Evidence-based nursing

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This article is about the general nursing field. For the nursing journal, see Evidence Based Nursing (journal).

Evidence-Based Nursing or EBN is an approach to making quality decisions and providing nursing care based upon personal clinical expertise in combination with the most current, relevant research available on the topic. EBN implements the most up to date methods of providing care, which have been proven through appraisal of high quality studies and statistically significant research findings. The goal of EBN is to improve the health and safety of patients while also providing care in a cost-effective manner to improve the outcomes for both the patient and the healthcare system. EBN is a process founded on the collection, interpretation, appraisal, and integration of valid, clinically significant, and applicable research. The evidence used to change practice or make a clinical decision can be separated into seven levels of evidence that differ in type of study and level of quality. To properly implement EBN, the knowledge of the nurse, the patient’s preferences, and multiple studies of evidence must all be collaborated and utilized in order to produce an appropriate solution to the task at hand. These skills are taught in modern nursing education and also as a part of professional training.[1]

The Steps of EBN[edit]

Cultivate Spirit of Inquiry A spirit of inquiry refers to an attitude in which questions are encouraged to be asked about existing practices. Cultivating a spirit of inquiry allows healthcare providers to feel comfortable with questioning current methods of practice and challenging these practices to create improvements and change. A culture that fosters this should have a philosophy that incorporates EBP, access to tools that can enhance EBP, and administrative support and leadership that values EBP.

Ask Clinical Question (PICOT) PICOT formatted questions address the Patient population, Issue or intervention, Comparison group, Outcome, and Time frame. Asking questions in this format assists in generating a search that produces the most relevant, quality information related to a topic, while also decreasing the amount of time needed to produce these search results. An example of a quality PICOT question would be: In total knee arthroplasty patients (Population), what is the effect of nerve blocks (Intervention) compared to opioid pain medication (Comparison) in controlling post-operative pain (Outcome) within the first 24 hours after surgery (Time)?

Search for and Collect Relevant Evidence To begin the search for evidence, use each keyword from the PICOT question that was formed. Once results have been found on the intervention or treatment, the research can be rated to determine which provides the strongest level of evidence. There are seven levels of evidence, with a level I being of the strongest quality and a level VII being of the weakest quality: Level I: Evidence from systematic reviews or meta-analysis of randomized control trials Level II: Evidence from well-designed randomized control trials Level III: Evidence from well-designed control trials that are not randomized Level IV: Evidence from case-control or cohort studies Level V: Evidence from systematic reviews of descriptive or qualitative studies Level VI: Evidence from a single descriptive or qualitative study Level VII: Evidence from expert opinions The strongest levels of evidence, systematic reviews and meta-analyses, summarize evidence related to a specific topic by finding and assessing studies that specifically relate to the question being asked. Meta-analyses are systematic reviews that also use quantitative measures such as statistics to summarize the results of the studies analyzed.

Critically Appraise the Evidence To begin the critical appraisal process, three questions may be asked to determine the validity, reliability, and applicability of the evidence found. The three questions are: 1. Are the results of the study valid? In order to be valid, the results of the study must be as close to the truth as possible. Also, the study must be conducted using best available research methods. 2. What are the results? This question measures the reliability of the study. In an intervention study, reliability consists of: whether the intervention worked, how large the effect was, and whether a clinician could repeat the study with similar results. For a qualitative study, reliability would be measured by determining if the research accomplished the purpose of the study. 3. Will the results be applicable in caring for patients? The study may be used in practice when caring for patients if the subjects are similar to the patients being cared for, the benefit outweighs the harm, the study is feasible, and the patient desires the treatment. After asking these three questions, evidence appraisal continues by creating an evidence synthesis. This synthesis compares multiple studies to see if they are in agreement with each other.

Integrate the Evidence After appraising the evidence, it is necessary to integrate it with the provider's expertise and patient's preferences. The patient is encouraged to practice autonomy and participate in the decision-making process. Therefore, even if the study had successful outcomes, the patient may refuse to receive a treatment. Assessment findings and patient history may reveal further contraindications to a certain evidence-based treatment. Lastly, availability of healthcare resources may limit the implementation of a treatment even if it is found to be effective in a study.

Evaluate Outcomes The next step in the evidence-based practice process is to evaluate whether the treatment was effective in terms of patient outcomes. It is important to evaluate the outcomes in a real-world clinical setting to determine the impact of the evidence-based change on healthcare quality.

Disseminate Outcomes The last step is to share the information especially if positive outcomes are achieved. By sharing the results of evidence-based practice process, others may benefit. Some methods to disseminate the information include presentations at conferences, rounds within one's own institution, and journal publications. [2]

Qualitative Research Process[edit]

One method of research for Evidence based practice in nursing is 'Qualitative Research': "The word implies a entity and meanings that are not experimentally examined or measured in terms of quantity, amount, frequency, or intensity." With qualitative research, researchers learn about patient experiences through discussions and interviews. The point of qualitative research is to provide beneficial descriptions that allow insight into patient experiences. "Hierarchies if research evidence traditionally categorize evidence from weakest to strongest, with an emphasis on support for the effectiveness of interventions. That this perspective tends to dominate the evidence-based practice literature makes the merit of qualitative research unclear;" 1 Some people view qualitative research as less beneficial and effective, with its lack of numbers, the fact that it is "feeling-based" research, makes the opponents associate it with bias. Nevertheless, the ability to empathetically understand an individual's experience (whether it be with cancer, pressure ulcers, trauma, etc.), can benefit not only other patients, but the health care workers providing care.

For qualitative research to be reliable, the testing must be unbiased. To achieve this, researchers must use random and non-random samples to obtain concise information about the topic being studied. If available, a control group should be in use, if possible with the qualitative studies that are done. Evidence should be gathered from every available subject within the sample to create balance and dissolve any bias. There should also be several researchers doing the interviewing to obtain different perspectives about the subject. Researchers must also obtain negative information as well as the positive information gathered to support the data. This will help to show the researchers were unbiased and were not trying to hide negative results from readers, and actually makes it possible to objectively understand the phenomenon under investigation. The inclusion of this negative information will strengthen the researchers initial study, and may actually work in favor to support the hypothesis. Any data that has been gathered must be appropriately documented. If the data collected was obtained from interviews or observation, it must all be included. Dates, times and gender of the sample may be needed, providing background on subjects, such as breast cancer in women over thirty-five. Any pertinent information pertaining to the sample must be included for the reader to judge the study as worthy.

In addition, the current evidence-based practice (EBP) movement in healthcare emphasizes that clinical decision making should be based on the "best evidence" available, preferably the findings of randomized clinical trials. Within this context qualitative research findings are considered to have little value and the old debate in nursing has been re-ignited related as to whether qualitative versus quantitative research findings provides the best empirical evidence for nursing practice. In response to this crisis qualitative scholars have been called upon by leaders in the field to clarify for outsiders what qualitative research is and to be more explicit in pointing out the utility of qualitative research findings. In addition, attention to "quality" in qualitative research has been identified as an area worthy of renewed focus. Within this paper two key problems related to addressing these issues are reviewed: disagreement not only among "outsiders" but also some nursing scholars related to the definition of "qualitative research", and a lack of consensus related how to best address "rigor" in this type of inquiry.

Based on this review a set of standard requirements for qualitative research published in nursing journals is proposed that reflects a uniform definition of qualitative research and an enlarged yet clearly articulated conceptualization of quality. The approach suggested provides a framework for developing and evaluating qualitative research that would have both defensible scholarly merit and heuristic value. This will help solidify the argument in favor of incorporating qualitative research findings as part of the empirical "evidence" upon which evidence-based nursing is founded.

How to Critique a Research Article[edit]

The critiquing process is the building block and foundation for the multiple steps that are to follow in the successful implementation of EBP. This is so because you must first ensure that the material and research that you are trying to convince others to accept is reliable and accurate. By taking the time to thoroughly critique a study you can point out both the strengths and weaknesses of the findings and weigh them accordingly. Successful completion of this vital step will help "weed out" the material lacking the needed proof of effectiveness, therefore minimizing useless, or even harmful, implementation of new practices in the healthcare field.

Critiquing criteria are the standards, evaluation guides, or questions used to judge (critique) an article. In analyzing a research report, the reader must evaluate each step of the research process and ask questions about whether each step of the process meets the criteria. Remember when you are doing a critique, you are pointing out strengths, as well as the weaknesses. To critique an article you must have some knowledge on the subject matter. There is no replacement for reading the article many times. The reader must search the article for contradictions, illogical statements, and faulty reasoning. It is important to evaluate every section of the research article. Each section has different criteria to meet, in order to be considered a well-written addition to the article.

Introduction, Purpose, and Hypothesis[edit]

Introductions need to at least include a literature review and a purpose statement, but they may also contain a theoretical framework, a research question, and a hypothesis. The research question presents the idea that is to be examined in the study and is the foundation of the research study. A well-developed research question guides a focused search for scientific evidence about assessing, diagnosing, treating, or assisting patients with understanding of their prognosis related to a specific health problem. The hypothesis attempts to answer the research question. A hypothesis is a declarative statement about the relationship between two or more variables that predicts an expected outcome. Characteristics of a hypothesis include a relationship statement, implications regarding testability, and consistency with a defined theory base. They can be formed by either a directional or nondirectional method. The literature review needs to explain the reason the study was conducted and why it was important for the study to be conducted now. The theoretical framework and the literature review should also work together. The purpose statement needs to explain what the study wants to accomplish. The purpose, aims, or objectives often provide the most information about the intent of the research question and hypothesis and suggest the level of evidence to be obtained from the findings of the study. The introduction should cover these topics, and should not throw in a lot of excess, useless knowledge. The research question, hypothesis, and the study should all correlate together. You have to be careful when critiquing research articles because sometimes researchers will try to cover up a poor study with lots of information that does not belong. It may look good to the reader at first glance so it is always a good idea to reread the articles a few times to fully understand it and to see if there are any discrepancies.

Methodology[edit]

The methodology section must start off by gathering a sample. There are a few definitions you must understand first. 'Population' is the group that you want your study findings to apply to. A 'sample frame' is the target population, in which the study will affect. There are three different ways to select a population. The researchers can choose who they want in the study, the participants can choose if they want to be in the study, or it can be a random selection in which neither the researcher or the participant chooses. The study must either have external validity or internal validity. If the study has external validity then the study's findings have different settings, procedures, and participants. External validity will also question what types of subjects and conditions in which the same results can be expected to occur. If the study has internal validity then the findings are held true within the sample. The researchers will rule out factors or threats as rival explanations of the relationship between the variables that are present. Be careful with internal validity and external validity because there are a number of threats for both that can affect the outcome of the study. These should be considered by the researchers who are planning the study and by consumers before implementing the results into practice. Phenomenological method In qualitative research phenomenological methods are used to learn and construct the meaning of the human experience through intensive dialogue with persons who are living the experience. The researcher's goal is to explain the meaning of the experience to the participant. This is achieved through a dialogic process, which is more than a simple interview.

Results and Discussion[edit]

The results section puts forth the findings of a study in a clear, logical, and unbiased manner. It presents the findings according to the variables studied without extrapolating beyond what those variables yielded. Qualitative studies do not contain statistical tests. Therefore, the themes, concepts, observational or print data are described in the "Methods" or "Data Collection" subtitles and are reported in the "Results" or "Findings" section. A good results section should also make use of descriptive statistics. Descriptive statistics are used to summarize, reduce, and organize the data and characteristics of the data into an easily understood, manageable format. Finding data's mode, median, and mean are three techniques used to easily recognize central tendency. Techniques such as range and standard deviation are used to measure variability and scatter plots are used to measure correlation. After analyzing the data and finding central tendency, variability, and correlation, this information should be worked into an easily understood format such as a frequency distribution table, chart, or graph. The reader should be able to easily recognize and interpret the data. However, the reader must be on alert to recognize that this may yet be another opportunity for the author of the study to make the results appear more grandiose than they are. Always look at what the actual numbers amount to instead of just looking at how significant the graph or chart makes the data look. In a good results section, the author will not try to make insignificant data look significant, but simply show the results. If the numerical data of a study does not show the same claims that the researcher stated then this is a major flaw in the study and raises significant concerns about the study's validity and reliability; therefore, a nurse and other healthcare providers should not only stay current on new research but should be able to decipher the research in order to determine its true value to the medical practice.

The very last section of a research study is known as the discussion section. Here, the researchers draw all the pieces from the study together to present the whole picture. The researchers review the literature and discuss how the results compare and contrast previously completed studies. The researchers often present biased opinions in the discussion section but these should always be supported by the research and not just the interpretation of the researchers. This overview of the study serves to make a comparison with the background literature. The results and discussion sections can sometimes be combined into one by the researcher, but normally, the researcher will report the findings into separate "results" and "discussion" sections. One way is not better than the other when it comes to combining or dividing the findings into sections. Any new or unexpected results are usually described in the discussion section as well.

Evaluating the conclusion[edit]

A conclusion can be identified as paragraphs that state the main claims that came out of the findings that were read earlier in the article. It should have a summary of the findings (strengths and weaknesses), status of the hypothesis, limitations, and recommendations, implications, or applications. In each section the best and worst needs to brought forth. In a quality conclusion section the author will only state what has been found, or not, without adding anything extra. The hypothesis will be proven true or false and nothing in between. Limitations will be discussed such as the statistical framework or design errors made in the beginning. The researcher should also present the limitations or weaknesses of the study. This presentation is important because it affects the studies generalizability. The generalizations or inferences about similar findings in other samples also are presented in light of the findings. Recommendations will be few in quality research. If no loopholes or oversights are made at the beginning, then these will not have to be expressed at the end. When all of these come together in a simplified manner, then a conclusion can be considered strong.

A limitation is an admission of how certain aspects of the study, such as the sampling, were not as unbiased as they should have been. This lets the reader know that improvements can be made from what was accomplished in the article.

The last thing the conclusion should do is give the reader a recommendation. This recommendation should be derived from the results gathered earlier in the article. Based on the results, the reader will be able to judge whether the data and hypothesis should be applied to nursing practice.[3]

Legal and Ethical Issues of Research[edit]

Both legal and ethical issues are important in considering patient-based research. The American Nurses Association (ANA) has set up five basic rights for patient protection:

  1. Right to self-determination
  2. Right to privacy and dignity
  3. Right to anonymity and confidentiality
  4. Right to fair treatment
  5. Right to protection from discomfort and harm.

These rights apply to both researchers and participants. Informed consent is one area that nurses must be familiar with in order to complete research. Informed consent is "the legal principle that governs the patients ability to accept or reject individual medical interventions designed to diagnose or treat an illness". Informed consent can only be obtained before the procedure and after potential risks have been explained to the participant. When dealing with the ethical portion of Evidence based practice, the Institutional Review Boards (IRB) review research projects to assess that ethical standards are being followed. The institutional review board is responsible for protecting subjects from risk and loss of personal rights and dignity. The IRB also come into play when deciding on which populations can be included in research. Vulnerable groups such as children, pregnant women, physically disabled or elderly maybe excluded from the process. Nurses must notify the IRB of any ethical or legal violations.

It is important to be up to date on all the appropriate state laws and regulations regarding vulnerable populations. This may mean consulting with lawyers, clinicians, ethicists, as well as the affiliated IRB. It is imperative that researchers act as advocates for these vulnerable persons that cannot do so for themselves.

Barriers to promoting Evidence Based Practice[edit]

The use of evidence based practice depends a great deal on the nursing student's proficiency at understanding and critiquing the research articles and the associated literature that will be presented to them in the clinical setting. According to, Blythe Royal, author of Promoting Research Utilization in nursing: The Role of the Individual, Organization, and Environment, a large amount of the preparation requirements of nursing students consists of creating care plans for patients, covering in depth processes of pathophysiology, and retaining the complex information of pharmacology. These are indeed very important for the future of patient care, but their knowledge must consist of more when they begin to practice. Evidence based nursing in an attempt to facilitate the management of the growing literature and technology accessible to healthcare providers that can potentially improve patient care and their outcomes.[4] Nancy Dickenson-Hazard states, "Nurses have the capacity to serve as caregivers and change agents in creating and implementing community and population-focused health systems."[5] There is also a need to overcome the barriers to encourage the use of research by new graduates in an attempt to ensure familiarity with the process. This will help nurses to feel more confident and be more willing to engage in evidence based nursing. A survey that was established by the Honor Society of Nursing and completed by registered nurses proved that 69% have only a low to moderate knowledge of EBP and half of those that responded did not feel sure of the steps in the process. Many responded, "lack of time during their shift is the primary challenge to researching and applying EBP."[6] There is always and will always be a desire to improve the care of our patients. The ever increasing cost of healthcare and the need for more accuracy in the field proves a cycle in need of evidence based healthcare. The necessity to overcome the current issues is to gain knowledge from a variety of literature not just the basics. There is a definite need for nurses, and all practitioners, to have an open mind when dealing with the modern inventions of the future because these could potentially improve the health of patients.

There are many barriers to promoting evidence based practice. The first of which would be the practitioner's ability to critically appraise research. This includes having a considerable amount of research evaluation skills, access to journals, and clinic/hospital support to spend time on EBN. Time, workload pressures, and competing priorities can impede research and development. The causes of these barriers include nurse's and other professional practitioners lack of knowledge of research methods, lack of support from professional colleagues and organizations, and lack of confidence and authority in the research arena.[7] Another barrier is that the practice environment can be resistant to changing tried and true conventional methods of practice. This can be caused because of reluctance to believe results of research study over safe, traditional practices, cost of adopting new practices, or gaining momentum to rewrite existing protocols.[8] It is important to show nurses who may be resistant to changes in nursing practice the benefits that nurses, their patients, and their institutions can reap from the implementation of evidence-based nursing practice, which is to provide better nursing care.[9] Values, resources and evidence are the three factors that influence decision-making with regard to health care. All registered nurses and health care professionals should be taught to read and critically interpret research and know where to find articles which relate to their field of care. In addition, nurses need to be more aware of how to assess the information and determine its applicability to their practice.[10]

Another barrier to implementing EBN into practice is lack of continuing education programs.[11] Practices do not have the means to provide workshops to teach new skills due to lack of funding, staff, and time; therefore, the research may be tossed dismissed. If this occurs, valuable treatments may never be utilized in patient care. Not only will the patients suffer but the staff will not have the opportunity to learn a new skill. Also, the practitioners may not be willing to implement change regardless of the benefits to patient care.

Another barrier to introducing newly learned methods for improving treatments or patients' health is the fear of "stepping on one's toes". New nurses might feel it is not their place to suggest or even tell a superior nurse that newer, more efficient methods and/or practices are available.

The perceived threat to clinical freedom offered by evidence-based practice is neither logical nor surprising. Resistance to change and to authority is part of human nature. When we make decisions based upon good quality information we are inconsistent and biased. Human nature offers many challenges to evidence-based practice. Can we do a better job of promoting evidence-based practice? And even if we find and use the evidence, will we make consistent unbiased decisions?

Even if clinicians do act consistently it is possible that their decisions are consistently biased. People put different values on gains and losses. Tversky and Kahneman gave people the two identical problems (with the same probabilities of life and death outcomes - see fig 1) but framed the outcome choices as either lives saved or as deaths.10 Most people wanted to avoid taking risks with gains which could be safeguarded, but would take risks with losses which might be avoided; this is a framing effect. If people are given identical options but different words are used to emphasize a gain rather than a loss, then a different response is given by a large proportion of the population under study. Such a change in response appears to be inconsistent.[12]

See also[edit]

References[edit]

  1. ^ Melnyk, B.M. (2011). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia, PA: Lipincott Williams & Wilkins. pp. 3–7. ISBN 978-1-60547-778-7. 
  2. ^ Melnyk, B.M. (2011). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia, PA: Lipincott Williams & Wilkins. pp. 11–17. ISBN 978-1-60547-778-7. 
  3. ^ "ETSU Online Campus". 
  4. ^ Royal J, Blythe J (July 1, 1998). "Promoting research utilisation in nursing: the role of the individual, organisation, and environment. Evidence-Based Nursing" 1(3). pp. 71–72. 
  5. ^ Nancy Dickenson-Hazard (2004) Global Health Issues and Challenges Journal of Nursing Scholarship 36 (1) , 6–10.
  6. ^ "The Honor Society of Nursing". Sigma Theta Tau International. 
  7. ^ Taylor S; Allen D Nurse Researcher, 2007; 15 (1): 78-83 (journal article)CINAHL
  8. ^ Loyd, G. 2008. EBP Readings. Nursing Theory Research Handout. East Tennessee State University, Johnson City, TN.
  9. ^ Med-Surg Matters, Jul2007; 16 (4): 1, 13 (journal article) CINAHL
  10. ^ Castledine G British Journal of Nursing (BJN), CINAHL 10/9/97; 6 (18): 1077 (journal article)
  11. ^ Salmond, Susan W. EdD. "Advancing Evidence-Based Practice: A Primer." Orthopaedic Nursing, March/April 2007, Volume 26, Number 2, pgs 114-123.
  12. ^ Health Education Authority. Oral Health Effectiveness Review No 7. Effectiveness of oral health promotion. London: HEA, 1998

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