1. Evidence-Based Practice
Jane H. Barnsteiner, PhD, RN, FAAN

2. Evidence-Based Practice: As Used in this Module
Integrating best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care.

3. Key Message
The key message of this module is: 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.

4. Learner Objectives
By the end of this module, the learner will be able to:
Define Evidence-Based Practice and Translation Research.
Describe activities in research synthesis.
Describe how to evaluate merit and usability of existing research.
Describe the process from research generation, dissemination, implementation and evaluation.
Analyze personal and patient preferences/values implementing research findings.

5. Introduction

6. Introduction
We are living in a fast-moving world where our understanding of what can be achieved in health care 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.

7. Introduction
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. 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.
(Hughes, 2008; Kirchoff, 2004; Leape, 2005)

8. Introduction
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)

9. The Role of Evidence
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.
It incorporates the development of skills in locating knowledge, critical thinking and clinical discernment.
(Estabrooks, 2006; Rycroft-Malone et al., 2004)
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).

10. History of EBP in Nursing
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. 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 framework of Everett Rogers, they developed a guide that described, from an organizational perspective, how to advance nursing practice via use of research findings.
(Haller, Reynolds, & Horsley,1979)

11. History of EBP in Nursing
The CURN project demonstrated that synthesized research put into clinical protocols would be used by clinicians with beneficial results to patients.
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.
(Haller et al., 1979)
Many of the current approaches to EBP draw on this model.

12. Definitions

13. Synonymous Terms with EBP
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
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.

14. Synonymous Terms with EBP
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.

15. Synonymous Terms with EBP
Translational research is the testing of the effect of interventions aimed at promoting the rate and extent of adoption of EBP by healthcare providers.
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.
(Titler et al., 2001; Titler, 2006)
(DiCenso et al., 2005; Newhouse et al., 2005)

16. Models and Steps to EBP

17. Models and Steps to EBP
Numerous models have been published to guide nurses in moving to EBP. Commonly used nursing models include the Iowa, STAR, Hopkins and University of Arizona. They share a common foundation in that they use a Planned Action theoretical approach but do not necessarily cover all 16 elements in moving knowledge to practice.
(Titler et al., 2001; Stevens, 2004; Melynk & Fineout-Overhold, 2004; Newhouse et al., 2005; Rosswurm,1999; Stetler, 2003)
(Strauss, Tetroe, & Graham, 2009).

18. Models and Steps to EBP
Identify problem and formulate a specific question
Identify need for change
Identify change agents
Identify target audience
Identify stakeholders
Locate the body of knowledge, synthesize and extract the clinical meaning
Adapt the knowledge/design the innovation to the local users
Assess the barriers to using the knowledge
Develop the dissemination plan
Develop evaluation plan
Pilot test the EB practice
Evaluate the process
Implement the practice change
Evaluate the outcome
Maintain the change
Disseminate the results of the practice change
The 16 steps taken together incorporate the process for locating and synthesizing knowledge and the systematic use of the change process for integrating and sustaining EB the changes in practice.

19. 1. Identify Problem and Formulate a Specific Question
The PICO model is often used to define a problem and formulate a specific question:
Population
Intervention
Comparison
Outcome
Numerous resources exist to assist in framing a searchable question.
(Sackett et al., 2000)

20. 1. Identify Problem and Formulate a Specific Question
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.

21. 2. 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.

22. 3. 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.

23. 4. 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.

24. 5. 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.

25. 6. 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.

26. 6. Locate the Body of Knowledge, Synthesize and Extract the Clinical Meaning
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.

27. 6. Locate the Body of Knowledge, Synthesize and Extract the Clinical Meaning
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

28. 6. Locate the Body of Knowledge, Synthesize and Extract the Clinical Meaning
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.
orldviews on Evidence-Based Nursing is a nursing journal focused on syntheses of clinical topics and research abstracts.  

29. 6. Locate the Body of Knowledge, Synthesize and Extract the Clinical Meaning
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 has multiple links to appraisal checklists for evaluating studies as does AHRQ

30. 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.

31. Hierarchy of Evidence / Strength of Evidence
The Center for Evidence Based Medicine uses Level and grade: Level 1 (a,b,c), Level 2, (a, b, c), Level 3 (a & b) and Level 4, and Level 5. 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 .
(2009)
(Gibbons, 2004)

32. Hierarchy of Evidence / Strength of Evidence
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) The US Preventive Task Force uses a consistent set of criteria in assessing strength of evidence
(Guyatt, 2006).

33. Hierarchy of Evidence / Strength of Evidence
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.
(1999)
(2001)
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.
In a nursing model, Rosswurm and Larrabee recommend the use of four levels while Stetler’s nursing model contains six.

34. Hierarchy of Evidence / Strength of Evidence
The wiki Evidence-Based Medicine Librarian 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.

35. 7. 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.

36. 8. 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.

37. 9. 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. Active interventions such as self-study, learning labs, reminders, and decision supports are more likely to induce change than passive education.
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.

38. 10. 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.

39. 11. Pilot Test the EB Practice
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.

40. 12. 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?

41. 13. 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.

42. 14. 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.

43. 15. 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.

44. 16. Disseminate the Results of the Practice Change
Inform clinicians and all stakeholders of the results of the practice change including financial and clinical improvements.

45. Tailoring the EBP to Users
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.
When tailoring the EBP to users and developing the implementation plan, Rogers identifies five steps that need to be considered.
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.
(2003)

46. Tailoring the EBP to Users
Relative advantage—whether the new EBP is viewed as being better than the previous practice. This includes economic considerations and making a business case
Compatibility—how the EBP is perceived as consistent with the needs of the adopters or with past practice.
Complexity—how difficult the EBP is to use and understand.
Triability—degree to which the EBP may be "tried out" to solve any glitches in the process.
Observability—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.

47. Barriers to EBP

48. 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).

49. Barriers to EBP 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
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.
(Funk, 1995; Pravikoff, 2005).
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.

50. Knowledge Explosion

51. 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. A search for synthesized knowledge should be completed prior to embarking on collecting studies for synthesis.
(Pravikoff, 2005)

52. Sources of Synthesized Knowledge
Sources of synthesized knowledge include:
National Guidelines Clearing House
Sigma Theta Tau International
Evidence-Based Nursing
Worldviews on Evidence-Based Nursing
The Johanna Briggs Institute
Cochrane Collaborative
Health Information Resources
(Pravikoff, 2005)

53. Clinical Practice Guidelines
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.

54. EB Summaries of Systematic Reviews
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

55. Clinical Expertise and Patient Values in the Equation

56. 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 health care.
However, research evidence alone is not sufficient to ensure sound clinical decisions necessary for effective health care.

57. Clinical Expertise
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. 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.
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 as important as excellent external evidence in recognizing when evidence may be inapplicable or inappropriate for an individual patient (Jennings & Loan, 2001).

58. Incorporating Patient / Family Preferences
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 includes assessing knowledge, experience, and understanding of their health behavior and status so they are able to make informed choices.
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).

59. Incorporating Patient / Family Preferences
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. Some 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.
(Fatiman, 1997)
Keirns and Goold (2009)
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.

60. Ethics and EBP

61. Ethical Dimensions to 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.

62. Ethical Dimensions to EBP
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.

63. Ethical Dimensions to EBP
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.

64. Evidence-Based Culture

65. Evidence-Based Culture
 An EBP culture is one in which all clinicians value—and are committed to—each of the stages of the EBP process. The organization is a knowledge-driven system with strong leadership and a clear strategic vision and data that form the basis of information. In teaching students how to deliver safe, effective patient care, knowledge and skill development needs to incorporate how to question evidence substantiating practice as well as how to evaluate existing research.
There is an understanding of the complexity of EBP yet encouragement for innovation.
It includes the benefits of valuing the use of clinical expertise and patient preferences and values in addition to current best research evidence.