Evidence-Based Practice

Evidence based practice (EBP) is a problem-solving approach used in the clinical setting. The approach incorporates the use of current evidence from well-designed studies, including the clinician’s expertise and patient values and preferences (Melnyk & Fineout-Overholt, 2005). When EBP is used in the context of a caring environment, healthcare providers have improved clinical decision-making and better patient outcomes. Due to the rapid changes in the healthcare system and the complex patient population, healthcare organizations, the federal agencies, and a variety of other organizations, have emphasized the use of EBP in clinical practice (Fineout-Overholt, Melnyk & Schultz, 2005).

The evidence-based practice (EBP) movement began in 1972 when a British epidemiologist, Dr. Archie Cochrane, found the medical profession was not providing care using evidence from systematic reviews (known as strong evidence). Cochrane evaluate current interventions for care and found they were not based on evidence, which led to the creation of The Cochrane Collaboration. The Cochrane Collaboration published systematic reviews that led to the establishment of evidence-based medicine (Shah & Chung, 2009).

As a result of Dr. Cochrane’s work, an electronic database was created, known as the Cochrane Library. The primary purpose of the Cochrane organization is to assist healthcare professionals, researchers, and others, in making evidence-based decisions about health care by developing, maintaining, and updating systematic reviews of interventions/treatments and by making these reviews accessible to the public (Cochrane, 2020). For access to systematic reviews, visit the Cochrane Library.

Nurses have been passionate about conducting research since Florence Nightingale’s era during the late 1800s. Nightingale’s pioneering research during the Crimean War found reduced mortality rates on ill and injured soldiers by improving sanitary conditions and using trained nurses. Nightingale’s scientific research findings were presented in her book, Notes on Nursing, published in 1860 (McDonald, 2001). Nightingale’s work is an example of a nurse having a question about how practice can be altered to improve a clinical problem.

Standards of Professional Practice

Application of EBP is one of the many expectations of professional nursing. As discussed in Week 1, the Scope and Standards of Practice, developed by the American Nurses Association (ANA, 2015c), serves as a template for professional nursing practice for all registered nurses. Standard 13, Evidence-Based Practice and Research, states, “The registered nurse integrates evidence and research findings into practice” (p. 77). The following is a summary of the competencies of the Evidence-Based Practice and Research standard:

  • Uses current EBP nursing knowledge, including research findings, to guide practice.
  • Incorporates evidence when initiating changes in nursing practice.
  • Appraises nursing research for optimal application in practice and the healthcare setting.
  • Shares peer-reviewed research findings with colleagues to integrate knowledge into nursing practice (ANA, 2015c, p. 77)
arrows with old way and new way

Basic Introduction to Levels of Evidence

The purpose of this basic introduction to levels of evidence is to help the reader differentiate between the different types of research studies. Some research studies are designed to guide practice changes (used as EBP), whereas other studies are used gather new knowledge about a practice topic. The intent of sharing this information is not to gain a thorough understanding of each type of research study, but to have the awareness of which studies are used to guide practice change. You will gain a more thorough understanding of nursing research in NURS 302: Principles of Nursing Research and Evidence Based Practice.

The list below shares seven levels of evidence, ranging from the strongest to the weakest research studies. Studies that share the most reliable information offer strong evidence and are referred to as Level I evidence (used for EBP). The strength of the research studies are weaker towards the bottom of the list to Level VII evidence. The list below shares the definitions for each level of evidence:

Level I: Systematic Review or Meta-Analysis

A synthesis of evidence from all relevant randomized controlled trials.

Level II: Randomized Controlled Trial

An experiment in which subjects are randomized to a treatment group or control group

Level III: Non-Randomized Controlled Trial

An experiment in which subjects are non-randomly assigned to a treatment group or control group.

Level IV: Case-Control or Cohort Study

Case-control study: a comparison of subjects with a condition (case) with those who don’t have the condition (control) to determine characteristics that might predict the condition.

Cohort study: an observation of a group(s) (cohort[s]) to determine the development of an outcome(s) such as a disease.

Level V: Systematic Review of Qualitative or Descriptive Studies

A synthesis of evidence from qualitative or descriptive studies to answer a clinical question.

Level VI: Qualitative or Descriptive Study

Qualitative study: gathers data on human behavior to understand why and how decisions are made.

Descriptive study: provides background information on the what, where, and when of a topic of interest.

Level VII: Expert Opinion or Consensus

Authoritative opinion of expert committee (Fineout-Overholt, Melnyk, Stillwell, & Williamson, 2010).

levels of evidence

Karp, 2019

Developing a basic understanding of the different types of research is the first step to understanding how EPB is generated. For example, using Level VII evidence cannot be used to guide practice changes, though it can offer new insights on a topic to stimulate critical thinking and further research.

As discussed earlier integrating research findings is a standard of professional nursing practice. When searching the literature for information on a practice issue, searching the databases for the strongest research studies (Level I or II) will offer the nurse valuable information that can be used when considering a practice change.

The scenarios below illustrate which level of evidence is used for a particular need and situation.

The nurse manager (NM) of an ICU finds nurses are calling out sick more often, more requests to transfer to different units, and some of the most senior nurses are resigning. The NM wants to learn how to improve retention and create an environment where nurses are satisfied and content in their job and have positive relationships with other nurses and team members. A Level I article offers evidence the NM can use to create a healthy workplace environment. To view an example of a Level I article, read this article on job satisfaction among critical care nurses.

A nurse who is new to working at an oncology clinic is interested in understanding the experience of cancer patients undergoing chemotherapy treatment for the first time. To learn more about this topic, the nurse would need to read Level V or VI evidence. To view an example of a Level V or VI article, read this article to understand cancer patients’ experiences.

A staff nurse has been asked to create a presentation on the factors related to opioid-related addiction, drug diversion, and overdose in their unit at the upcoming staff meeting. The nurse can choose an article that offers Level VII evidence if the focus is to share a general overview of the topic. To view an example of a Level VII article, an expert panel, read this article on on best practices for prescription drug monitoring in the ED setting. If the intent of the presentation is to find evidence to alter practice, a higher level article will be needed, such as Level I or II.

National Institute of Nursing Research

In the mid 1940s, about 80 years after Nightingale published her groundbreaking research, nursing scientists created a formal nursing research program at the federal level, called the Division of Nursing (National Institute of Nursing Research (NINR, n.d.). Federal support for scientific nursing research continued for many years, then in 1985 the research program was renamed to National Institute of Nursing Research (NINR, n.d.), and is now a division of the National Institutes of Health (NIH). The NINR conducts high level scientific research on a wide variety of healthcare issues, offers research funding opportunities, grant and research training, and more. The following is a brief list of the extraordinary research conducted by nurse researchers at NINR:

  • Palliative Care Intervention Improves Well-being of Cancer Patients and their Caregivers in Community Practice Setting
  • Identification of a Potential Blood-based Biomarker for Diagnosing Mild Traumatic Brain Injuries
  • Brain Imaging Shows that Damage Caused by Sleep Apnea Differs by Sex
  • Micronutrient Deficiencies are Associated with Poor Heart Failure Outcomes
  • Microbiome Associated with Differences in Symptoms and Quality of Life in Women with Irritable Bowel Syndrome

Nurses can ask the following questions and search for research evidence to find answers:

  • What can I do to prevent falls for peri-natal patients?
  • What is most important to patients when they are admitted to the hospital?
    • Hot food?
    • Pain control?
    • Fast response to a call light?
  • Is it okay to test the foley catheter balloon prior to insertion?
  • Why do nurses fear repercussions from doctors during communication?
  • What can a new nurse do to successfully transition to nursing practice without being bullied by their peers?
  • Is a BSN education worth the time and money?
  • Are ADN grads equally as competent as BSN grads?
  • Why do I have to perform regular mouth care for ventilated patients?
  • When is hand sanitizer just as good as soap and water?
  • Does specialty certification improve patient outcomes?

These and other common questions can be answered using research evidence. By using the correct level of evidence, nurses can inform practice by improving outcomes, quality, and patient satisfaction, improve nurse morale and reduce burnout, or simply obtain a better understanding of a variety of topics relevant to nursing practice. Taking control of one’s practice, and instituting change based on research evidence is crucial to performing at one’s highest potential. Seeking out opportunities to learn and share knowledge with peers is essential for the nursing profession.

Barriers and Facilitators to Implementation of EBP

There are a multitude of barriers for implementing EBP, from lack of knowledge, motivation, access to databases, poor technology, lack of time and interest, and the list goes on. Some barriers can be modified though training and mentoring, others require a more focused approach during nursing education training. In order for EBP to take hold within the nursing profession, a concerted effort to from the nurse and the organization is needed.

Solomons and Spross (2011) conducted a review of the literature to determine the barriers and facilitators of implementing of EBP. The following shares an exhaustive list of barriers from the nurse, manager, and organization level:

Barriers

Nurse:

  • time constraints
  • lack of resources
  • demanding workload, high acuity of patients
  • performing EBP takes too long
  • resistant to change
  • lack of authority to change practice
  • lack of respect for research
  • “doesn’t apply to what I do”, “not related to bedside care” and “nurses are not trained to think deductively”
  • lack of training to participate effectively in multidisciplinary teams
  • difficulty accessing resource materials
  • lack of confidence in evaluating the quality of the research
  • lack of information-seeking skills
  • lack of understanding of online research databases such as CINAHL and MEDLINE
  • Using Google or Yahoo! for a literature search rather than the scientific research databases
  • Difficulty understanding the analysis, statistics found in the research studies
  • found research to be overwhelming
  • Lack of awareness of research
  • too many journals (Solomons & Spross, 2011, pp. 115-117)

Management:

  • EBP is not a priority
  • lack of infra-structure for research-related activities
  • resistant to change
  • perceived that nurses were not interested or ready to adopt EBP
  • would not be possible to adopt EBP, lack of authority to change practice (Solomons & Spross, 2011, pp. 115-117)

Organization:

  • information systems are not powerful enough to support EBP efforts
  • poor information systems
  • hospital blocked access to online bibliographic databases and other online resources
  • lack of a library (Solomons & Spross, 2011, pp. 115-117)

Facilitators

  • integrate EBP philosophy and skills into job descriptions and clinical ladders for promotion
  • have a nursing presence on hospital-wide committees that support EBP
  • incorporate EBP into new employee orientation
  • give nurses time during the workday to read and develop practice change activities
  • management includes the definition of EBP in all communications
  • offer resources for EBP training
  • create an EBP council or committee, members should assume leadership roles
  • create a newsletter for the organization to disseminate research activities and the importance of EBP
  • develop EBP champions throughout the organization, aimed at cultivating staff interest and ownership in research
  • attend an annual research symposium
  • reward staff for critical thinking
  • develop a culture of respect across all disciplines
  • hands-on training sessions on how to access and interpret research, develop a manual for nurses
  • for a subcommittee to promote the use of EBP among nurses
  • include time devoted to learning and understanding research into monthly meetings
  • quarterly research workshops and yearly grand rounds
  • convert research findings into a format that is easy to understand
  • share research knowledge through email and online forums
  • use a bulletin board to display current EBP (Solomons & Spross, 2011, pp. 115-117)