The development of evidence-based nursing

The development of evidence-based nursing

Peter French PhD BA(Hons) STD(Lond) DipN(Lond) RGN, RMN CPsychol FRSH

Principal, The Hospital Authority Institute of Advanced Nursing Studies,

Queen Elizabeth Hospital, 30 Gascoigne Road, Kowloon, Hong Kong

Accepted for publication 9 December 1997

FRENCH P. (1999) Journal of Advanced Nursing 29(1), 72±78

The development of evidence-based nursing

This paper argues that the current conception of evidence-based medicine has

its limitations in the promotion of research which effects the quality of service

in any health care system. It also poses something of a dif®culty for the

development of evidence-based nursing in particular. This paper advocates the

more broad based concept of evidence-based practice and discusses its potential

for addressing theory/practice problems and the uptake of nursing research. The

broader conceptualization of evidence-based practice focuses on the integration

of available evidence and the tacit knowledge of the investigator. An evidence-

based practice project undertaken in Hong Kong is outlined as this provided the

basis of many of the conclusions made in this paper. Three vignettes are given in

order to demonstrate the nature of the evidence-based practice projects which

have been conducted. The critical elements of evidence-based practice projects

are outlined. Finally issues concerning the process of generating evidence, the

relationship to continuous quality improvement and the cost effectiveness of

evidence-based practice are discussed in more detail.

Keywords: evidence-based practice, nursing, research

INTRODUCTION

The use of the phrase `evidence-based' is increasingly

entering the rhetoric in nursing and health care develop-

ment. As a derivative of the concept of evidence-based

medicine (EBM) it has captured the attention of adminis-

trators because of its potential to rationalize costs in health

care delivery. This paper attempts to add to the ensuing

debate on the promotion of evidence-based nursing (EBN)

in particular. One assumption which has encouraged the

production of this paper is that essentially the concept is

still very unsophisticated as a scienti®c construct and that

this may lead to many problems associated with its use

and misuse. The concept of EBN has also generated a great

deal of interest because of its association with the widely

reported problems associated with the adoption of

research ®ndings. Indeed the theory/practice debate has

also taken on a new dimension by incorporating this

concern for the uptake of nursing research (Burrows &

Mcheish 1995, Kitson et al. 1996, Hunt 1996). It is still

said that many nursing practices in the 1990s are based on

experience, tradition, intuition, common sense and un-

tested theories (Burrows & Mcheish 1995, Kitson et al.

1996, Hunt 1996). It is argued that the lack of implemen-

tation of nursing research ®ndings is because (Hunt 1996):

� nurses do not know about the research ®ndings;

� nurses do not understand the research ®ndings;

� nurses do not believe the research ®ndings;

� nurses do not know how to use them; and

� nurses are not allowed to use the research ®ndings.

Going further Hunt (1996) argues that there are various

recurring features of nursing research which sustain this

situation, in that nurses:

� do not produce their ®ndings in usable form;

� do not study the problems of practitioners;

� do not manage to persuade and convince others of their

value;

� do not develop the necessary programmes for the

acceptance and introduction of innovation; and

Journal of Advanced Nursing, 1999, 29(1), 72±78 Issues and innovations in nursing practice

72 Ó 1999 Blackwell Science Ltd

� do not have the necessary authority or access.

This paper will attempt to demonstrate how the concept of

evidence-based practice (EBP) and the conduct of evi-

dence-based practice projects (EBPP) can alleviate many

of the inhibiting factors succinctly described by Hunt

(1996). This demonstration will begin with an analysis

and clari®cation of the concept.

Concept clari®cation

Having taken up a role devoted to the application of the

concept of EBP in nursing the author, by necessity, had to

differentiate the new concept from the older concepts of

applied research in order to contemplate how it could be

moved from rhetoric to actuality. The concept of EBN is at

the moment often interlinked with the concept of EBM.

Work on an evidence-based practice project (EBPP) has

led to a conclusion that EBM, as it is currently conceived,

may have a deleterious effect on the development of

nursing and health care because there are limitations in its

value for the development of a health service. There are

three major reasons for this conclusion. The ®rst is that the

concept of EBM further medicalizes the health care

environment and can neglect other scienti®c perspectives

which generate relevant evidence for the development of

the health care system as a whole. For instance there

seems to be limited application to preventative health

care. The second is that EBM seems to value the positivist,

even experimental, perspective on research and as such

inevitably de®nes èvidence' in purely quantitative terms

disregarding qualitative and hermeneutic forms of evi-

dence. A ®nal point is that most of the current rhetoric

seems to say very little about making links between the

practitioners' understanding of the situation and the

evidence which already exists. A great deal of evidence

which already exists is not used. This is a common

enough phenomenon in both medicine and nursing

(Smith 1996, Castledine 1996). This is a serious issue

because it is considered reasonable for the cost-conscious

health service manager to ask the question: Why generate

more research if that which already exists is not acted

upon? It is suggested here that any newly advocated

process, aimed at the promotion of research, should now

have the facility to determine how ®ndings will be

implemented.

It is because of these three reasons that it can be argued

that the concept of EBP should be adopted as a generic

term and that the operationalization of this term as a

scienti®c construct is of prime importance if it is to have

any utility at all.

A common starting point for the de®nition of evidence-

based practice is the concept of EBM as de®ned by Sackett

and his colleagues (Sackett et al. 1996). Evidence-based

medicine is de®ned by them as the `conscientious and

judicious use of current best evidence in making decisions

about the care of individual patients' (Sackett et al. 1996).

They also say that it is a process of integrating individual

clinical expertise with the best external clinical evidence

from systematic research. The literature on EBM, however,

has a strong `clinical trials' orientation and this is not very

helpful in the promotion of relevant nursing research. A

little imagination suggests a broader application. Essen-

tially the concept of EBP appears to be similar to applied

research with some minor differences which have proved

to be quite signi®cant as experience with the evidence-

based nursing practice project (EBPP) has increased. The

de®nition given above by Sackett et al. was reconsidered

in some depth. The critical elements seemed to be `current

best evidence' `making decisions' and `care of individual

patients' The term `best evidence' was taken to mean

èmpirical' or `scienti®c' evidence. The meaning of

`scienti®c' was taken broadly and would include positivist

and interpretative perspectives. If the èvidence' were to

be applied to the investigator's own patients then it would

need to be relevant to the context of that investigator, the

investigators' colleagues and the client group in question.

As such previous evidence needs to be evaluated and

validated in the practitioner's own context whenever

possible. This brings forth a strong rationale for the

undertaking of `small-scale' research projects in the

practice setting. Within this formulation it is believed

that the term `small-scale' should not be taken to mean a

lack of rigour or that the research is of less importance

than more costly or time consuming projects. This con-

ceptualization of EBP suggests a way in which theory or

propositional knowledge (Schon 1983) could be further

incorporated into practice. In this formulation there seems

to be more facility for practitioners to evaluate up-to-date

research ®ndings in terms of their own practice problems

and as such this could encourage the earlier adoption of

research ®ndings.

One signi®cant attribute of the concept of EBP is the

focus on the practitioner's own experience and the prac-

tice context. In terms of minimizing the theory/practice

gap this is considered particularly important as it suggests

that the practitioner's own knowledge and experience has

an important part to play in the process of determining the

relevant research. In essence the èvidence-based practice'

approach to research is determined by the practitioner

researcher's personal judgement regarding the aims, rele-

vance, feasibility, constraints and signi®cant variables

associated with the particular research issue. Thus there is

an assimilation of the tacit knowledge of the investigator.

Tacit knowledge has been de®ned as knowledge which is

not in the scienti®c literature but is well known to

practitioners (Carroll 1988). EBP encourages the integra-

tion of tacit and empirical knowledge by requiring that the

investigator establishes the relevance of previous research

to her/his own context and then validates this in his/her

Issues and innovations in nursing practice Evidence-based nursing

Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(1), 72±78 73

own context. A product of this approach is that the

difference between EBP reports and traditional research

reports is that the author must talk speci®cally about his/

her own context and not make vague generalizations about

the broad relevance of the ®ndings and recommendations

for other practitioners or the academic community. This

does not, however, mean that generalization should not be

the aim of EBP, rather that this should be subsumed

within the major aim of making the research ®ndings

relevant to the practitioner's own context in the ®rst place.

The accumulation of evidence by different investigators

can then lead to meta-analysis and subsequent general-

izabilty of ®ndings to other nursing contexts.

As a consequence of this analysis the de®nition of

evidence-based practice is suggested as follows:

The systematic interconnecting of scienti®cally gener-

ated evidence with the tacit knowledge of the expert

practitioner to achieve a change in a particular practice for

the bene®t of a well de®ned client/patient group.

This concept analysis and clari®cation informed the

construction of an EBPP which initially aimed to enhance

research into nursing practice. Evidence-based nursing

practice was just one variation on the theme of EBP, co-

existing side by side with EB medical practice, EB

radiography practice, EB accountancy practice, EB educa-

tional practice and EB management practice.

THE EVIDENCE-BASED NURSING PRACTICEPROJECT

At the outset it was considered that ®ve elements needed

to be made explicit in order to achieve EBP development:

� A de®nition of the situation (context) from the practi-

tioner's point of view.

� The tacit knowledge of the practitioner.

� The ®ndings of previous research related to the problem.

� The ®ndings of the research undertaken by the practi-

tioner.

� Speci®c recommendations for change which are set in

the practitioners' own context and applicable to spe-

ci®c client groups.

The nature of the project

In order to meet the above criteria it was decided that the

participants would ideally need to be baccalaureate

degree graduates, with previous research knowledge,

who had achieved a high level of tacit knowledge as a

result of experience in their own practice context. The

aim would be to enable them to complete a practice-

based research project and to facilitate their professional

development. As such a number of outcomes were

identi®ed. These outcomes formed the criteria for the

successful completion of the project and are stated in the

form of processes.

Outcomes

The principal investigators would:

1 Complete an EBP project related to their own area of

practice and produce a report for formal assessment at

the end of 6 months.

2 Deliver a paper based on their EBP research report at a

1-day colloquium held under the auspices of the

Hospital Authority Institute of Advanced Nursing

Studies.

3 Submit a jointly authored paper based on their project

to a nursing journal.

It was expected that these outcomes would ensure that

both the promotion of EBP and personal professional

development would be achieved.

Participants

To meet the requirements of the project it was decided to

invite initial applications from senior nurses. Because of

the need for baccalaureate quali®ed individuals and the

experience requirement it was decided to target mostly

nurse specialists for the inaugural project.

Entry requirements

The following were the major criteria used to select

participants for the project:

1 To be currently registered by the Hong Kong Nurses

Board.

2 To be currently in employment with the Hong Kong

Hospital Authority and agree to continue this employ-

ment during the 7-month duration of the course.

3 To hold at least a university diploma but normally a

Bachelors degree or any documentary evidence of

achievement on a course on nursing research princi-

ples.

4 The submission of a two-page research proposal (750

words) on application which met the criterion for EBP

development.

Project format

The project lasted for 30 weeks and consisted of 42 hours

of workshop time and a minimum 12 hours of meetings

with the project manager and facilitator (minimum aver-

age 2 ´ 1-hour meetings per month). Participants were

expected to spend at least 10 additional hours per week in

independent work on their research project. After 2

introductory days the participants attended 10 half-day

workshops during the progression of their research pro-

ject. Participants, therefore, carried out their research

project for a period of 6 months in collaboration with a

project facilitator allocated by the Institute of Advanced

P. French

74 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(1), 72±78

Nursing Education. All projects were supervised by the

project manager. Students met their facilitators face-to-

face during each study day and informally. Other forms of

communication, e.g. telephone, fax or e-mail communica-

tions, were used during the project.

Target dates

Target dates were set for all of the above requirements

and in addition participants were expected to submit

the partial write up of their report at 2-monthly inter-

vals.

Outline of workshops

Although participants were encouraged to make sugges-

tions about the content and depth of their learning needs

the following workshops were incorporated as a means of

updating and enhancing their knowledge. Each session

attempted to inform the participant at each stage of their

research process and provide exercises which encouraged

problem solving at particular stages. The workshops

included:

1 Introduction to evidence-based practice principles; 12

hours.

2 Survey methods and questionnaire design; 3 hours.

3 Experimental designs and action research; 3 hours.

4 Field work and data collection issues; 3 hours.

5 Data handling and presentation; 3 hours.

6 Inferential statistics; 3 hours.

7 Data analysis software; 3 hours.

8 Session by request (e.g. analysing and critiquing liter-

ature); 3 hours.

9 Publication and conference presentation; 3 hours.

The process of promoting EBP in the form of the project

has produced a large number of studies. Three vignettes

are presented in order to give some idea of the utility of

EBPP in the promotion of quality care.

Vignettes

Vignette 1The ®rst study to be described demonstrates the classic

expression of EBP within the positivist paradigm,

which utilizes quantitative data and tends toward a

medical model. The study aimed to identify the opti-

mum interval for catheter replacement for long-term

catheterized patients. The usual custom of leaving all

urinary catheters in place for a set period of time was

the practice in the hospital under study. Most of the

wards adopted the traditional practice of replacing the

catheters weekly. The principal investigator, however,

believed that the catheters were being replaced unnec-

essarily in many cases and asked the question: What is

the most suitable interval for catheter replacement?

According to the information obtained from the manu-

facturer, the silicone treated latex catheter is for inter-

mediary use of 3±4 weeks. The Center for Disease

Control (1981) recommended that the catheter should be

replaced only when obstruction develops. In addition

the catheter change should be kept to a minimum in

order to reduce the risk of urinary tract infection.

Therefore the frequent replacement of unblocked cath-

eters could be considered a waste of materials and

nursing time, in addition to causing unnecessary dis-

tress to patients.

Previous studies had demonstrated that there is con-

siderable variation among patients in the tendency to

form encrustation. The evidence indicated that there was

a large inter-individual variation in the tendency to

catheter encrustation (Hukins et al. 1983). Hedelin et al.

(1991) found that the urinary pH is related to the

persistant presence of urease-producing micro-organism

and the amount of phosphate precipitated on the cath-

eters is linked to urinary pH. Studies had shown that

precipitation is 10 times greater in individuals with a

urinary pH above 6á8 than in those with a mean pH

below 6á7 (Kunin et al. 1987, Hedelin et al. 1991). Kunin

et al. (1987) suggested that it was possible to divide

patients with long-term indwelling catheters into two

groups: blockers, with massive precipitation of catheter

encrustation; and non-blockers, with low precipitation.

These studies showed that if the mean pH remains below

6á8, precipitation will usually be low. Monitoring the

progress and care of all patients is fundamental to

nursing practice, and an individualized programme

should form the focus of catheter management. The clas-

si®cation of catheterized patients into broad categories of

`blockers' and `non-blockers' was thought to be useful in

predicting those who would experience recurrent

catheter bockage.

Twenty-six patients on long-term catheterization in

orthopaedic and medical extended care wards participat-

ed in the study. Urinary pH and the duration of catheter

retention were observed. The degree of correlation

between these two variables was calculated and the

distinguishing pH for `blockers' and `non-blockers'

estimated. The ®ndings showed that the critical point for

differentiating `blockers' from `non-blockers' was a urinary

pH of 7á3 or more. This differed from the ®ndings of

previous studies. The ®ndings supported a conclusion

that `non-blockers' with urinary pH 7á3 or below, should

have their urinary catheter routinely replaced after

28-days or longer while the blockers should be changed

at 14-day intervals. Whilst this study only managed to

secure a small number of subjects because of the ethical

protocol the clinical signi®cance was thought to be

suf®cient to enable a decision to be made about nursing



practice whilst waiting for a larger sample to demonstrate

statistical signi®cance (Or 1996).

Vignette 2In another study there was a concern for the effectiveness

of a cardiac rehabilitation programme (CRP) delivered by

nurses. This simple study demonstrates the potential of

EBPPs to validate the ®ndings of other research in a health

education (secondary prevention) situation. After

surveying the literature it was discovered that patients

misconceptions and inadequate understanding of their

disease can have serious consequences during the recov-

ery process (e.g. Newens et al. 1996). It was decided that

the CRP should be evaluated in terms of its effect on

clients' misconceptions about their disease, prognosis and

lifestyle.

A quasi-experimental research design was adopted

comparing a group who had undertaken the `cardiac

rehabilitation programme' and group who had not. A

cardiac Misconception Scale was adapted after reference

to the work of Maeland & Havik (1987). Ten questions

explored patient's misconceptions, which were related to:

post-acute myocardial infarction risks; complications;

recovery; recurrence; physical exercise; daily activities;

normal life resumption; and return to work. The data were

collected by telephone survey. The results showed that

there was a signi®cant difference between the two groups.

The mean test score of participants was 7á7 and the non-

participants 3á4. The mean for the participants still indi-

cated, however, that there were still misconceptions in

almost 50% of the CRP participants. These misconcep-

tions were that physical training after a typical heart attack

is dangerous and should be performed under medical

supervision, that after a typical heart attack, the risk of

recurrence will remain high inde®nitely and that air travel

may be dangerous after a typical heart attack. These three

items gave clear directions for modi®cations which had to

be made to the CPR programme (Lee 1997).

Vignette 3A ®nal example of the evidence-based practice process

demonstrates the use of a phenomenological study in

which hermeneutic data can be utilized to validate the

®ndings of research conducted in other contexts. In the

obstetric unit under study, there were around 4500

deliveries in a year. Among these deliveries, 5% of the

clients experienced perinatal loss. The available evidence

made it clear that bereavement support services have a

signi®cant effect on the outcomes of the grieving process

in clients suffering perinatal loss (Henley & Kohner 1991,

Too 1995, Pagano et al. 1996). Perinatal bereavement

intervention was not widely practised in the unit under

study. It was believed that some of the interventions, such

as encouraging parents to see and hold the dead foetus and

taking photos for later reminiscence, were believed to

have negative consequences for the clients and carers

because of various cultural nuances which were said to

exist. It was therefore decided to investigate the lived

experience of clients, nurses and doctors in this situation.

This qualitative nursing research used a phenomenolog-

ical perspective to explore the experience of nurses and

doctors and their therapeutic relationship with female

clients experiencing perinatal loss.

Six clients, eight nurses and six doctors participated in

the study. All six female clients were interviewed after

their postnatal check up. Using an open-ended question-

ing technique, interviews lasted from 15 to 45 minutes. All

interviews were tape recorded and then transcribed for

analysis. The major issues that emerged from the latent

and manifest content analysis of transcripts were mother's

feelings, focus of nursing intervention, seeing the dead

foetus, mother's responses and the focus of the doctor's

intervention. Important similarities and differences

between the lived experience of the clients, nurses and

doctors were identi®ed. Seeing the dead foetus was

signi®cant in both clients' and nurses' comments, while

the focus of doctor's intervention and mother's responses

were present in both patients' and doctors' responses.

Nurses' attitudes and photo taking were only present in

nurses' reports. The inadequacy of doctors and dif®culty

in handling the situation were only signi®cant in the

doctors' group.

This study resulted in the conclusion that the `medical'

beliefs that there were cultural inhibitors to the supportive

process found in the literature were unfounded. In actual

fact clients needed more supportive intervention. Numer-

ous programmes were introduced including structured

opportunities for seeing and holding the dead foetus,

photo and footprint taking and counselling services

amongst others (Chong 1996).

DISCUSSION

The critical features of evidence-based practice

As a result of the development of the project it is now

possible to re-af®rm a number of typical features of

EBPPs. The process can be considered as applied research

with a number of special emphases. The particular

emphases are:

1 EBP is problem based and located in the context of the

practitioner's current experience.

2 EBP brings together the best available evidence and

current practice by combining research with tacit

knowledge.

3 EBP facilitates the application of research ®ndings by

incorporating ®rst- and second-hand knowledge.

4 EBP is concerned with the quality of service and as

such is a quality assurance activity.

P. French


5 EBP projects require team involvement and collabora-

tive action.

6 This form of research development is most cost effec-

tive; low in cost and high in relevance.

A process for verifying and generating evidence

It can be argued that EBNP differs from previous formu-

lations of the applied nursing research principle because

it is practice driven, from the outset there is an active

integration of tacit and propositional knowledge, it is

inextricably linked to quality assurance processes and is

immediately applicable to the researcher's daily work.

A critical feature of the EBP process is that it makes

explicit and intentionally integrates the previous research

®ndings relevant to the investigator's continuous quality

improvement commitment, the tacit knowledge of the

investigator and the ®ndings of studies carried out by the

investigator in the investigator's own context. These three

aspects of integration are necessary in order to collect the

relevant evidence. The latter two can be considered as

®rst-hand sources of knowledge and the ®rst as a second-

hand source of knowledge. Is not uncommon, for instance,

to ®nd that evidence-based practice projects take the form

of replication studies or adaptations of other studies. For

instance in the EBP project it is not uncommon to ®nd that

data collection instruments have been translated into

Chinese and the validity and reliability re-tested. In a

multicultural context replica studies are common yet

when one considers the arguments presented above they

should be considered the central core of evidence-based

practice work. In terms of theory/practice discrepancies it

has often been said in the past that nursing should ®nd

ways such as this to apply theory to practice.

Evidence-based practice as a quality improvementprocess

A second key feature of EBP is that it is inextricably tied

up with continuous quality improvement processes. Ten

steps have been described in total quality management in

nursing (Katz & Green 1992). The 10 steps of this moni-

toring and evaluation model re¯ect similar processes

which exist in EBP development. They are to:

� assign responsibility;

� delineate the scope of care and service;

� identify important aspects of care and service;

� identify indicators;

� establish threshold for evaluation;

� collect and organize data;

� evaluate;

� take action;

� assess actions and document improvement; and

� communicate relevant information.

Taking account of these aspects of quality management it

can be concluded that EBP development cannot occur

unless all the stakeholders or power brokers involved in

the problem are committed to a change in practice. Should

this be absent at the outset then there will be no change in

practice and the activity should not be considered as an

EBP development. The ®ndings of the prospective research

have to be considered necessary for subsequent change

before the project is undertaken. The application of ®nd-

ings occurs at the beginning of the project not at the end. It

is a ®rm conviction of this author that EBP can only be

developed where quality assurance processes support and

inform the process. This is probably the most fundamental

distinction between EBP projects and research projects.

A cost effective research process

One of the assumptions which has been central to the

author's research career has been that good research

requires substantial resources. The rule seems to be that

the only good research is expensive research. This paper

argues that this assertion may be true some of the time but

is not true all of the time. The EBNPP provides an example

of ways in which effective research can be conducted by

utilizing resources which are normally available. Research

resources are often hidden, they may take the form of staff

development funding, job descriptions which identify

time which should be devoted to research or information

technology which stands idle or is only used for word

processing. As such EBP can be developed by utilizing

existing resources normally utilized for quality assurance

and the delivery of an ef®cient service. Indeed, as has been

argued here, EBP is so inextricably linked to these two

processes that large amounts of extra funding should not

normally be necessary.

Conclusion

At the time this paper was submitted for publication three

rounds of the EBP project had been conducted, resulting

in 30 completed studies. Current projects include: action

research on the introduction of pressure sore prevention

protocols in intensive care units; patient-related barriers

to cancer pain management in a palliative unit; pain

practices and attitudes in a general surgical unit; a

comparative study of axillary and rectal temperature on

term and pre-term babies; factors affecting performance of

activities of daily living in continuous ambulatory perito-

neal dialysis patients; the impact of hospice inpatient care

on the quality of life of terminally ill cancer patients;

action research on the introduction of patient-centred

hand-over reporting in medical ward; and the training

needs of health care staff in the management of patients

with aggressive and violent behaviours in psychiatric

wards.



The concept of EBP and the conduct of EBPP has great

potential for enhancing the reputation of nursing research

and continuous quality improvement. It can do this

because it is possible to demonstrate the part which the

evidence plays in the practitioner's daily work, in the

promotion of continuous quality improvement and in

enabling cost-effective health care whilst at the same time

applying the principles of rigorous scienti®c research.

Acknowledgements

My thanks to Or May-chun, Lee Siu-fong and Chong Yuen-

chun, for the privilege of supervising the studies

described in the vignettes.

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The development of evidence-based nursing

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