EVIDENCE BASED PRACTICE IN

NURSING

Evidence based practice

• EBP is the conscientious use of current best evidence in making clinical

decision about patient care.

• A basic feature of EBP as a clinical problem solving strategy is that it de-

emphasizes decisions based on custom, authority, opinion, or ritual.

• The emphasis is on identifying the best available research evidence and

integrating it with other factors.

• Evidence based practice do not minimize the importance of

clinical expertise.

• It should include best research evidence with clinical

expertise, patient preferences and circumstances and

awareness of the clinical setting and resource constraints.

• Key concept – personalise the evidence to fit a specific

patient’s need and particular clinical situation.

Research utilization and EBP

• RU is the use of findings from a disciplined study or set of

studies in a practical application that is unrelated to the

original research.

• The emphasis is on translating empirically derived knowledge

into real world applications.

• The genesis of the process is a research based innovation or

new knowledge.

• EBP is broader than RU because it incorporates research

findings with other factors as just noted.

• RU begins with research itself

• The start point of EBP is a clinical question.

Research utilization – 3 types• Indirect research utilization – involves changes in

nurses thinking• Direct research utilization – involves the direct use of

findings to give patient care• Persuasive utilization – involving the use of findings to

persuade others to make changes in policies and practices relevant to nursing care.

EBP in Nursing

• The EBP movement has given rise to considerable

debate with both logical advocates and critics.

Overview of the EBP movement

• One of the cornerstone of the EBP movement was the Cochrane

Collaboration which was founded in the UK based on the work of Archie

Cochrane.

• He called for efforts to make research summaries of clinical trial available

to physicians and other healthcare providers.

• This eventually lead to the development of the Cochrane centre in Oxford

& an international collaboration called Cochrane collaboration.

• A group from McMaster medical school in Canada developed a clinical

strategy they called evidence-based medicine.

• The EBM movement has shifted over time to a border conception of using

best evidence by all health care providers.

• In the EBP environment, a skilful clinician can no longer rely on a repository

of memorised information, but rather must be adapt in accessing,

evaluating, synthesizing, and using new research evidence.

Why is EBP important to nursing practice?• It results in better patient outcomes• It contributes to the science of nursing• It keeps practice current and relevant• It increases confidence in decision-making• Policies and procedures are current and include the latest research• Integration of EBP into nursing practice is essential for high-quality

patient care and achievement

Factors to be considered to carry out

EBN

-sufficient research must have been published on the

specific topic

-the nurse must have skill in accessing and critically

analyzing research

-the nurse's practice must allow her/him to implement

changes based on EBN

Evidence-based Nursing Practice: solves problems encountered by nurses by carrying out four steps:

I. Clearly identify the issue or problem based on accurate analysis of current nursing knowledge and practice

II. Search the literature for relevant research

III. Evaluate the research evidence using established criteria regarding scientific merit

IV. Choose interventions and justify the selection with the most valid evidence

Models for research utilization in nursing to understand evidence-based nursing

practice.

The Stetler Model of Research Utilization

The Stetler Model of Research Utilization applies research findings at the individual practitioner level. The model has six phases: (1) preparation, (2) validation, (3) comparative evaluation, (4) decision making, (5) translation and application, and (6) evaluation.

Critical thinking and decision making are emphasized.

Iowa Model for Research in Practice

• The Iowa Model of Research in Practice infuses research into practice to improve the quality of care.

• Research utilization is seen as an organizational process. • Planned change principles are used to integrate research and practice. • The model integrates evidence-based healthcare acknowledges and

uses a multidisciplinary team approach.

ACE star model of knowledge transmission

The Star Model of Knowledge Transformation is a model

for understanding the cycles, nature, and characteristics

of knowledge that are utilized in various aspects of

evidence-based practice (EBP). The Star Model

organizes both old and new concepts of improving care

into a whole and provides a framework with which to

organize EBP processes and approaches.

The Star Model depicts various forms of knowledge in a relative sequence, as research

evidence is moved through several cycles, combined with other knowledge and integrated

into practice.

The ACE Star Model provides a framework for systematically putting evidence-based

practice processes into operation.

STAGES OF KNOWLEDGE TRANSFORMATION

1. Discovery

2 . Evidence Summary3. Translation 4. Integration5. Evaluation

1. Discovery • This is a knowledge generating stage. • In this stage, new knowledge is discovered through the traditional

research methodologies and scientific inquiry. • Research results are generated through the conduct of a single study. • This may be called a primary research study and research designs

range from descriptive to correlational; and from randomized control trials to qualitative.

• This stage builds the corpus of research about clinical actions.

2. Evidence Summary

Evidence summary is the first unique step in EBP—the task is to synthesize the corpus of

research knowledge into a single, meaningful statement of the state of the knowledge

• This stage is also considered a knowledge generating stage, which occurs simultaneously

with the summarization.

• Evidence summary produces new knowledge by combining findings from all studies to

identify bias and limit chance effects in the conclusions.

• The systematic methodology also increases reliability and reproducibility of results

3.Translation • The transformation of evidence summaries into actual practice requires two stages:

translation of evidence into practice recommendations and integration into practice.

• Recommendations are generically termed clinical practice guidelines (CPGs) and may be

represented or embedded in care standards, clinical pathways, protocols, and algorithms.

• Summarized research evidence is interpreted and combined with other sources of

knowledge (such as clinical expertise and theoretical guides) and then contextualized to the

specific client population and setting.

4. Integration

• Integration is perhaps the most familiar stage in healthcare because of society’s long-

standing expectation that healthcare be based on most current knowledge, thus,

requiring implementation of innovations.

• This step involves changing both individual and organizational practices through formal

and informal channels.

• Major factors addressed in this stage are those that affect individual and organizational

rate of adoption of innovation and integration of the change into sustainable systems.

5. Evaluation

• The final stage in knowledge transformation is evaluation. • In EBP, a broad array of endpoints and outcomes are evaluated.

These include evaluation of the impact of EBP on patient health outcomes, provider and patient satisfaction, efficacy, efficiency, economic analysis, and health status impact.

• As new knowledge is transformed through the five stages, the final outcome is evidence-based quality improvement of health care.

Barriers to implementing evidence-based practice• Lack of value for research in practice • Difficulty in changing practice • Lack of administrative support • Lack of knowledgeable mentors • Insufficient time to conduct research • Lack of education about the research process

Barriers to implementing evidence-based practice• Lack of awareness about research or evidence-based practice • Research reports/articles not readily available • Difficulty accessing research reports and articles • No time on the job to read research • Complexity of research reports• Lack of knowledge about EBP and critique of articles • Feeling overwhelmed by the process