research is the exact, methodical, and objective analysis of concepts. It emphasizes
numerical data, statistical analysis, and controls in order to avoid bias in the conclusions.

7. Types of Quantitative Method
a. Experimental research- The standard of care is compared to an intervention (e.g., a new
medicine, therapy, or instructional method). Subjects are randomly assigned to either the
control or treatment group.
b. Nonexperimental Research. Nonexperimental descriptive studies describe, explain, or predict
phenomena (an observable fact, event, or occurrence). Example: A case-control study
investigates if one or more predictor variables are associated with the condition.
Correlational research explicates the connection between two variables (e.g., the age of the
adolescents and whether the adolescents smoke). The researcher determines whether and to what
extent the two variables are connected or associated with one another.
c. Surveys collect data about people's habits, perceptions, education, experience, and opinions.
A survey's primary function is description. Surveys collect a lot of data on the population and
the study issue. In surveys, the population sampled must be large enough to minimize sampling
error.
d. Evaluation research determines why a program (or some program components) is effective or
ineffective. When programs are failing, evaluation research identifies program faults, potential
for change, and implementation hurdles.
2. Qualitative Research
Qualitative nursing research examines difficult-to-quantify or-categorize phenomena, such as
patients' views of sickness or quality of life. This research approach describes information gathered
in a nonnumerical manner, for as data in the form of transcribed interview transcripts.
It uses inductive reasoning to generate generalizations or hypotheses from specific observations or
interviews
RESEARCH PROCESS
The research process consists of a sequence of phases that enable a researcher to progress from posing a
researchquestion to discovering the answer. Typically, the solution to the initial researchquestion generates
more questions and study fields. The research procedure generates knowledge applicable to comparable
circumstances.
RIGHTS OF HUMAN SUBJECT
1. INFORMED CONSENT means that research subjects
a. are given full and complete information about the purpose of a study, procedures, data
collection, potential harm and benefits, and alternative methods of treatment.
b. are capable of fully understanding the research and the implications of participation.
c. have the power of free choice to voluntarily consent or decline participation in the research.
d. understand how the researcher maintains confidentiality or anonymity.
2. CONFIDENTIALITY guarantees that any information a subject provides will not be reported in any
manner that identifies the subject and will not be accessible to people outside the research team.

8. COMPARISON OF STEPS OF THE NURSING PROCESS WITH THE RESEARCH PROCESS
NURSING
PROCESS
RESEARCH PROCESS
Assessment Identify area of interest or clinical problem.
 Review literature.
 Formulate theoretical framework.
 Reflect on personal practice and/or discuss clinical issues with experts to
better define the problem.
Diagnosis Develop research question(s)/hypotheses.
Planning Determine how study will be conducted:
 Select research design/methodology.
 Identify plan to recruit sample, taking into consideration population,
number, and assignment to groups.
 Identify study variables: specific interventions (independent variable) and
outcomes (dependent variables).
 Select data collection methods.
 Select approach for measuring outcomes: questionnaires, surveys,
physiological measures, interviews, observations.
 Formulate plan to analyze data: statistical methods to answer research
questions/hypotheses.
Implementation Conduct the study:
 Obtain necessary approvals.
 Recruit and enroll subjects.
 Implement the study protocol/collect data.
Evaluation Analyze results of the study:
 Continually analyze study methodology. Is study consistently carried out?
Are all investigators following study protocol?
 Interpret demographics of study population.
 Analyze data to answer each research question/hypothesis.
 Interpret results, including conclusions, limitations.
Use of the findings:
 Formulate recommendations for further research.
 Determine implications for nursing.
 Disseminate the findings: presentations, publications, need for further
study, how to apply findings in practice.
Performance Improvement
 Performance improvement (PI) is a systematic method for analyzing processes connected to health
care.
 It is the attempt to achieve measurable improvements in the efficiency, effectiveness, performance,
accountability, results, and other quality indicators of services or processes.
Performance Improvement Programs
 It focuses on processes or systems that significantly contribute to an organization's outcomes and
plans to sustain measurable gains over time. Facilities need a structured way to ensure everyone
supports continual performance improvement.
 The Performance Improvement (PI) process begins with staff involvement in detecting quality
issues. Staff employees must know the organization's results and the practice standards or rules
that define quality.

9. EXAMPLES OF PERFORMANCE IMPROVEMENT MODELS
PERFORMANCE
IMPROVEMENT MODEL
SUMMARY DESCRPTION
Balanced Scorecard A multidimensional framework for strategy management that links
objectives, initiatives, targets, and performance measurements across
major organizational viewpoints.
Root cause Analysis (RCA) A standardized strategy for analyzing major adverse occurrences. A basic
principle of root cause analysis is to discover underlying problems that
increase the chance of errors without falling into the trap of focusing on
errors.
Six Sigma A process improvement methodology that employs a wide array of
instruments based on thorough data analysis to discover sources of
performance variation and methods for eliminating them.
Plan-Do-Study-Act
(PDSA)
A method of experiential learning that involves assessing a quality problem
and testing a change by making a strategy to test the change (Plan),
executing the test (Do), seeing the results and learning from them (Study),
and identifying which improvements should be made to the test (Modify)
(Act).
THE RELATIONSHIP BETWEEN EBP, RESEARCH, AND PERFORMANCE IMPROVEMENT
EBP, research, and performance improvement (PI) are intertwined and create a clinical scholarship
continuum. To give the finest patient care, you must use all three procedures. As a nurse, you must know
the differences and which approach to use when dealing with clinical issues or improving patient care.
Although you will utilize them all in nursing, it is crucial to understand their similarities and distinctions.
Before starting an EBP project, it is critical to review relevant research and PI data. This data helps you
understand the scope of a problem in your organization. PI data provide information about how processes
run within an organization and hence how to change EBP. EBP and PI can indicate research prospects.

10. SIMILARITIES AND DIFFERENCES AMONG EVIDENCE-BASED PRACTICE, RESEARCH, AND
PERFORMANCE IMPROVEMENT
EVIDENCE-BASED
PRACTICE
RESEARCH PERFORMANCE
PURPOSE Utilization of research,
expert opinion, personal
experience, and patient
preferences to determine
safe and effective nursing
interventions with the aim
of enhancing patient
outcomes.
Systematic inquiry
provides answers to
questions, solves issues,
and contributes to the
generalizable body of
nursing knowledge; yet it
may or may not improve
patient care.
Improves local work
processes to enhance
patient outcomes and
health system efficiency;
findings are typically not
generalizable.
FOCUS Implementation of evidence
already known into practice
To discover answers to
unanswered questions
regarding nursing
practice, new information
is developed.
Evaluates the effects of
practice and/or practice
modification on a
particular patient
population.
DATA SOURCES Multiple research studies,
expert opinion, personal
experience, patients
The qualities of subjects or
participants that
determine their inclusion
or exclusion from a study
are predefined.
Researchers collect and
evaluate data from
people.
Data from patient
records or patients who
are located in a certain
place, such as on a
patient care unit or who
have been admitted to a
specific hospital.
Who conducts
the activity?
Practicing nurses and
possibly other members of
the health care team
Researchers who may or
may not be hired by the
health care organization
and who are typically not
members of the clinical
health care team.
Employees of a health
care agency, including
nurses, doctors, and
pharmacists
Is the activity part
of the regular
clinical practice
Yes No Yes
Is IRB approval
needed?
Sometimes Yes Sometimes
Funding sources Internal, from health care
agency
Typically, funding is
external, such as a
government grant.
However, foundations of
larger health care
organizations frequently
offer internal funds.
Internal, from health
care agency
The example below illustrates how the three stages combine to enhance nursing practice:
Recently, a nursing unit has seen a drop in patient satisfaction with pain management. PI data highlight
factors linked with pain treatment (e.g., typical pain medication orders, patient reports of pain alleviation)
 Following a thorough evaluation of PI data, a unit-based quality council team of nurses implements
the best evidence available to improve their pain-management policy for the unit's patients. The
team revises the pain management protocol and evaluates it. Despite the improved pain-
management approach, patient satisfaction remains low. So, to better understand this clinical issue
and improve patient care, staff perform a research study.

12. KEY ELEMENTS
1. EBP assists nurses and other healthcare professionals in making timely, effective, and appropriate
clinical decisions.
2. Cultivate a spirit of inquiry, formulate a clinical question using the PICOT format, search for the
most relevant and best evidence, critically appraise the evidence, integrate the best evidence,
evaluate the outcomes of the practice change, and communicate the results of the change are the
steps of EBP.
3. Defining a PICOT question requires using problem- and knowledge-focused triggers to think
critically about clinical and operational nursing unit concerns.
4. A PICOT question allows you to search the scientific literature for proof.
5. If, after evaluating the evidence for a PICOT question, the question remains unresolved and a
knowledge gap exists, the research process is the next option for acquiring new evidence.
6. The research process consists of six sequential steps that allow the researcher to progress from
identifying the problem to answering the research question.
7. The hierarchy of evidence provides a framework for evaluating literature or information and
determining if a source is relevant, reliable, and appropriate for use in clinical settings.
8. A RCT represents the pinnacle of experimental research.
9. Use your clinical skills and consider the values and preferences of patients to ensure that you use
the evidence safely and correctly in practice.
10. Research is a systematic process that generates information and provides a scientific foundation
for nursing practice by posing and answering questions.
11. Well-designed, methodically conducted research projects provide the strongest scientific evidence.
12. Although EBP, research, and PI are closely related, they are distinct nursing processes that need the
utilization of the best available evidence to provide high-quality patient care.