Evidence-Based Nursing Practice

Sharon A. Denham, PhD, RN, CNE

Professor, Houston J. & Florence A. Doswell Endowed Chair in Nursing for Teaching
Excellence
Texas Woman's University, College of Nursing

Identifythekeyconceptsofevidencebasednursingpractice.
Applytheconceptsofevidencebasedpracticewhencaringfor
specificpatientpopulationsand/orto aspecificclinicalsetting.
Identifyanduseavailableresourcesforbestpracticeinformation.
Identifytheinstitutionsprocessforusingevidenceintherevisionof
standards,guidelines,policies, andprocedures.
Explain how to criticallyappraisearesearchstudy.
Knowhowtoparticipateinanevidencebasedpracticeproject.

Learning Competencies

Nurses Need NEW Skills to Assume NEW Roles.

Provide patient - centered care

Work in interdisciplinary teams

Employ evidence-based practices

Apply quality improvement - Errors, risks, safety

Use informatics -Communicate, manage knowledge, use information

technology

History

Quality: Services (interventions), targeted health outcomes, &

consistency with current knowledge (research evidence)

Crossing the Quality Chasm (IOM, 2001): Between the health care we
have and the care we could have lies not just a gap but a chasm (p.1).

Aim to close the quality chasm.

Systematic and rigorous literature reviews, clinician experience, and

individual values

Evidence-Based Nursing Practice

"An ongoing process by which evidence, nursing theory and
the practitioners clinical expertise are critically evaluated
and considered, in conjunction with patient involvement, to
provide delivery of optimum nursing care for the individual.

Scott, K. & McSherry, R. (2009). Evidence Based Nursing: clarifying the

concepts for nurses in practice. Journal of Clinical Nursing, 18(8): 1085-95.

Purposes of EBP

Know ways to use critically appraised and scientific evidence to

deliver quality health care.

Provide standards for care delivery.

Know where to locate the best evidence related to practice.

Know employers expectations about use of best evidence.

Identify ways to locate literature that provides evidence.

Understand steps for participating in an evidence-based project.

Barriers to EBP

Uncertain about what defines evidence-based scientific knowledge.

Lack of mentoring by nurses with EBP experience.

Inability to understand statistical terms and research jargon.

Uncertain about ways to rigorously conduct an effective search

strategy and inability to locate useful and comprehensive information.

Make sustainable changes across systems and organizational culture

based upon evidence.

Stay current with the continually growing breadth of new evidence.

Evidence-Based Practice

Dr. David Sackett & colleagues at McMasters University in

Ontario, Canada, initially proposed EBM (2000)

Systematic Review
Research question
Search strategy (years, study designs, geographic

location, population, setting)

Inclusion criteria
Critical appraisal
Synthesis

Critical Appraisal
Research design (mixed methods)
Sample
Instruments
Confounding concerns
Strengths (internal/external validity)
Limitations
Clinical significance
Credibility of results
Intervention applicable to your setting
Benefits/risks

Synthesis
Clear statements of the findings
Consistency of the evidence
Strength of the body of evidence
Gaps in knowledge about the topic
Recommendations for future research

Feasibility, Benefits, & Risks of New Practice

Design practice change
Key variables of new practice
Identify needed resources
Outcome variables desired & expected
Evaluation plan
Implementation plan (Pilot, marketing, timelines)

Steps of Evidence-Based Practice

Ask or identify important clinical questions.

Collect the best and most pertinent evidence.

Critically analyze and rate the evidence.

Integrate the evidence with your own clinical expertise, patient knowledge,
and patient values in making practice decisions or suggesting changes.

Implement the practice change if authorized.

Evaluate how the practice change has influenced or affected your practice
area.

Disseminate and share this evidence with peers or colleagues.

Hierarchy of Evidence

Systematic review or meta-analysis of random control trials (RCT) or

established EBP clinical guidelines.

Evidence from at least one well-designed RCT.

Evidence from well designed controlled trial without randomization or

a systematic review of correlational/observational studies.

Evidence from a well-designed case-control and cohort studies that are

correlational or observational.

Evidence from a single descriptive, qualitative or physiologic study.

Evidence from the opinion of authorities/experts and/or case reports of

expert committees.

PICO Questions
P = Patient Problem:
How would you describe a group of patients similar to yours? What are the most
important characteristics of the patient? This may include the primary problem,
disease, or co-existing conditions. Sometimes the gender, age or race of a patient
might be relevant to the diagnosis or treatment of a disease.
I = Intervention, prognostic factor or exposure:
Which main intervention, prognostic factor, or exposure are you considering? What
do you want to do for the patient? Prescribe a drug? Order a test? Order surgery? Or
what factor may influence the prognosis of the patient - age, co-existing problems,
or previous exposure?
C = Comparison:
What is the main alternative to compare with the intervention? Are you trying to
decide between two drugs, a drug and no medication or placebo, or two diagnostic
tests? Your clinical question may not always have a specific comparison.
O = Outcome:
What can you hope to accomplish, measure, improve or affect? What are you trying
to do for the patient? Relieve or eliminate the symptoms? Reduce the number of
adverse events? Improve function or test scores?

Patient Problem

obese, diabetes type 2, male

Intervention

stomach stapling (gastric bypass surgery;

bariatric surgery)

Comparison

standard medical care

Outcome

remission of diabetes; weight loss; mortality

The clinical question: In male patients with type 2 diabetes and

obesity, is bariatric surgery more effective than standard medical
therapy at increasing the probability of remission of diabetes?

ACE Star Model of Knowledge Transformation

(Stevens, 2004)

Resources for Knowledge Forms in the Star Model

Form of Knowledge

Description of Resources

Point 1 - Discovery

Databases such as CINAHL - Provide single research

reports in most cases.

Point 2 - Evidence Summary

Cochrane Collaboration Database of Systematic Reviews

- Provides reports of rigorous systematic reviews on
clinical topics.

Point 3 - Translation into Guidelines

National Guidelines Clearinghouse - Sponsored by AHRQ,

provides online access to evidence-based clinical
practice guidelines.

Point 4 - Integration into Practice

AHRQ Health Care Innovations Exchange - Sponsored by

AHRQ, provides profiles of innovations, and tools to
improve care processes, includes adoption guidelines
and information to contact the innovator.

Point 5 - Evaluation of Process and

Outcome

National Quality Measures Clearinghouse - Sponsored by

AHRQ, provides detailed information on quality
measures and measure sets.

Focused Knowledge Development

Asking compelling questions directly applicable to social needs

Healthy People 2020:

http://www.healthypeople.gov/2020/topicsobjectives2020/defaul
t

NINR:
http://www.ninr.nih.gov/aboutninr/keythemes#.VXL_KGBPH8s

Joanna Briggs Institute

http://www.nursingcenter.com/evidencebasedpracticenetwork/Home/JBI-EBPNetwork.aspx

Joanna Briggs Institute Library ($287 yr)

Journal Club ($20 yr)

Sumari (suite of tools - $30 yr)

CAN - Implement (practice guidelines tailored for local use - $30 yr)

Continuing education - pay by course

National Guideline Clearinghouse

http://www.guideline.gov/browse/by-topic.aspx
Spend time reviewing multiple resources for clinical
practice guidelines

AHRQ EB Reports

Comprehensive, science-based information on common, costly

medical conditions, new health care technologies & strategies.

13 Evidence-based practice centers

Clinical reports:
http://www.ahrq.gov/research/findings/evidence-based-reports/in
dex.html

Topics:
http://www.ahrq.gov/research/findings/evidence-based-reports/az/#Dtopics

Cochrane Library: Systematic Reviews

http://www.cochranelibrary.com

Six Databases:

Cochrane Database of Systematic Reviews (CDSR)

Cochrane Central Register of Controlled Trials (CENTRAL)
Cochrane Methodology Register (CMR)
Database of Abstracts of Reviews of Effects (DARE)
Health Technology Assessment Database (HTA)
NHS Economic Evaluation Database (EED)

POEMs Research Summaries

Patient-Oriented Evidence that Matters

https://www.essentialevidenceplus.com/content/poems
Synopses of new evidence carefully filtered for relevance to
patient care and evaluated for validity

EBP Resources

ACP Journal Club: https://acpjc.acponline.org

Clinical Evidence:
http://www.clinicalevidence.bmj.com/x/index.html
Dynamed: http://www.dynamed.com/home/about
Essential Evidence:
http://www.essentialevidenceplus.com/index.cfm
UptoDate: http://www.uptodate.com/home

National Nurses Practice Network

http://www.nnpnetwork.org

The mission of the NNPN is to:

Foster exceptional healthcare outcomes of individuals, groups,
and communities receiving nursing care in a variety of healthcare
environments;
Advance professional nursing practice through application of
evidence in care delivery;
Support nursing leadership development for EBP; and
Increase the understanding of mechanisms and strategies that
foster use of evidence by those delivering healthcare services.

Care of the Person and Family