Nursing

Keywords: evidence-based practice, health care delivery, nursing, Delivery of Health Care, Evidence-Based Practice, Nursing

Evidence-based practice (EBP) is the conscientious use of current best evidence in making decisions about patient care (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). It is a problem-solving approach to the delivery of health care that integrates the best evidence from research with a clinician's expertise and a patient's preferences and values (Melnyk & Fineout-Overholt, 2015). When delivered in a context of caring and in an organizational culture that supports EBP, the best patient outcomes are achieved. Although it is well recognized that EBP improves the quality and safety of health care as well as decreases hospital costs and patient morbidities, evidence-based care is not consistently implemented by point-of-care clinicians and health care systems across the United States. Unfortunately, it typically takes well over a decade to translate findings from research into clinical practice to improve care and patient outcomes. Recognition of the long research–practice time lag resulted in the Institute of Medicine setting a goal that by the year 2020, 90% of clinical decisions will be supported by the best available evidence (Institute of Medicine, 2008).

For clinicians to use evidence to make daily decisions about patient care, there must be an understanding of the two types of evidence in EBP: (a) external evidence that is generated through rigorous research and (b) internal evidence that is generated through quality improvement, outcomes management, and EBP-implementation projects within clinicians’ own practice settings. Internal evidence is important in evidence-based decision making to demonstrate outcomes from evidence-based interventions as well as when rigorous studies do not exist to guide best practices. Evidence for interventions is leveled from level 1 (i.e., systematic reviews of randomized controlled trials), which is the strongest level of evidence to guide clinical practice, to level 7 (i.e., evidence from expert opinion). The level of the evidence plus the quality of that evidence as determined from critical appraisal determines the strength of the evidence, which provides clinicians the confidence to act on the evidence and implement best practices (Melnyk & Fineout-Overholt, 2015).

Dr. Archie Cochrane, a British epidemiologist, is credited with starting the EBP movement when he challenged the public to pay only for health care that had been supported as efficacious through research (Enkin, 1992). In 1972, he criticized the medical profession for not providing rigorous systematic reviews of evidence so that organizations and policy makers could make decisions about health care. He contended that thousands of low-birth-weight premature infants had died needlessly because the results of several randomized controlled trials were not synthesized into a systematic review to support the practice of routinely providing corticosteroid injections to high-risk women in preterm labor to halt the premature birth process. Archie Cochrane considered systematic reviews to be the strongest level of evidence to guide practice decisions (Cochrane Collaboration, 2001). Although he died in 1988, Dr. Cochrane's influence was responsible for the launching of the Cochrane Center in Oxford, England, in 1992 and the founding of the Cochrane Collaboration (2001) a year later. The purpose of the Cochrane Collaboration is to provide and routinely update rigorous systematic reviews of health care interventions to guide best practices.

In the United States, the U.S. Preventive Services Task Force, an independent panel of 16 experts in primary care, research, and prevention, systematically reviews the evidence of effectiveness and develops gold standard recommendations for clinical preventive services that include screening, counseling, and preventive medications. The U.S. Preventive Services Task Force produces a Guide to Clinical Preventive Services every year that includes its updated evidence-based recommendations for primary care providers (see www.ahrq.gov/professionals/clinicians-providers/guidelinesrecommendations/guide/index.html).

In EBP there are seven steps, which include the following:

1. Cultivate a spirit of inquiry

2. Ask the burning clinical question in PICOT (P = patient population, I = intervention or area of interest, C = comparison intervention or group, O = outcome, and T = time) format

3. Search for and collect the most relevant evidence

4. Critically appraise the evidence (i.e., rapid critical appraisal, evaluation, and synthesis)

5. Integrate the best evidence with one's clinical expertise and patient preferences and values in making a practice decision or change

6. Evaluate outcomes of the practice decision or change based on evidence

7. Disseminate the outcomes of the EBP decision or change (Melnyk & Fineout-Overholt, 2015)

Without a spirit of inquiry, nurses and other clinicians may find it challenging to ask burning clinical questions about their practices (e.g., In intensive care unit patients, how does early ambulation compared with delayed ambulation affect the number of ventilator days? In orthopedic patients, how does analgesia administered by the triage nurse compared with waiting for physician-ordered analgesia affect pain and length of time in the emergency department?). Asking questions in PICOT (population/patient problem, intervention, comparison, outcome, time) format leads to a more time efficient and effective search for evidence. Articles from the search are then rapidly critically appraised, evaluated, and synthesized to determine whether a practice change on the basis of the best evidence is indicated. Relevant, reliable evidence is then integrated with the clinician's expertise and patient preferences and values in making a practice decision or change. Clinician expertise involves health care provider skills and interpretation of patient assessment data, internal evidence, use of health care resources, and other important information that is relevant to the clinical decision and outcome. Once an evidence-based change is made in clinical practice, measurement of key outcomes is necessary to demonstrate that the impact expected of the change indeed occurred in a clinician's own practice setting. The final step in EBP is disseminating the outcomes of the evidence-based change so that others might benefit from the process.

Although EBP produces better outcomes than care that is steeped in tradition and a known process exists for implementing evidence-based care, there are multiple barriers that exist within individuals and institutions that are slowing the widespread adoption of evidence-based care. Barriers in individuals include (a) the perception that EBP takes too much time, (b) the inadequate knowledge and skills in EBP, and (c) a lack of confidence to implement change. System barriers include (a) contextual environment and culture that does not support EBP, (b) lack of resources required for EBP, (c) lack of EBP mentors who can assist with EBP implementation at point of care, and (d) nurse leaders and managers who do not model EBP (Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012). Conversely, there are a number of factors that facilitate the implementation of EBP, including (a) EBP knowledge and skills, (b) beliefs about the value of EBP and the ability to implement it, (c) a context and culture that supports EBP and provides the necessary tools to support evidence-based care (e.g., time to search for evidence, access to computer databases at point of care), (d) EBP mentors (i.e., typically advanced practice nurses with expertise in EBP as well as organizational and individual behavior change strategies) who work directly with clinicians at the point of care in implementing EBP, and (e) supportive leadership behaviors (Melnyk, 2014; Melnyk & Fineout-Overholt, 2015; Stetler, Ritchie, Rycroft-Malone, & Charns, 2014).

EBP competencies for practicing nurses and advanced practice nurses now exist. These competencies were generated by a panel of national experts in EBP and validated through research by conducting two rounds of a Delphi survey with EBP mentors throughout the country (Melnyk, Gallagher-Ford, Long, & Fineout-Overholt, 2014). All health care systems should require that nurses and advanced practice nurses meet these EBP competencies as doing so should greatly enhance the quality and safety of health care. In addition, all nursing and other health sciences students should be taught EBP in their academic programs so that they are meeting these competencies on graduation.

There are several conceptual models that have been developed to facilitate a change to EBP in individuals and health care systems. These models include (a) the EBP decision-making model by DiCenso, Ciliska, and Guyatt; (b) the Stetler model of EBP; (c) the Iowa model of EBP to promote quality care created by Marita Titler and colleagues; (d) the model for EBP change by Rosswurm and Larabee; (e) the Advancing Research and Clinical Practice Through Close Collaboration model by Melnyk and Fineout-Overholt; (f) the Promoting Action on Research Implementation in Health Services framework by Rycroft-Malone, Kitson, and colleagues; (g) the clinical scholar model by Schultz; and (h) the Johns Hopkins nursing EBP model by Newhouse and colleagues (Dang et al., 2015). It is increasingly recognized that efforts to change practice should be guided by conceptual models (Graham, Tetroe, & the KT Theories Research Group, 2007). As these models are supported by evidence from research, they will become even more valuable in helping clinicians deliver evidence-based care.

In summary, EBP is necessary to ensure the highest quality of cost-effective care and the best patient outcomes. Nurses must ensure that their patients are receiving the highest quality of care by consistently ensuring the delivery of evidence-based care in their practices. Efforts in the future must be accelerated and placed on (a) educating both practicing clinicians and health professional students in the EBP process with emphasis on the building of EBP skills; (b) creating cultures of EBP that provide resources, EBP mentors, and support to clinicians to engage in and sustain evidence-based care; (c) providing incentives for EBP; and (d) establishing evidence-based clinical practice guidelines and policies that are incorporated into technology (e.g., electronic health records) to facilitate best practice by clinicians at the point of care (Melnyk & Williamson, 2010). More implementation research is needed to determine the best strategies for accelerating the speed at which research is translated into real-world practice settings to improve care and people's health outcomes.

• Cochrane Collaboration. (2001). Retrieved from http://www.cochrane.org/cochrane/cc-broch.htm#cc.
• Dang, D.; Melnyk, B. M.; Fineout-Overholt, E.; Ciliska, D.; DiCenso, A.; Cullen, L.; Stevens, K. (2015). Models to guide implementation of evidence-based practice. In B. M. Melnyk; E. Fineout-Overholt (Eds.), Evidence-based practice in nursing & healthcare. A guide to best practice (3rd ed., pp. 235-247). Wolters Kluwer/Lippincott Williams & Wilkins Philadelphia PA.
• Enkin, M. (1992). Current overviews of research evidence from controlled trials in midwifery obstetrics. Journal of the Society of Obstetricians and Gynecologists of Canada, 9, 23-33.
• Graham, I. D.; Tetroe, J.; KT Theories Research Group. (2007). Some theoretical underpinnings of knowledge translation. Academic Emergency Medicine, 14(11), 936-941.
• Institute of Medicine. (2008). Evidence-based medicine and the changing nature of health care: 2007 IOM annual meeting summary. National Academies Press Washington, DC.
• Melnyk, B. M. (2014). Building cultures and environments that facilitate clinician behavior change to evidence-based practice: What works? Worldviews on Evidence-Based Nursing, 11(2), 79-80.
• Melnyk, B. M.; Fineout-Overholt, E. (2015). Evidence-based practice in nursing & healthcare. A guide to best practice (3rd ed.). Wolters Kluwer/Lippincott Williams & Wilkins Philadelphia PA.
• Melnyk, B. M.; Fineout-Overholt, E.; Gallagher-Ford, L.; Kaplan, L. (2012). The state of evidence-based practice in US nurses: Critical implications for nurse leaders and educators. Journal of Nursing Administration, 42(9), 410-417.
• Melnyk, B. M.; Gallagher-Ford, L.; Long, L. E.; Fineout-Overholt, E. (2014). The establishment of evidence-based practice competencies for practicing registered nurses and advanced practice nurses in real-world clinical settings: Proficiencies to improve healthcare quality, reliability, patient outcomes, and costs. Worldviews on Evidence-Based Nursing, 11(1), 5-15.
• Melnyk, B. M.; Williamson, K. (2010). Using evidence-based practice to enhance organizational policies, healthcare quality and patient outcomes. In A. S. Hinshaw; P. Grady (Eds.), Shaping health policy through nursing research (pp. 87-98). Springer Publishing New York NY.
• Sackett, D. L.; Straus, S. E.; Richardson, W. S.; Rosenberg, W.; Haynes, R. B. (2000). Evidence-based medicine: How to practice and teach EBM. Churchill Livingstone London UK.
• Stetler, C. B.; Ritchie, J. A.; Rycroft-Malone, J.; Charns, M. P. (2014). Leadership for evidence-based practice: Strategic and functional behaviors for institutionalizing EBP. Worldviews on Evidence-Based Nursing, 11(4), 219-226.

Bernadette Mazurek Melnyk
Ellen Fineout-Overholt