Evidence-Based Nursing Practice

Sharon A. Denham, PhD, RN, CNE

Professor, Houston J. & Florence A. Doswell Endowed Chair in Nursing for Teaching
Excellence
Texas Woman's University, College of Nursing

Identify the key concepts of evidence­based nursing practice.
• Apply the concepts of evidence­based practice when caring for 
specific patient populations and/or to a specific clinical setting.
• Identify and use available resources for best practice information.
• Identify the institution’s process for using evidence in the revision of 
standards, guidelines, policies, and procedures.
• Explain how to critically appraise a research study.
• Know how to participate in an evidence­based practice project.

Learning Competencies

Nurses Need NEW Skills to Assume NEW Roles.

Provide patient - centered care

Work in interdisciplinary teams

Employ evidence-based practices

Apply quality improvement - Errors, risks, safety

Use informatics -Communicate, manage knowledge, use information
technology

History

Quality: Services (interventions), targeted health outcomes, &
consistency with current knowledge (research evidence)

Crossing the Quality Chasm (IOM, 2001): “Between the health care we
have and the care we could have lies not just a gap but a chasm (p.1).”

Aim to close the quality chasm….

Systematic and rigorous literature reviews, clinician experience, and
individual values

Evidence-Based Nursing Practice
"An ongoing process by which evidence, nursing theory and
the practitioners’ clinical expertise are critically evaluated
and considered, in conjunction with patient involvement, to
provide delivery of optimum nursing care for the individual.”

Scott, K. & McSherry, R. (2009). Evidence Based Nursing: clarifying the
concepts for nurses in practice. Journal of Clinical Nursing, 18(8): 1085-95.

Purposes of EBP

Know ways to use critically appraised and scientific evidence to
deliver quality health care.

Provide standards for care delivery.

Know where to locate the best evidence related to practice.

Know employers expectations about use of best evidence.

Identify ways to locate literature that provides evidence.

Understand steps for participating in an evidence-based project.

Barriers to EBP

Uncertain about what defines evidence-based scientific knowledge.

Lack of mentoring by nurses with EBP experience.

Inability to understand statistical terms and research jargon.

Uncertain about ways to rigorously conduct an effective search
strategy and inability to locate useful and comprehensive information.

Make sustainable changes across systems and organizational culture
based upon evidence.

Stay current with the continually growing breadth of new evidence.

Evidence-Based Practice

Dr. David Sackett & colleagues at McMasters University in
Ontario, Canada, initially proposed EBM (2000)

Systematic Review
 Research question
 Search strategy (years, study designs, geographic

location, population, setting)
 Inclusion criteria
 Critical appraisal
 Synthesis

Critical Appraisal
 Research design (mixed methods)
 Sample
 Instruments
 Confounding concerns
 Strengths (internal/external validity)
 Limitations
 Clinical significance
 Credibility of results
 Intervention applicable to your setting
 Benefits/risks

Synthesis
 Clear statements of the findings
 Consistency of the evidence
 Strength of the body of evidence
 Gaps in knowledge about the topic
 Recommendations for future research

Feasibility, Benefits, & Risks of New Practice
 Design practice change
 Key variables of new practice
 Identify needed resources
 Outcome variables desired & expected
 Evaluation plan
 Implementation plan (Pilot, marketing, timelines)

Steps of Evidence-Based Practice

Ask or identify important clinical questions.

Collect the best and most pertinent evidence.

Critically analyze and rate the evidence.

Integrate the evidence with your own clinical expertise, patient knowledge,
and patient values in making practice decisions or suggesting changes.

Implement the practice change if authorized.

Evaluate how the practice change has influenced or affected your practice
area.

Disseminate and share this evidence with peers or colleagues.

Hierarchy of Evidence

Systematic review or meta-analysis of random control trials (RCT) or
established EBP clinical guidelines.

Evidence from at least one well-designed RCT.

Evidence from well designed controlled trial without randomization or
a systematic review of correlational/observational studies.

Evidence from a well-designed case-control and cohort studies that are
correlational or observational.

Evidence from a single descriptive, qualitative or physiologic study.

Evidence from the opinion of authorities/experts and/or case reports of
expert committees.

PICO Questions
P = Patient Problem:
How would you describe a group of patients similar to yours? What are the most
important characteristics of the patient? This may include the primary problem,
disease, or co-existing conditions. Sometimes the gender, age or race of a patient
might be relevant to the diagnosis or treatment of a disease.
I = Intervention, prognostic factor or exposure:
Which main intervention, prognostic factor, or exposure are you considering? What
do you want to do for the patient? Prescribe a drug? Order a test? Order surgery? Or
what factor may influence the prognosis of the patient - age, co-existing problems,
or previous exposure?
C = Comparison:
What is the main alternative to compare with the intervention? Are you trying to
decide between two drugs, a drug and no medication or placebo, or two diagnostic
tests? Your clinical question may not always have a specific comparison.
O = Outcome:
What can you hope to accomplish, measure, improve or affect? What are you trying
to do for the patient? Relieve or eliminate the symptoms? Reduce the number of
adverse events? Improve function or test scores?

Patient Problem

obese, diabetes type 2, male

Intervention

stomach stapling (gastric bypass surgery;
bariatric surgery)

Comparison

standard medical care

Outcome

remission of diabetes; weight loss; mortality

The clinical question: “In male patients with type 2 diabetes and
obesity, is bariatric surgery more effective than standard medical
therapy at increasing the probability of remission of diabetes?”

ACE Star Model of Knowledge Transformation

(Stevens, 2004)

Resources for Knowledge Forms in the Star Model
Form of Knowledge

Description of Resources

Point 1 - Discovery

Databases such as CINAHL - Provide single research
reports in most cases.

Point 2 - Evidence Summary

Cochrane Collaboration Database of Systematic Reviews
- Provides reports of rigorous systematic reviews on
clinical topics.

Point 3 - Translation into Guidelines

National Guidelines Clearinghouse - Sponsored by AHRQ,
provides online access to evidence-based clinical
practice guidelines.

Point 4 - Integration into Practice

AHRQ Health Care Innovations Exchange - Sponsored by
AHRQ, provides profiles of innovations, and tools to
improve care processes, includes adoption guidelines
and information to contact the innovator.

Point 5 - Evaluation of Process and
Outcome

National Quality Measures Clearinghouse - Sponsored by
AHRQ, provides detailed information on quality
measures and measure sets.

Focused Knowledge Development

Asking compelling questions directly applicable to social needs

Healthy People 2020:
http://www.healthypeople.gov/2020/topicsobjectives2020/defaul
t

NINR:
http://www.ninr.nih.gov/aboutninr/keythemes#.VXL_KGBPH8s

Joanna Briggs Institute

http://www.nursingcenter.com/evidencebasedpracticenetwork/Home/JBI-EBPNetwork.aspx

Joanna Briggs Institute Library ($287 yr)

Journal Club ($20 yr)

Sumari (suite of tools - $30 yr)

CAN - Implement (practice guidelines tailored for local use - $30 yr)

Continuing education - pay by course

National Guideline Clearinghouse

http://www.guideline.gov/browse/by-topic.aspx
Spend time reviewing multiple resources for clinical
practice guidelines

AHRQ EB Reports

Comprehensive, science-based information on common, costly
medical conditions, new health care technologies & strategies.

13 Evidence-based practice centers

Clinical reports:
http://www.ahrq.gov/research/findings/evidence-based-reports/in
dex.html

Topics:
http://www.ahrq.gov/research/findings/evidence-based-reports/az/#Dtopics

Cochrane Library: Systematic Reviews

http://www.cochranelibrary.com

­ 

Six Databases:





Cochrane Database of Systematic Reviews (CDSR) 
Cochrane Central Register of Controlled Trials (CENTRAL) 
Cochrane Methodology Register (CMR) 
Database of Abstracts of Reviews of Effects (DARE) 
Health Technology Assessment Database (HTA) 
NHS Economic Evaluation Database (EED) 

POEMs Research Summaries
“Patient-Oriented Evidence that Matters”

https://www.essentialevidenceplus.com/content/poems
Synopses of new evidence carefully filtered for relevance to
patient care and evaluated for validity

EBP Resources


ACP Journal Club: https://acpjc.acponline.org
Clinical Evidence:
http://www.clinicalevidence.bmj.com/x/index.html
Dynamed: http://www.dynamed.com/home/about
Essential Evidence:
http://www.essentialevidenceplus.com/index.cfm
UptoDate: http://www.uptodate.com/home

National Nurses Practice Network

http://www.nnpnetwork.org

The mission of the NNPN is to:
Foster exceptional healthcare outcomes of individuals, groups,
and communities receiving nursing care in a variety of healthcare
environments;
• Advance professional nursing practice through application of
evidence in care delivery;
• Support nursing leadership development for EBP; and
• Increase the understanding of mechanisms and strategies that
foster use of evidence by those delivering healthcare services.

Care of the Person and Family