Introduction:1

The evidence based practice is able to afford considerable assistance to nurses to improve
research utilisation in practice. Evidenced based practice is now almost institutionalised in
most industrialised countries, and many of these countries have established centres for
evidence based health care, evidence based medicine and evidence based nursing.1A key
ingredient in evidence based practice is the effort to personalise best evidence to a specific
patient’s needs within clinical context.

Definition1,2

According to David Sackett, evidence based practice “is the integration of best research
evidence with clinical expertise and patient values.”

The definition proposed by Sigma Theta Tau International (2008) captures current thinking
about EBP within nursing community. ” The process of shared decision making between
practitioner, patient and other significant to them based on research evidence, the patient’s
experiences and preferences, clinical expertise or know how, and other available robust
sources of information.”

It is the combination of individual clinical or professional expertise with the best available
external evidence to produce practice that is most likely to lead positive outcome for a client
or patient.

Evidence based practice: the use of the best scientific evidence, integrated with clinical
experience and incorporating patient values and preferences in the practice of professional
nursing care.

Goals of evidence based practice in nursing:

• Provide practicing nurses with the best evidence-based data

• Resolve problems in the clinical setting
• Achieve excellence in care delivery
• Reduce variations in nursing care
• Promote effective nursing interventions
• Assist with efficient and effective decision- making

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Research utilization and EBP:2

The term research utilization and evidence based practice are sometimes used synonymously.
Although there is an overlap between two concepts, they are distinct. Research utilization is a
narrower concept; it is the use of findings from a study or set of studies in a practical
application that is unrelated to the original research. In RU, the emphasis is on translating
new knowledge into real world applications. Evidence based practice is broader concept
because it incorporates research findings with other factors. The start point of EBP is a
clinical question (what does the evidence say is the best approach to solving clinical
problem?). Research utilization was an important concept in nursing before evidence based
practice took hold.

Models for EBP2,4

Several models have been developed. These models offer frameworks for designing and
implementing EBP projects in practice settings. Some models also focus on use of research
from perspectives of individual clinicians.

Selected models for evidence based practice are:

 ACE star model of knowledge transformation (Academic centre for education based
practice, 2009)
 Advanced research and clinical practice through close collaboration model (Melnyk
and Fineout-overholt, 2011)
 Clinical nurse scholar model ( Schultz,2005)
 Iowa model of evidence based practice to promote quality care ( Tilter et al, 2001)
 John Hopkins Nursing EBP model ( Newhouse et al, 2005)
 Stetler model of research utilization ( settler,2001)

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Process of evidenced based practice:2,3

According to Myers and Meccariello (2006) “outdated practices are barriers to decreased
length of stay, favourable patient outcomes, and lowered costs.” To move evidenced based
practice forward, a realistic approach for allowing bedside nurses to actively engage in the
process must be determined and used.

Melnyk and Fineout- Overholt 2011 suggest that the process of EBP involves five critical
steps:

1. Raise the urgent clinical question using a format that includes the key aspects of the
issue.
2. Assemble the most appropriate evidence that addresses the issue identified.
3. Evaluate the evidence critically to determine its validity, relevance and applicability.
4. Assimilate the evidence into clinical practice.
5. Assess the changes resulting from the use of the best evidence.

1. Raise the urgent clinical question using a format that includes the key aspects of the
issue.

Converting information needs into well worded clinical questions that can be answered with
research evidence is a critical first step of evidence based practice.

Background questions are primarily inquiry types of questions. Background questions usually
centre around understanding the basis of the problem of interest — for example, What is normal
physiology and the pathophysiology of the patient’s problem; How does a particular drug or
a diagnostic test work?, What type of treatments are used for a certain disease process?

Foreground questions, in contrast, are formulated to find out specific information needed to make
clinical decisions.

The components included in a foreground question are captured in the mnemonic PICO(TS)

PICOT is an acronym for the elements of the clinical question: patient population (P),
intervention or issue of interest (I), comparison intervention or issue of interest (C),
outcome(s) of interest (O), and time it takes for the intervention to achieve the outcome(s)
(T). Using the PICOT format to structure the clinical question helps to clarify these
components, which will guide the search for the evidence.A well-built PICOT question

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increases the likelihood that the best evidence to inform practice will be found quickly and
efficiently.

Di Censo and colleagues in 2005 anf Guyatt and colleagues in 2008 advise hat, for questions
that call for quantitative information, for example, the effectiveness of treatment, three
components should be indentified:

 The population, for example, what are the characteristics of the clients?
 The intervention or exposure, for example, what is the intervention of interest? Or
what is the potentially harmful exposure about which we are concerned
 The outcome, for example, what is the outcome in which we are interested?

For questions that can be answered with qualitative information, for example, about the
meaning of an experience or health problem, DiCenso suggested two components:

 The population
 The situation, example: what condition, experience or circumstances are we interested
in understanding.
2. Assemble the most appropriate evidence that addresses the issue identified.

The best play to begin is to search for evidence in a systematic review or other pre appraised
sources. Pre processed sources are prepared by number of researchers, which means
conclusions are cross-validated.

Types of Evidence and Hierarchy of evidence:

In nursing, the best evidence refers to finding from research that is methodologically
appropriate, rigorous, and clinically relevant for pressing clinical questions, questions not
only about efficacy, safety and cost effectiveness of nursing interventions but also reliability
and precisions of nursing assessment measures, the antecedents or determinants of health and
well being, and also the nature of patient’s experience.

Most evidence hierarchies, which rank types of evidence sources according to strength of
evidence they provide are given in the flow chart.

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 Level 1
a. systematic review of RCTs
b. Sysematic review of nonrandomised trials.

Level 2
a. Single RCT
b. Single nonrandomized trial

Level 3
Systematic review of correlational/observational studies

Level 4
Single correlational/observational studies

Level 5
Systematic review of
descriptive/qualitative/physiological studies

Level 6
Single descriptive/qualitative/physiological
studies

Level 7
opinions of authorities, expert committees
etc.

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What evidence based practice is not:2

 Not a clinical problem solving

 Not solely randomised controlled trial
 Not a cookbook medicine
 Not same as the theory
 Not evidence based medicine

Resources for evidence based practices:

 Pre appraised evidences

Pre-processed or pre-appraised evidence is evidence that has been slected from
primary studies and evaluated by the clinicians.
 Systematic reviews
Systematic reviews are pivotal component of EBP, their bottom line is the summary
of what is the best evidence is at time the review was written. A systematic review in
itself is methological, scholarly inquiry that follows many of the same steps as those
of primary studies. It can take many forms i.e narrative reviews, meta-analysis etc.
Meta analysis has emerged as an important EBP tool. It is a method of integrating
qualitative finding statistically.
 Clinical decision support tools
Clinical decision support tools are designed to help nurses and other health care
professionals to organise information, guide their assessments, and apply appropriate
interventions.
 Other pre appraised evidence
Several other types of pre-appraised evidences are;
 Synopses of systematic reviews and of single studies available.
 The American association of critical care nurses regularly publish practices
alerts which are evidence based recommendations for practice changes.

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3. Evaluate the evidence critically to determine its validity, relevance and applicability.

Once you have the literature collected, you’ll need to critically appraise the original studies
(reports of single randomized controlled trials or observational studies for example) for reliability
and validity. The thoroughness of appraisal depends on several factors:

 Evidence quality: the first appraisal issue is to the extent to which the findings are valid.
That is, were the study methods sufficiently rigorous that the evidence is credible? Pre
appraised evidence is already screened and evaluated, but we still need to judge its
integrity.
 Magnitude of effects: Apart from checking validity of evidence, it is important to see the
magnitude of the effect i.e. how powerful is the effect. For example, the use of
compression stockings lowers the risk of deep vein thrombosis in high risk patient. Based
on reliable evidence, the result is that compression stockings are effective and the
magnitude of effect, in terms of risk reduction is substantial. Thus, advising for
compression stocking is appropriate, without appraisal of related other factors.
 Financial issue: another issue is financial cost of using the evidence.
 Clinical relevance: it is important to see if the evidence can be used in the specific
clinical setting in which the nurse is practising and also to the relevant patient.

4. Assimilate the evidence into clinical practice.

As definition of EBP implies, research evidence needs to be integrated with other types of
information such as, our own clinical experience and knowledge. A discussion with the
patient can also reveal negative or positive attitude towards potential benefit, possible
impediments, contraindications etc.

5. Assess the changes resulting from the use of the best evidence.

After the first four steps, now we can use the result or information to make evidence based
decision. Part of evaluation involves determining whether your actions achieved goals or
outcomes or not. Another part concerns an evaluation of how well performed EBP.

Importance in nursing:

 Keep abreast of important developments and read journals related to speciality,

including research reports in them.
 Attend professional conferences which are of specific clinical relevance.

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 Pursue and participate in EBP projects.

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References:

1. Pearson Alan. Nursing Models of Practice. 3rd edition. China. Elsevier. 2005 page no:
12-18
2. Polit F. Denise. Nursing research: generating and assessing evidence for nursing
practice.9th edition. Philadelphia: Lippincott Williams & Wilkins;
3. Sharma k. Suresh. Nursing research & statistics. New Delhi: Elsevier ;2011
4. Schmidt A Nola. Evidence based practice for nurses: appraisal and application of
research. 3rd edition.US. William Brotmiller.

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