The document discusses evidence-based practices in nursing. It begins by defining evidence-based practice and outlining the key components of EBP, which include best research evidence, clinical expertise, and patient values. Recent examples of EBP in nursing are then provided, such as optimal techniques for blood pressure measurement and gastric tube placement verification. Challenges to implementing EBP are also examined, like lack of knowledge, negative attitudes towards research, and organizational constraints.

2. RECENT EVIDENCE BASED PRACTICES
&
CHALLENGES ENCOUNTERED IN NURSING CARE
Mr. Asokan.R,
Asso. Professor, KINS,
KIIT Deemed to be University, Bhubaneswar.

3. At the end of this session you will be able to:
• Know the basics of Evidence Based Practice
• Some of the recent Evidence Based Nursing Practice
• Challenges of implementing EBP
• Barrier faced by Nursing staff to implement recent Evidence Based
Practices in Nursing.
• Access the Research Database for EBP

4. What is Evidence-based practice ?

5. Knowing that what we do is the best practice.

6. How do we know in Nursing?

7. • Tradition
• Authority
• Borrowing
• Trial and error
• Personal experience
• Role modeling and mentorship
• Intuition and reasoning
• Nursing research

8. Evidence based practice is the process by which Nurses make clinical
decisions using the best available research evidence, their clinical expertise and
patient preferences, in the context of available resources.
(DiCenso et al, 1998).

9. In nursing, this approach
has been emphasized but there
is a great focus on participation
of the client, the clinical
judgment, and the resources
available in the healthcare
system.

10. However, there are many challenges that are facing the
implementation of this system especially for the new nurses who have
not gained enough experience.

11. How should follow
the process of EBP?

13. Nursing outcomes
Nursing action
Clinical
expertise
Practice context
Best
Research
Evidence
Patient
values / User
perspectives

14. Clinical Expertise
• Knowledge gained from practice over time
• Inductive reasoning (supplying some evidence for the truth of the
conclusion)

15. Patient Values / User perspectives
• Unique preferences
• Concerns
• Expectations
• Financial resources
• Social supports

16. Best Research Evidence
• Arising from well conducted and reviewed research studies, ideally
conducted in clinical areas.
• Published in peer reviewed journals and other sources (Cochrane
library) and exposed to external/expert scrutiny
• Clinical expertise and the user voice may be present in published
research.

17. Where will find out the Best Research Evidence?

18. Best Research Evidence
• Randomized controlled trials
• Laboratory experiments
• Clinical trials
• Epidemiological research
• Outcomes research
• Qualitative research
• Expert practice knowledge

19. Why is Evidence Based Practice important and why now?

20. • Changing patient demographics require new approaches to care.
• The Evidence based practice is rapidly expanding and growing in
complexity for Nursing and other disciplines.

21. What are the Significance of EVIDENCE BASED PRACTICED?

22. • Best practices that have been greatly research in details while handling their
patients.
• EBP puts the client value at the center of the health care practices.
• EBP ensure that client values and practices are considered while providing
healthcare.
• Creates a patient preference, needs and values acts as guide to all clinical
decision made by healthcare providers.
• Most appropriate clinical decision that takes care of all the above aspects.

23. Benefit for Nurses?

24. Reduced likelihood of making type 1 and type 2 errors in practice
Type 1 – Acceptance of a practice that is incorrect.
Example: Administration of a wrong dose, using the wrong
procedure, teaching patients using the wrong information.
Type 2 – Rejection of a practice that is correct.
Example: Failing to screen patients for fall or pressure ulcer
risks; failing to wash hands before and after patient contact; failing to
provide patients with smoking cessation information.

25. What are the Recent Evidence based practices?

26. “Instillation of normal saline before endotracheal suctioning:
helpful or harmful?”
• EBP recommendations – resources of EBP recommendations are
unanimous in their recommendation that instillation of normal saline
should not be performed as a routine step with endotracheal
suctioning.

27. Why?

28. Most hospital policies and procedures for management of
artificial airways include instilling 5 to 10 mL of normal saline before
endotracheal suctioning is done. This nursing and respiratory therapy
routine was advocated as a way to improve oxygenation and removal of
secretions by thinning thick secretions and stimulating coughing to
assist with mobilization of secretions.

29. • Effect on Oxygenation: An interesting finding in studies that showed
decreases in oxygenation after instillation of saline before
suctioning was that return to baseline oxygenation levels did not occur
until at least 3 to 5 minutes after the suctioning procedure was
finished.

30. • Effect on Thinning Secretions: who believe that normal saline thins secretions, try
the following experiment to see for what impact administration of a bolus of normal
saline has on thick secretions.
• The next time you use suctioning, use a mucus trap to collect some of the thick
secretions.
• Then, insert 5 to 10 mL of normal saline into the trap and observe how the saline
remains separate from the mucus, even after vigorous shaking.
• Let the mixture sit a while to validate that even with exposure over time, the mucus
and fluid remain separate from each other.
• If normal saline cannot thin thick secretions in a mucus trap with really vigorous
shaking, it certainly cannot do it in a patient’s lungs.

31. • Risks of Bacterial Contamination: In 2 studies researchers reported that instillation of
normal saline may place the patient at risk for hospital-acquired pneumonia.
• A study found that the rims of the individual-dose vials of normal saline were often
contaminated with bacterial organisms just before insertion of the fluid into the
endotracheal tube.
• On the basis of the type of bacterial organisms found on the rim, they hypothesized that
the contamination of the vial had occurred when clinicians had “popped” the top off the
vial with a thumb.
• Although the researchers did not evaluate infection of patients, introduction of bacterial
organisms because of contamination during administration of the fluid is certainly
theoretically possible.

32. • Surveys of Nursing Practice: In several reports since 1996, researchers have
described how often nurses and respiratory therapists instill normal saline
before endotracheal suctioning.
• In most of the studies, 25% to 33% of nurses routinely or frequently instilled
normal saline before suctioning.
• Twice as many respiratory therapists as nurses instilled normal saline.
• Most of the hospitals surveyed indicated that instillation of normal saline
before endotracheal suctioning was included in the hospital’s policy/
procedure for suctioning.

33. “Verification of proper placement of gastric and post-pyloric tubes:
what is the best way?”
• EBP recommendations – National guidelines and expert opinion
indicate that the best method for confirming the location of blindly
inserted GI tube is chest radiography.

34. • Methods of Detecting Inadvertent Pulmonary Placement: A variety of
methods have been advocated to detect when a gastric or post pyloric
tube has been introduced into the pulmonary system:
auscultation during air insufflation through the tube,
pH testing of aspirated fluid,
visual inspection of aspirated fluid,
detection of carbon dioxide in the tube,
and radiographic tube verification.

35. • Auscultation during Air Insufflation through the Tube: Auscultation
over the gastric abdominal area during rapid insufflation of air into the
distal end of a gastrointestinal tube is commonly performed after a
tube is inserted.
• Research on air insufflation has never documented that this technique
is accurate for identifying inadvertent intubation of the lungs.

36. • Visual Inspection of Aspirated Fluid: Visual inspection of the color of fluid
aspirated from the tube has been advocated as a method to differentiate gastric
fluid (green, dark yellow) from pulmonary fluid (white, light yellow).
• In the only study in which visual inspection of fluid was evaluated as a way of
determining gastric or pulmonary location of the tube, visual inspection was a
poor predictor of tube location.
• Similar to gastric pH, the colors of gastric and pulmonary secretions are
altered by a variety of conditions, making development of a standard difficult.

37. “The Glasgow coma scale in neurological assessment”
• EBP recommendations – best clinical practice for neurological
assessments includes
optimal and consistent use of GCS plus inclusion of other
neurological data such as
assessments of brain stem reflexes; pupil reactivity and extra
ocular movement; vital signs; and respiratory rate, depth & pattern.

38. • Limitations of the GCS in Neurological Evaluation: The GCS was initially
intended to standardize patients’ assessment and improve communication
about neurological status.
• The GCS is widely used but does have some important drawbacks and
limitations. Patients with specific clinical states such as locked-in
syndrome, catatonia, and psychogenic coma may have a GCS score
indicating depression of consciousness and responsiveness.
• These patients may actually have a higher degree of brain responsiveness
than initially estimated solely on the basis of GCS assessment.

39. • In locked-in syndrome, patients are awake and can follow commands such
as select eye movements. Additional skeletal muscle movement is not
possible because of paralysis below the third cranial nerve.
• In catatonic states, patients may appear unresponsive, but
electroencephalographic evaluation indicates low-amplitude, high-frequency
activity rather than slow-wave, high-amplitude activity associated with
unresponsive states due to structural or metabolic brain injury.
• In psychogenic coma, electroencephalographic evaluation indicates an
awake rhythm.

40. • Predictive Value of GCS Scores: Available research supports, Patients with a
GCS score of 3 and fixed, dilated pupils after brain trauma have no reasonable
chance for survival.
• Aggressive resuscitation and physiological support may be appropriate to
preserve the option of organ donation for family members.
• GCS scores determined in the prehospital setting and after arrival in the acute
care setting correlate closely and are predictive of outcome as well as potential
need for neurosurgical intervention.
• A GCS score of 3 in a patient with reactive pupils is predictive of potentially
better outcomes and suggests that the patient might benefit from aggressive
resuscitation.

41. “Accurate Measurements of Blood Pressure”
In addition to the National guidelines for blood pressure
measurement, a growing body of evidence supports specific procedural
techniques that will improve the accuracy and reliability of
noninvasive and invasive measurement of arterial blood pressure.

42. • How Do You Pick the Correct Cuff Size? : Selection of the
appropriate cuff size is important because a cuff that is too small
yields an overestimation of blood pressure and a cuff that is too
large yields an underestimation of blood pressure.

43. • Does Arm Position Make a Difference for Noninvasive Measurement of
Blood Pressure? : As with intra-arterial blood pressure monitoring, the
appropriate reference level for noninvasive measurement of blood
pressure is the heart.
• Blood pressure will be overestimated if the arm is below the heart and
underestimated if the arm is positioned above the heart.
• Correct positioning of the arm is particularly important if the patient is
sitting up or standing.
• If the arm is parallel to the patient or supported on the arm-rest, the
systolic and diastolic blood pressures may be 10 mm Hg higher than if
the arm is supported horizontally at heart level and in patients with
hypertension, the difference in arm position can cause an
overestimation of systolic blood pressure 20 mm Hg.

44. • With the patient supine, the arm should be supported at the level of the
phlebostatic axis (one-half the distance from the sternum to the back)
rather than placed on the bed, a situation that causes an overestimation
of systolic and diastolic blood pressures of 3 to 5 mm Hg.
• If a patient is in a lateral recumbent position, the noninvasive
measurements of blood pressure taken from the “up arm” may be 13 to
17 mm Hg lower than measurements in supine patients, and blood
pressure measurements from the “down arm” are either inconsistent or
similar to measurements obtained with the patient supine.

45. • How Should Blood Pressure Be Measured in Obese Patients? : Obesity
alone does not affect the accuracy of blood pressure measurements.
• Blood pressure measured in the forearm can be used if a correct cuff cannot
be found; however, blood pressure in the forearm may be higher than blood
pressure in the upper arm.
• For example, in a study of patients who were morbidly obese, only 19% had
systolic and 28% had diastolic blood pressure measurements in the forearm
within 10 mm Hg of the measurements in the upper arm.

46. • The challenge with measuring blood pressure in patients who are
morbidly obese is finding an appropriately sized cuff, although new
cuffs are being developed that have long length but normal width.
• For every 5-cm increase in arm circumference (starting at 35 cm), use of
a standard cuff leads to an overestimation of systolic blood pressure
by 3 to 5 mm Hg and diastolic blood pressure by 1 to 3 mm Hg
compared with an appropriately sized large cuff.

47. To size the cuff correctly, measure the circumference of the
patient’s arm midway between the elbow and the wrist. Cuff size should
be similar to that specified in the guidelines for upper arm
circumference. The cuff should be centered between the elbow and
wrist, and the arm should be supported at the level of the heart.

48. EBP Recommendations
EBP practice recommendations for positioning are as follows:
• If a patient experiences consolidated pneumonia in one lung, positioning
with the good lung down will result in better oxygenation.
• Progressive mobilization to dangling legs, standing, and walking are safe
for intubated patients.
• Patients breathe better and experience improved oxygenation with higher
elevations of the head of the bed if their hemodynamic status is such that
they can tolerate the elevation.

49. • For many critically ill patients, turning every 2 hours is not enough to preserve
the oxygenating ability of the lungs or to prevent health care–acquired
pneumonia.
• Kinetic and continuous lateral rotation therapy reduces the risk of VAP in
patients receiving mechanical ventilation. Optimal benefit depends on early
placement and more than 18 hours of rotation per day. Research has not yet
determined whether the degree or the frequency of rotation is the crucial
factor.
• Prone positioning improves oxygenation but has not yet been shown to affect
mortality.

50. Using music to reduce anxiety in patients with CHD
• A Cochrane review suggests music may have the potential to reduce anxiety for
patients who are undergoing interventions to treat coronary heart disease.
How successful is out-of-hospital bystander CPR?
• A Swedish study has found that bystander cardiopulmonary resuscitation doubled the
likelihood of survival in people who experienced out-of-hospital cardiac arrest.
Intravenous Catheter Size and Blood Administration
• Nurses should follow EBP when using intravenous catheters to administer blood for
packed red blood cell transfusions (PRBC). The protocol indicates that nurses should
use a smaller-gauge catheter, which increases patient comfort.

51. Oxygen Use in Patients with COPD
• belief that providing oxygen to these patients can create serious issues
such as hypercarbia, acidosis or even death, the evidence-based
protocol is to provide oxygen to COPD patients.
• This practice can help prevent hypoxia and organ failure. Giving
oxygen, which is the correct treatment based on the evidence, can
enhance COPD patients’ quality of life and help them live longer.

52. Examples of How Evidence-Based Care Changed Nursing
• Intramuscular injections are no longer aspirated due to the possibility of
tissue trauma
• Implementation of nurse-driven protocols
• Use of smaller catheters for infusion of packed red blood cells to promote
patient comfort.

53. Challenges encountered in Nursing care

54. CHALLENGES OF IMPLEMENTING EBP

55. There are many nurses who are struggling to implement EBP in their
practice due to a number of reasons.
lack of knowledge on use of evidence based practices. It has
been shown that most nurses do not have enough knowledge to integrate
research findings in their practices. Research findings shows that there
is little evidence that shows that most nurses especially novice nurses
have knowledge on the implementation of EBP in their practices.

56. Misperception and negative attitude on research and evidence
based practices. Most nurses have a negative attitude towards research
do not understand what entails EBP. This problem has persisted
especially in old nurses due to fear of change of what can be identified
as a practice culture. It is a fear for change.

57. Lack of knowledge on how to carry out search and appraise
best practices.
It has been identified that three factors which determine nurse
utilization of research include individual characteristics of nurse,
characteristics of organizations, and environmental characteristics. Most
nurses are not well equipped to carry out research which leads to
effective practice of EBP.

58. Overload of nursing work that leaves them with no time to carry
out research. With increase shortage in nursing and in other areas of
medical care, workload has become a major problem not only in
implementation of EBP but also in provision of general healthcare.

59. Constraints within the organization. For one to carry out
extensive research there must be resources. There has to be adequate
nursing journals, books, internet, and other resources with credible
research findings.

60. Contradictory patient’s expectations.
For example, there are some patients who may demand to be given
antibiotics for upper respiratory tract infection which may not be indicated in
their physician’s prescription. Most patient who come to seek healthcare
services come with preconceived ideas about the prescription they will
received which has been contributed by wide scale dissemination of inaccurate
medical information. Most nurses therefore feel they are not doing the right
thing or simply avoid creating scenes with patients and hence restrain from
implementing EBP.

61. Fear for one to have different practice from what other nurses
or medical peers are practicing which directly emanates from
organizational culture.
Most nurses have found out when they join a health care facility,
there is culture of care that has been carried over. Nurses will therefore
fear implementation EBP as it may deviate from the normal practices.

62. Large amount of information that can be found in nursing
journals and books which sometimes may be confusing to practitioners.
There is a large amount of information from different research
findings and some of the information has been found to be inaccurate and
hence confusing to most nurses.
Nurses therefore find it difficult to identify the correct information
to use in EBP.

63. Barrier faced by Nursing staff to implement Recent
Evidence Based Practices in Nursing

64. • Lack of skill: by knowing the new practice also unable to apply upon patients.
• Fear of outcome: unable to apply on patient as outcome for that particular
situation is unknown.
• Negative beliefs of patients or patient relatives.
• Gap between knowledge and practice.
• Patient & relatives are aware about all kind of treatment as internet is very
much available now a days.
• Treatment of choice of doctors: if any particular consultant do not believe in
that EBP.

65. • Lack of support from nurse managers.
• Lack of evidence based practice mentors in health care systems.
• Acceptance of traditional approaches is more than evidence based practices
among patients.
• Unavailable of fund from authority during first trial of evidence based
practices.
• Recruitment and retention of new nurses in practices.
• In some cases expectation of patient is too much high regarding a new
therapy.

66. • Lack of continuing education programs
• Staff will not have the opportunity to learn a new skill
• Practitioners may not be willing to implement change
• New nurses might feel it is not their place to suggest or even tell a
superior nurse that newer, more efficient methods and/or practices are
available.
• Not aware of how to assess the information and determine its
applicability to their practice.
• Considerable amount of research evaluation skills, access to journals,
and clinic/hospital support to spend time on EBN.
• lack of knowledge of research methods, lack of support from
professional colleagues and organizations, and lack of confidence and
authority in the research area.
• Practice environment can be resistant to changing.

67. Determine Your Resources
Know the databases that are available to collect the best evidence
to answer the Research question.

68. Databases
• MEDLINE
World’s most comprehensive source of life science and biomedical bibliographic
information. It contains nearly 11 million records from over 7,300 publications
dating from 1965 to present. The listing is updated weekly.
• PubMed
A service of the U.S. National Library of Medicine that includes over 16 million
citations from MEDLINE and other life science journals for biomedical articles
back to the 1950s. PubMed includes links to full text articles and other related
resources.

69. • CINAHL
Covers nursing and allied health literature from 1982 to the present.
• National Guidelines Clearinghouse
A public resource for evidence-based clinical practice guidelines,
sponsored by the Agency for Healthcare Research and Quality.

70. • Cochrane Library
The Cochrane Library consists of a regularly updated collection of
evidence-based medicine databases, including The Cochrane Database
of Systematic Reviews.
Reviews are based on the best available information about health care
interventions. They explore the evidence for and against the
effectiveness and appropriateness of treatments (medications, surgery,
education) in specific circumstances.
.

73. References
Ackley, B., Ladwig, G. (2008). Evidence-based Nursing Care Guidelines: Medical-
Surgical Interventions, 1st Ed. St Louis, MO, Mosby, Inc.
Burns, N. & Grove, S. K. (2004) The Practice of Nursing Research: Conduct, Critique
& Utilization, 2-3.
Fineout-Overholt, E., Melnyk, B.M., & Schultz, A. (2005). Transforming health care
from the inside out: Advancing evidence-based practice in the 21st century. Journal
of Professional Nursing, 21(6), 335-344.
http://ccn.aacnjournals.org/content/28/2/98.full
https://www.nursingtimes.net/evidence-based-practice/11015.subject
https://www.amsn.org/sites/default/files/documents/practice-resources/evidence-
based-practice/Evidence_Based_Practice_Module_I.pdf
https://degree.astate.edu/articles/nursing/examples-of-evidence-based-practice-in-
nursing.aspx
https://online.franu.edu/news/2018/04/23/implementing-evidence-based-practice-
nursing