EVIDENCE-BASED PRACTICE IN NURSING 1

The Importance of Evidence-Based Practice in Nursing

Gracie Moravecky

College of Nursing, University of South Florida

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The Importance of Evidence-Based Practice in Nursing

Evidence-based practice (EBP) is a concept that is relatively new to the field of nursing

as in years prior to the 21st century, EBP was more exclusively seen in medicine and doctoral

practice (Mackey & Bassendowski, 2017, p. 52). However, in their review of the history of EBP,

Mackey and Bassendowski explain that EBP is becoming more prevalent in the field of nursing

as the scope of nursing practice has broadened and thus, patient outcomes are more heavily

reliant on the actions of nurses (p. 54). Evidence-based practice can be defined as an approach

for improving patient outcomes that involves an extensive review of recent evidence, verification

of its reliability and relevance, and ultimately the implementation of the evidence in the clinical

setting (Melnyk & Fineout-Overholt, 2018, p. 753). The individual(s) or institution

implementing the evidence should always have improved outcomes, safety, and quality

improvement at the forefront of their practice.

EBP plays a crucial role in the clinical setting because as previously stated, the role of the

nurse is rapidly growing which means the outcomes of patients are increasingly dependent on the

care provided by and practice of the nurse. Additionally, modern technology has made it possible

for the average client and nurse to access the latest research which has precipitated an increased

demand for a review of current practices in the healthcare field (Mackey & Bassendowski, 2017,

p. 52). For EBP to be most effective, it is necessary to implement an interdisciplinary approach

that involves individuals, experts, and stakeholders across a variety of disciplines. According to a

study conducted to determine what makes EBP most successful, an EBP model that involves a

multidisciplinary approach creates a supportive environment in which nurses are more likely and

able to provide evidence-based care, which ultimately improves patient outcomes (Duff et al.,
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2020, p. 3). The following paper will discuss EBP in the clinical setting, the importance of an

interdisciplinary approach to EBP, and analyze the various EBP models.

Clinical Experience

When considering the use of EBP in the clinical setting, the situation that comes to mind

is when I encountered a medication error. In this scenario, a patient was to be administered 1 mg

of hydromorphone (Dilaudid) every 4 hours as needed for pain rated >7 out of 10 on the numeric

pain scale. However, there was an additional order entered that read to administer 1 mg of the

medication every 4 hours as needed for pain rated 5-7 out of 10 on the numeric scale. An order

written this way can be confusing because it is entered as two separate orders and the nurse must

be aware that the provider’s intention is for only one of these orders to be followed every 4 hours

depending on what the client states their pain level is. The nurse misinterpreted the orders and

instead administered both 1 mg doses within a 4-hour window, totaling 2 mg of hydromorphone

every 4 hours over the course of a 12-hour shift. The nurse likely did not perform all 5 rights of

medication administration which would include verifying the right patient, right drug, right dose,

right time, and right route. Performing the 5 rights of medication administration is a part of

evidence-based practice taught in nursing school that aims to prevent medication errors from

occurring.

The responsibility for this medication error does not fall solely onto the nurse, but rather

there was an entire interdisciplinary team at play. For example, the provider likely made an error

when writing the order because it should not have been written as two separate orders with the

same dosage. The second order should have been a lower dose and specified that it is to be given

for breakthrough pain when the next dose is due. Additionally, the order then goes through the

pharmacy who is supposed to verify and approve the order. The nurse is the last line of defense
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in the event that there is a mistake in the order and should have contacted the provider for

clarification. Other members of the interdisciplinary team that should have an understanding of

EBP priorities include the nurse manager, the charge nurse, and the facility’s legal and ethical

team. The implications of an error like this could be dire including overdosing the patient which

may result in serious illness or death as well as the revocation of the nurse’s license. Following

EBP could have prevented this error from occurring because EBP recommends performing the 5

rights of medication administration. EBP also recommends utilizing the interdisciplinary team to

prevent such errors from occurring. The pharmacist failed to catch the provider’s error in the

order and the nurse failed to contact the provider or pharmacy for order clarification. Each part

of the interdisciplinary team must collaborate to implement effective EBP and prevent such

potentially devastating errors.

Evidence-Based Practice Models

There are various approaches, or models, of EBP that each aim to promote quality

improvement and ensure that current healthcare practices are rooted in the most relevant and

significant scientific evidence. One of the most commonplace EBP models is the Revised Iowa

Model. According to an article from the Journal of Pediatric Nursing, this model consists of a

stepwise approach to implementing EBP that begins with identifying a “trigger” or issue in the

clinical setting and putting the issue into the form of a question. Then, a collaborative

multidisciplinary team will be formed that will systematically review current evidence, design

and implement a potential solution to the clinical issue, and finally share the solution with other

units and/or facilities if the results prove the solution to be effective (Hanrahan et al., 2019, p. 1).

The Iowa Model may be implemented in a variety of ways in nursing practice. For example, an
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interdisciplinary nursing team may use the Iowa Model to answer the question of how to

decrease the incidence of falls in the hospital setting.

The Stetler Model is a similar EBP model that involves a multi-phase approach to

improving nursing practice and patient outcomes. The phases of the Stetler Model include

preparation, validation, comparative evaluation/decision-making, translation/application, and

evaluation of results (Melnyk & Fineout-Overholt, 2018, p. 262). Preparation begins with

identifying a potential issue and data/evidence collection. Validation involves extensive review

and assessment of credibility of the evidence. Comparative evaluation is the process of

determining which evidence to implement in the clinical setting. The translation phase involves

formulating a plan to implement the evidence into the clinical setting and the final phase is the

evaluation of the effectiveness of the solution (Stetler, 2001, p. 272). Like the Iowa Model, the

Stetler Model may be used to address myriad issues in the clinical setting. An example may be to

determine the best methods for preventing and reducing the rate of nosocomial infections on a

medical-surgical unit.

Another well-known EBP model in the nursing research community is the Johns Hopkins

Nursing Evidence-Based Practice (JHNEBP) Model. This model seeks to expedite the process of

implementing EBP in the clinical setting by focusing on making EBP more attainable and

comprehendible to bedside nurses (Melnyk & Fineout-Overholt, 2018, p. 412). In simplified

terms as described by Melnyk and Fineout-Overholt, this model involves an inquiry phase that is

broken down into subphases of formulating a practice question, gathering evidence, and

translating that evidence into the clinical setting. The interdisciplinary team will then determine

the best practice based on review of the patient outcomes, which will lead to the process starting

over again indefinitely to promote continuous improvements in nursing practice (p. 413). One
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example of how the JHNEBP Model can be implemented in the clinical setting was brought

forward in a research experiment conducted by the Weinberg Peri-Anesthesia Unit that involved

determining the best ways to improve the Post-Anesthesia Care Unit (PACU) environment in

order to promote therapeutic healing in patients. (Anicoche & Kaiser, 2020, p. 21). This proposal

involved the development of a PICO (problem, intervention, comparison, outcome) question,

gathering of evidence, implementation of the evidence into the clinical setting, and evaluation of

the outcomes.

All three of these models aim to promote improved patient outcomes and ensure that the

most relevant and credible evidence is being implemented in the clinical setting. All three

models share similarities in their structure in that they all involve the identification of an issue

and formulation of an inquiry. There is also an extensive research and evidence selection process

that ultimately ends with implementing the best practice into the clinical setting and evaluating

the outcomes. All the EBP models promote working with a team because this provides a

supportive environment that involves various perspectives, collaboration, and accountability.

While these EBP models share a multitude of similarities, there are a few notable differences as

well. For example, the JHNEBP Model varies from the Iowa and Stetler models because it is a

more continuous, constantly evolving cycle that has more variables. The Iowa and Stetler models

offer a more step-by-step approach to EBP in the field of nursing. Although there are more steps

involved in these models, the steps may be perceived as more straightforward while the JHNEBP

Model can be interpreted as broader. Additionally, while all of the models support a teamwork

approach to EBP, the Iowa Model places more emphasis on multiple discipline collaboration

because the development of an interdisciplinary team is actually built into one of the steps of the

model.
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Conclusion

EBP has become increasingly prevalent in the field of nursing due to the progression of

technology and the growing scope of practice of the nurse. Because the role of the nurse has

broadened, patient outcomes are significantly more dependent on the actions of the nurse. EBP is

crucial to the field of nursing because it is proven to improve patient outcomes by implementing

the best and safest practices rooted in credible, scientific evidence. Interdisciplinary

collaboration is the key to effective EBP because it promotes an environment that supports the

nurse to conduct and ultimately implement EBP. A collaborative approach offers a variety of

backgrounds and perspectives, provides support, and enhances accountability. Because nurses

are the last line of defense when providing patient care, the importance of the nurse to practice

EBP is paramount. Additionally, the nurse has first hand exposure to issues in the clinical setting

which means they hold the responsibility of identifying potential problems to be researched.

Unfortunately, while most nurses acknowledge the value of EBP, many do not feel

confident or prepared in their ability to research and implement best practices. According to a

literature review from the American Journal of Nursing Science, one of the most prevalent

barriers to EBP in nursing is a lack of proper education or training on how to effectively conduct

research, implement best practice, and evaluate outcomes (Munirah et al., 2020, p. 38). However,

the responsibility nurses have in the proliferation of EBP is only continuing to grow and will not

cease any time soon. With more education and training on how to identify issues, conduct

research, and implement EBP, nurses would likely feel more confident in their ability to do so

and thus, be more willing to. Implementing EBP education in nursing schools is a fantastic first

step in producing confident nurses capable of following various EBP models with the aim of
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improving patient outcomes. Hospitals and other facilities may also offer continuing education

on the importance of EBP and training on how to implement various EBP models in the clinical

setting. Once nurses become more confident and educated in their EBP implementation skills,

the improvement seen in patient outcomes and nurses’ satisfaction will be monumental.
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References

Anicoche, M. L., & Kaiser, L. (2020). The Johns Hopkins evidence-based practice (EBP)

model: Weinberg perianesthesia interventions for a healing environment. Journal of

PeriAnesthesia Nursing, 36(4), 21. https://doi.org/10.1016/j.jopan.2021.06.064

Duff, J., Cullen, L., Hanrahan, K., & Steelman, V. (2020). Determinants of an evidence-based

practice environment: an interpretive description. Implementation Science

Communications, 1(85), 1-9. https://doi.org/10.1186/s43058-020-00070-0

Hanrahan, K., Fowler, C., & McCarthy, A. M. (2019). Iowa model revised: research and

evidence-based practice application. Journal of Pediatric Nursing, 48, 121-122.

https://doi.org/10.1016/j.pedn.2019.04.023

Mackey, A., & Bassendowski, S. (2017). The history of evidence-based practice in nursing

education and practice. Journal of Professional Nursing, 33(1), 51-55.

https://doi.org/10.1016/j.profnurs.2016.05.009

Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-Based Practice in Nursing &

Healthcare (4th ed.). Lippincott Williams & Wilkins.

Munirah, A., Eman, A., Fatimah, A., Kawakeb, A., Rehab, R., Sara, A., & Maram. B. (2020).
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Barriers of implementing evidence-based practice in nursing profession: a literature

review. American Journal of Nursing Science. 9(1), 35-42.

https://doi.org/10.11648/j.ajns.20200901.16

Stetler, C. (2001). Updating the Stetler model of research utilization to facilitate evidence-based

practice. Nursing Outlook, 49(6), 272-279. https://doi.org/10.1067/mno.2001.120517.