Evidence Based Practice in Nursing Healthcare A Guide To Best Practice

Evidence-Based Practice in Nursing &
Healthcare: A Guide to Best Practice

Visit to download the full and correct content document:
https://ebookmass.com/product/evidence-based-practice-in-nursing-healthcare-a-guid
e-to-best-practice/
University of Iowa College of Nursing
University of Iowa
EBP Scientist
Office of Nursing Research, EBP and Quality
Department of Nursing and Patient Care Services
University of Iowa Hospitals and Clinics
Iowa City, Iowa
Maria Cvach, DNP, RN, FAAN

Assistant Director
Nursing, Clinical Standards
The Johns Hopkins Hospital
Baltimore, Maryland
Deborah Dang, PhD, RN, NEA-BC
Graduate School of Nursing

Johns Hopkins University
Director of Nursing, Practice, Education, & Research
Central Nursing Administration
The Johns Hopkins Hospital
Baltimore, Maryland
Lynn Gallagher-Ford, PhD, RN, DPFNAP, NE-BC, FAAN
Senior Director
Director, Clinical Core
The Helene Fuld Institute for Evidence-based Practice in Nursing and Healthcare
College of Nursing
The Ohio State University
Columbus, Ohio
Martha J. Giggleman, RN, DNP
Consultant
Evidence-based Practice
Livermore, California
Doris Grinspun, RN, MSN, PhD, LLD (hon), Dr (hc), O.ONT
Adjunct Professor
Lawrence S. Bloomberg Faculty of Nursing
University of Toronto
Chief Executive Officer
Registered Nurses’ Association of Ontario (RNAO)
Toronto, Ontario
Tami A. Hartzell, MLS
8
Senior Librarian
Werner Medical Library
Rochester General Hospital
Rochester, New York
Marilyn J. Hockenberry, PhD, RN, PPCNP-BC, FAAN

Associate Dean for Research Affairs
Bessie Baker Professor of Nursing
Center for Nursing Research
Duke University School of Nursing
Durham, North Carolina
Robin Kretschman, HC-MBA, MSN, RN, NEA-BC

Vice President Clinical Business Strategic Operations
Nursing Administration
OSF HealthCare
Peoria, Illinois
June H. Larabee, PhD, RN
Professor Emeritus
West Virginia University and West Virginia University Hospitals
Charleston, West Virginia
Lisa English Long, PhD, RN
Consultant
Evidence-based Practice
Cincinnati, Ohio
Jacqueline M. Loversidge, PhD, RNC-AWHC
Associate Professor of Clinical Nursing

College of Nursing
Columbus, Ohio
Pamela Lusk, DNP, RN, PMHNP-BC, FAANP, FNAP

Associate Professor of Clinical Practice
College of Nursing
Columbus, Ohio
Psychiatric/Mental Health Nurse Practitioner
Pediatrics Yavapai Regional Medical Center
Prescott, Arizona
Tina L. Magers, PhD, MSN, RN-BC
Nursing Excellence and Research Coordinator
9
Mississippi Baptist Medical Center
Jackson, Mississippi
Kathy Malloch, PhD, MBA, RN, FAAN

Clinical Professor
College of Nursing
Ohio State University
Columbus, Ohio
Mikki Meadows-Oliver, PhD, RN, FAAN

Associate Professor
Department of Nursing
Quinnipiac University School of Nursing
North Haven, Connecticut
Dianne Morrison-Beedy, PhD, RN, WHNP, FNAP, FAANP, FAAN
Chief Talent & Global Strategy Officer

Centennial Professor of Nursing
College of Nursing
Columbus, Ohio
Dónal P. O’Mathúna, PhD
Associate Professor
Fuld Institute for Evidence-based Practice College of Nursing
Columbus, Ohio
Associate Professor
School of Nursing & Human Sciences
Dublin City University
Glasnevin, Dublin 9, Ireland
Tim Porter-O’Grady, DM, EdD, APRN, FAAN, FACCWS
Clinical Professor
School of Nursing
Emory University
Clinical Wound Specialist
Street Medicine Program/Clinic
Mercy Care of Atlanta
Atlanta, Georgia
Cheryl C. Rodgers, PhD, MSN, BSN

Associate Professor
Duke University School of Nursing
10
Durham, North Carolina
Jo Rycroft-Malone, PhD, MSc, BSc(Hons), RN

Professor and Pro Vice-Chancellor Research & Impact
School of Health Sciences
Bangor University
Bangor, United Kingdom
Alyce A. Schultz, RN, PhD, FAAN

Consultant
Clinical Research and Evidence-based Practice
Bozeman, Montana
Kathryn A. Smith, RN, MN, DrPH

Associate Professor of Clinical Pediatrics
Department of Pediatrics
Keck School of Medicine
General Pediatrics
Children’s Hospital Los Angeles
Los Angeles, California
Cheryl B. Stetler, RN, PhD, FAAN
Retired Consultant
Kathleen R. Stevens, RN, MS, EdD, ANEF, FAAN

Castella Endowed Distinguished Professor
School of Nursing
University of Texas Health Science Center San Antonio
San Antonio, Texas
Susan B. Stillwell, DNP, RN ANEF, FAAN
EBP Expert Mentor and Independent Consultant

Vancouver, Washington
Timothy Tassa, MPS
Network for Excellence in Health Innovation

Washington, District of Columbia
Amanda Thier, RN, MSN
Staff Nurse
Specialty Care Unit
Baylor University Medical Center
Dallas, Texas
Kathleen M. Williamson, RN, PhD
Professor, Chair
Wilson School of Nursing
11
Midwestern State University
Wichita Falls, Texas
Jennifer Yost, PhD, RN

Associate Professor
M. Louise Fitzpatrick College of Nursing
Villanova University
Villanova, Pennsylvania
Cindy Zellefrow, DNP, MSEd, RN

Director, Academic Core and Assistant Professor of Practice
The Helene Fuld Health Trust
National Institute for Evidence-based Practice in Nursing and Healthcare at The Ohio State University
College of Nursing
Reynoldsburg, Ohio
12
Reviewers
Ashley Leak Bryant, PhD, RN-BC, OCN

Assistant Professor
School of Nursing
The University of North Carolina at Chapel Hill
Clinical Nurse
North Carolina Cancer Hospital
UNC Healthcare
UNC Lineberger Comprehensive Cancer Center
Chapel Hill, North Carolina
Lynne E. Bryant, EdD, MSN, RN, CNE

Professor
Ron and Kathy Assaf College of Nursing
Nova Southeastern University
Fort Lauderdale, Florida
Mary Mites-Campbell, PhD

Assistant Professor
College of Nursing
Nova Southeastern University
Fort Lauderdale, Florida
Lisa Chaplin, RN, NP-C, DNP

Assistant Professor
Department of Advanced Practice Nursing
School of Nursing and Health Studies
Georgetown University
Karyn E. Holt, RN, PhD

Director of Online Quality and Faculty Development and Clinical Professor
College of Nursing and Health Professions
Drexel University
Philadelphia, Pennsylvania
Kathy James, DNSc

Associate Professor of Nursing
University of San Diego
San Diego, California
Lynette Landry, PhD, RN

Professor and Chair, Nursing and Health Science
Nursing Program
California State University, Channel Islands
Camarillo, California
Susan Mullaney, EdD
13
Professor and Chair
Framingham State University
Framingham, Massachusetts
Mary Ann Notarianni, PhD, RN

Professor
School of Nursing
Sentara College of Health Sciences
Chesapeake, Virginia
Doreen Radjenovic, PhD, ARNP

Associate Professor
School of Nursing, Brooks College of Health
University of North Florida
Jacksonville, Florida
Theresa Skybo, PhD, RN, CPNP

Associate Professor
Mt. Carmel College of Nursing
Columbus, Ohio
Margaret (Peggy) Slota, DNP, RN, FAAN

Associate Professor
Director, DNP Graduate Studies
School of Nursing and Health Studies
Georgetown University
Ida L. Slusher, PhD (RN, PhD, CNE)

Professor
Baccalaureate & Graduate Nursing
Eastern Kentucky University
Richmond, Kentucky
Debbie Stayer, PhD, RN-BC, CCRN-K

Assistant Professor
Bloomsburg University
Bloomsburg, Pennsylvania
Ann Bernadette Tritak, RN, EdD, MA, BSN

Professor and Associate Dean
Department of Graduate Nursing
Felician University
Lodi, New Jersey
Supakit Wongwiwatthananukit, PharmD, MS, PhD

Professor
Pharmacy Practice
The Daniel K. Inouye College of Pharmacy
University of Hawai’i at Hilo
Hilo, Hawaii
14
15
Foreword
Like many of you, I have appreciated healthcare through a range of experiences and perspectives. As someone
who has delivered healthcare as a combat medic, paramedic, nurse, and trauma surgeon, the value of evidence-
based practice is clear to me. Knowing what questions to ask, how to carefully evaluate the responses,
maximize the knowledge and use of empirical evidence, and provide the most effective clinical assessments
and interventions are important assets for every healthcare professional. The quality of U.S. and global
healthcare depends on clinicians being able to deliver on these and other best practices.
The Institute of Medicine (now the National Academy of Medicine) calls for all healthcare professionals
to be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing
evidence-based practice, quality improvement approaches, and informatics. Although many practitioners
support the use of evidence-based practice, and there are indications that our patients are better served when
we apply evidence-based practice, there are challenges to successful implementation. One barrier is
knowledge. Do we share a standard understanding of evidence-based practice and how such evidence can best
be used? We need more textbooks and other references that clearly define and provide a standard approach to
evidence-based practice.
Another significant challenge is the time between the publication of research findings and the translation
of such information into practice. This challenge exists throughout public health. Determining the means of
more rapidly moving from the brilliance that is our national medical research to applications that blend new
science and compassionate care in our clinical systems is of interest to us all.
As healthcare professionals who currently use evidence-based practice, you recognize these challenges and
others. Our patients benefit because we adopt, investigate, teach, and evaluate evidence-based practice. I
encourage you to continue the excellent work to bring about greater understanding and a more generalizable
approach to evidence-based practice.
Richard H. Carmona, MD, MPH, FACS
17th Surgeon General of the United States
16
Preface
OVERVIEW OF THIS BOOK

The evidence is irrefutable: evidence-based practice (EBP) is key to meeting the quadruple aim in healthcare.
It improves the patient experience through providing quality care, enhances patient outcomes, reduces costs,
and empowers clinicians, leading to higher job satisfaction. Although there are many published
interventions/treatments that have resulted in positive outcomes for patients and healthcare systems, they are
not being implemented in clinical practice. In addition, qualitative evidence is not readily incorporated into
care. We wrote this book to address these issues and many others as well. We recommend that learners read
this book, then read it again, engage in the online resources, the appendices, the glossary . . . then read it
again. It is chock-full of information that can help learners of all disciplines, roles and educational levels
discover how to be the best clinicians. We hope you find that EBP pearl that is just the right information you
need to take the next step in your EBP journey to deliver the best care!
Purpose
The purpose of Evidence-Based Practice in Nursing and Healthcare has never changed. The purpose of this
edition, as with the last three, is to incorporate what we have learned across the years to provide resources and
information that can facilitate clinicians’ ready translation of research findings into practice, as well as their
use of practice data to improve care and document important outcomes, no matter the clinician’s healthcare
role. Each edition has provided additional features and resources for readers to use in their journey to become
evidence-based clinicians. Since the first book was published, there has been some progress in the adoption of
EBP as the standard of care; however, there is still much work to be done for EBP to the paradigm used in
daily clinical decision making by point-of-care providers. Clinicians’ commitment to excellence in healthcare
through the intentional integration of research findings into practice while including patients in decisions
remains a daunting endeavor that will take anywhere from years to decades. Therefore, increased efforts across
the healthcare industry are required to provide a culture that fosters empowered point-of-care clinicians with
the knowledge, skills, attitudes, and resources they need to deliver care that demonstrates improved healthcare
system, clinician, and patient outcomes.
We will always believe that anything is possible when you have a big dream and believe in your ability to
accomplish that dream. It was the vision of transforming healthcare with EBP, in any setting, with one client–
clinician encounter at a time and the belief that this can be the daily experience of both patients and care
providers, along with our sheer persistence through many “character-building” experiences during the writing
and editing of the book, that culminated in this user-friendly guide that aims to assist all healthcare
professionals in the delivery of the highest quality, evidence-based care.
The fourth edition of this book has been revised to assist healthcare providers with implementing and
sustaining EBP in their daily practices and to foster a deeper understanding of the principles of the EBP
paradigm and process. In working with healthcare systems and clinicians throughout the nation and globe and
17
conducting research on EBP, we have learned more about successful strategies to advance and sustain
evidence-based care. The new material throughout the book, including new chapter material, a unit-by-unit
EBP example, new chapters, EBP competencies, and tools to advance EBP, are included so that clinicians can
use them to help with daily evidence-based decision making.
Worldview
A solid understanding of the EBP paradigm, or worldview, is the first mastery milestone for readers of this
EBP book. The next milestone is using the paradigm as the foundation for making clinical decisions with
patients. This worldview frames why rigorously following the steps of the EBP process is essential, clarifies
misperceptions about implementing evidence-based care, and underpins practical action strategies that lead to
sustainable evidence implementation at the point of care. It is our dream that the knowledge and
understanding gained from thoughtfully and intentionally engaging the contents of this book will help
clinicians across the country and globe accelerate adoption of the EBP paradigm until evidence-based care is
the lived experience for clinicians, patients, and health professions students across various healthcare settings
and educational institutions.
NEW FEATURES AND RESOURCES FOR THIS EDITION

The book contains vital, usable, and relatable content for all levels of practitioners and learners, with key
exemplars that bring to life the concepts within the chapters. Each unit now begins with “Making
Connections: An EBP Exemplar.” This unfolding case study serves as a model or example of EBP in real-life
practice. We recommend that learners read each unit exemplar before they engage in that unit’s content; the
characters in the healthcare team in the exemplar use the information within the unit’s chapters to carry out
the steps of EBP, leading to a real evidence-based change to improve the quality and safety of care. These
characters may be fictional, but the exemplar is based on an important quality indicator (i.e., hospital falls) and
an actual synthesis of published research that offers the opportunity for readers to better understand how they
can use EBP in their clinical practice or educational setting to improve outcomes. Readers may wish to refer
back to the exemplar as they are reading through the chapters to see how the healthcare team used the
information they are learning. Furthermore, it is recommended that readers follow the team as they make
evidence-based decisions across the units within the book. There are online resources as well as resources
within the appendices of the book that will be used in the exemplar, offering readers the opportunity to see
how the team uses these resources in evidence-based decision making.
Our unit-ending feature, “Making EBP Real: A Success Story,” has been updated and continues to
provide real-life examples that help readers to see the principles of EBP applied. Readers can explore a variety
of ways that the steps of the EBP process were used in real EBP implementations. Clinicians who desire to
stimulate or lead change to a culture of EBP in their practice sites can discover in both of these unit-level
features how functional models and practical strategies to introduce a change to EBP can occur, including
overcoming barriers in implementing change, evaluating outcomes of change, and moving change to
sustainability through making it standard of care.
To help recognize that knowledge and understanding of EBP terms and language is essential to adopting
the EBP paradigm, in this edition, we added EBP Terms to Learn that features key terms at the beginning of
18
each unit and chapter. Readers can review terms in the glossary before reading the chapters so that they can
readily assimilate content. Furthermore, we have provided learning objectives at the unit and chapter level to
continue to reinforce important concepts and offer the opportunity for readers to quickly identify key chapter
content. When readers come across bolded terms within the chapter, they are encouraged to go to the glossary
at back of the book to further explore that concept. EBP Fast Facts is an important feature at the end of each
chapter that we retained for this edition, offering readers some of the most important pearls of wisdom from
the chapter. These elements in our fourth edition will help learners master the terminology of EBP and
identify important content for developing EBP competence.
Finally, for faculty, there is new content in the chapter on teaching EBP in academic settings that can help
educators to parse teaching EBP across academic learning degrees. Educators are encouraged to review the
online resources that can facilitate teaching EBP in both academic and clinical settings.
Further resources for all readers of the book include appendices that help learners master the process of
evidence-based change, such as rapid critical appraisal checklists (be sure to check online on for Word
versions of RCA checklists for readers to use), sample instruments to evaluate EBP in both educational and
clinical settings, a template for asking PICOT questions, and more. Some appendices appear online only on
, including an appraisal guide for qualitative evidence, an ARCC model EBP mentor role description,
and examples of a health policy brief, a press release, and an approved consent form for a study. More details
about the great resources available online can be found below.
ORGANIZATION OF THE BOOK

As in prior editions, the Table of Contents is structured to follow the steps of EBP:
• Chapters 1 to 3 in Unit 1 encompass steps 0, 1, and 2 of the EBP process. This unit gets learners started by building a strong foundation
and has significant content updates in this new edition.
• Chapters 4 to 8 in Unit 2 delve deeply into step 3 of the EBP process, the four-phased critical appraisal of evidence. In this edition,
Chapters 7 and 8 were moved into Unit 2 to better align the steps of the EBP process with the chapters, including the important
consideration of patient concerns, choices, clinical judgment, and clinical practice guidelines in the recommendation phase of critical
appraisal.
• In Unit 3, Chapters 9 to 12 move the reader from recommendation to implementation of sustainable practice change. To facilitate
understanding how to implement evidence-based change, Chapter 11 was added to describe the context, content, and outcome of
implementing EBP competencies in clinical and academic settings.
• Unit 4 promotes creating and sustaining a culture of EBP. In this unit, we included new content and resources in the chapters on teaching
EBP in educational and healthcare settings (Chapters 16 and 17, respectively). Educators can be most successful as they make the EBP
paradigm and process understandable for their learners.
• Unit 5 features a new Chapter 19 on health policy. In today’s political climate, nurses and healthcare professionals need to understand how
to ensure sustainable change through influencing the formulation of policies governing healthcare, fully supported by the latest and best
evidence. This new chapter joins Chapter 20 on disseminating evidence.
• In Unit 6, Chapter 21 now combines two previous chapters’ content on generating evidence through qualitative and quantitative research,
greatly streamlining the material for enhanced understanding of important concepts and making the information more accessible to learners.
Chapter 23 provides updated information on ethics in EBP and research generation.
• The glossary is one of the best resources within this book. Readers are encouraged to use it liberally to understand and master EBP
language, and thereby enhance their fluency.
Often, educators teach by following chapters in a textbook through their exact sequence; however, we
recommend using chapters of this fourth edition that are appropriate for the level of the learner (e.g., associate
degree, baccalaureate, master’s, doctoral). For example, we would recommend that associate degree students
19
benefit from Units 1, 3, and 4. Curriculum for baccalaureate learners can integrate all units; however, we
recommend primarily using Units 1 to 4, with Unit 5 as a resource for understanding more about research
terminology and methods as readers learn to critical appraise evidence. Master’s and doctoral programs can
incorporate all units into their curricula. Advanced practice clinicians and doctorally-prepared clinical experts
will be able to lead in implementing evidence in practice, thoughtfully evaluate outcomes of practice, and
move to sustainable change, whereas those learning to become researchers will understand how to best build
on existing evidence to fill gaps in knowledge with valid, reliable research that is clinically meaningful.
An important resource for educators to use as a supplement to this EBP book is the American Journal of
Nursing EBP Step-by-Step series, which provides a real-world example of the EBP process from step 0
through 6. We recommend this series as a supplement because the series was written to expose readers to the
EBP process in story form, but used alone it does not provide the level of learning to establish competence in
evidence-based care. In the series, a team of healthcare providers encounters a challenging issue and uses the
EBP process to find a sustainable solution that improves healthcare outcomes. If educators choose to use this
series, we caution on using it as the sole source for learning about EBP. Rather, assigning the articles to be
read before a course begins or in tandem with readings from this book that match the article being read
provides a complete learning opportunity, including context and adequate content for competence—the goal
of learning about EBP, regardless of the learner’s level of education or clinical practice. For example, the first
three chapters of the book could be assigned along with the first four articles, in an academic or clinical
setting. The learners could use discussion boards or face-to-face group conference-type settings to discuss how
the team used the content the learners studied within the chapter, allowing educators opportunity for
evaluation of content mastery (see suggested curriculum strategy at this book’s companion website on ,
http://thepoint.lww.com/Melnyk4e). Multiple approaches are offered for educators and learners to engage
EBP content, and, in doing so, we believe that this book continues to facilitate changes in how research
concepts and critical appraisal are being taught in clinical and academic professional programs throughout the
country.
UPDATED FEATURES
This edition of Evidence-Based Practice in Nursing & Healthcare includes many features that readers have come
to expect. These features are designed to benefit both learners and educators:
• Quotes: As proponents of cognitive-behavioral theory, which contends that how people think directly influences how they feel and behave,
we firmly believe that how an individual thinks is the first step toward or away from success. Therefore, inspirational quotes are intertwined
throughout our book to encourage readers to build their beliefs and abilities as they actively engage in increasing their knowledge and skills
in EBP to accomplish their desired learning goals.
• Clinical Scenarios describe a clinical case or a supervisory decision clinicians could encounter in clinical practice, prompting readers to seek
out best evidence and determine a reasonable course of action.
•
Web Tips: With the rapid delivery of information available to us, web tips direct readers to helpful Internet resources and sites that can
be used to further develop EBP knowledge and skills.
• EBP Fast Facts act as a chapter-closing feature, highlighting important points from each chapter. Reviewing these pearls can help readers
know if they retained the important concepts presented within the chapter.
• Making EBP Real: A successful real-world case story emphasizing applied content from each unit.
• NEW: Learning Objectives: Each unit and chapter now begins with learning objectives, to help learners focus on key concepts.
• NEW: EBP Terms to Learn: Each unit and chapter also now includes a list of the key terms discussed or defined in the chapter that are to
help students build familiarity with the language and terminology of EBP.
20
• NEW: Making Connections: An EBP Exemplar: Opening each unit, this new feature walks the learner through the EBP process in an
unfolding case study that is applicable to a real-time important practice issue.
ADDITIONAL RESOURCES ON
Evidence-Based Practice in Nursing and Healthcare, fourth edition, includes additional resources for both
learners and educators that are available on the book’s companion website at
http://thepoint.lww.com/Melnyk4e.
Learner Resources Available on

Learners who have purchased Evidence-Based Practice in Nursing and Healthcare, fourth edition, have access to
the following additional online resources:
• Appendices D, E, F, G, H from the book

• Learning Objectives for each chapter
• Checklists and templates in MS Word format include checklists for rapid critical appraisal, conducting an evidence review, or holding a
journal club; sample templates for PICOT questions and for evaluation and synthesis tables; an ARCC model EBP mentor role description;
and more.
• A searching exercise to help develop mastery of systematic searching.
• Journal articles corresponding to book chapters to offer access to current research available in Wolters Kluwer journals.
• The American Journal of Nursing EBP Step-by-Step Series, which provides a real-world example of the EBP process as a supplement to
learning within the EBP book.
• An example of a poster (to accompany Chapter 20).
• A Spanish–English audio glossary and Nursing Professional Roles and Responsibilities
See the inside front cover of this book for more details, including the passcode you will need to gain access to
the website.
Educator Resources Available on

Approved adopting instructors will be given access to the following additional resources:
• An eBook allows access to the book’s full text and images online.
• Test generator with updated NCLEX-style questions. Test questions link to chapter learning objectives.
• Additional application case studies and examples for select chapters.
• PowerPoint presentations, including multiple choice questions for use with interactive clicker technology.
• An image bank, containing figures and tables from the text in formats suitable for printing, projecting, and incorporating into websites.
• Strategies for Effective Teaching offer creative approaches.
• Learning management system cartridges.
• Access to all learner resources.
COMPREHENSIVE, INTEGRATED DIGITAL LEARNING SOLUTIONS

We are delighted to introduce digital solutions to support educators and learners using Evidence-Based Practice
in Nursing & Healthcare, Fourth Edition. Now for the first time, our textbook is embedded into an integrated
digital learning solution that builds on the features of the text with proven instructional design strategies. To
learn more about this solution, visit http://nursingeducation.lww.com/, or contact your local Wolters Kluwer
representative.
21
Lippincott CoursePoint is a rich learning environment that drives academic course and curriculum success to
prepare learners for practice. Lippincott CoursePoint is designed for the way students learn. The solution
connects learning to real-life application by integrating content from Evidence-Based Practice in Nursing &
Healthcare with video cases, interactive modules, and evidence-based journal articles. Ideal for active, case-
based learning, this powerful solution helps students develop higher-level cognitive skills and asks them to
make decisions related to simple-to-complex scenarios.
Lippincott CoursePoint for Evidence-Based Practice features:
• Leading content in context: Digital content from Evidence-Based Practice in Nursing & Healthcare is embedded in our Powerful Tools,
engaging students and encouraging interaction and learning on a deeper level.
• The complete interactive eBook features annual content updates with the latest evidence-based practices and provides students with
anytime, anywhere access on multiple devices.
• Full online access to Stedman’s Medical Dictionary for the Health Professions and Nursing ensures students work with the best medical
dictionary available.
• Powerful tools to maximize class performance: Additional course-specific tools provide case-based learning for every student:
• Video Cases help students anticipate what to expect as a nurse, with detailed scenarios that capture their attention and integrate clinical
knowledge with EBP concepts that are critical to real-world nursing practice. By watching the videos and completing related activities,
students will flex their problem-solving, prioritizing, analyzing, and application skills to aid both in NCLEX preparation and in
preparation for practice.
• Interactive Modules help students quickly identify what they do and do not understand so they can study smartly. With exceptional
instructional design that prompts students to discover, reflect, synthesize, and apply, students actively learn. Remediation links to the
eBook are integrated throughout.
• Curated collections of journal articles are provided via Lippincott NursingCenter, Wolters Kluwer’s premier destination for peer-reviewed
nursing journals. Through integration of CoursePoint and NursingCenter, students will engage in how nursing research influences
practice.
• Data to measure students’ progress: Student performance data provided in an intuitive display lets instructors quickly assess whether
students have viewed interactive modules and video cases outside of class, as well as see students’ performance on related NCLEX-style
22
quizzes, ensuring students are coming to the classroom ready and prepared to learn.
To learn more about Lippincott CoursePoint, please visit: http://nursingeducation.lww.com/our-

solutions/course-solutions/lippincott-coursepoint.html
A FINAL WORD FROM THE AUTHORS

As we have the privilege of meeting and working with clinicians, educators, and researchers across the globe
to advance and sustain EBP, we realize how important our unified effort is to world health. We want to thank
each reader for your investment of time and energy to learn and use the information contained within this
book to foster your best practice. Furthermore, we so appreciate the information that you have shared with us
regarding the benefits and challenges you have had in learning about and applying knowledge of EBP. That
feedback has been instrumental to improving the fourth edition of our book. We value constructive feedback
and welcome any ideas that you have about content, tools, and resources that would help us to improve a
future edition. The spirit of inquiry and life-long learning are foundational principles of the EBP paradigm
and underpin the EBP process so that this problem-solving approach to practice can cultivate an excitement
for implementing the highest quality of care. As you engage in your EBP journey, remember that it takes time
and that it becomes easier when the principles of this book are placed into action with enthusiasm on a
consistent daily basis.
As you make a positive impact at the point of care, whether you are first learning about the EBP
paradigm, the steps of the EBP process, leading a successful, sustainable evidence-based change effort, or
generating evidence to fill a knowledge gap or implement translational methods, we want to encourage you to
keep the dream alive and, in the words of Les Brown, “Shoot for the moon. Even if you miss, you land among
the stars.” We hope you are inspired by and enjoy the following EBP rap.
Evidence-based practice is a wonderful thing,

Done with consistency, it makes you sing.
PICOT questions and learning search skills;
Appraising evidence can give you thrills.
Medline, CINAHL, PsycInfo are fine,
But for Level I evidence, Cochrane’s divine!
Though you may want to practice the same old way
“Oh no, that’s not how I will do it,” you say.
When you launch EBP in your practice site,
Remember to eat the chocolate elephant, bite by bite.
So dream big and persist in order to achieve and
Know that EBP can be done when you believe!
© 2004 Bernadette Melnyk

Bernadette Mazurek Melnyk and Ellen Fineout-Overholt
Note: You may contact the authors at bernmelnyk@gmail.com

ellen.fineout.overholt@gmail.com
23
Acknowledgments
This book could not have been accomplished without the support, understanding, and assistance of many
wonderful colleagues, staff, family, and friends. I would first like to acknowledge the outstanding work of my
coeditor and cherished friend, Ellen—thank you for all of your efforts, our wonderful friendship, attention to
detail, and ongoing support throughout this process; I could not have accomplished this revised edition
without you. Since the first edition of this book, I have grown personally and professionally through the many
opportunities that I have had to teach and mentor others in evidence-based practice across the globe—the
lessons I have learned from all of you have been incorporated into this book. I thank all of my mentees for
their valuable feedback and all of the authors who contributed their time and valuable expertise to this book.
Along with my wonderful husband John and my three daughters, Kaylin, Angela, and Megan, I am
appreciative for the ongoing love and support that I receive from my mother, Anna May Mazurek, my brother
and sister-in-law, Fred and Sue Mazurek, and my sister, Christine Warmuth, whose inspirational words to
me “Just get out there and do it!” have been a key to many of my successful endeavors. I would also like to
thank my wonderful colleagues and staff at The Ohio State University for their support, understanding, and
ongoing commitment to our projects and their roles throughout this process, especially Dr. Margaret Graham
and Kathy York. Finally, I would like to acknowledge the team at Wolters Kluwer for their assistance with
and dedication to keeping this project on track.
Bernadette Mazurek Melnyk
Now is the time to join together to ensure that EBP is the paradigm for clinical decision making. Healthcare
providers and educators have made tremendous strides across the years to establish that EBP is an expectation
of providers, educators, and systems. I am grateful to the American Nurses Credentialing Center (ANCC) for
the impact of the Magnet movement as well as educational accrediting agencies (e.g., Commission on
Collegiate Nursing Education [CCNE], National League for Nurses Accreditation Commission [NLNAC],
Liaison Committee on Medical Education [LCME], Accreditation Council of Pharmacy Education
[ACPE]) for putting forward standards that have had an impact on adoption of the EBP paradigm and
process in education, practice, and policy. As a result, all of us across the wonderful diversity of providers who
make up the healthcare team are supported as we choose the EBP paradigm as the foundation for daily
clinical decisions. Thank you to the students, clinicians, healthcare leadership, clinical educators, faculty, and
researchers for demonstrating the ownership of practice that is the key to placing EBP at the center of
healthcare transformation. We are at a tipping point . . . let’s see it through to fruition!
To those of you who have shared with me personally the difference this book has made in your practice,
educational endeavors, and teaching, I heartily extend my deepest thanks. The value of our work is measured
by the impact it has on advancing best practice in healthcare and how it helps point-of-care providers and
educators make a difference in patients’ and students’ lives and health experiences. You help us know that we
are making progress on achieving our dream of transforming healthcare—one client–clinician/learner–
24
educator relationship at a time. Bern, almost 30 years ago, we started our work together—not knowing where
our path would take us. Thank you for seeing the potential and taking the chance—I have enjoyed the
wonderful privilege to work alongside you to bring our dream to life. To my colleagues at University of Texas
at Tyler, thank you for the privilege of joining the family—you are the best!!
With the writing of this fourth edition, my life experiences, and those of contributors to the book, have
helped me recognize more completely how blessed I am to have the support of my precious family and friends
and to have wonderful people in my life who are committed to this often-arduous journey toward best care for
all patients. My sweet family has trekked with me across these four editions. With the first edition, our eldest
daughter wasn’t yet one year old; now, she is a senior in high school. Our youngest daughter was a dream who
is now is in eighth grade. Every day, these sweet young ladies inspire me to continue to strive to achieve the
goal of evidence-based care as the standard for healthcare. Their gift of love and laughter delivered in
packages of hugs is invaluable—Thank You, Rachael and Ruth! Thank you to my steadfast husband, Wayne,
who faithfully offers perspective and balance that are so important to me—your support for this work is
invaluable! Thank you to my mother, Virginia (Grandginny), who continues to help me see the best and not
best in healthcare as she experiences it as an older old adult (now 87). Her encounters remain a reminder that
advocating for evidence-based consumers is an imperative. Thank you to my brother John, and his family,
Angela, Ashton, and Aubrey—your music lifts my spirits; your healthcare experiences serve as fodder for this
work. To those of you who have prayed for me during this writing adventure—thank you so very much!
During my extenuating health issues that have flavored this fourth edition, my Savior and Friend’s continual
care for me has been profound. I am eternally grateful. Healthcare should serve all of us well. Let us all strive
to ensure that every encounter is an experience in excellent care.
Finally, I am grateful to each of you who choose to read this book, take the knowledge contained in its
pages, and make the EBP paradigm and process come alive in your work. You make our dream of healthcare
transformation through EBP live! The Wolters Kluwer team with whom we have had the privilege to work
has been so helpful to make this fourth edition the best yet!! Thank you so much! This book is not written by
one person—or even two. It is written by many people who give of their expertise and wisdom so that readers
can have such a wonderful resource. I am very grateful for each of the faithful contributors to this work and
their decision to join us in advancing EBP as the solution for improving healthcare.
Ellen Fineout-Overholt
25
Contents
UNIT 1 Steps Zero, One, Two: Getting Started

Chapter 1 Making the Case for Evidence-Based Practice and Cultivating a Spirit of Inquiry
Chapter 2 Asking Compelling Clinical Questions

Ellen Fineout-Overholt and Susan B. Stillwell
Chapter 3 Finding Relevant Evidence to Answer Clinical Questions

Tami A. Hartzell and Ellen Fineout-Overholt
Unit 1 Making EBP Real: A Success Story. Using an Evidence-based, Autonomous Nurse Protocol to Reduce Catheter-
Associated Urinary Tract Infections in a Long-term Acute Care Facility
UNIT 2 Step Three: Critically Appraising Evidence

Chapter 4 Critically Appraising Knowledge for Clinical Decision Making
Ellen Fineout-Overholt and Kathleen R. Stevens
Chapter 5 Critically Appraising Quantitative Evidence for Clinical Decision Making

Dónal P. O’Mathúna and Ellen Fineout-Overholt
Chapter 6 Critically Appraising Qualitative Evidence for Clinical Decision Making

Mikki Meadows-Oliver
Chapter 7 Integration of Patient Preferences and Values and Clinician Expertise into Evidence-Based Decision Making
Ellen Fineout-Overholt, Lisa English Long, and Lynn Gallagher-Ford
Chapter 8 Advancing Optimal Care With Robust Clinical Practice Guidelines

Doris Grinspun, Bernadette Mazurek Melnyk, and Ellen Fineout-Overholt
Unit 2 Making EBP Real: A Success Story. Intradermal Lidocaine Intervention on the Ambulatory Unit: An Evidence-
Based Implementation Project
UNIT 3 Steps Four and Five: Moving From Evidence to Sustainable Practice Change
Chapter 9 Implementing Evidence in Clinical Settings
Cheryl C. Rodgers, Terri L. Brown, and Marilyn J. Hockenberry
Chapter 10 The Role of Outcomes and Evidence-Based Quality Improvement in Enhancing and Evaluating Practice
Changes
Anne W. Alexandrov, Tracy L. Brewer, and Barbara B. Brewer
Chapter 11 Implementing the Evidence-Based Practice Competencies in Clinical and Academic Settings to Ensure
Healthcare Quality and Improved Patient Outcomes
Bernadette Mazurek Melnyk, Lynn Gallagher-Ford, and Cindy Zellefrow
Chapter 12 Leadership Strategies for Creating and Sustaining Evidence-Based Practice Organizations
Lynn Gallagher-Ford, Jacalyn S. Buck, and Bernadette Mazurek Melnyk
Unit 3 Making EBP Real: A Success Story. Improving Outcomes for Depressed Adolescents With the Brief Cognitive
Behavioral COPE Intervention Delivered in 30-Minute Outpatient Visits
Creating and Sustaining a Culture and Environment for Evidence-Based Practice
26
Innovation and Evidence: A Partnership in Advancing Best Practice and High Quality Care
UNIT 4 Chapter 13 Kathy Malloch and Tim Porter-O’Grady
Chapter 14 Models to Guide Implementation and Sustainability of Evidence-Based Practice

Deborah Dang, Bernadette Mazurek Melnyk, Ellen Fineout-Overholt, Jennifer Yost, Laura Cullen, Maria Cvach,
June H. Larabee, Jo Rycroft-Malone, Alyce A. Schultz, Cheryl B. Stetler, and Kathleen R. Stevens
Chapter 15 Creating a Vision and Motivating a Change to Evidence-Based Practice in Individuals, Teams, and
Organizations
Chapter 16 Teaching Evidence-Based Practice in Academic Settings

Ellen Fineout-Overholt, Susan B. Stillwell, Kathleen M. Williamson, and John F. Cox III
Chapter 17 Teaching Evidence-Based Practice in Clinical Settings

Ellen Fineout-Overholt, Martha J. Giggleman, Katie Choy, and Karen Balakas
Chapter 18 ARCC Evidence-Based Practice Mentors: The Key to Sustaining Evidence-Based Practice
Ellen Fineout-Overholt and Bernadette Mazurek Melnyk
Unit 4 Making EBP Real: A Success Story. Mercy Heart Failure Pathway
UNIT 5 Step Six: Disseminating Evidence and Evidence-Based Practice Implementation

Outcomes
Chapter 19 Using Evidence to Influence Health and Organizational Policy
Jacqueline M. Loversidge and Cheryl L. Boyd
Chapter 20 Disseminating Evidence Through Presentations, Publications, Health Policy Briefs, and the Media
Cecily L. Betz, Kathryn A. Smith, Bernadette Mazurek Melnyk, and Timothy Tassa
Unit 5 Making EBP Real: A Success Story. Research Projects Receive Worldwide Coverage
UNIT 6 Generating External Evidence and Writing Successful Grant Proposals

Chapter 21 Generating Evidence Through Quantitative and Qualitative Research
Bernadette Mazurek Melnyk, Dianne Morrison- Beedy, and Denise Cote-Arsenault
Chapter 22 Writing a Successful Grant Proposal to Fund Research and Evidence-Based Practice Implementation Projects
Chapter 23 Ethical Considerations for Evidence Implementation and Evidence Generation

Dónal P. O’Mathúna
Unit 6 Making EBP Real: Selected Excerpts From A Funded Grant Application. COPE/Healthy Lifestyles for Teens: A
School-Based RCT
Appendix A Question Templates for Asking PICOT Questions
Appendix B Rapid Critical Appraisal Checklists
Appendix C Evaluation Table Template and Synthesis Table Examples for Critical Appraisal
Appendix I ARCC Model Timeline for an EBP Implementation Project
Appendix J Sample Instruments to Evaluate EBP in Educational Settings
Appendix K Sample Instruments to Evaluate EBP in Clinical Settings
Glossary
Index
APPENDICES AVAILABLE ON
27
Appendix D Walking the Walk and Talking the Talk: An Appraisal Guide for Qualitative Evidence
Appendix E Example of a Health Policy Brief
Appendix F Example of a Press Release
Appendix G Example of an Approved Consent Form for a Study
Appendix H System-Wide ARCC Model Evidence-Based Practice Mentor Role Description
28
UNIT
1 Steps Zero, One, Two: Getting Started
To accomplish great things, we must not only act, but also dream; not only plan,
but also believe.
—Anatole France
EBP Terms to Learn

Background questions
Bibliographic database
Body of evidence
Boolean connectors
Clinical inquiry
Critical appraisal
EBP competencies
Evidence-based practice (EBP)

Evidence-based quality improvement (EBPI)
External evidence
Foreground questions
Grey literature
Internal evidence
Keywords
Meta-analysis
Outcomes management
PICOT format
Point-of-care resources
Preappraised literature
Proximity searching
Randomized controlled trials (RCTs)

Reference managers
Search strategy
Subject headings
Yield
UNIT OBJECTIVES
Upon completion of this unit, learners will be able to:
Identify the seven steps of evidence-based practice (EBP).
Describe the differences among EBP, research, and quality improvement.
Explain the components of a PICOT question: population, issue or intervention of interest, comparison of interest, outcome, and
time for intervention to achieve the outcome.
29
Discuss basic and advanced strategies for conducting a systematic search based on the PICOT question.
Describe a body of evidence based on the evidence hierarchy for specific types of clinical questions.
MAKING CONNECTIONS: AN EBP EXEMPLAR

On the orthopedic unit of a tertiary hospital in the Eastern United States, a nurse manager, Danielle, and the unit EBP Council
representative, Betsy, were discussing recent quality improvement (QI) reports in the staff lounge. Danielle noted that the unit’s patient
satisfaction rates had dropped as their fall rates had increased.
To help provide context, Betsy, who has a passion for fall prevention (Step 0: Spirit of Inquiry), shared the story of Sam, an elderly
patient who sustained a fall with injury during the last quarter, despite the fact that he was not a high fall risk. As Sam’s primary nurse,
Betsy had initiated universal fall prevention precautions as recommended by the Agency for Healthcare Research & Quality in their Falls
Prevention Toolkit (AHRQ; https://www.ahrq.gov/sites/default/files/publications/files/fallpxtoolkit.pdf). Betsy hoped that Sam’s story
would help illuminate some of the issues that surround falls that are more challenging to predict.
Sam had awakened from a deep sleep and needed to void. He was oriented when he went to bed, but upon waking he became confused
and couldn’t locate his call light because, although it was placed close to him, it had been covered by his pillow. In an interview after he fell,
Sam told Betsy that he had to go so badly that he just didn’t think about looking under the pillow. He also forgot that there was a urinal on
the bedside table. He simply focused on getting to the bathroom, and when he tried to get out of bed with the rails up, he pinched his wrist,
causing a hematoma and soft tissue injury.
Danielle had more information that shed light on the rising fall rates. All of the falls during the past quarter occurred during the night
shift. Over a period of several weeks, a number of the night nurses had been ill, leading to per-diem and float staff covering those positions.
Staff had documented rounding, but Betsy and Danielle wondered whether introducing regularly scheduled rounding could prevent future
falls like Sam’s.
Danielle and Betsy discussed some tools that they had heard could help structure regular rounding; both agreed that staff would need
more than just their recommendation for the implementation of any tool to be successful. They gathered a group of interested staff who had
reviewed the fall data to ask about their current regular rounding habits. The nurses indicated that they rounded on a regular basis, but
sometimes up to three hours might pass between check-ins with more “stable” patients like Sam, particularly if there were other urgent
needs on the unit. One of the newer nurses, Boqin, mentioned that in nursing school he had written a paper on hourly rounding and
perhaps that may be a solution.
All of the unit nurses agreed that the outcome of a rising fall rate required evaluation and that hourly rounding may help, so Betsy
guided the group in crafting a properly formatted PICOT question (P: population; I: intervention or issue of interest; C: comparison
intervention or condition; O: outcome to see changed; T: time for the intervention to achieve the outcome or issue to be addressed). After
reviewing the QI data, discussing the context of the clinical issue, and looking at case studies for clues about why the outcome was
occurring, the question that the group posed was, In elderly patients with low risk for falls with universal precautions in place, how does hourly
rounding at night compared to no hourly rounding affect preventable fall rates within 3 months of initiation? (Step 1: Ask a Clinical Question in
PICOT Format).
The nurses became excited about answering the question and asked Betsy about the next steps in the EBP process. Betsy already had a
great relationship with their hospital librarian, Scott, who was well versed in EBP and had demonstrated his expertise at systematic
searching when helping with previous EBP Council projects. Betsy e-mailed the group’s PICOT question to Scott and asked him to
conduct a systematic search (Step 2: Systematic Searching). Scott knew that his initial search terms had to come from the PICOT question,
so he carefully considered what the nurses had asked. He knew a great start would be finding a systematic review that contained multiple
studies about the impact of hourly rounding on fall rates within elderly patients who were at low risk for falls, so he began his search with
the O: fall rates. In addition, all studies Scott would consider including in his body of evidence would need to have the outcome of
preventable fall rates; otherwise, the studies could not answer to the clinical question.
30
Figure 1: Systematic search of Comprehensive Index of Nursing and Allied Health Literature (CINAHL) database. (Source: EBSCO
Information Services)
A systematic search using the advance search interface of the Cochrane Library to find systematic reviews that included the terms hourly
rounding AND falls yielded no hits. The term hourly rounding yielded one hit, a systematic review focused on the impact of hourly rounding
on patient satisfaction. Scott decided to keep that review, since Betsy had mentioned that their patient satisfaction had varied at the same
time as their fall rates. Using the same approach, Scott continued the systematic search in the Comprehensive Index of Nursing and Allied
Health Literature (CINAHL) database, beginning with the same terms, hourly rounding and falls and their associated subject headings.
Scott used the focus feature in CINAHL for each subject heading to make sure the topic was the major point of the article. This search
yielded 22 articles. A systematic search of PubMed with the same approach yielded 12 studies (see Figures 1 and 2 for details of these
searches).
Figure 2: Systematic search of PubMed database. (From National Library of Medicine, www.pubmed.gov)
Now that all three databases had been searched, the total yield of 35 studies were available for Scott’s review to see if they were keeper
studies to answer the PICOT question. Eight hits were found to be redundant among databases and were removed from the yield (N = 27).
When inclusion criteria of fall preventions as the outcome was applied, 14 more were removed (N = 13). One article was proprietary and
could not be accessed through interlibrary loan or via the Internet (N = 12). Three articles were not owned by the library and were requested
through interlibrary loan (N = 15). Finally, two relevant articles, one of which was a master’s thesis, were found by hand searching, which
resulted in 17 articles to enter into the critical appraisal process. After review of the study designs, the final cohort of studies that Scott
currently had (i.e., the body of evidence) included one systematic review, no single randomized controlled trials, four quasi-experimental
studies, eight evidence-based or quality improvement projects, and one expert opinion article (see Table 1). He knew he had three more
articles to add to the body of evidence when they came in from interlibrary loan; however, Scott thought it was important to discuss the
current body of evidence with Betsy and Danielle, who decided to take the current articles to the EBP Council.
Join the group at the beginning of Unit 2 as they continue their EBP journey.
TABLE
31
1 Synthesis: Levels of Evidence
32
1, Brown; 2, Callahan; 3, Dyck; 4, Goldsack; 5, Hicks; 6, Krepper; 7, Leone; 8, Lowe; 9, Mitchell; 10, Olrich; 11, Stefancyk; 12, Tucker; 13,
Waszynski; 14, Weisgram.
References
Brown, C. H. (2016). The effect of purposeful hourly rounding on the incidence of patient falls. Nursing Theses and Capstone Projects. Retrieved
from http://digitalcommons.gardner-webb.edu/nursing_etd/246
Callahan, L., McDonald, S., Voit, D., McDonnell, A., Delgado-Flores, J., & Stanghellini, E. (2009). Medication review and hourly nursing
rounds: An evidence-based approach reduces falls on oncology inpatient units. Oncology Nursing Forum, 36(3), 72.
Daniels, J. F. (2016). Purposeful and timely nursing rounds: A best practice implementation project. JBI Database of Systematic Reviews and
Implementation Reports, 14(1), 248–267. doi:10.11124/jbisrir-2016-2537.*
Dyck, D., Thiele, T., Kebicz, R., Klassen, M., & Erenberg, C. (2013). Hourly rounding for falls prevention: A change initiative. Creative
Nursing, 19(3), 153–158.
Goldsack, J., Bergey, M., Mascioli, S., & Cunningham, J. (2015). Hourly rounding and patient falls: What factors boost success? Nursing,
45(2), 25–30.
Hicks, D. (2015). Can rounding reduce patient falls in acute care? An integrative literature review. MEDSURG Nursing, 24(1), 51–55.
Jackson, K. (2016). Improving nursing home falls management program by enhancing standard of care with collaborative care multi-
interventional protocol focused on fall prevention. Journal of Nursing Education and Practice, 6(6), 85–96.*
Krepper, R., Vallejo, B., Smith, C., Lindy, C., Fullmer, C., Messimer, S., . . . Myers, K. (2014). Evaluation of a standardized hourly rounding
process (SHaRP). Journal for Healthcare Quality, 36(2), 62–69. doi:10.1111/j.1945-1474.2012.00222.x
Leone, R. M., & Adams, R. J. (2016). Safety standards: Implementing fall prevention interventions and sustaining lower fall rates by promoting
the culture of safety on an inpatient rehabilitation unit. Rehabilitation Nursing, 41(1), 26–32.
Lowe, L., & Hodgson, G. (2012). Hourly rounding in a high dependency unit. Nursing Standard, 27(8), 35–40.
Mitchell, M. D., Lavenberg, J. G., Trotta, R. L., & Umscheid, C. A. (2014). Hourly rounding to improve nursing responsiveness: A systematic
review. The Journal of Nursing Administration, 44(9), 462–472. doi:10.1097/NNA.0000000000000101
33
Morgan, L., Flynn, L., Robertson, E., New, S., Forde-Johnston, C., & McCulloch, P. (2017). Intentional rounding: A staff-led quality
improvement intervention in the prevention of patient falls. Journal of Clinical Nursing, 26(1/2), 115–124.*
Olrich, T., Kalman, M., & Nigolian, C. (2012). Hourly rounding: A replication study. MEDSURG Nursing, 21(1), 23–36.
Stefancyk, A. L. (2009). Safe and reliable care: Addressing one of the four focus areas of the TCAB initiative. American Journal of Nursing,
109(7), 70–71.
Tucker, S. J., Bieber, P. L., Attlesey-Pries, J. M., Olson, M. E., & Dierkhising, R. A. (2012). Outcomes and challenges in implementing hourly
rounds to reduce falls in orthopedic units. Worldviews on Evidence-Based Nursing, 9(1), 18–29.
Waszynski, C. (2012). More rounding means better fall compliance. Healthcare Risk Management, 34(2), 21.
Weisgram, B., & Raymond, S. (2008). Military nursing. Using evidence-based nursing rounds to improve patient outcomes. MEDSURG
Nursing, 17(6), 429–430.
________
*Waiting for interlibrary loan.
34
Making the Case for Evidence-Based Practice and
1 Cultivating a Spirit of Inquiry
Believe you can and you’re half-way there
—Theodore Roosevelt
EBP Terms to Learn

Critical appraisal
EBP competencies
Evidence-based practice (EBP)
Evidence-based quality improvement

Evidence-based quality improvement projects
Evidence-based theories
External evidence
Internal evidence
Meta-analyses
Outcome management
Predictive studies
Quadruple aim in healthcare

Quality improvement (QI)
Randomized controlled trials (RCTs)
Randomly assigned
Rapid critical appraisal
Research
Research utilization
“so-what” outcomes
Spirit of inquiry
Synthesis
Systematic reviews
Translational research
Learning Objectives
After studying this chapter, learners will be able to:
Discuss how evidence-based practice (EBP) assists hospitals and healthcare systems achieve the
quadruple aim.
Describe the differences among EBP, research, and quality improvement.
35
Another random document with
no related content on Scribd:
DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI
Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)
The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.
NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.
MAKONDE LOCK AND KEY AT JUMBE CHAURO

This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]
MODE OF INSERTING THE KEY
With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
“We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
BRAZIER
Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT
SMOOTHING WITH MAIZE-COB
CUTTING THE EDGE

FINISHING THE BOTTOM
LAST SMOOTHING BEFORE

BURNING
FIRING THE BRUSH-PILE

LIGHTING THE FARTHER SIDE OF
THE PILE
TURNING THE RED-HOT VESSEL
NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK
DRAWING THE BARK OFF THE LOG
REMOVING THE OUTER BARK

BEATING THE BARK
WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT
MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN

Evidence Based Practice in Nursing Healthcare A Guide To Best Practice

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Evidence Based Practice in Nursing Healthcare A Guide To Best Practice

Uploaded by

Copyright:

Available Formats

Evidence-Based Practice in Nursing &

Healthcare: A Guide to Best Practice

Maria Cvach, DNP, RN, FAAN

Deborah Dang, PhD, RN, NEA-BC

Graduate School of Nursing

Lynn Gallagher-Ford, PhD, RN, DPFNAP, NE-BC, FAAN

Martha J. Giggleman, RN, DNP

Doris Grinspun, RN, MSN, PhD, LLD (hon), Dr (hc), O.ONT

Tami A. Hartzell, MLS

Marilyn J. Hockenberry, PhD, RN, PPCNP-BC, FAAN

Robin Kretschman, HC-MBA, MSN, RN, NEA-BC

June H. Larabee, PhD, RN

Lisa English Long, PhD, RN

Jacqueline M. Loversidge, PhD, RNC-AWHC

Associate Professor of Clinical Nursing

Pamela Lusk, DNP, RN, PMHNP-BC, FAANP, FNAP

Tina L. Magers, PhD, MSN, RN-BC

Nursing Excellence and Research Coordinator

Kathy Malloch, PhD, MBA, RN, FAAN

Mikki Meadows-Oliver, PhD, RN, FAAN

Dianne Morrison-Beedy, PhD, RN, WHNP, FNAP, FAANP, FAAN

Chief Talent & Global Strategy Officer

Dónal P. O’Mathúna, PhD

Tim Porter-O’Grady, DM, EdD, APRN, FAAN, FACCWS

Cheryl C. Rodgers, PhD, MSN, BSN

Jo Rycroft-Malone, PhD, MSc, BSc(Hons), RN

Alyce A. Schultz, RN, PhD, FAAN

Kathryn A. Smith, RN, MN, DrPH

Cheryl B. Stetler, RN, PhD, FAAN

Kathleen R. Stevens, RN, MS, EdD, ANEF, FAAN

Susan B. Stillwell, DNP, RN ANEF, FAAN

EBP Expert Mentor and Independent Consultant

Timothy Tassa, MPS

Network for Excellence in Health Innovation

Amanda Thier, RN, MSN

Kathleen M. Williamson, RN, PhD

Jennifer Yost, PhD, RN

Cindy Zellefrow, DNP, MSEd, RN

Ashley Leak Bryant, PhD, RN-BC, OCN

Lynne E. Bryant, EdD, MSN, RN, CNE

Mary Mites-Campbell, PhD

Lisa Chaplin, RN, NP-C, DNP

Karyn E. Holt, RN, PhD

Kathy James, DNSc

Lynette Landry, PhD, RN

Susan Mullaney, EdD

Mary Ann Notarianni, PhD, RN

Doreen Radjenovic, PhD, ARNP

Theresa Skybo, PhD, RN, CPNP

Margaret (Peggy) Slota, DNP, RN, FAAN

Ida L. Slusher, PhD (RN, PhD, CNE)

Debbie Stayer, PhD, RN-BC, CCRN-K

Ann Bernadette Tritak, RN, EdD, MA, BSN

Supakit Wongwiwatthananukit, PharmD, MS, PhD

Richard H. Carmona, MD, MPH, FACS

17th Surgeon General of the United States

OVERVIEW OF THIS BOOK

NEW FEATURES AND RESOURCES FOR THIS EDITION

ORGANIZATION OF THE BOOK

Learner Resources Available on

• Appendices D, E, F, G, H from the book

Educator Resources Available on

COMPREHENSIVE, INTEGRATED DIGITAL LEARNING SOLUTIONS