AACN, QSEN Evidence Based Practice

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Evidence Based Practice Competency Resource Paper

Jane H. Barnsteiner, PhD, RN, FAAN

Professor of Pediatric Nursing

University of Pennsylvania, School of Nursing

Philadelphia, PA 19104-4231

Revised December, 2010

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Definition Integrating best current evidence with clinical expertise and patient/family

preferences and values for delivery of optimal health care.

Key Message Safe, effective delivery of patient care requires the use of nursing practices

consistent with the best available knowledge. This includes use of clinical expertise and patient

preferences and values in addition to current best research evidence.

Learner Objectives

1. Define Evidence Based Practice and Translation Research 2. Describe activities in research synthesis 3. Describe how to evaluate merit and usability of existing research. 4. Describe the process from research generation, dissemination, implementation and

evaluation.

5. Analyze personal and patient preferences/values implementing research findings.

Introduction

We are living in a fast-moving world where our understanding of what can be achieved in

healthcare is constantly being reframed by advances in science and technology. A major

challenge in health care is valuing the continual discovery of new knowledge, assessing it for

appropriateness for inclusion in care delivery and putting into practice the knowledge that exists.

It is said that it takes 10 to 20 years for scientific findings to be integrated into practice and that

only 20% or less of health care is based on research (Hughes, 2008; Kirchoff, 2004; Leape,

2005). The challenge we face is how to increase the rate of adoption and continue the movement

from a profession based on ritual and tradition to using a wide range of evidence. It is estimated

that 30 – 40% of patients do not receive treatments of demonstrated effectiveness, whereas 20 –

25% receive treatments that are not needed or are potentially harmful (Halm, 2010). Evidence-

based practice (EBP), integrating best current evidence with clinical expertise and patient/family

preferences and values for delivery of optimal health care, provides the direction for the way to

think about clinical practice and lead practice change (Cronenwett et al., 2007; Cronenwett et al.,

2009).

Students need an appreciation and understanding of the role of evidence, which includes how to

select an evidence-based practice, and how clinical expertise and patient values and preferences

should form the basis for nursing intervention (Estabrooks, 2006; Rycroft-Malone et al., 2004). It

incorporates the development of skills in how to frame a question, locating knowledge, critical

thinking and clinical discernment. An EB approach to clinical decision making is embedded with

an appreciation for the continuous generation of knowledge and a philosophy of life-long

learning (Craig & Smyth, 2007).

Evidence-based practice was first systematically introduced in nursing with the Conduct and

Utilization of Research in Nursing (CURN) project in the late 1970’s by Horsley and Crane

(Haller, Reynolds, & Horsley,1979). They reviewed the research on 10 common nursing

procedures including Structured Preoperative Teaching, Preventing Decubitus Ulcers, and

Reducing Diarrhea in Tube-fed Patients. The project developed research-based clinical protocols,

systematically implemented them into practice, and measured the outcomes. Applying the

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framework of Everett Rogers, they developed a guide that described, from an organizational

perspective, how to advance nursing practice via use of research findings. The CURN project

demonstrated that synthesized research put into clinical protocols would be used by clinicians

with beneficial results to patients (Haller et al., 1979). Many of the current approaches to EBP

draw on this model (Barnsteiner, et al 2010). Today we have progressed from research utilization

to EBP and translational research. Faculty and students need an understanding of the process of

getting to EBP and the potential for positive impact on patient care.

Definitions

A variety of terms are used interchangeably with EBP. These include research utilization,

research implementation science, dissemination, diffusion, research use, knowledge transfer,

uptake, knowledge to action, and translational research. Tetroe and colleagues (2008) reported

more than 33 different terms in use to describe EBP and translational research. Each of these fits

into the schema of EBP and it is important to have a clear understanding of the differences

among the conduct of research, research utilization, EBP and translational research.

Research conduct is the systematic investigation of clinical phenomenon or the generating of

new knowledge. Research Utilization (RU) was a term used in the 1980’s and 90’s to describe a

2 step process of dissemination and implementation. Dissemination is the systematic efforts to

make research available and implementation is the systematic implementation of scientifically

sound, research-based innovation. EBP as is noted above builds on RU and integrates clinical

expertise and patient/family preferences and values.

Translational research consists of the activities to transform ideas, insights and discoveries

generated through basic science inquiry and from clinical or population studies into effective and

widely available clinical applications (Mitchell, et al 2010). It includes the testing of the effect of

interventions aimed at promoting the rate and extent of adoption of EBP by healthcare providers

(Titler et al., 2001; Titler, 2006).

Translational research further subdivided to describe both T1, which is moving research findings

from "bench to bedside" and T2, the translation of results from clinical studies

into everyday

clinical practice and health decision making. The work in this competency is directed to T2

(Barnsteiner, et al 2010; DiCenso et al., 2005; Newhouse et al., 2005).

Models and Steps to EBP

Numerous models have been published to guide nurses in moving to EBP. Indeed, Mitchell and

colleagues have identified 47 models from the literature on knowledge translation (Mitchell, et

al, 2010). Commonly used nursing models include the Iowa, STAR, Hopkins and University of

Arizona (Titler et al., 2001; Stevens, 2004; Melynk & Fineout-Overhold, 2004; Newhouse et al.,

2005; Rosswurm,1999; Stetler, 2003). They share a common foundation in that all use a Planned

Action theoretical approach but do not necessarily cover all 16 elements in moving knowledge to

practice (Strauss, Tetroe, & Graham, 2009). The 16 steps taken together incorporate the process

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for locating and synthesizing knowledge and the systematic use of the change process for

integrating and sustaining EB the changes in practice. The steps in moving knowledge to practice

are:

1. Identify problem and formulate a specific question 2. Identify need for change 3. Identify change agents 4. Identify target audience 5. Identify stakeholders 6. Locate the body of knowledge, synthesize and extract the clinical meaning 7. Adapt the knowledge/design the innovation to the local users 8. Assess the barriers to using the knowledge 9. Develop the dissemination plan 10. Develop evaluation plan 11. Pilot test the EB practice 12. Evaluate the process 13. Implement the practice change 14. Evaluate the outcome 15. Maintain the change 16. Disseminate the results of the practice change

Identify problem and formulate a specific question. Numerous resources exist to assist in framing

a searchable question (see resources). The PICO model is often used to define a problem and

formulate a specific question: Population, Intervention, Comparison and Outcome. (Sackett et

al., 2000). An example of the PICO is as follows: In hospitalized patients over 60 years of age,

how effective is a falls-prevention program in comparison to the normal standard of care in

decreasing falls and falls injury rates by 50%? The question guides the search for evidence so the

more explicit the question the easier it is to develop the search strategies.

Identify need for change. It is important to identify where the need for change has arisen. It may

be related to new knowledge that needs to be examined for implementation into the clinical

setting while there has not been any concern with current practice noted; or it may be related to a

clinical problem which has been identified by clinicians and existing knowledge is being sought

to provide solutions or improvements to the clinical problem.

Identify change agents. The earlier that participants who will be instrumental in bringing about

the change are identified and included in the process, the more likely the change is to be

successful.

Identify target audience. In this step those who will be affected by the change are identified so

the practice change can be tailored to fit the audience.

Identify stakeholders. Knowing the individuals or groups who have a vested interest in the

project and anticipating their acceptance, support, or resistance is critical to the success of the

project.

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Locate the body of knowledge, synthesize and extract the clinical meaning. Searching for

evidence in the healthcare literature is difficult and complex. Numerous templates are used for

conducting systematic reviews. Detailed search strategies are necessary to locate and compile the

studies to address the question, and appraisal methods need to be chosen to summarize the state

of the knowledge. Information is gathered from several sources including locating systematic

reviews, clinical practice guidelines, and searching journal publications for pertinent research

articles. It includes using multiple search engines such as Medline and CINAHL and databases

such as the Cochrane collection, clearly identifying search terms and inclusion and exclusion

criteria, developing a Table of Evidence to lay out the findings, grading the research for strength

of evidence, searching for bias, determining the benefit versus the risk and burdens of the

treatment/care, and extracting the implications for practice.

There are numerous approaches to locating the body of knowledge to answer a question. Clinical

practice guidelines, which are systematically developed statements gleaned from summaries of

best available evidence, may have been developed to assist clinicians to make decisions about

specific clinical circumstances. Examples include pain management, falls prevention, congestive

heart failure management, and others. These may be found on the AHRQ National Guidelines

Clearing House web site at http://www.guideline.gov/compare/synthesis.aspx.

High quality systematic reviews provide the foundation for knowledge synthesis and they are

indexed in both large, CINAHL and MEDLINE, and small databases such as the Cochrane and

Campbell Collaborations. The journal Evidence-Based Nursing has research abstracts and expert

commentary on research articles that have met certain quality criteria and that are applicable to

nursing practice. Worldviews on Evidence-Based Nursing is a nursing journal focused on

syntheses of clinical topics and research abstracts (Stillwell, S., Fineout-Overholt, E., Melnyk,

B., & Williamson, K. 2010).

There are instances where quality summaries of evidence or EB guidelines or systematic reviews

are not available and databases are used to locate individual journal articles for review and

synthesis. Knowledge synthesis is the analysis and interpretation of the results of individual

studies. A librarian is very helpful in assisting with the search for evidence. Once the studies are

located they must be critically appraised to determine if the quality of the study is sufficiently

sound to use the results and if the findings are applicable in a particular setting. The web site

http://www.shef.ac.uk/scharr/ir/netting/ has multiple links to appraisal checklists for evaluating

studies as does AHRQ http://www.ahrq.gov/clinic/epcsums/strengthsum.htm.

Hierarchy of Evidence/Strength of Evidence

Much has been written about the importance of grading evidence. A hierarchy of evidence model

developed for questions regarding the effectiveness of an intervention or therapy has been widely

applied to all questions related to health care (AHRQ, 2002). Numerous hierarchical models for

rating strength, quality and consistency of research evidence have been disseminated. The

models, which use anywhere from four to eight levels for rating strength of evidence, have

largely originated from medicine. This hierarchy posits the randomized clinical trial (RCT) as the

strongest evidence for EBP questions. The Center for Evidence Based Medicine uses Level and

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grade: Level 1 (a,b,c), Level 2, (a, b, c), Level 3 (a & b) and Level 4, and Level 5 (2009). The

American Heart Association uses Level A, B, C for the estimate of certainty of the treatment

effect and then adds Class I, IIa, IIb and III for the size of the treatment effect (Gibbons, 2004).

The ACCP describes the grading recommendations on the strength of recommendation (Grade

I=strong and Grade 2=weak) and then further classifies the quality of the methodology as A

(RCT), B (downgraded RCTs or upgraded observational studies) and C (Observational studies or

RCTs with major limitations) (Guyatt, 2006). The US Preventive Task Force uses a consistent

set of criteria in assessing strength of evidence

http://odphp.osophs.dhhs.gov/pubs/guidecps/PDF/Frontmtr.PDF.

In a nursing model, Rosswurm and Larrabee (1999) recommend the use of four levels while

Stetler’s (2001) nursing model contains six. When grading strength of evidence in nursing what

needs to be kept in mind is that different questions have different hierarchies and the RCT is not

necessarily the gold standard to be applied across all of healthcare. For each type of question

there is an appropriate research design. For example, examining the pattern or outcome of a

health problem, cohort studies, or case-control studies may be the best match for the question.

The wiki Evidence-Based Medicine Librarian

http://ebmlibrarian.wetpaint.com/page/3.+Appraising+the+evidence

is a community of librarians involved in teaching and supporting EBP. On this site are listed

numerous tutorials and resources for grading evidence for various clinical questions. Toolkits are

available to guide clinicians in the critical appraisal of studies to determine if study results are

valid, interpreting the results in the context of the patient population and determining if the

results apply to the clinical setting. When there is clear evidence to guide practice we need to be

certain it is not applied inappropriately to other population groups. For example many clinical

trials have been in adults and serious consideration needs to be taken before results are applied to

infants and children or the aged.

Adapt the knowledge/design the innovation to the local users. This is often referred to as

academic tailoring and is the adapting of the protocol or message to fit the audience. It includes

identifying any processes that may be peripheral to the clinicians who will implement the EBP

change and should be developed in consideration of any barriers for change. In nursing this may

include pharmacy, information technology, and other professional disciplines.

Assess the barriers to using the knowledge. Consideration of barriers that may be encountered

and resolving them prior to dissemination will help to ensure the success of the EBP. This

includes identifying resources that may be necessary and plans to garner them.

Develop the dissemination plan. A comprehensive and detailed plan including communication

of the change to all those affected, training requirements, development of detailed protocols, and

notifying other departments and individuals who may be affected by the change is included in

the dissemination plan. A timeline is helpful in laying out the specific steps and estimating how

long each will take to complete. Passive educational interventions such as procedures, lectures,

and conferences are not likely to change clinician behavior when used alone. Active

interventions such as self-study, and learning labs and reminders and decision supports are more

likely to induce change.

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Develop evaluation plan. Identifying the predictors of success and developing a plan for

collecting and analyzing data are components of the evaluation plan. This includes identifying

who will be responsible for collecting, analyzing, and reporting the data and at what intervals.

Pilot test the EB practice. It is always preferable to pilot test a practice change. Research is

conducted under controlled conditions and it is uncertain how the intervention will work when

applied to real world conditions. Doing small tests of change allows for identification of

challenges and refining of the protocol.

Evaluate the process. Determine how the practice change is used. Audit and feedback

demonstrates the gap between actual and desired results and address questions such as did the

clinicians receive the information about a practice change and did they adhere to the practice

change. How difficult or smooth was it to use the new way?

Implement the practice change. When the practice change has been modified sufficiently so that

it is working as expected, it is ready to be implemented in other areas. A dissemination plan

similar to the steps outlined above is needed to ensure a smooth implementation process. This

includes planning for communication, training, and obtaining sufficient resources.

Evaluate the outcome. Quality of Care has assumed increasing importance. The public,

government, and third-party payers want to know the outcomes of our interventions and the

outcomes of care being delivered. Does it make a difference in the patient’s health, the provider

components of care, and is it cost effective? Increasingly, nursing is being held accountable for

the quality of nursing care delivered. We need to evaluate and understand whether and how the

EBPs we put into place work in real world environments. In evaluating outcomes we are

answering how we know what we are doing is making a difference. It entails specifying what

outcomes are expected to be achieved, baseline data and results that will be collected, and

frequency of monitoring.

Maintain the change. A plan for continued monitoring with feedback to clinicians promotes

sustainability of the EBP change over time and allows for assessment of achievement of desired

results.

Disseminate the results of the practice change. Inform clinicians and all stakeholders of the

results of the practice change including financial and clinical improvements.

EBP may be about an individual having a clinical question or discovering knowledge that may

improve one’s own practice or it may be related to widespread implementation and organization

system change. If the EBP will be related to one’s individual practice then the process may not

need to incorporate steps 3-5, 9, and 16, as described above. If a wider scale implementation is

envisioned then systematically going through all steps increases the likelihood of adoption.

When tailoring the EBP to users and developing the implementation plan, Rogers (2003)

identifies five steps that need to be considered.

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1) Relative advantage- whether the new EBP is viewed as being better than the previous

practice. This includes economic considerations and making a business case

2) Compatibility- how the EBP is perceived as consistent with the needs of the adopters or

with past practice.

3) Complexity–how difficult the EBP is to use and understand.

4) Triability–degree to which the EBP may be "tried out" to solve any glitches in the process.

5) Observabilty–how visible the EBP is to others. The more visible a change the more likely

clinicians are to take up a new practice. Hand-hygiene campaigns using products such as

ultraviolet lights that show how well hands were cleansed are more effective than those that do

not have some observable component.

Barriers to EBP

Much has been written describing barriers to EBP and little has changed in nurses responses over

the past 15 years, regarding why nurses do not use evidence in their practice (Funk, 1995;

Pravikoff, 2005, Melnyk, et al 2010). Barriers identified include lack of time to locate and

synthesize knowledge, negative attitudes towards research and EBP, lack of skill to search the

literature and to interpret evidence, access to the internet and computerized resources, and the

perception of lack of authority to change practice. These barriers need to be kept in mind even as

one moves through the steps in the process.

A number of developments may serve to decrease the barriers. Professional organizations are

increasing their involvement in synthesizing knowledge related to their specialties. Graduates are

entering the workforce with skills in literature searching and knowledge synthesis, and as

electronic health records are widely implemented access to the internet and computer resources

will increase. Lastly, transformational leadership behaviors have been demonstrated to influence

nurses to find new practices appealing, adopt them and perceive fewer gaps between current and

EPBs (Halm, 2010).

Knowledge Explosion

Lifelong learning is an important value in EBP. Keeping up with the latest evidence, however, is

an increasingly difficult task. It is estimated that more than 6,000 pages are published daily and

with internet resources expanding the numbers only increase (Pravikoff, 2005). A search for

synthesized knowledge should be completed prior to embarking on collecting studies for

synthesis. Many sources of synthesized knowledge are available. These include the National

Guidelines Clearing House, Sigma Theta Tau International, publications such as Evidence-Based

Nursing and Worldviews on Evidence-Based Nursing, The Johanna Briggs Institute, Cochrane

Collaborative, Health Information Resources, and others are helpful resources. Professional

nursing societies have often taken a lead on developing specialty practice systematic reviews and

evidence-based syntheses (Mallory, 2010).

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EB clinical practice guidelines are systematically developed statements that help clinicians and

patients make decisions about health care for specific clinical circumstances. They often are

developed by a multidisciplinary group, followed by external review prior to publication. The

National Guidelines Clearinghouse has guidelines developed in the US as well as internationally.

Evidence summaries or systematic reviews provide a foundation for EBP activities. Clinicians

often do not have the time to summarize the total evidence for a question. Systematic reviews

may be published and indexed in large databases such as Medline and CINAHL. Numerous

organizations provide concise summaries of the best available evidence from systematic reviews.

The Cochrane and Campbell Collaborations and the Joanna Briggs Institute produce high-quality

clinically relevant systematic reviews on all areas of healthcare. One can search all these

resources through the TRIP (Turning Research Into Practice) database at www.tripdatabase.com/

Clinical expertise and patient values in the equation

Little has been written regarding patient/family preferences and values related to EBP as well as

the role of clinical expertise. Generally EBP has focused on the translation of research into

practice. One of the complaints of EBP is that it is cookbook. However, research evidence alone

is not sufficient to ensure sound clinical decisions necessary for effective health care.

There are times when evidence is not available to guide practice or it is equivocal and no clear

direction is obvious. Clinical decision making is a complex process and requires more than

research to guide practice. Sackett et al. (2000) defined clinical expertise as the ability to use our

clinical skills and past experience to rapidly identify each patient’s unique health state and

diagnosis, their individual risks and benefits of potential interventions, and their personal values

and expectations. Clinical expertise is the proficiency and judgment that individual clinicians

acquire through clinical experience and clinical practice. Increased expertise is reflected

in

numerous ways, but especially in more effective and efficient assessments and diagnoses and

thoughtful identification and compassionate use of individual patients' predicaments, rights, and

preferences in making clinical decisions about their care. Experienced clinicians use both

individual clinical expertise and the best available external evidence. Clinical expertise is as

important as excellent external evidence in recognizing when evidence may be inapplicable or

inappropriate for an individual patient (Jennings & Loan, 2001).

One of IOM’s 10 rules for health care calls for the patient to be at the center of decision making.

As such, incorporating patient/family preferences and values includes asking patients about their

preferred role in decision making, clarifying their values, and asking about support or undue

pressure. It is defined as the unique preferences, concerns, and expectations each patient brings

to a healthcare encounter and which must be integrated into clinical decisions if they are to

serve the patient (Sackett et al., 2000). It includes assessing knowledge, experience, and

understanding of their health behavior and status so they are able to make informed choices.

Question prompts for patients, and coaching to develop skills in questioning clinicians and

deliberating about options improve patient/family member decision-making abilities. Kleinman’s

questions for ascertaining patients’ beliefs and values may serve as a useful reference (Fatiman,

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1997). Narayan (2010) uses the Kleinman framework to describe how nurses might assess their

personal cultural norms concerning pain as well as how to interview patients for pain assessment.

Keirns and Goold (2009) make the case that patient-centered care may at times conflict with

evidence-driven care and that patient preferences have priority over evidence-based

recommendations. Clinicians have a responsibility to ensure patients have the knowledge to

understand the short and long-term consequences of their choices and yet accept that decisions

need to be made consistent with the patient’s goals.

Ethics and EBP

There are certainly ethical dimensions to EBP. Some examples of ethical dilemmas include:

priority setting in deciding which innovations to support or promote; when is it safe to translate

new knowledge into practice; and what processes should be subject to ethics oversight and the

mechanisms for this. Trevor-Deutsch and colleagues (2009) propose two ethical principles–

utility and justice–as the basis for a bioethics framework.

From a utility perspective, maximization of benefits and minimization of risk should guide

implementation of EBPs. Considerations should include beneficial outcomes, achieving greatest

benefit for greatest numbers when there are competing innovations, and consideration of

potential benefit when allocating resources to EBP. Justice mandates the fair distribution of

benefits among beneficiaries.

Questions often arise regarding ethical aspects of implementing and studying the outcomes of

EBP. Issues such as privacy concerns, protection of participants' physical well-being, the data

being collected and analyzed and any potential conflicts of interest determine if Institutional

Review Board approval is needed for an EBP practice project.

Teaching Strategies There are multiple ways to teach EBP to students. Examples include:

• Cite research publications for classroom presentations and discussions • Working in teams, have students construct a question using PICO and do a synthesi

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