Chapter 1
Making the Case for Evidence-
Based Practice and Cultivating
a Spirit of Inquiry
Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins
The Components of Evidence-Based
Practice (EBP)
Figure 1.1: The components of evidence-based practice. (From Melnyk,
B. M., & Fineout-Overholt, E. [2011]. Evidence-based practice in nursing &
healthcare. A guide to best practice. Philadelphia, PA: Wolters
Kluwer/Lippincott Williams & Wilkins.)
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Types of Evidence Used in EBP
External evidence includes:
Evidence generated through rigorous research
Systematic reviews
Evidence-based theories
National benchmarks
Opinion leaders and expert panels
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Types of Evidence Used in EBP—(cont.)
Internal evidence is generated through such things as:
Practice initiatives
− Outcomes management
− Evidence-based quality improvement projects
Patient assessment and evaluation
Use of available resources within your organization
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Question
Is the following statement true or false?
Finding a quasi-experimental research study that tests a
protocol for the frequency of turning for immobile patients
published in a peer-reviewed journal is an example of
external evidence.
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Answer
True
Rationale: External evidence includes research articles
published in peer-reviewed journals.
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EBP vs. Research vs. Quality
Improvement (QI)
EBP is:
•A decision-making process
•Based on a body of evidence that has been identified,
critically appraised and synthesized
•Generating new knowledge about practice through
implementation of evidence-based recommendations
•Not generalizable, but rather transferrable
•Sometimes requiring submission to Institutional Review
Board (IRB) (NOTE: varies from organization to
organization)
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EBP vs. Research vs. Quality
Improvement (QI)—(cont.)
Research:
•Tests an hypothesis
•Generates new knowledge to fill a knowledge gap
•Results are generalizable
•Requires review by an Institutional Review Board (IRB)
NOTE: Research Utilization is use of results from a
single study to inform practice decisions.
Translational Research studies how evidence-based
interventions are translated into real-world settings.
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EBP vs. Research vs. Quality
Improvement (QI)—(cont.)
Quality Improvement:
•Uses a systematic process (quality improvement model
such as PDSA/PDCA) to identify and address issues within
the organization
•Looks at structures and processes to identify issues that
are impeding quality and safety
•Uses internal evidence to identify and track trends
•Results are not generalizable
•Typically does not require review by an Institutional
Review Board (IRB)
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Question
Which of the following involves bringing the body of
evidence together with clinical expertise and patient
preferences and values to identify best practice?
A.Evidence-based practice
B.Research
C.Translational research
D.Research utilization
E.Evidence-based quality improvement
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Answer
A. Evidence-based practice
Rationale: Evidence-based practice is bringing
together the best evidence with clinical expertise and
patient preferences and values to make the best
practice decisions.
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The Merging of Science and Art: The
Interaction Between Culture, Context
and EBP
Figure 1.2: The merging of science and art: Evidence-based practice
(EBP) within a context of caring and an EBP culture and environment
result in the highest quality of healthcare and patient outcomes.
© Melnyk & Fineout-Overholt, 2017.
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Evidence-Based Practice and the
Quadruple Aim
Moving from the Triple Aim to the Quadruple Aim. (go to
http://www.ihi.org/communities/blogs/the-triple-aim-or-
the-quadruple-aim-four-points-to-help-set-your-strategy
for more information from the Institute of Healthcare
Improvement (IHI)).
The Quadruple Aim:
• Improved patient experience
• Improved outcomes
• Cost reduction
• Organization-driven and often includes such things
as joy in work (improved clinician experience vs.
equity vs. organizational readiness)
Evidence-based practice helps us get there!
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Key Initiatives to Advance EBP
• Institute of Medicine’s (IOM) Roundtable on Evidence-
Based Medicine put forth that by 2020, 90% of clinical
decisions will be supported by evidence. (Go to
https://www.ncbi.nlm.nih.gov/books/NBK52847/ for more
information)
• Key initiatives to advance EBP include:
− United States Preventive Services Task Force (USPSTF)
− Community Services Task Force
− Patient-Centered Outcomes Research Institute (PCORI)
− American Nurse Credentialing Center’s (ANCC) Magnet
Designation and Pathways to Excellence
− Helene Fuld Health Trust National Institute for
Evidence-based Practice in Nursing and Healthcare
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Question
Is the following statement true or false?
Although organizational culture and context are important,
they are not necessary for evidence-based practice to be
implemented and sustained in the organization.
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Answer
False
Rationale: An EBP culture and environment must be
created within an organization if EBP is to be
implemented and sustained.
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Steps of the EBP Process
0. Cultivate a spirit of inquiry within the environment
1. Ask the burning clinical question in PICOT format
2.Search for and collect the most relevant best evidence
3.Critically appraise the evidence (i.e., rapid critical
appraisal, evaluation, and synthesis)
4. Integrate the best evidence with one’s clinical expertise
and patient preferences and values in making a practice
decision or change
5. Evaluate outcomes of the change
6. Disseminate the outcomes of the evidence-based change
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Question
Is the following statement true or false?
According to Melnyk & Fineout-Overholt, there are six steps
to the evidence-based practice process.
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Answer
False
Rationale: Initially there were six steps to the evidence-
based practice process according to Melnyk & Fineout-
Overholt, but a seventh step (Step 0) was later added after
research supported the importance of organizational
culture to EBP implementation and sustainability. These
steps must be implemented in sequence and rigorously
engaged to accomplish the end goal of improved patient,
provider, and system outcomes.
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Barriers and Facilitators to Evidence-
Based Practice
• Within healthcare organizations and settings where care
is provided, both barriers and facilitators exist that
influence the uptake and sustainability of EBP.
• Practitioners must learn how to overcome barriers and
leverage facilitators in order to implement EBP
• Organizational barriers, facilitators, culture, and
readiness for system-wide implementation of EBP should
be assessed.
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Examples of Barriers to EBP
• Lack of administrative/management support
• Resistance to change
• Misperceptions or negative attitudes about EBP
• Lack of EBP knowledge and skills
• Lack of time and resources
• Lack of EBP mentors
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Strategies to Eliminate Barriers to Using
Evidence-Based Practice
• Establishing a clear philosophy and organizational vision
in which EBP is valued and expected
• Developing a strategic plan to create a culture and
environment that fosters EBP
• Dispelling misperceptions about EBP
• Teaching the basics of EBP
• Encouraging questions about currently used clinical
practices
• Developing EBP mentors
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Examples of Facilitators of EBP
• Support and encouragement from
administration/management
• EBP mentors with excellent EBP skills, knowledge, and
proficiency in individual and organizational change
strategies
• Evidence-based policies and procedures
• EBP education
• Proper integration of EBP into health professions
curricula
• Proper tools to assist with and support EBP
• EBP councils
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Question
Scenario: EBP is identified as a core value in our organization’s
new strategic plan. This plan includes making sure all policies are
supported by evidence within 3 years. In order to accomplish
this, units begin hosting unit-based journal clubs from noon until
1 p.m. once a week to teach advanced critical appraisal skills.
Staff are permitted to attend if census and staffing ratios allow.
Which of the following is the barrier in the scenario above
A.Having a new strategic plan
B.The plan goal of making sure all policies and procedures are
supported by evidence within the 3 years.
C.Hosting unit-based journal clubs
D.The timing and stipulations for attendance of the unit-based
journal clubs
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Answer
D. The timing and stipulations of for attendance at the
unit-based journal clubs
Rationale: Having a strategic plan that identifies EBP as a
core value, setting a goal to have all policies and
procedures be supported by evidence within 3 years, and
hosting unit-based journal clubs to support advancement of
EBP skills are all facilitators to EBP. However, proper
support and structure must be put into place to allow
nurses to be able to attend the journal clubs. The timing
and stipulations for attendance at the unit-based journal
clubs (held from 12 noon till 1 p.m. with no staffing support
or release time) is a barrier to EBP.
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