Nursing Evidence-Based Practice Nursing CE Course

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Nursing Evidence-Based Practice

Disclosure Statements

The purpose of this module is to provide an overview of the importance, process, and barriers of nursing evidence-based practice (EBP).

At the completion of this module, learners will be able to:

• define and discuss the importance of EBP
• discuss the steps of the EBP process
• formulate a clinical question by using the PICOT method
• discuss the importance of appraisal of literature
• identify current barriers to EBP

Key Terms

• Appraisal of literature: The process of evaluating literature for its worth (i.e., validity, reliability, and applicability to clinical practice (Olson, 2023)
• Consistency of evidence: Whether studies with similar and distinctive designs report similar findings. Numerous studies are required to determine consistency (Berman et al., 2021)
• Dissemination of knowledge: The process of spreading or circulating knowledge (Berman et al., 2021)
• Evidence-based practice: The use of evidence to inform the nursing practice and impact patient outcomes in a positive manner (Assessment Technologies Institute [ATI], 2022)
• Levels of hierarchy of evidence: A ranking of evidence by the type of design or research methodology that would answer the question with the least amount of error and provide the most reliable finding (Berman et al., 2021)
• Qualitative research: The systematic analysis of narrative data that can include subjective data (Berman et al., 2021)
• Quantitative research: The systematic analysis and interpretation of statistical and numerical data (Berman et al., 2021)
• Quality of evidence: The confidence that the information gained from a study is adequate to support a specific recommendation (Venes, 2021)
• Quantity of evidence: The number of studies that have evaluated the specific clinical issue, the sample size among studies, the magnitude of the treatment effect, and the strength of the assessment of the interventions (Venes, 2021)

Introduction to Evidence-Based Practice

Evidence-based practice (EBP) involves using published research in addition to one's clinical expertise and patient preferences and values (ATI, 2022). Nurses should use research and evidence to determine appropriate nursing actions and share knowledge with others (Berman et al., 2021). EBP is a core component of clinical practice across all levels of nursing education. EBP is a healthcare standard that is a required competency for professional nurses (Olson, 2023). Accrediting bodies require all baccalaureate and higher degree nursing programs to include EBP in their coursework (Berman et al., 2021). The American Association for Colleges of Nurses (AACN) developed research role expectations for nurses according to their level of education (see Table 1). A more advanced degree is associated with more advanced research expectations. Nurses practicing across clinical settings are at the forefront of healthcare. These nurses are critical in bridging the gap between practice and theory. The consistent application and integration of EBP into all levels of nursing practice leads to the following:

• high-quality healthcare
• better patient outcomes
• healthcare cost savings
• enhanced critical thinking
• lifelong learning
• nurse autonomy
• the relevancy of nursing practice (American Nurses Association [ANA], 2023)

Table 1

Research Expectations for the Level of Education 

(Berman et al., 2021)

To increase the use of EBP, nurses must develop a solid foundation in the EBP process (Rudman et al., 2020). The seven-step model developed by Melnyk and Fineout-Overholt (2022) can guide the process of EBP. The steps (numbered from zero to six) are:

0) cultivate a spirit of inquiry

1) ask a clinical question

2) find information/evidence to answer the clinical question

3) appraise the evidence

4) combine evidence with clinical experience and patient preference

5) evaluate the result

6) disseminate the results (Melnyk and Fineout-Overholt, 2022; Olson, 2023)

The Process of Evidence-Based Practice

Nurses and other healthcare team members often wonder why clinical practices are performed in a certain way or if those practices could be improved. Nurses are trained to think critically and apply this enhanced thought process to all aspects of patient care. This thinking cultivates a spirit of inquiry (step 0 of EBP) and leads to clinical questions (ATI, 2022).

Step 0: Cultivate a Spirt of Inquiry 

EBP begins with a spirit of inquiry in which there is a desire to understand the skills and knowledge required to provide quality care for patients and families. This spirit of inquiry is a foundation for developing best practices and inspires nurses to explore their problem-solving approach. Nurses who use the spirit of inquiry may question current practices and apply the process of EBP to revise them (ATI, 2022; Melnyk et al., 2010).

Step 1: Clinical Question 

Asking a clinical question is Step 1 of the EBP process. Nurses can examine areas with insufficient evidence by asking "why” and “how” (ATI, 2022; Melnyk et al., 2010). The nurse should understand the rationale for their actions, and if unable to identify the rationale, then the nurse should examine the evidence to support interventions. Clinical questions can be formed in a subjective (qualitative) or objective (quantitative) manner. One common method of developing a high-quality clinical question is the PICOT method. The acronym PICOT helps clarify and refine a broad idea into a more specific, focused clinical question (Granger, 2020). A good research question must be specific enough to define the problem clearly but broad enough to make finding evidence possible. It helps break down the question into searchable key terms for use in academic databases (e.g., Cochrane, PubMed, CINAHL) to find the best evidence (Olson, 2023). Clinical questions that are broad and nonspecific can lead to false assumptions, may not be answerable, or challenging to search for evidence. The components of the PICOT technique are listed in Table 2, and an example of how to develop a research question using this method from a sample case scenario is provided in Table 3.

Table 2

Components PICOT Question 

...purchase below to continue the course

(ATI, 2022)

Research questions can also be classified according to their domain (i.e., intervention, diagnosis, etiology, prevention, prognosis/prediction, QOL/meaning, and therapy). Intervention indicates the treatment or management of an illness. Diagnosis deals with identifying the underlying cause of a disease or condition. Etiology is the cause or origin of disease. Prevention is the identification and modification of risk factors and screening techniques. Prognosis/prediction questions seek to forecast the course of a disease. Quality of life (QOL)/meaning questions address how a patient feels about or experiences their condition. Finally, therapy questions explore treatment options with a positive benefit-to-risk ratio, doing more harm than good and justify their cost or effort (Northern Arizona University, 2023).

Table 3 

Using a Case Scenario and PICOT to Develop a Research Question

Steps 2 and 3: Research and Appraisal

Finding information or evidence to answer the clinical question and appraising the evidence are steps two and three of the EBP process. This involves searching credible databases for factual evidence and evaluating the findings by analyzing the evidence obtained. The researcher should ensure that the information obtained is reliable and valid. Reliability, or external validity, looks at the consistency of the research and whether the information has been evaluated or reviewed several times (generalizability). Internal validity examines the quality of the research and the accuracy of its conclusions or findings based on sound research methodology and minimizing bias or confounding factors. The degree to which the research may be biased directly affects how plausible any alternative explanations for the results may be. Commonly used sources include randomized controlled trials (RCTs), peer-reviewed journals, credible websites (e.g., those ending in .gov, .org, or .edu, national associations such as the American Heart Association [AHA]), published clinical practice guidelines, and textbooks. Many journals can be accessed for free via the National Institute of Health (NIH), the US National Library of Medicine (Medline, PubMed.gov), the nursing database, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane database. Clinical practice guidelines can be accessed via the public resource website National Guideline Clearinghouse. Using scholarly databases and entering filters to narrow search results is the most efficient method of researching a topic. Each keyword from the research question is used in the search (ATI, 2022; Berman et al., 2021; Center for Evidence-Based Management [CEBMa], n.d.; Melnyk et al., 2010; Venes, 2021).

There are common formats for journal articles. The most common is an original research article, which offers new and original data with corresponding conclusions and associated questions for the future. Quantitative studies use data to answer their question, while qualitative studies explore real-world problems to offer insight by reporting subjects’ experiences, opinions, thoughts, and actions. The most valid of these in scientific research is the RCT, which uses controls and randomization to enhance their internal validity by reducing the chance for bias. A review article looks at several original research articles. A literature review gives detailed information about all available published work. A systematic review uses search criteria to synthesize findings on a particular topic qualitatively and quantitatively. Finally, a meta-analysis combines multiple scientific studies to compare their results. Non-randomized studies (i.e., quasi-experimental, observational, or correlational) have lower interval validity and a higher chance of bias than RCTs. A case report or case study seeks to describe a particular occurrence in detail, although not often representative of what is generally expected. Case studies and surveys tend to have the highest chance of bias. Finally, commentaries or letters may simply reflect the opinion of a single expert in a particular field (CEBMa, n.d.; Mazumdar, 2022; Tenny et al., 2022).

In the research and literature review process, the quality of the evidence is examined, as well as the level of evidence. Each article obtained from the literature search should be organized and analyzed. The researcher can organize their findings by creating a table of evidence (see Table 5). The quality of the evidence is based on how confident a researcher is that the information gained from a study is sufficient to help formulate a recommendation (Olson, 2023). The type of evidence determines the level of evidence, whether it is a study, literature review, clinical practice guideline, or expert panel opinion. Several organizations have developed their own evidence levels, and a sample is outlined below in Table 4.

Table 4

Levels of EBP in Human in-vivo Studies

(Burns et al., 2011; SUNY Downstate Medical Research Library of Brooklyn, 2022)

Table 5

Example of a Table of Evidence Tool 

 (ATI, 2022)

When researching a clinical question, the researcher must determine the strength of the literature in terms of quality, quantity, and consistency (see definitions). It is often difficult for a new researcher to evaluate the evidence. Novice researchers should not be afraid to ask for help interpreting the information and statistical data in the collected studies. It is necessary to correctly appraise the literature to ensure the scientific validity and applicability to the selected patient population. Some questions that should be asked when evaluating literature include (Berman et al., 2021):

• What are the actual results of the study?
• Are the results trustworthy and credible?
• Will the results help me in caring for my patient population?

The Critical Appraisal Skills Program (CASP) is recommended by Quality and Safety Education for Nurses (QSEN) to train people to perform critical appraisals. CASP aims to help clinical decision-makers understand scientific evidence worldwide by operationalizing the three questions outlined above. CASP can be utilized by nurses who want to implement research evidence into their practice. The website offers appraisal tools, checklists for nurses while reading the research, and workshops to help nurses better understand the research. Once each study has been appraised, the collected evidence is synthesized (Long et al., 2020).

Steps 4 and 5: Integrate the Intervention and Evaluating Results

Step four of the EBP process is integrating the best evidence in the literature with clinical expertise and patient preferences. The premise of evidence-based nursing care is integrating medical evidence with nursing experience, clinical decision-making, and patient preferences. For this reason, many nurses report being more comfortable with EBP mid-career after ten or more years of practice. Nursing experience over time provides a solid foundation to support clinical decision-making and critical thinking. There may be times when the resources to implement treatments deemed best practice by EBP are unavailable. The nurse must find practical alternatives and potentially begin the literature review process again in search of alternative methods (Berman et al., 2021; Melnyk et al., 2010; Rudman et al., 2020).

The nurse must thoroughly assess and educate the patient on the risks and benefits of the recommended intervention, allowing for ample time to discuss concerns and fears fully and clarify understanding. Sometimes, compelling evidence for specific treatments will conflict with a patient's values or beliefs. Despite compelling evidence, the patient has the right to decide in these instances (Berman et al., 2021).

Once the EBP has been implemented into the nurse's practice, the next step is to evaluate the outcomes and effectiveness of the change. Outcomes must be measured based on their impact on healthcare quality and/or patient outcomes. The results do not always reflect those found in research; this may be due to differences in implementation or discrepancies in the characteristics or demographics of the patient population (Berman et al., 2021). It is important to remember that not all variables can be controlled; patients may not mirror those included in research studies, and the outcomes may differ. Outcome evaluation is important to assess how research translates into real-world use. Outcomes should be measured before, shortly after, and then again within a reasonable time after implementation. Data from each of these points is important to evaluate the change fully. The EBP team should be a part of collecting and assessing the outcomes data (Olson, 2023).

Implementing an EBP change across an organization is a more extensive undertaking. Typically, the organization will need to enact change incrementally. Some organizations may develop an EBP implementation team to generate new tools and processes to integrate the practice. This team can be multidisciplinary and involve team members from all levels of management. Implementing EBP may change the daily workflow and staff routines. Motivated nurses can have difficulty practicing in a continuously changing environment and require support from their administration. Piloting minor changes and adjusting based on staff feedback can ensure positive attitudes and successful adaptation to the new process. The results should be shared with all staff involved at the end of each pilot to ensure open communication, maintain motivation, and receive feedback. Pilot testing in selective patient care areas efficiently identifies and remedies problems before organization-wide implementation. The pilot areas can then be used as training sites for the rest of the organization when widespread use is initiated (Boswell et al., 2020).

In the previous case scenario (see Table 3), the research study's results suggested that HAPI rates rapidly declined after initiating an annual competency and training. Six months after implementation, the HAPI rate for the medical-surgical unit decreased from 4% to 0%. A simple explanation is that the initial assessment and correct staging of pressure injuries helped the staff identify pressure injuries during the admission process. By implementing the EBP process, the wound nurse and task force can make a sustainable, substantial organizational change and improve patient outcomes.

Step 6: Dissemination of Knowledge

Once research has been completed and the results of the evidence-based process have been collected, it is important for the knowledge obtained to be shared with others. Other clinicians, facilities, and patients can benefit from one individual’s or team's hard work, and additional research may be prompted. This knowledge dissemination also inspires other nurses to form their own clinical questions and orchestrate research. It boosts confidence and a feeling of autonomy in nursing practice. Some facilities have EBP champions/teams or nurse mentors to educate staff about current evidence. The distribution of results is the final reward in the long EBP process. Preparing and presenting a poster is an effective method of dissemination, as is publishing findings in a peer-reviewed journal to share with others. In the previous sample case scenario (see Table 3), the wound care nurse created a poster presentation, which was presented at Samford University's annual conference. The poster is also displayed at the local nursing school and on the medical-surgical unit where the study was completed (Berman et al., 2021; Melnyk et al., 2010; Olson, 2023).

Barriers to Evidence-Based Practice

There are many barriers to the use of EBP. According to ATI (2022), nurses are hindered from using EBP because of a lack of knowledge about the EBP process, including finding, evaluating, and implementing EBP. The use of EBP by frontline nurses can be challenging due to decreased engagement in EBP by clinicians, lack of organizational support, traditional cultures, and decreased EBP mentors. Some undergraduate nursing students report positive feelings about using EBP and research but are unprepared to apply EBP. Undergraduate nurses must be comfortable with EBP because they will spend the most time with patients, providing direct patient care (Hooge et al., 2022). The clinical learning environment, instructor, and clinical experience design influence student engagement with EBP. Clinical course activities should include foundational competencies emphasizing applying and searching for evidence for each patient in the clinical setting to overcome these barriers (Lam et al., 2020).

Nurses also report a lack of resources required to implement EBP. EBP must be prioritized at the institutional and governmental levels for nurses to have the resources and training needed (Lam et al., 2020). Nurses report cultural disadvantages and negative attitudes about EBP, which leads to a lack of confidence in practicing EBP (Hooge et al., 2022). Another barrier to EBP is the time delay between collecting and applying research results. Nurses report that improved education, increased motivation, and acceptance of EBP by their employer increase the use of EBP (Boswell et al., 2020).

Conclusion

EBP is important to delivering high-quality healthcare, improving outcomes, and controlling care costs. Not only does EBP enhance healthcare for patients, but it also increases the nurse's autonomy and fosters a feeling of empowerment (Leufer, 2020). Improving understanding and expanding the use of EBP in undergraduate and graduate nurses will lead to growth throughout the nursing profession. EBP can be a lengthy process that begins with a nurse using clinical expertise to question current practices. EBP combines the nurse's experience, patient preference, and the most compelling evidence to improve healthcare and patient outcomes continuously. Using the PICOT format to refine the clinical question will enable the nurse to identify pertinent research and current evidence. The outlined EBP process will allow the nurse to complete the process and answer the clinical questions. There may be barriers to EBP at all levels. Increasing education on EBP in undergraduate nursing programs will help produce nurses more comfortable with the process. Practicing nurses can improve their understanding of the EBP process by participating in workshops and completing continuing education unit (CEU) offerings related to EBP. Subscribing to nursing journals and discussing research literature is a wonderful way to consider and develop clinical questions. Forming task forces and formal teams, using mentors, journal clubs, and EBP rounds are also effective ways to instill the use of EBP into an organization. Forming an EBP team can help to facilitate the process and implement change. Team members should be enthusiastic about EBP to build excitement within the organization and light a fire in the staff to drive change (Hooge et al., 2022).

References

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Berman, A., Snyder, S., & Frandsen, G. (2021). Kozier & Erb's fundamentals of nursing: Concepts, process, and practice (11th Ed.). Pearson

Boswell, C., Ashcraft, A., Long, J., Cannon, S., DiVito, T. P., & Delaney, T. (2020). Self‐efficacy: Changing the tide of evidence‐based practice. Worldviews on Evidence-Based Nursing, 17(2), 129–135. https://doi.org/10.1111/wvn.12434

Burns, P. B., Rohrich, R. J., & Chung, K. C. (2011). The levels of evidence and their role in evidence-based medicine. Plastic and reconstructive surgery, 128(1), 305–310. https://doi.org/10.1097/PRS.0b013e318219c171

Center for Evidence-Based Management. (n.d.). What are the levels of evidence? Retrieved October 13, 2023, from https://cebma.org/faq/what-are-the-levels-of-evidence/

Granger, B. (2020). Life after PICOT: Taking the next step in a clinical inquiry project. AACN Advanced Critical Care, 31(1), 92-97. https://doi.org/10.4037/aacnacc2020986

Hooge, N., Allen, D. H., McKenzie, R., & Pandian, V. (2022). Engaging advanced practice nurses in evidence‐based practice: An e‐mentoring program. Worldviews on Evidence-Based Nursing, 19(3), 235–244. https://doi.org/10.1111/wvn.12565

Lam, C. K., Schubert, C. F., & Herron, E. K. (2020). Evidence‐based practice competence in nursing students preparing to transition to practice. Worldviews on Evidence-Based Nursing, 17(6), 418–426. https://doi.org/10.1111/wvn.12479

Leufer, T. (2020). Teaching core EBP skills to postgraduate nursing students. Worldviews on Evidence-Based Nursing, 17(5), 404–405. https://doi.org/10.1111/wvn.12431

Long, H. A., French, D. P., & Brooks, J. M. (2020). Optimising the value of the critical appraisal skills programme (CASP) tool for quality appraisal in qualitative evidence synthesis. Research Methods in Medicine & Health Sciences, 1(1), 31–42. https://doi.org/10.1177/2632084320947559

Mazumdar, M. (2022). Different types of research articles in journals. https://researcher.life/blog/article/types-of-researcher-articles/

Melnyk, B. M., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. M. (2010). Evidence-based practice: Step by step: The seven steps of evidence-based practice. The American Journal of Nursing, 110(1), 51–53. https://doi.org/10.1097/01.NAJ.0000366056.06605.d2

Melnyk, B., & Fineout-Overholt, E. (2022). Evidence-based practice in nursing and healthcare (5th ed). Wolters Kluwer.

Northern Arizona University. (2023). Ask: Write a focused clinical question. https://libraryguides.nau.edu/c.php?g=665927&p=4682772

Olson, J. (2023). Implementing evidence-based practice. CINAHL Nursing Guide. https://ceu.cinahl.com/?an=5000016491

Rudman, A., Bostrom, A., Wallin, L., Gustavsson, P., & Ehrenberg, A. (2020). Registered nurses' evidence-based practice revisited: A longitudinal study in mid-career. Worldviews on Evidence-Based Nursing, 17(5), 348-355. https://doi.org/10.1111/wvn.12468

SUNY Downstate Medical Research Library of Brooklyn. (2022). Evidence-based medicine course. https://guides.downstate.edu/ebm

Tenny, S., Brannan, J. M., and Brannan, G. D. (2022). Qualitative study. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK470395/

Venes, D. (2021). Taber's cyclopedic medical dictionary (23rd ed.). F.A. Davis Company.