Building An Evidence-Based Nursing Practice: Elvie A. Imason-Ramos, Man, RN

BUILDING AN EVIDENCE-BASED
NURSING PRACTICE
By: ELVIE A. IMASON-RAMOS, MAN, RN

Chap 2: BUILDING AN EVIDENCE-BASED
NURSING PRACTICE
Learning Outcomes:
At the end of the chapter, the
learner should be able to:
Define evidence-based
practice
List source of evidence for
nursing practice
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Learning Outcomes:
Identify barriers to the
adoption of EBP and pinpoint
strategies to overcome them.
Explain how the process of
diffusion facilitates moving
evidence into nursing
practice
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“Facts are stubborn

things; and whatever
may be our wishes,
our inclinations, or
the dictates of our
passions, they cannot
alter the state of facts
and evidence.”
- John Adams
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Evidence-based Practice
Started in the field of medicine
Dr. Archie Cochrane (1971)
was concerned that evidence
was not being critically
examined. He stressed that
random clinical trials are the
“gold standard” for generating
reliable and valid evidence.
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Evidence from clinical
research should be used over
intuition, unsystematic clinical
experience, and
pathophysiology (Cullum, et.
al., 2008)
An important approach to
provide the best quality care
to patients and their families.
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Maintained that practice
based on evidence can help
decrease uncertainty
commonly experienced by
both patients and health care
professionals particularly
nurses in today’s complex
health care system (Mylnek &
Finecout-Overholt, 2004)
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Research has shown that
patients who receive care
based on evidence from
well designed studies
experience better
outcomes and early
recovery.
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Simply the integration of the
best possible research
evidence with clinical
expertise and with patients
needs (Porter-O’Grady,
2006)
Three Factors Merge.doc
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Evidence-based Practice: Five (5) Key Steps
1. Formulation of a clinical
question;
2. Gathering the best evidence to
answer the clinical question;
3. Critical appraisal of the best
evidence or research based
information;
4. Integration of the evidence with
the nurse own expertise,
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Evidence-based Practice: Five (5) Key Steps
assessment of patients
condition, available resources
and patients’ preferences and
values to implement a clinical
decision;
5. Evaluation of the practice
change, as a result of
implementing the evidence.
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PICOT Format
Introduced by Melynk &
Finecout-Overholt (2004)
advocate asking clinical
questions in the PICOT
Format:
P – patient population
I – intervention of interest
C – comparison intervention
O – outcome
T – time target
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P – Patient Population
It is necessary to have a
clear description of the
patient population and
setting retrieve the most
relevant evidence;
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I – Intervention of Interest
This may include, but is not
limited to any treatment,
patient perception, exposure
or diagnostic test.
The more defined the
intervention, the more
focused the search for
evidence will be;
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C – Comparison Intervention
The standard of care is

compared to a new
treatment or procedure.
The comparison can be
a true control such as
placebo;
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O - Outcome
Specific identification of
the outcome variable
facilitates the search for
evidence that has
investigated the same
outcome;
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T – Time Target
Specific time for the

intervention to achieve the
best outcome.
The authors maintained that
asking the questions in
this format will yield the
most relevant and best
evidence. eaimason74
NURSING PRACTICE
Remember: it is common
for nurses to implement
change fail to evaluate the
effectiveness based on
evidence but of that
change.
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Evaluation of practice
change is paramount in
order to determine how a
particular treatment worked
or the effectiveness of
clinical decision.
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Problem solving approach,
EBP therefore incorporates
research based information,
nurse’s clinical expertise and
research skills, patient’s
reference, values and
expectations within the
context of caring to generate
the best patient outcome.
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Combined the three nature
of EBNP.
 Level I: Evidence obtained

from at least one properly
designed randomized
controlled trials;
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 Level II: Evidence obtained
from well designed
controlled trials without
randomization, well
designed case control
analytic studies or multiple
time series with or without
intervention; and
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 Opinions of respected
authorities based on clinical
experiences, descriptive
studies or report of experts.
 The elements of EBP
1. Nurse clinical experience and
expertise
2. Client preferences
3. Research based information
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NURSING PRACTICE
The of Evidence-based Nursing Practice
The nurse clinical decision
required for evidence-based
health care. It is informed by
factors such as valid, relevant
research findings or best
evidence, client preferences,
sound judgment, skills and
expertise of the nurse as well as
the resources available to the
nurse and the client. eaimason74
NURSING PRACTICE
Is about providing care that is
supported by research and
clinical trials.
Not all practice can be
evidence based, nurses must
used the best available
information on which to base
their interventions.
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NURSING PRACTICE
To incorporate research findings
into practice is essential in
developing a science based
practice.
Evidence for research studies
encourage nurse practitioners to
adopt the practices that have been
found useful and to abandon those
usefulness has not been
supported by evidence.
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Nurses should discriminate
between those that studies have
been characterized as:
 Beneficial forms of care
 Care that are likely beneficial
 Care with trade off between
beneficial and adverse effects
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 Care with unknown
effectiveness
 Care that are unlikely beneficial,
and
 Care that are likely to be
ineffective or harmful.
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To justify the worth of
evidence:
Systematic review of
randomized controlled trials
are conducted to determine
biased or consistent
findings.
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Latest protocol guideline
issued by WHO through
DOH issued A.O. 2009-
0025 Essential Newborn
Care (ENC) under the
umbrella of the “Unang
Yakap”
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Issued by DOH,
mandating all hospital to
implement the four (4)
steps of newborn care
time-bound intervention to
lessen neonatal deaths.
WHO-DOH.doc
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As a result of systematic
reviews, the best practice
and better ways to achieve
nursing goals in its
operational, clinical and
financial perspective can
be improved.
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Nurses have now the
resources with which to
identify successful
practices and use them as
standards for safe
practice.
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Similar to benchmarking
which supports and
promotes continual quality
improvement and helps
nurses remain steadfast
and competitive in the
health care market.
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Evidenced based research
also uses collaborative
benchmarking which
involves sharing of
strategies and outcomes.
Evidence was arranged in a
hierarchy according to level
of credibility (Ferguson &
Day, 2005) Pyramid of evidence.doc
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Each sources of evidence is
necessary within the context
on which type of evidence
are suggested.
The primary challenge for
nurses is the establishment
of criteria for assessing and
determining acceptable
evidence.
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Characteristics Evidence-based Practice in Nursing
EBP is a problem solving
approach to nursing
practice that involve the
conscientious use of
current best evidence in
making decisions about
patient care.
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It is also consider the nurse
expertise and patients
values and expectations.
The nurse capacity to
identify each patient’s
unique health status and
diagnosis, potential risks,
and benefits of nursing
interventions.
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It can come up with best
available evidence by using
research in combination with
theory. Research and theory
allows for accuracy of the
nursing care plans, diagnostic
tests, prognosis, and safety
of therapeutic and preventive
interventions.
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It allows client preferences
and values to be heard. As
nurses and clients interact,
the preferences, concerns,
and expectations of each
client are all integrated into
making clinical decisions.
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Research Utilization (RU) & Evidence-based Practice
RU is the process of
synthesizing, disseminating,
and using research-generated
knowledge into the nurse
clinical practice.
RU facilitates the transfer of
innovation and purposive
application of research findings
to the current nursing practice
(Polit & Beck, 2008)
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RU is often used
interchangeably with
evidence-based practice
since research utilization is
but a part of evidence-based
practice
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DISSEMINATION – is a
part of RU, is the process
of knowledge transfer. It
includes consideration of
what, when, and how of
moving ideas and
information from the
source(s).
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e.g. researchers to intended
recipient(s) such as client or
patients.
Research findings remain
out of the reach for their
intended users such as
health workers and patients.
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Knowledge and
interventions produced by
nursing research remain
untapped due to
researchers’ limited
resources and lack of
identified utilization goals
and targets.
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Purpose of research is to
confirm current practice or to
change it.
The process of
understanding and applying
research findings into
practice usually takes years,
decades, or even
generations.
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It is necessary to move
carefully, new research output
needs to evaluated, replicated
and refined.
The change process is
evaluated, not by a rigorous
review and refinement, but the
gap between the research
community and the standard of
practice. eaimason74
NURSING PRACTICE
e.g. it took some time, 264
years, from the discovery of
citrus juice as preventive
measure for scurvy and its
use on British ship before it
was widely accepted.
(Glaser, Abelson, &
Garrison, 1993, cited by
Houser, 2008)
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First Asia Pacific
Conference in Nursing
Research held in 2008
sought to address the issue
and proposed measures to
bridge the gap between
research and its utilization in
the Philippines.
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Gathering and accounting

for research outcomes and
analyzing them for viability
requires considerable
financial resources.
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Guide to Evidence-based Practice in Nursing
Seven (7) models
Stetler, Iowa and Roger’s
Theory of Diffusion of
Innovations has gained the
general acceptance.
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Common elements of
these models which
include: synthesis of
evidence, implementation,
evaluation of impact on
patient care, and
consideration of the
context/setting in which
evidence is implemented.
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Stetler Model of Research
Utilization (Stetler, 2001)
Iowa Model of Research in
Practice (Titler et. al., 2001)
Roger’s Theory of Diffusion
of innovations (1995)
Ottawa Model of Research
Use (Logan & Graham, 1998)
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Evidence-based
Multidisciplinary Practice Model
(Goode & Peidalue, 1999)
Model for Change to Evidence-
based Practice (Rosswurm &
Larrabee, 1999)
Center for Advanced Nursing
Practice Model (Soukup, 2000)
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STETLER MODEL
Presents a structure for using
the research outcomes and
suggests a vehicle for changing
policies and procedures.
Nurse practitioner, educators,
and policymakers, make a
summary of research done and
use it to influence educational
programs, make practice
decision, and policies.
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STETLER MODEL
Encompasses several steps:
Preparation
Validation
Comparative Evaluation
Decision Making
Translation/Application
Evaluation
(Burns & Grove, 2007)
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STETLER MODEL: Preparation
Involves identifying the
purpose and focus of the
literature review
Research literature may be
reviewed to solve a difficult
clinical, managerial, or
educational problem
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STETLER MODEL: Preparation
To provide the basis for

policy, standard or protocol
To prepare for an in-service
program or other type of
professional presentation
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STETLER MODEL: Validation
A key consideration in
validation is to determine
whether the information is
applicable and relevant to
the current needs and
problems of the nursing
profession.
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STETLER MODEL: Comparative Evaluation
A review of findings of
similar studies.
The end result of the
comparative evaluation is to
make a decision about using
the study findings for
practical purposes
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STETLER MODEL: Decision Making
The researcher chooses

from four possible options:
To use; To consider use;
To delay use; Reject the
findings altogether
If the decision is negative,
no further steps are
necessary
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STETLER MODEL: Translation/Application
The preparation for the
actual implementation of the
findings in the practice.
The main question here is
“how research knowledge
should be applied?” keeping
in mind always the beneficial
effects to all consumers of
health care.
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STETLER MODEL: Evaluation
Final stage which

determines the impact of
research findings on
practice, policy, and
patient care
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STETLER MODEL: Evaluation
Identifying validated
research findings and
utilizing the model,
possible administrative
policies could be
designed to address the
needs and problems of
the nurse practitioner.
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IOWA MODEL
Provides direction for the
development of evidence-
based practice in clinical
agency
Initially developed by Titler
and colleagues in 1994,
revised in 2001.
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IOWA MODEL
The health agency, there are
triggers that initiate the need
for change, which is best
made based on research
evidence.
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IOWA MODEL: Knowledge-focused triggers
The pressure to change can
be generated by a heightened
awareness of new research
findings derived from journal
readings, participation in
scientific conferences, and
exposure to EBP guidelines
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IOWA MODEL: Knowledge-focused triggers
e.g. pain management,
prevention of skin breakdown,
assessing placement NGT or
nasogastro-intestinal tube
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IOWA MODEL: Problem-focused triggers
It has its roots in a clinical or
organizational problem.
Discovery of these problems
are usually by-products of
quality improvement activities,
risk surveillance, data
benchmarking, review of
financial performance among
others.
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IOWA MODEL: Three Critical Decision Points
1. The problem is a sufficient
priority for the organization
exploring possible changes;
2. There is a sufficient research
base; and
3. The change is appropriate
for adoption in practice
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Roger’s Theory of Diffusion Model
Is a theory of How, Why, and
At What rate new ideas and
technology spread through
cultures
Concept was first studied by
(French) Gabriel Tarde and
by (German) Friedrich
Ratzel or Leo Frobenius
(1890)
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Everette Rogers (1995) first
discussed this theory in his
textbook
Rogers’ defines diffusion as
“the process by which an
innovation is communicated
through certain channels over
time among members of a
social system”
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Diffusion of Innovations
theory by Rogers includes five
stage process:
1. Knowledge Stage
2. Persuasion Stage
3. Decision Stage
4. Implementation Stage
5. Confirmation Stage
K-P DIC Process
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Roger’s Theory of Diffusion Model: Knowledge Stage
These consists of the

initial awareness of the
existence of an innovation
or a new idea for use in
practice
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Roger’s Theory of Diffusion Model: Persuasion Stage
The nurse develop

an attitude toward the
innovation
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Roger’s Theory of Diffusion Model: Decision Stage
A choice is made to
adopt or reject the
innovation
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Roger’s Theory of Diffusion Model: Implementation Stage
This involves using

the new idea to
change the current
practice.
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Roger’s Theory of Diffusion Model: Confirmation Stage
Nurses seeks
reinforcement of their
decision leading to either
a continuance of the
adoption of the evidence
or its rejection.
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Rogers’ model could serve
as useful guide during the
early stages of research
and can provide direction
in implementing research-
based intervention in
nursing practice.
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The use of strategies to
apply innovations into
practice such as the use of
evidence and other research
findings to practice
environment (Logan &
Geraham, 1999)
There six components of
this model.
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1. Practice environment
2. Potential research use
3. Evidenced based
innovations
4. Strategies to apply
innovations
5. Use of evidence
6. Health and other
outcomes
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Evidence Based Model
Similar to Roger’s theory
of diffusion of innovation
Involves comprehensive
information on certain
issues and weighing
pieces of evidence in
relation to literature
reviewed as basis to draw
conclusion
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Evidence Based Model
Nurses to get the best from
research findings, they must
take into account much of
the evidences possible,
organized and synthesized
in a rigorous manner geared
towards making accurate
decisions for safe and
effective patient care.
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Do yo
u have
quest
ions?
eaimason74

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BUILDING AN EVIDENCE-BASED

By: ELVIE A. IMASON-RAMOS, MAN, RN

“Facts are stubborn

Three Factors Merge.doc

The standard of care is

Specific time for the

 Level I: Evidence obtained

Gathering and accounting

To provide the basis for

The researcher chooses

Final stage which

These consists of the

The nurse develop

This involves using

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