Evidence-Based Practice in Nursing

Define: Evidence-based practice

Systematic approach to rational decision making that facilitates achievement of best practices

Six steps to EBP

1. Ask a clinical question2. Collect the most relevant and best evidence3. Critically appraise the evidence you gather4. Integrate all evidence with one's clinical expertise and patient preferences and values in making a practice decision or change5. Evaluate6. Share outcomes of EBP changes with others

Ask a clinical question

• A problem or area of interest that could be performed more efficiently, consumes healthcare dollars, or does not make sense• A knowledge focused trigger• Clinical trends• Utilization of PICOT format to state your clinical question

Why should I use PICOT format to state my clinical question?

• The questions you ask will eventually lead you to the evidence for an answer• You want to be able to read the BEST four-to-six articles that specifically address your practice question• The more focused a question you ask, the easier it becomes to search for evidence in the scientific literature

PICOT question

P = Patient population of interestI = Intervention of interestC = Comparison of interestO = OutcomeT = Time

Collect the best evidence- what kind and includes

• Search for evidence! • Evidence includes but is not limited too*: agency policy and procedure manuals, quality improvement data, existing clinical practice guidelines, agency experts, staff educators, risk managers, infection control nurses, and peer reviewed articles (specifically within the most recent 5 years from the present date)

Critically appraise the evidence you gather

• The most difficult step in the EBP process• Involves evaluation, determining if information is valuable and can be easily applied, and if there is enough evidence for making a nursing practice change• Thorough review of elements included in evidence-based articles

Integrate the evidence

• How will you incorporate the evidence into practice?• Integrate evidence with use of teaching tools, clinical practice guidelines, policies and procedures, and new assessment documentation tools• Consider staff support and available resources• Conduct a pilot study and attempt to answer your PICOT question

Evaluate and share outcomes

• Did it work? Is it effective? • Communicate the results to various groups of nurses or other care providers (facility nursing practice council or research committee)

PICO four-step process

P - population of interestI - interventionC - comparisonO - outcome

Utilization of the research process

• Identification of a researchable problem• Review of the literature• Formulation of the research question or hypothesis• Design of the study• Implementation of the study• Drawing conclusions based on findings• Discussion of clinical implications• Dissemination of findings

Identification of a researchable problem

• Sources: * clinical situations * the literature * theories• Repeat the study or design a similar one• Test theoretical models

Review of the literature

• Comprehensive and covers all relevant research• Essential to locate similar or related studies that have already been completed and on which a new study can build• Answer the question "what have other researchers and theorists written about this problem?

Two major categories in designing study

experimental (require quantitative methodology)nonexperimental (can be quantitative or qualitative methodology)

Implementation of the study involves two main task:

Data collection (collected by those familiar with the study)Data analysis (arrange information into meaningful patterns

Drawing conclusions based on findings, Answer the question:

What do these findings mean?

Discussion of clinical implications

• Suggest actions that can be taken as a result of the research findings in the future• Other questions to answer: Will the procedure be effective with patients who have a different diagnosis? • Will age make a difference? What else do we need to know to improve the care of patients?• Also known as the rigor (potential threats to the validity and reliability of the study)

Dissemination of findings two major vehicles:

• Articles published in professional journals• Presentations given at conferences

Nursing student role in research

Learning about research: doing honors projects or assisting in labs

BSN role in research

Identifies problems that can be studied; may do data collection for research studies

MSN role in research

Replicates earlier research; beginning independent research

Doctorate role in research

Generate and test theory; establish independent research career

Academician role in research

Independent research with external funding (e.g., NIH, foundation grants)

After formulation of the research question or hypothesis, the next step in the research process is to:A. Select the populationB. Review the literatureC. Design the study protocol D. Discussion and/or clinical implications

C. Design the study protocolAfter formulation of the research question or hypothesis, the next step in the research process is to design the study. The study design will influence the data collection process. Selecting the population is a component of this phase of the research process. Obtaining necessary approvals is part of conducting the study, which follows the design phase in the research process. Identification of the instrument to use for data analysis occurs during the process of designing the study protocol. This step would occur during the study design phase of the research process after the problem identification and literature review has taken place.

Research is the same as problem solving. T or F

FalseResearch is different from problem solving. Problem solving is specific to a given situation and is designed for immediate action, whereas research is generalizable (transferable) to other situations and deals with long-term solutions rather than immediate ones.

During the first step of evidence-based practice (EBP), development of a clinical question:A. Must follow the sequence of PICOTB. Does not allow for identification of key wordsC. Must contain all of the PICOT elementsD. Does not have to follow the sequence of PICOT

D. Does not have to follow the sequence of PICOTA well designed PICOT question does not have to follow the sequence of PICOT. In addition, Intervention (I), comparison (C), and time (T) are not appropriate to be used in every question. The aim is to ask a question that contains as many of the PICOT elements as possible. Proper question formatting allows you to identify keys words to use when conducting your literature search

Research Utilization (RU)


Evidence Based Practice (EBP)


Research Utilization (RU): Instrumental


Research Utilization (RU): Conceptual

- Indirect- Use of findings to enhance one's understanding of a problem or issue in nursing.

Research Utilization (RU): Persuasive


RU Beginnings

- 1970s research begins to be incorporated in nursing curricula.- 1970s WICHE Western Interstate Commission for Higher Education.- 6 year project to address feasibility of fostering research through regional collaborations.- First major project addressing RU.- Findings: resulted in increase in RU, but not enough sounds, reliable studies with implications for nursing care.- 1970s CURN: Conduct and Utilization of Research in Nursing project (run by MNA, funded by Division of Nursing).- Major objective --> increase use of research findings in clinical nursing practice by: disseminating current findings, facilitating organizational changes, encouraging collaborative research.- Must have relevance to practice and be widely disseminated.

Steps of Research Utilization Similarities to Nursing Process

(ADPIE)- Identification of clinical problem (D).- Gathering information form existing studies, critical evaluation of research (A).- Relevance to practice setting/patient population (P), definition of patient outcomes (P).- Education/training (protocol) needed for change (I).- Evaluation/follow-up of new practice (E).

RU 1980s-1990s

- 1980s and 1990s RU generally at institutional level, innovation effectiveness evaluation.- 1990s push for EBP.

Cochrane Collaboration


EBM (Evidence Based Medicine)

David Sackett, McMaster Medical School

EBP Initiatives

- Institute of medicine's Roundtable on EBM.- US Preventative Services Task Force (USPSTF).- Agency for Healthcare Research and Quality (AHRQ).- Nation Consortium for the Advancement of pEdiatric and Adolescent Evidence Based Practice (NCPAEP).- Magnet Recognition Program by the American Nurses Credentialing Center.

Evidence Based Practice

- A life-long problem-solving approach to clinical practice that integrates...- Search, critical appraisal, and synthesis of the most relevant and best research (external evidence).- One's own clinical expertise, which includes internal evidence generated from outcomes management or quality improvement projects, patient assessment, and evaluation.- Patient preferences and values.

Evidence Based Medicine/Evidence Based Practice

- Distinct- Not just RCT's- Evidence hierarchies- Philosophical differences

EBP Continuum



- Best evidence: findings of quantitative research studies.- Clinical expertise: expert panels; consensus statements; practice groups; practitioner experience.- Patient preferences: satisfaction; QOL; treatment burden; Qualitative studies.

Research Process


Research Utilization


Evidence Based Nursing Practice


Evidence Hierarchies


RU/EBP Resources

- Systematic reviews that integrate evidence about a topic in a rigorous, systematic way.- Traditional narrative reviews are being placed.- Meta-analyses that integrate findings across quantitative studies statistically.- Meta-syntheses that integrate and amplify findings across qualitative studies.- Other reappraised evidence (clinical practice guidelines, syncopes of studies in EBP journals, critically appraised topics).- Models and theories for EBP or RU.

Levels of Evidence

1) Systematic reviews of RCTs2) Individual RCT3) Systematic reviews non-RCT (correlational)4) Individual correlational studies5) Systematic reviews of descriptive studies6) Individual descriptive studies7) Exert opinion of respected authorities or expert panelsHighest level of evidence is systematic review of findings from MULTIPLE RCTs.

Barriers to RU/EBP


Nursing Barriers




Steps of Evidence Based Practice

- Cultivate a spirit of inquiry.- Ask the burning clinical question in PICOT format.- Search for and collect the most relevant best evidence.- Critically appraise the evidence (i.e., rapid critical appraisal, evaluation, and synthesis).- Integrate the best evidence with one's clinical expertise and patient preferences and values in making practice decision or change.- Evaluate outcomes of the practice decision or change based on evidence.- Disseminate the outcomes of the EBP decision or change.

EBP in Organizational Setting

- Select a topic or problem.- Knowledge-focused triggers - begins with an innovation or research finding (e.g., might emerge in a journal club).- Problem-focused triggers - begins with a perplexing or troubling clinical situation.


- foundation questions about a clinical issue.- What is osteoporosis and what is it's pathology?



Types of Questions

- Etiology- Diagnosis- Therapy- Prevention- Prognosis- Qualitative (meaning; insight into patients experience/perspective).

Asking the Nursing Question

(PICOT)- Patient population- Intervention or issue of interest- Comparison intervention or group- Outcome- Time frame - not always specified.

Components for Qualitative Evidence

- Population- Situation (processes, experiences, cultures, history, condition of interest).

Question Templates

- Templates can greatly facilitate wording of questions, e.g., an intervention question:In (population), what is the effect of (intervention), in comparison to (comparison) on (outcome) in (timeframe)?

Search For Evidence

- CINAHL- MEDLINE- Cochran collaboration (www.cochrane.org)- Agency for Healthcare Research and Quality (www.ahrg.gov)- National Guideline Clearinghouse (www.guidelines.gov, www.guidelines.gove/content.aspx?id=32669&search-falls)

Appraising the Evidence


Rating the Strength of Evidence

- Not necessarily synonymous with "hierarchy of evidence."- High-level study design does not necessarily mean high quality.- Grading the strength of a body of evidence addresses three domains - quality, quantity, and consistency.

Rating the Strength of Evidence: Quality

The event to which a study's design, conduct, and analysis has minimized selection,measurement and confounding biases (internal validity).

Rating the Strength of Evidence: Quantity

The number of studies that have evaluated the question, overall sample size across all studies, magnitude of the treatment effect, strength from causality assessment, such as relative risk or odds ratio.

Rating the Strength of Evidence: Consistency

Whether investigations with both similar and different study designs report similar findings (requires numerous studies).

Integrate Evidence, Clinical Expertise, Pt. Preference

- This is the "implementation" step.- EBP is not based solely on research and published evidence.- Patient's histories and circumstances have a significant bearing on the nurse's choice of intervention.- Availability of resources must also be considered: feasibility, cost benefit, transferability.

EBP Models

- Dozens of models exist.- The Stetler Model of research utilization to promote evidence based practice.- The IOWA Model of evidence based practice to promote quality of care.- Rogers' Diffusion of Innovations Theory.

Evaluate Outcomes of the Practice Decision or Change Based on Evidence


Disseminate Outcomes of the EBP Decision or Change


Rogers' Theory of Diffusion of Innovations

- Theory for communicating knowledge developed through research. Includes a five stage process:1) Knowledge - knows but lacks info, not inspired to find info.2) Persuasion - interested, seeks info.3) Decision - weighs advantages/disadvantages, accepts of rejects.4) Implementation - determines usefulness, many seek more info.5) Confirmation - finalizes decision. May be interpersonal (cognitive dissonance) or interpersonal (good job group!).

Iowa Model


Stetler Model


Other Models of Quality Improvement


Other Quality Measurements

- You may hear the following terms in regard two quality improvement at hospitals:- HCAPS - Hospital Consumer Assessment of Healthcare Providers and Systems --> National survey analyzed by centers for medicare and medicaid services (CMS).- Press Ganey - Private, for profit organization that polls health care consumers to assess quality of care (HCAPS included in survey).

Case Study:Chris was caring for a 27 year old woman who just delivered her first infant by emergency Cesarean birth. The mother was upset because she believed she would have to deliver subsequent children by cesarean birth. She asked Chris about the risks of birth complications with vaginal birth after cesarean (VBAC). Chris decided to look for the best possible evidence to answer her question.

- Is Chris engaging in an RU or an EBP effort? - EBP- Would the trigger be described as problem-focused or knowledge-focused? - Problem-focused- Would Chris need to pose a clinical background question or a clinical foreground question to identify relevant evidence? - Clinical foreground question.- In searching for evidence, Chris would need to ask a well-worded clinical question that would include identifying the population. What would be the population? - Women who have had a cesarean birth.- Chris's clinical question would identify an intervention or exposure. What would that be? - Having a vaginal birth.- Would Chris likely find the answer to a question about future risks of birth complications from VBAC in a meta-synthesis? - No, the question is not about meaning or process; it is about the effect of a certain exposure.- Would Chris need to assess implementation potential in this effort? - No, this is an individual EBP effort, not an institutional effort.

Case Study:- A group of nurses working in a community health center were unsure of how to answer questions from patients about appropriate means of cleansing children's wounds in home settings.- Most nurses felt that sterile saline should be recommended to minimize the risk of infection, but others believed that tap water was adequate fro cleansing acute wounds.- The nurses decided to examine the evidence and located a systematic review in the Cochrane database. Among the studies that had been conducted, the review concluded that there were no differences in rates of infection or healing with use of tap water versus sterile saline win the cleansing of wounds.- However, few of the studies that had been done involved the use of childcare, and most had been conducted in health-care settings.- The nurses decided to initiate a new study to gather more focused and informative evidence about the effects of saline solution versus tap water in cleansing children's wounds.

- Does this summary describe an EBP effort? - Yes, the nurses wanted to determine the best practices with regard to cleaning of children's wounds.- Would the trigger be described as problem-focused or knowledge focused? - Problem-focused- Did the nurses use pre-appraised evidence? - Yes, a systematic review from the Cochrane database is an example of pre-appraised evidence.- The nurses decided to initiate a new study because they deemed the evidence base inadequate.- Would their new study be a qualitative or quantitative study? - Quantitative

Strategies/Role for Nurses in EBP




1. The student nurse is listening to a lecture on the different types of research. Which statement by the student nurse indicates that teaching has been effective?A. "Quantitative research involves systematic distortion of a finding from the data."B. "Quantitative research is known as naturalistic inquiry."C. "Qualitative research requires standardized experimental designs."D. "Qualitative research does not involve manipulation of variables.

D. "Qualitative research does not involve manipulation of variables.

2. The nurse professor is presenting a lecture on pure science. Which statement from one of the students indicates that the teaching has been effective?A. "Pure science involves systematic distortion of a finding from the data." B. "Pure science involves manipulation of variables." C. "Pure science summarizes and explains the universe without regard for whether the information is immediately useful." D. "Pure science is the practical application of scientific theory and laws.

C. "Pure science summarizes and explains the universe without regard for whether the information is immediately useful.

3. The student nurse is listening to a lecture on inductive and deductive reasoning. Which statement indicates that further teaching is needed?A. "Inductive reasoning begins with a particular experience and proceeds to generalizations."B. "Research requires the use of only inductive reasoning." C. "Deductive reasoning proceeds from the general case to the specific."D. "Conclusions drawn from deductive reasoning are called valid rather than true.

B. "Research requires the use of only inductive reasoning." [Research requires both inductive and deductive reasoning]

4. The nurse professor is giving a lecture on the difference between research and problem solving. Which statement by one of the students indicates that teaching has been effective?A. "Research is specific to a given situation."B. "Research is designed for immediate action."C. "Problem-solving is generalizable."D. "Research deals with long-term solutions.

D. "Research deals with long-term solutions." [Research is generalizable, can be used in other situations and deals with long-term solutions.]

5. How should the nurse initiate the research process?

Identify a researchable problem.[The first step in the research process is to identify a researchable problem.]

6. The nurse researcher is presenting a lecture on data-collection instruments. Which statement indicates the need for further education?A. "Data collection tools must be high tech and complex to be accurate." B. "Researchers must consider how the data will be collected."C. "The selected instrument must be reliable."D. "The tool must be valid.

A. "Data collection tools must be high tech and complex to be accurate."[data collection tools, range from simple survey forms to complex radiographic scanning devices. ]

7. The nurse is listening to a lecture on the outcomes of research in the nursing practice. Which statement indicates a need for further education?A. "Research has not created a lot of changes in nursing." B. "Research has improved the care of patients with skin breakdown."C. "Research has prevented sleep deprivation by decreasing light and noise."D. "Research has led to scheduling pain medication more frequently after surgery.

A. "Research has not created a lot of changes in nursing.

8. Which statement by the nurse indicates an understanding of how nursing research positively affects nursing?A. "Research creates changes that are not always good."B. "Research expands the nursing profession." C. "Research creates more work for staff nurses."D. "Research leads to less pay for union nurses.

B. "Research expands the nursing profession.

9. Which statement about financial support for nursing research indicates a need for further teaching?A. "Nursing research is often fairly inexpensive." B. "Over the years, more funding for nursing research has been identified."C. "It is difficult for new researchers to obtain funding."D. "Nursing associations fund nursing research.

A. "Nursing research is often fairly inexpensive." [Nursing research can be EXPENSIVE, and often support takes many different forms]

10. The nurse is would like to research how to best keep confused patients from wandering. What is the first step that the nurse should take?A. Review the literature.B. Create a study design.C. Call the local community college about funding.D. Identify a researchable problem

D. Identify a researchable problem

PPT: A nurse compares patient compliance after an interactive video instruction compared to usual verbal instructions among patients with a new diagnosis of diabetes mellitus. The study design most likely describes: 1. Descriptive research design2. Exploratory research design3. Modified experimental design4. True experimental design

3. Modified experimental design

Scientific Method

step by step process with observable results used by scientists to solve problems

Quantitative Research

Measurable variables

Qualitative Research

Because there are no variables being manipulated - qualities of the human experience are described and interpreted.

5 Components of the Nursing Process


Mixed-Methods Research

Combination of Qualitative and Quantitative Research


data collection, collecting, organizing, documenting, and validating data

Nursing Diagnosis

process by which the assessment data are sorted and analyzed so that specific actual and potential health problems are identified


a series of steps by which the nurse and the patient set priorities and goals to eliminate or diminish the identified problems


carrying out the nursing interventions in a systemic way


assessing the patients response to the nursing interventions

Critical Thinking

directed, purposeful, mental activity by which ideas are evaluated, plans are constructed, and desired outcomes are decided

Problem Solving Process


Goals of the nursing process



S - SpecificM - MeasurableA - AttainableR - Realistic / RelevantT - Time

Evidence-based Practice (EBP)

an approach to the delivery of health care that "integrates the best evidence from [research] studies and patient care data with clinician expertise and patient preferences and values.

Nursing Process

way of thinking and acting based on the scientific methods

The Nursing Process

the tool for identifying patients problems and an organized method for meeting patients needs

Novice Thinking

Focus on action with out assessment, unaware of resource, need clear cut rules, anxiety and lack of self confidence.

Expert Thinking

Assesses then acts, aware of resources and how to use them, knows how to bend the rules, focused.

Critical Thinking in Nursing

A way of thinking in nursing practiceReflective thinkingCritical thinkingQuality of thinking improves over timeNovice to ExpertCreative approach to thinkingDynamic approach to patient care

Research Process

Identify a researchable problemReview the literatureForm a research question or hypothesisDesign of the studyImplementation of the studyDrawing conclusions based on findingsDiscussion and/or clinical implicationsDissemination of findings