Chapter 1 Making the Case for Evidence-Based Practice and Cultivating a Spirit of Inquiry

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.)

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

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

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.

Answer True Rationale: External evidence includes research articles published in peer-reviewed journals.

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)

EBP vs. Research vs. Quality Improvement (QI)—(cont.) 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.

EBP vs. Research vs. Quality Improvement (QI)—(cont.) 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)

Question Which of the following involves bringing the body of evidence together with clinical expertise and patient preferences and values to identify best practice? Evidence-based practice Research Translational research Research utilization Evidence-based quality improvement

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.

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.

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!

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

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.

Answer False Rationale: An EBP culture and environment must be created within an organization if EBP is to be implemented and sustained.

Steps of the EBP Process 0. Cultivate a spirit of inquiry within the environment 1. Ask the burning clinical question in PICOT format Search for and collect the most relevant best evidence 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

Question Is the following statement true or false? According to Melnyk & Fineout-Overholt, there are six steps to the evidence-based practice process.

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.

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.

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

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

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

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 Having a new strategic plan The plan goal of making sure all policies and procedures are supported by evidence within the 3 years. Hosting unit-based journal clubs The timing and stipulations for attendance of the unit-based journal clubs

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.