Health Care and Evidence Based Practice
Evidence Based Practice
Evidence-based
practice (EBP) refers to nursing practice that uses research findings as the
foundation for nurses’ decisions, activities, and interactions with clients.
Another term which is often used synonymously but is slightly different is the
term “research utilization.”
Research utilization specifically refers
to the practical utilization of findings from one or more scientific studies
and is a predecessor of EBP. EBP is broadly conceptualized as a continuum of
synthesized information used to improve practice and patient outcomes (Bakken,
2001).
These two terms encompass the burgeoning interest in developing a
practice in which there is solid evidence from scientific research that
explicit nursing actions are clinically relevant, cost effective, and result in
positive quality outcomes for clients.
The focus of EBP is its emphasis on
integrating the best available research evidence within the clinical, patient,
and organizational context of an institution to attain high-quality and
cost-effective care.
According to Hewitt-Taylor (2002), evidence-based practice
is a process that entails six elements:
(a) selecting an area of practice that
requires an evidence base.
(b) making decisions about what constitutes
evidence.
(c) conducting a systematic search for evidence.
(d) evaluating
individual pieces of evidence.
(e) synthesizing the findings of these sources
into a cohesive whole.
(f) applying this evidence appropriately to patient
care situations.
Historical Overview
The
desire to explore the path and timing of research to practice began in the
1960s and 1970s. N. Caplan and Rich (1975) coined the terms instrumental
utilization (changing practice based on empirical evidence) and conceptual
utilization (inability to change behavior based on the results, but a new
awareness during caregiving).
The slow evolution of practice change was called
knowledge creep and decision accretion by C. Weiss (1980). Practice changes
occur slowly over time as nurses and other health care providers repeatedly
come into contact with new knowledge during readings, discussions, and at local
and national meetings.
Estabrooks (1999) reported three types of research
utilization: indirect (changes in nurses’ thinking), direct (incorporating
findings into patient care), and persuasive (using findings to change decision
makers’ behaviors and beliefs).
Efforts Leads to Evidence Based Practice
Two
formal efforts undertaken in the 1970s to bridge the gap between nursing
research and nursing practice were the Western Interstate Commission for Higher
Education (WICHE) Regional Program and the Conduct and Utilization of Research
in Nursing (CURN) projects.
In the WICHE project, although nurses were
successful in increasing research utilization, they noted a dearth of
scientifically sound nursing research with identifiable nursing implications.
The goal of the CURN project was to increase the use of research results in
daily practice by disseminating current findings, encouraging collab orative
research with relevance to nursing issues, and enhancing administrative and
organizational change supportive of implementing new evidence.
The Cochrane
Collaboration, which was founded in the United Kingdom in the 1970s, was a
foundation of the evidence-based practice movement. British epidemiologist
Archie Cochrane, noting the paucity of evidence supporting care, advocated for
the availability of clinical summaries upon which health care providers could
base their decisions.
This led to the formation of the Cochrane Collaboration
(www.cochrane.org), whose aim is the preparation and dissemination of
systematic reviews of the results of health care interventions. As the Cochrane
movement was going on, Dr. David Sackett pioneered evidence-based medicine
(EBM) at McMaster Medical School.
She has conceptualized EBM as “the
conscientious, explicit, and judicious use of current best evidence in making
decisions about the care of individual patients. The practice of EBM means
integrating individual clinical expertise with the best available external
evidence from systematic research” (Sackett , Rosenberg, Muir Gray, Haynes,
& Richardson, 1996, p. 71).
Evaluation Evidence Based Practices
Rigorous
rating systems for evaluating evidence have been developed by Sackett and
others (1996), Stetler and others (1998), as well as the AHCPR (2003) (now
Agency for Healthcare Research and Quality (AHQR)].
In
general, the rating systems order the types of evidence in the following
manner: meta analyses of randomized, controlled trials (RCT) (strongest
evidence); (or RCT); quasi experimental studies (time series, nonequivalent control
group) or matched case control studies; nonexperimental studies (correlational,
descriptive); and program evaluations, quality improvement projects, case
reports, authoritative opinions (weakest evidence).
Evaluation Models
Two
models ( Stetler Model, Iowa Model) that were originally designed for research
utilization have been adapted for use in EBP projects. These models have been
the inspiration for the following steps to change practice:
(a) identify a
clinical problem.
(b) collect the evidence about clinical issue (literature
review, integrative review).
(c) review, evaluate, and synthesize available
evidence.
(d) plan the EBP change.
(e) design, implement, and evaluate a pilot
EBP project.
(f) design, implement, and evaluate a larger EBP project; and
finally.
(g) disseminate the results (Polit & Beck, 2004).
Currently,
informatics has become a key contributor to EBP and the promotion of quality
patient care (Bakken, Cimino, & Hripesak , 2004). Although this is not yet
the standard, the methodology exists and presents an opportunity to impact
quality of care through using up-to-date evidence about best practice
tailor made for an individual patient.
For example, a patient is admitted for a
specific operating procedure; Reminders are sent to the physician and nurses regarding
type of antibiotics, changes in care and testing based on laboratory functions,
and best educational methodologies for the patient based on his demographics.
These care processes are changed based on the most current and best evidence
for care and treatment. Computer based reminders have been demonstrated to
decrease errors of omission and enhance adherence to clinical practice
guidelines ( Overhage , Tierney, Zhou, & McDonald, 1997).
There
is some concern by practitioners that the systematic reviews used by clinicians
are a watered-down version of the scientific method and raw data.
Although
Cochrane reviews, summarizations, and meta syntheses of data are used by
clinicians in the formation of guidelines, nurses continue to appreciate the
scholarly merit of single study or a series of studies excellently formulated
and conducted.
In this author’s experience, since the nature of nursing
problems do not always fit the structure of a randomly controlled trial,
evidence in one or a series of studies is evaluated and considered for their
scientific soundness and clinical significance.
Polit
and Beck (2004) recommend eight strategies for promoting the use of research
findings in current practice.
Researchers should collaborate with staff nurses
to: identify current clinical problems, use rigorous designs, replicate
findings, write clear research reports and share the information, report
findings that are conducive to meta analysis, present clinical implications of
the research, disseminate findings energetically in multiple media (journals,
conferences), and finally, prepare integrative and critical research reviews
and make them available to busy practicing nurses.
Polit
and Beck (2004) also identify nursing and organizational barriers to the
utilization of evidence by practicing nurses. Bedside nurses may not be
prepared to critically appraise the evidence.
Nurses may not only lack the
motivation to make changes, but be resistant to making changes that impact
their comfortable practice. For organizations, administrators can foster a
climate conducive to innovation.
They can offer emotional, moral, and
instrumental support for innovation, and can reward nurses for innovative and
evidence based practice at the bedside as well as support organizational initiatives.