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Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 2

Evidence-Based Nursing Practice: Fundamentals


Research Utilization Versus Evidence-Based Practice

• Research utilization (RU)

– The use of study findings in a practical application unrelated to the original research

• Evidence-based practice (EBP)

– Basing clinical decisions on best possible evidence, typically high-quality research


Types of Research Utilization

• Instrumental (direct) utilization

• Conceptual (indirect) utilization

• Persuasive utilization


History of RU in Nursing Practice• Studies identified knowledge–practice gaps

(e.g., Ketefian, 1975).

• RU projects sought to address the gap (1970s and 1980s):

– e.g., the Conduct and Utilization of Research in Nursing (CURN) project

• RU efforts began to be superceded by call for EBP, 1990s


Key proponents of the EBP• Archie Cochrane

– Efforts led to development of Cochrane Center in Oxford and the Cochrane Collaboration

– Proposed an evidence hierarchy for weighing evidence

• David Sackett

– EBP pioneer at McMaster Medical School


Question

Staff nurses are proposing to their facility’s administration a change in a nursing protocol for skin care, based on research findings. This is an example of which type of research utilization?

a. Instrumental

b. Conceptual

c. Direct

d. Persuasive


Answer

c. Persuasive

– Persuasive utilization involves the use of findings to persuade others (typically those in decision-making positions) to make changes in policies or practices relevant to nursing care.


Evidence Hierarchies

• Involve ranking evidence sources according to the strength of evidence they provide

• Typically, hierarchies rank evidence relating to the effectiveness of health care interventions.

• Evidence hierarchies are not meaningful for certain types of questions (e.g., about meaning and process).


Example of an Evidence Hierarchy• Levels of evidence (from strongest to weakest):

– I. Systematic reviews of RCTs

– II. Individual RCTs

– III. Systematic reviews of non-RCTs (correlational)

– IV. Individual correlational studies

– V. Systematic reviews of descriptive studies

– VI. Individual descriptive studies

– VII. Opinions of respected authorities and expert committees


Barriers to RU and EBP in Nursing

• Research-related barriers

– e.g., scarcity of published replications

• Nurse-related barriers

– e.g., inadequate skills in locating and appraising evidence

• Organizational barriers

– e.g., lack of financial support and staff release time for EBP


Question

Is the following statement True or False?

• The strongest level of evidence is obtained from individual correlational studies.


Answer

• False

– The strongest level of evidence is obtained from systematic reviews of randomized clinical trials (RCTs).


Key Resources for RU/EBP• Systematic reviews that integrate evidence

about a topic in a rigorous, systematic way

• Traditional narrative reviews are being replaced by:

– Meta-analyses that integrate findings across quantitative studies statistically

– Meta-syntheses that integrate and amplify findings across qualitative studies


Key Resources for RU/EBP (cont.)• Other preappraised evidence, e.g.,

– Clinical practice guidelines

– Synopses of studies in EBP journals

– Critically appraised topics (CATs)

• Models and theories for EBP or RU


Models for Evidence-Based Nursing Practice

• Dozens of models exist

• Three widely-referenced models:

– The Stetler Model of research utilization to promote evidence-based practice

– The IOWA Model of evidence-based practice to promote quality care

– Rogers’ Diffusion of Innovations Theory


EBP in Individual Nursing Practice

• Nurses are called upon to make decisions or give advice daily.

• Many clinical scenarios provide opportunity for EBP, e.g.,

– Is there a reliable assessment tool for early detection of foot complications in patients with end-stage renal disease?

– Are there ways to reduce anxieties of children undergoing allergy scratch tests?


Question


• Meta-analyses use statistics to integrate findings across quantitative studies.


Answer

• True

– Statistics are involved with meta-analyses to integrate findings across quantitative studies. Meta-syntheses integrate and amplify findings across qualitative studies.


Steps in Individual EBP Efforts

1. Ask questions that are answerable with research evidence.

2. Search for and assemble evidence.

3. Appraise and synthesize evidence.

4. Integrate evidence with other sources.

5. Assess effectiveness of decision or advice.


Asking Well-Worded Clinical Questions

• Components for quantitative evidence

– Population

– Intervention (exposure, issue)

– Comparison*

– Outcome

– Time*

*Not always specified


Asking Well-Worded Clinical Questions (cont.)

• Components for qualitative evidence

– Population

– Situation (conditions, experiences, circumstances of interest)


Templates for Clinical Questions

• Templates can greatly facilitate wording of questions, e.g., an intervention question:

In _____ (population), what is the effect of ________ (intervention), in comparison to _______ (comparison), on __________(outcome)?


QuestionWhich of the following would be the first step

when personally investigating evidence for a specific nursing care problem?

a. Search for possible evidence.

b. Ask answerable clinical questions.

c. Assess effectiveness of decision.

d. Assemble available evidence.


Answer

b. Ask answerable questions.

– The first step in individual EBP efforts is to ask questions that are answerable with research evidence. Searching for, assembling, appraising, and synthesizing would occur next in that order. Assessing effectiveness is the last step.


Appraising the Evidence: Key Questions

• What is the quality of the evidence?

• What is the magnitude of effects?

• How precise are estimates of effects?

• Is there evidence of side effects?

• What are the costs?

• Is there relevance to my clinical situation?


EBP in an Organizational Context

• Select a topic or problem

– Knowledge-focused triggers

Begins with an innovation or research finding (e.g., might emerge in a journal club)

– Problem-focused triggers

Begins with a perplexing or troubling clinical situation


EBP in an Organizational Context (cont.)

• Assemble and evaluate evidence

– Evidence-based clinical practice guidelines invaluable, if available

– Guidelines must be appraised (e.g., using AGREE instrument)


EBP in an Organizational Context (cont.)

• Assess implementation potential

– Transferability

– Feasibility

– Cost–benefit ratio

• Develop evidence-based protocols

• Implement and evaluate the innovation


Question


• Clinical practice guidelines put evidence into a usable form.


Answer

• True

– Clinical practice guidelines give specific recommendations for evidence-based decision-making, putting evidence into a usable form for implementation.


Strategies for Nurses to Play a Role in RU/EBP

• Read widely and critically.

• Attend professional conferences.

• Learn to expect evidence that a procedure is effective.

• Become involved in a journal club.

• Pursue and participate in RU/EBP projects.


End of Presentation

chapter002

Documents

utilization of research

strength of evidence

strongest level of evidence

best possible evidence

ranking evidence sources

research findings

nursing practice studies

nursing care