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Chapter 1 Using Evidence in Nursing Practice OBJECTIVES

Mastery of content in this chapter will enable the nurse to: Define the key terms listed. Discuss the benefits of evidence-based practice. Describe the six steps of evidence-based practice. Develop a PICO question. Explain the levels of evidence in the literature. Discuss elements to review when critiquing the scientific literature. Discuss ways to apply evidence in practice.
2

1.1

1.2

KEY TERMS
Bias Clinical guidelines Evidence-based practice (EBP) Hypothesis Peer reviewed PICO question Variable

Cathy works on a medical oncology floor, a unit where patients undergo extensive chemotherapy and radiation for leukemia, lymphoma, and other serious forms of cancer. The age of patients ranges from young to very old adults. Because of their chemotherapy, many patients experience drops in their platelet counts and clotting factors, increasing their risk for bleeding. Cathy recently cared for a 42-yearClinical Nursing Skills & Techniques, 7th Edition Page 1 of 21

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platelet counts and clotting factors, increasing their risk for bleeding. Cathy recently cared for a 42-yearold woman, who fell while trying to get to the bathroom and hit her head against the bed frame, resulting in a serious intracranial bleed. Cathy discusses the situation with two nurse colleagues and asks, How can we reduce the number of falls and injuries in our patients on the oncology unit? The nurse specialist for the unit tells Cathy, I heard about an approach to fall prevention on one of the surgical floors; it involves hourly rounding. Let's ask this question, Will the incidence of and injuries related to falls decline following use of hourly rounding compared with our current fall prevention protocol?' Feeling frustrated that their existing fall prevention protocol was not effective in reducing falls, the group agreed that the question was the right one to search in the literature. The nurse specialist conducted a literature search on the basis of the question and identified four articles pertaining to risk factors for falls and outcomes from hourly rounding. During their unit practice committee meeting, Cathy and her colleagues reviewed the articles carefully and chose three that offered good evidence for a way to implement hourly rounding and identify risk for and prevent falls. The staff noted that one of the articles recommended hourly rounding during daytime hours and rounding every 2 hours during evening and night hours. Another article summarized fall risks for patients in an acute care hospital and highlighted factors such as medications (e.g., antihistamines, sedatives, analgesics, and antiemetics), weakness, altered mental status, history of falls, and toileting needs to include in a nursing assessment. Based on their experience and a review of their unit fall index reports, the staff knew that patients on the oncology unit commonly experienced falls during all hours of the day. The unit practice committee recommended incorporating a new hourly rounds program along with focused nursing assessments for key fall risk factors. Registered nurses (RNs) would begin to round on patients on all even hours and conduct focused assessments of fall risk factors such as weakness, pain, or the need to go to the bathroom. Nurses would carefully monitor patients receiving antihistamines before blood transfusions. Nursing assistive personnel (NAP) would round on odd hours and do follow-up observations to be sure patients had toileting needs met, were comfortable, and had no further needs. Each hour the nursing staff would inform patients that someone from the nursing team would return in an hour for another check. The unit practice committee planned a staff orientation and set a date for the start of the hourly rounding protocol. Three months after implementing the rounding protocol, the medical oncology unit was cautiously optimistic. Their average fall index dropped from 5.1 to 3.7, and the injury rate also dropped. Another benefit was the decline in patients' use of call lights, which was attributed to patients knowing their nurses would visit frequently. All nursing staff on the unit were enthused by the change and agreed that hourly rounding needed to be a routine part of their unit culture. The staff was also able to see that the protocol improved patient outcomes and gave them more time to coordinate care because there were fewer distractions from patient calls. Six months after starting the new protocol, the fall index continued to remain low. An added outcome was a significant increase in patient satisfaction. Cathy submitted

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to remain low. An added outcome was a significant increase in patient satisfaction. Cathy submitted their protocol for an abstract in the hospital's Nursing Research Day. Cathy's abstract, Using Evidence to Prevent Falls was well accepted by her peers and became a standard for other nursing units in the hospital.

This clinical case study highlights the value in finding current and relevant information to make informed changes in the way you care for patients. The evidence from research studies and the opinions of oncology nurse experts provided a basis for Cathy and her colleagues to make evidence-based changes to their fall prevention protocol. The use of evidence in practice enables clinicians like Cathy to provide the highest quality of care to their patients and families. So, how does a nurse routinely use evidence in practice? It takes a new philosophy of thinking. Evidence-based practice (EBP) requires nurses to always think about their practice, raise good clinical questions, search for the evidence that pertains to their questions, apply relevant evidence in practice changes, and evaluate the outcomes.
1.3

A CASE FOR EVIDENCE

Evidence-based practice is a guide for making accurate, timely, and appropriate clinical decisions. In this textbook, you will learn that use of evidence in nursing procedures or skills provides scientific guidelines for how to perform skills more effectively and to improve patient outcomes. It is very important to translate best evidence into best practices at the patient's bedside. For example, using a sliding board to transfer a patient from bed to stretcher instead of lifting, and using the research-based Braden scale to routinely assess a patient's risk for skin breakdown are examples of using evidence at the bedside. Evidence-based practice is a problem-solving approach to clinical practice that integrates the conscientious use of best evidence along with a clinician's expertise and patient preferences and values in making decisions about patient care (Melnyk and Fineout-Overholt, 2005; Sackett and others, 2000). As a professional nurse, you need to stay informed and be aware of the most current evidence. Typically, new students will diligently read their textbooks and the assigned scientific articles. A good textbook incorporates current evidence into the practice guidelines and nursing skills it describes. However, a textbook relies on the scientific literature; thus portions of a book often become outdated by the time it is published. Articles from nursing and the health care literature are available on almost any topic involving nursing practice. New research is reported every day. Although the scientific basis of nursing practice has grown, some practices are still not research based (based on findings from well-designed research studies), because findings are inconclusive or because researchers have not yet studied the practices (Titler and others, 2001). For example, in the past nurses applied antibiotic ointment to intravenous (IV) sites, assuming this would reduce the incidence of infection at the site. However, research showed that topical antibiotics offer no benefit, and thus the current standard of care is to simply apply a sterile transparent or gauze dressing to an intravenous site (Infusion Nurses

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care is to simply apply a sterile transparent or gauze dressing to an intravenous site (Infusion Nurses Society [INS], 2006). The challenge is to obtain the very best, most current information at the right time, when you need it for patient care. The best evidence comes from well-designed, systematically conducted research studies, found in scientific journals. Unfortunately, much of that evidence does not reach the bedside. Many health care settings do not have a process to help staff adopt new evidence in practice. Nurses in practice settings, unlike educational settings, do not have easy access to databases for scientific literature. Instead, nurses often care for patients on the basis of tradition or convenience. Because there are obstacles to research-based practice in clinical settings, it is important for administrators to provide a supportive environment and adequate facilitation of change (Rycroft-Malone and others, 2004). There are sources of evidence that do not originate from research. This includes quality improvement and risk management data; infection control data, retrospective or concurrent chart reviews; and clinicians' expertise. Although nonresearch-based evidence is often very valuable, it is important that you learn to not rely on it alone. Research-based evidence is more likely to be timely and relevant. When you face a clinical problem, always seek the best source of evidence that helps you find the best solution in caring for patients. Even when you use the best evidence available, application and outcomes will differ based on your patients' values, preferences, concerns, and/or expectations (Oncology Nursing Society [ONS], 2005). As a nurse, you will develop critical thinking skills to determine whether evidence is relevant and appropriate to your patients and to a clinical situation. For example, a single research article suggests that therapeutic massage administered 60 minutes after an analgesic will enhance pain relief. However, if you care for a patient from a culture in which touch is a taboo, the use of massage is inappropriate. Using your clinical expertise and considering patients' cultures, values, and preferences ensure that you will apply the evidence available in practice both ethically and appropriately. Evidence-based practice requires good nursing judgment; it is not finding research evidence and blindly applying it.
1.4

STEPS OF EVIDENCE-BASED PRACTICE

Evidence-based practice is a systematic approach to rational decision making that facilitates achievement of best practices (Newhouse and others, 2005). Using a step-by-step approach ensures that you will obtain the strongest available evidence to apply in patient care. There are six steps of EBP (Melnyk and Fineout-Overholt, 2005): 1 Ask a clinical question. 2 Collect the most-relevant and best evidence.

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2 Collect the most-relevant and best evidence. 3 Critically appraise the evidence you gather.

4 Apply or integrate evidence along with your clinical expertise, patient preferences, and values in making a practice decision or change. 5 Evaluate the practice decision or change. 6 Communicate your results.
1.4.1

Ask the Clinical Question

Always think about your practice when caring for patients. Question what does not make sense to you, and question what you think needs clarification. As demonstrated in the previous case study, think about a problem or area of interest that is time consuming, costly, or not logical (Callister and others, 2005). Often The Joint Commission standards (e.g., the annual patient safety goals) offer questions to pose about your patients. If you keep a clinical journal, your entries are a rich source for clinical questions. Titler and others (2001) suggest using problem- and knowledge-focused triggers to ask clinical questions. A problem-focused trigger is one you face while caring for a patient or a trend you see on a nursing unit. For example, a problem-focused trigger might arise while caring for an unconscious patient: What is the best antiinfective solution to use when giving oral care to this patient? Examples of problem-focused trends include the increase in number of pressure ulcers or incidence of urinary tract infections on a nursing unit. Such trends should lead you to ask, How do I reduce pressure ulcers on my unit? or What is the best way to prevent urinary tract infections in catheterized patients? A knowledge-focused trigger is a question regarding new information about a topic. For example, What is the current evidence to reduce phlebitis in peripheral intravenous catheters? Important sources of this type of information are standards and practice guidelines available from national agencies such as the Agency for Healthcare Research and Quality (AHRQ), the Infusion Nurses Society (INS), and the American Association of Critical Care Nurses (AACN). When you ask a question and search the scientific literature, you do not want to read 100 articles in order to find the handful that are most helpful. You want to be able to read the best 4 to 6 articles that specifically address your practice question. Melnyk and Fineout-Overholt (2005) suggest using a PICO format to state your question. Box 1-1 summarizes the four elements of a PICO question. The more focused a question you ask, the easier it is to search for evidence in the scientific literature. Examples of well-designed PICO questions follow: In abdominal surgery patients (P), is epidural analgesia (I) compared with patientcontrolled analgesia (C) more effective in reducing pain severity (O)? Is an adult patient's (P) blood

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controlled analgesia (C) more effective in reducing pain severity (O)? Is an adult patient's (P) blood pressure more accurate (O) while measuring with the patient's legs crossed (I) versus the patient's feet flat on the floor (C)? A well-designed PICO question does not have to include all four elements, nor does it have to follow the PICO sequence. However, the goal is to ask a question that contains as many of the PICO elements as possible in a logically framed question. Inappropriately formed questions (e.g., What is the best way to reduce pressure ulcers? What is the best way to measure blood pressure?) lead to many irrelevant articles in a literature search, making it difficult to find the best evidence. A clearly stated PICO question identifies knowledge gaps within a clinical situation. When you form well thought-out questions, the type of evidence you lack for clinical practice becomes more clear. Examples of different knowledge gaps include the following (ONS, 2005): Diagnosis: Questions about the selection and interpretation of diagnostic tests. Example: Does the use of a disposable oral thermometer compared with an electronic oral thermometer measure body temperature accurately in a patient with an endotracheal tube? Prognosis: Questions about a patient's likely clinical outcome. Example: Is there a difference in the incidence of deep vein thrombosis in surgical patients wearing sequential compression stockings compared to those who perform range-of-motion (ROM) exercises? Therapy: Questions about the selection of the most beneficial treatments. Example: What bowel regimen is most effective in relieving constipation caused by the administration of opioid therapy in patients with chronic pain? Prevention: Questions about screening and prevention methods to reduce the risk of disease. Example: Does performance of a prostate specific antigen (PSA) test in an older adult who is asymptomatic of prostate disease decrease his risk for mortality from prostate cancer? Education: Questions about best teaching strategies for colleagues, patients, or family members. Example: Is the use of visual aids compared with low-literacy teaching booklets more effective to educate low-literacy adults about therapeutic diets? Meaning: Questions that seek understanding of a phenomenon. Example: How do patients with cervical cancer perceive their quality of life?
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with cervical cancer perceive their quality of life?

1.4.1.1

BOX 1-1 Developing a PICO Question

P= I= Patient population of interest Identify your patients by age, gender, ethnicity, disease, or health problem Intervention of interest What is the intervention you think is worthwhile to use in practice (e.g., a treatment, diagnostic test, prognostic factor)? C= O= Comparison of interest What is the usual standard of care or current intervention you use now in practice? Outcome What result do you wish to achieve or observe as a result of an intervention (e.g., change in patient's behavior, physical finding, change in patient's perception)?

Remember, do not be satisfied with clinical routines. Always question and use critical thinking to consider better ways to provide patient care.
1.4.2

Collect the Best Evidence

Once you have a clear and concise PICO question, you are ready to search for evidence. Evidence exists in a variety of sources: agency policy and procedure manuals, quality improvement data, existing clinical practice guidelines, or computerized bibliographical databases. Do not hesitate to ask for help to find appropriate evidence. Your faculty is a key resource. When you are assigned to a health care setting, consider using experts such as advanced practice nurses, staff educators, risk managers, and infection control nurses. When searching the scientific literature for evidence, seek the assistance of a medical librarian when possible. A medical librarian knows the relevant databases (Box 1-2). A database is an electronic library of published scientific studies, including peer-reviewed research. A peer-reviewed article is one that has been evaluated by a panel of experts familiar with the article's topic or subject matter. The librarian helps translate the elements of your PICO question into the language or key words that will yield the best evidence search. For example, in the PICO question Does the use of computerized home instruction compared with a group class improve surgical patients' knowledge of postoperative activities?, the key words are surgical patient, computerized instruction, group class, knowledge, and postoperative activities. When conducting a search, it is necessary to enter and manipulate the different key words until you get the combination that gives you the articles you want to read about your question. When you enter a key word to search a database, be prepared for some confusion with the evidence you obtain. The vocabulary within published articles is often vague. The word you select sometimes has one meaning to one author and a very different meaning

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vague. The word you select sometimes has one meaning to one author and a very different meaning to another. A medical librarian helps you learn how to choose alternative words or terms that identify your PICO question and to obtain relevant evidence. In Fig. 1-1 we demonstrate the difference in the results of literature searches on two different questions. Question A is more general and not in a PICO format. Question B is a focused question using a PICO format. Note the difference in the number of articles in the last step of the search. Which group of articles would you prefer to review?
1.4.2.1

BOX 1-2 Searchable Scientific Literature Databases and Sources

CINAHL Cumulative Index of Nursing and Allied Health Literature. Includes studies in nursing, allied health, and biomedicine. http://www.cinahl.com MEDLINE Includes studies in medicine, nursing, dentistry, psychiatry, veterinary medicine, and allied health. http://www.ncbi.nim.nih.gov EMBASE Psyc INFO Cochrane Database of Systematic Reviews National Guidelines Clearinghouse PubMed Biomedical and pharmaceutical studies. http://www.embase.com Psychology and related health care disciplines. http://www.apa.org/psycinfo Full text of regularly updated systematic reviews prepared by the Cochrane Collaboration. Includes completed reviews and protocols. http://www.cochrane.org/reviews Repository for structured abstracts (summaries) about clinical guidelines and their development. Also includes condensed version of guideline for viewing. http://www.guideline.gov Health science library at the National Library of Medicine. Offers free access to journal articles. http://www.nlm.nih.gov On-Line Journal of Electronic journal containing articles that provide a synthesis of research and Knowledge Synthesis for an annotated bibliography for selected references. Nursing http://nursingsociety.org/publications/journals

MEDLINE, CINAHL, and PubMed are among the most comprehensive databases and represent the scientific knowledge base of health care (Melnyk and Fineout-Overholt, 2005). Among the many databases, some are available through vendors at a cost, some are free of charge, and some offer both options. Nursing students and nurses who work in academic medical centers usually have access to an institutional subscription through a vendor. One of the more common vendors is OVID,
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access to an institutional subscription through a vendor. One of the more common vendors is OVID, which offers several different databases. There are also databases available free on the Internet, such as PubMed and the Cochrane Library. The Cochrane Database of Systematic Reviews is a valuable source of synthesized evidence (i.e., preappraised evidence). The Cochrane database includes the full text of regularly updated systematic reviews and protocols for reviews currently happening. The National Guidelines Clearinghouse (NGC) is a database supported by the Agency for Healthcare Research and Quality (AHRQ). It contains clinical guidelines, systematically developed statements about a plan of care for a specific set of clinical circumstances involving a specific patient population. The NGC is a valuable source when you want to develop a plan of care for a patient.

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FIG. 1-1 Results of two literature searches on Mosby's Nursing Index. A, A search for the question What type of pain control reduces pain in patients who have had abdominal surgery? B, A search for the PICO question Does the use of epidural analgesia reduce pain severity compared with patientcontrolled analgesia in patients who have had abdominal surgery?

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The pyramid in Fig. 1-2 represents a hierarchy of available evidence. At this point in your nursing career, you are probably not an expert on all aspects of the types of studies conducted. But you can learn enough about the types of studies to help you know which ones have the best scientific evidence. Table 1-1, p. 7, describes types of studies in the evidence hierarchy, beginning with the study at the top of the hierarchy, a systematic review. If your PICO question leads you to a systematic review, celebrate! A systematic review is the perfect answer to a PICO question. Basically a researcher has asked the same PICO question you have asked and then examined all of the well-designed randomized controlled trials (RCTs) that ask the same question. A systematic review explains if the evidence that you are searching for exists and whether there is good cause to change practice. In the Cochrane Library, all entries include information on systematic reviews. Individual RCTs are the gold standard for research (Titler and others, 2001). An RCT establishes cause and effect and is excellent for testing therapies. Historically there have been few RCTs conducted in nursing. The nature of nursing causes researchers to ask questions that are not always answered best by an RCT. Nurses care for patients' responses to disease or health problems. For example, we assist patients with problems such as knowledge deficits, symptom management, and coping with psychological distress. An RCT cannot easily be designed to learn how patients experience health problems. Often descriptive studies or qualitative approaches are more helpful. What is most important is to have the research question match the appropriate research method. The use of clinical experts is at the bottom of the evidence pyramid, but do not consider clinical experts a poor source of evidence. Expert clinicians frequently use evidence as they build their own practice, and they are rich sources of information for clinical problems.

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practice, and they are rich sources of information for clinical problems.

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FIG 1-2 The evidence pyramid.

Modified from Guyatt G, Rennie D: User's guides to the medical literature. American Medical Association: AMA Press, 2002. Harris RP, and others: Current methods of the U.S. Preventive Services Task Force: A review of the process. Am J Prev Med 20:21-35, 2001.

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1.4.3

Critique the Evidence

Perhaps the most difficult step in the EBP process is critiquing or analyzing the evidence. The critiquing of evidence involves its evaluation, which includes determining the value, feasibility, and utility of evidence for making a practice change (ONS, 2005). When you critique evidence, you first evaluate the scientific merit and clinical applicability of each study's findings. Then with a group of studies and expert opinion, you determine what findings have a strong enough basis for use in practice. After critiquing the evidence, ask the following questions: Do the articles together offer evidence to answer my PICO question? Do the articles show the evidence is true and reliable? Will I be able to use the evidence in practice? It takes time to acquire the skills to critique evidence like an expert. When you read an article from the literature, do not let the statistics or technical wording cause you to put the article down and walk away. Know the elements of an article, and use a careful approach when reviewing each one. Evidence-based articles include the following elements: Abstract: A brief summary of the article that quickly tells you if the article is research or clinically based. An abstract summarizes the purpose of the study or clinical topic, the major themes or findings, and the implications for nursing practice. Introduction: Contains information about the article's purpose and the importance of the topic for the audience who reads the article. It usually contains brief supporting evidence as to why the topic is important from the author's point of view. Together, the abstract and introduction help determine if you want to continue to read the entire article. You will know if the topic of the article is similar to your PICO question or related closely enough to provide you useful information. Continue to read the next elements of the article: Literature review or background: A good author offers a detailed background of the level of scientific or clinical information that exists about the topic of the article. Therefore it offers an argument about what led the author to conduct a study or report on a clinical topic. Perhaps the article itself does not address your PICO question the way you desire, but possibly leads you to other more useful articles. The literature review of a research article usually gives you a good idea of how past research led to the researcher's question. Manuscript narrative: The middle section or narrative of a manuscript differs according to the type of evidence-based article, either clinical or research (Melnyk and Fineout-Overholt, 2005). A clinical article describes a clinical topic, which often includes a description of a patient population, the nature of a certain disease or health problem, how it affects patients, and the appropriate nursing therapies. Clinical articles often describe how to use a therapy or

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and the appropriate nursing therapies. Clinical articles often describe how to use a therapy or new technology. A research article describes the conduct of a research study, including its purpose, how the study was designed, and the results. A research article's narrative contains several standard subsections: Purpose statement: Explains the focus or intent of a study. It identifies what concepts will be researched. This includes research questions or hypotheses, predictions made about the relationship or difference between study variables (a concept, characteristic, or trait that varies within subjects).

Methods or design: Explains how a research study is organized and conducted in order to answer the research question or to test the hypothesis. This is where you learn the type of study (e.g., RCT, case control, or qualitative study). You also learn how many subjects or persons are in a study. In health care studies, subjects sometimes include patients, family members, or health care staff. The language in the methods section is sometimes confusing if it explains details about how the researcher designs the study to minimize bias so as to obtain the most accurate results possible. Use your faculty member as a resource to help interpret this section. Results or conclusions: Clinical and research articles have a summary section. In a clinical article, the author explains the clinical implications for the topic presented. In a research article, the author details the results of the study and explains whether a hypothesis is correct or how a research question is answered. A qualitative study presents a thorough summary of the descriptive themes and ideas that arise from the researcher's analysis of data. A quantitative study includes a statistical analysis. It is important to become familiar with common statistical terms, especially in clinical trials, to know if a tested intervention had a significant effect or if the effect size was large enough to adopt in practice. When reading the statistical analysis, ask these questions: Does the researcher describe the results? Were the results significant? What was the size of the effect of the intervention? What was the sample size? A good author will discuss any limitations to a study in the results section. The information on limitations helps you to decide if you want to use the evidence with your patients. Clinical implications: A research article includes a section that explains if the findings from the study have clinical implications. The researcher explains how to apply findings in a practice setting for the type of subjects studied. After you critique each article for your PICO question, synthesize or combine the findings from all of the articles to determine the state of the evidence. Use critical thinking to consider the scientific rigor or accurateness of the evidence and how well it answers your area of interest. Scientific rigor is
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rigor or accurateness of the evidence and how well it answers your area of interest. Scientific rigor is the extent to which a study's findings are valid, reliable, and relevant to your patient population of interest. Consider the evidence in light of your patients' concerns and preferences. Your review of articles offers a snapshot conclusion based on combined evidence about one focused topical area. As a clinician, judge whether to use the evidence for a particular patient or group of patients who usually have complex medical histories and patterns of responses (Melnyk and Fineout-Overholt, 2005). Ethically it is important to consider evidence that will benefit patients and do no harm. Decide if the evidence is relevant, easily applicable in your setting of practice, and has the potential for improving patient outcomes.

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for improving patient outcomes.

TABLE 1-1 Types of Studies in the Evidence Hierarchy

Study Type Systematic review or meta-analysis Description A panel of experts reviews the evidence from randomized controlled trials about a specific clinical question and summarizes the state of the science. In a metaanalysis, there is the addition of a statistical analysis that combines data from all studies. A researcher tests an intervention against the usual standard of care. Participants are randomly assigned to either a control group (receives standard care) or a treatment group (receives the experimental intervention), with both measured on the same outcomes to see if there is a difference. Researchers study one group of subjects with a certain condition (e.g., obesity) at the same time as another group of subjects who do not have the condition to determine if there is an association between the condition and predictor variables (e.g., exercise pattern, family history, history of depression). Study that describes the concepts under study. It sometimes examines the prevalence, magnitude, and/or characteristics of a concept. Studies examine individuals' experiences with health problems or life experiences and the contexts in which the experiences occur. Example Nine studies examined the use of continuous epidural analgesia (CEA) compared with intravenous opioid patient-controlled analgesia (PCA) in relieving post-operative abdominal pain. The review revealed that CEA is superior in relieving pain for up to 72 hours (Werawatganon and Charuluxanum, 2004). Researchers randomly assigned 107 critical care patients to receive intermittent nasogastric feedings (treatment group) or continuous feedings (control group). Patients in the intermittent feeding group had a higher total intake at day 7, earlier extubation, and a lower risk of aspiration pneumonia (Chen and others, 2006). Researchers from Singapore compared 61 patients with known ocular keratitis with 188 population-based and 178 hospitalized patients to determine what contact lens cleaning methods contributed to keratitis. The use of a specific contact lens cleaning solution was found to increase the risk for keratitis (Saw and others, 2007). Researchers explored nurses' and health care providers' perceptions of infection control practices in relation to management of infectious disease (Watkins and others, 2006). Researchers asked 392 nurses to discuss a care episode from their practice. Cases describing patients with cancer involved nurses' use of powerful emotive language. The influence of patients' cancer experience affects nurses personally and professionally (Kendall, 2007). Article reviews use of quality

Randomized controlled trial

Case control study

Descriptive study

Qualitative study

Quality improvement

Data collected within a health care

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professionally (Kendall, 2007).

Quality improvement data, risk management information

Data collected within a health care agency offers important trending information about clinical conditions and problems. Staff in the agency review the data periodically to identify problem areas and to then seek solutions. Accessing clinical experts on a nursing unit is an excellent way to learn about current evidence. Clinical experts often write clinical articles on topics that require application of evidence in the literature.

Article reviews use of quality improvement (QI) process in a nursing home setting where staff adopted best practices for pressure ulcer care for residents (Berlowitz and Frantz, 2007).

Clinical experts

Clinical article describes an evidencebased practice project, in which a team of nurses applied evidence from the literature to change their hospital's approach to intravenous (IV) site care and IV catheter stabilization (Winfield and others, 2007).

1.4.4

Apply the Evidence

Once you decide that the evidence is strong and applicable to your patients and clinical situation, incorporate the recommended evidence into practice. One way you may choose to use evidence is by applying the evidence in your care for a patient. For example, perhaps you find evidence for a new noninvasive pain therapy (e.g., music therapy). Use the article reference as the rationale for the intervention in your written care plan. Then try the intervention with a patient who is receptive to the therapy. Another option, particularly if you are working with a group of other nurses or health care providers, is to apply evidence in the form of new teaching tools, clinical practice guidelines, policies and procedures, and new assessment or documentation tools. Typically members of a nursing staff will define a clinical problem. After reviewing and critiquing the literature, the staff integrates the available evidence into a process that all health care providers can use. For example, it is common for hospitals to routinely review the evidence as part of their annual nursing policy and procedure review process. As in the case of this textbook, current evidence provides the foundation for routine nursing procedures. When you propose to change a procedure or policy on the basis of evidence, be sure to consider and review if your place of work is able to adopt the change. For example, evidence shows that toothbrushes are more effective than foam applicators in cleaning teeth and gums (Pearson and Hutton, 2002). Is your organization willing to purchase the toothbrushes? What planning is necessary to familiarize staff to any new hygiene guidelines? Any time you change a nursing procedure or adopt a new protocol, you will need to prepare all staff and communicate the change to your organization.

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your organization.

As a nursing student integrating evidence, your focus will begin with searching for and applying the best evidence to improve the care you directly provide your patients. The evidence available within nursing gives you an almost unlimited access to innovative and effective nursing interventions. Using an evidence-based practice approach will improve your skills and knowledge as a nurse and improve your patients' outcomes.
1.4.5

Evaluate the Practice Decision or Change

After applying evidence in your practice, your next step is to evaluate the effect. You do this by measuring outcomes; outcome measurement will tell you how an intervention worked. How effective was the clinical decision for your patient or practice setting? Sometimes your evaluation is as simple as determining if the expected outcomes you set for an intervention are met. For example, after the use of a new transparent IV dressing, does the IV dislodge or does the patient develop the complication of phlebitis? When using a new approach to preoperative teaching, does the patient learn what to expect after surgery? When an evidence-based practice change occurs on a larger scale, an evaluation is more formal. For example, after reviewing evidence about factors contributing to pressure ulcers, a nursing unit adopts a new skin care protocol. To evaluate the protocol, the nurses track the incidence of pressure ulcers over a course of time (e.g., 6 months to a year). In addition, the nurses collect data to describe both the patients who develop ulcers and those who do not. This comparative information is valuable in determining the effects of the protocol and whether modifications are necessary.

1.4.6

Communicating a Practice Change

After applying evidence, it is important to communicate the change in practice as well as the results to nursing and other health care colleagues. This is true if the results are successful or unsuccessful. There are many ways to communicate the outcomes of evidence-based practice: talking with a colleague, sharing results in staff meetings, presenting in workshops or seminars, submitting an abstract for a poster presentation, and publishing an article. As a professional, you are responsible for communicating important information about nursing practice. Sharing evidence and the effects of any practice change motivates others and gets them excited about practice improvements. When you have successfully adopted an evidenced-based practice way of thinking, it becomes very natural to talk about available evidence and to continue seeking solutions for problems in patient care.

1.5

IMPACT OF EVIDENCE-BASED PRACTICE ON NURSING

Numerous factors within the health care environment have created the initiatives for evidence-based practice. Patient safety and medical errors, the economics of health care, and variability in how disease

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practice. Patient safety and medical errors, the economics of health care, and variability in how disease conditions are treated are just some of the factors that have led government and private groups to support evidence-based practice. The use of evidence-based practice has the potential to improve the quality of care nurses provide, patient outcomes, and clinicians' satisfaction with their practice. This chapter provides a brief introduction to evidence-based practice. Of all of the initiatives introduced in health care, evidence-based practice may be the most important. With the rapid, ongoing expansion of research knowledge in health care, it is essential to remain accountable by applying evidence in patient care. When evidence exists on ways to improve patient outcomes, it becomes important for that evidence to reach the bedside. Your patients expect nursing professionals to be informed and to use the safest and most appropriate interventions. Use of evidence enhances nursing, improving patients' perceptions of excellent nursing care.

1.6

CRITICAL THINKING EXERCISES

Maria Gonzalez is a 45-year-old Hispanic woman who is admitted to the hospital with ulcerative colitis, which she has had for 2 years. The disease is an inflammation and ulceration of the colon. As a result, Maria has a recurrence of bloody diarrhea, abdominal cramping, and a fever. During her hospital stay Maria received intravenous fluids, corticosteroids, and antiinfective drugs. Jeanne is the nurse assigned to coordinate Maria's discharge home. Jeanne is concerned about Maria's diet at home and wonders how it might affect her disease, particularly the frequency of diarrhea. Jeanne learns that Maria eats a diet with sources of high carbohydrates. In consultation with the dietitian Jeanne asks if a lowcarbohydrate diet might be best for Maria. The dietitian suggests they do a literature search to see what the most current evidence suggests. 1 Given this clinical case study, write the PICO question that is the basis of Jeanne's inquiry. 2 The librarian helps Jeanne conduct a literature search. Among the articles located in the search is a systematic review. Explain why a systematic review is the best source of evidence. 3 One of the articles found by the librarian describes a study in which a researcher studied 45 patients with ulcerative colitis and 52 patients with normal intestinal function to determine if there is an association between frequency of diarrhea and ingestion of high protein intake. What type of study did this researcher conduct?
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protein intake. What type of study did this researcher conduct?

4 If Jeanne decides to educate Maria about changing her diet, what should she consider before applying the evidence that would be unique to Maria?
1.7

REVIEW QUESTIONS

1 Which statement best explains the goal of evidence-based practice? 1 Changes made in patient care are from suggestions in the literature. 2 It is based solely on current trends seen on the nursing unit. 3 It answers clinical questions by using appropriate, researched resources. 4 It makes changes in patient care after conferring with the patients' health care providers. 2 There are many steps of evidence-based practice. Select all that apply. 1 Ask a clinical question. 2 Obtain permission from the health care providers. 3 Communicate the findings. 4 Collect the most-relevant evidence. 5 Publish results of the project immediately. 6 Make certain the changes fit within the patients' culture. 3 A question focusing on the best solution to use to clean infected incisions would be what type of trigger? 1 Problem-focused 2 Knowledge-focused 3 Peer-focused 4 PICO-focused
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4 PICO-focused

4 Which question contains the primary components of a PICO question? 1 Are oral steroids or inhaled steroidal medications better for female adults with adult-onset asthma? 2 What steroid preparations are best for male teenagers with activity-induced asthma who play sports? 3 How can school-age asthmatic children be best controlled using steroidal preparations? 4 Do pulse oximetry readings or peak flows provide better monitoring of the effectiveness of inhaled steroids in asthmatic children between the ages of 7 and 9? 5 Which activity would require the most critical thinking? 1 Determining whether data are relevant for the situation 2 Counting the number of related articles to support the new interventions 3 Assessing patients to determine if they meet the study criteria 4 Designing the table that will be used to report the data
1.8

REFERENCES
DR Berlowitz, RN Frantz: Implementing best practices in pressure ulcer care, the role of continuous quality improvement. J Am Med Dir Assoc. 8(suppl 3), 2007, S37. LC Callister, et al.: Inquiry in baccalaureate nursing education: fostering evidence-based practice. J Nurs Educ. 44(2), 2005, 59. G Guyatt, D Rennie: In User's guides to the medical literature. 2002, AMA Press, (online). RP Harris, et al.: Current methods of the U.S. Preventive Services Task Force: a review of the process. Am J Prev Med. 20, 2001, 21. Infusion Nurses Society: Infusion nursing standards of practice. J Intraven Nurs. 29(suppl 1), 2006, S1. BM Melnyk, E Fineout-Overholt: In Evidence-based practice in nursing and healthcare: a guide to best practice. 2005, Lippincott Williams & Wilkins, Philadelphia.

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R Newhouse, et al.: Evidence-based practice: a practical approach to implementation. J Nurs Adm. 35(1), 2005, 35. Oncology Nursing Society: Evidence based practice resource areahttp:// www.onsopcontent.ons.org/toolkits/evidence/Definitions/index.shtml, accessed November 2005. DL Sackett, et al.: In Evidence-based medicine: how to practice and teach EBM. 2000, Churchill Livingstone, London.
1.9

RESEARCH REFERENCES
YC Chen, et al.: The effect of intermittent nasogastric feeding on preventing aspiration pneumonia in ventilated critically ill patients. J Nurs Res. 14(3), 2006, 167. S Kendall: Witnessing tragedy: nurses' perceptions of caring for patients with cancer. Int J Nurs Pract. 13(2), 2007, 111. LS Pearson, JL Hutton: A controlled trial to compare the ability of foam swabs and toothbrushes to remove dental plaque. J Adv Nurs. 39(5), 2002, 480. J Rycroft-Malone, et al.: An exploration of the factors that influence the implementation of evidence into practice. J Clin Nurs. 13, 2004, 313. SM Saw, et al.: Risk factors for contact lens related fusarium keratitis: a case control study in Singapore. Arch Ophthalmol. 125(5), 2007, 611. MG Titler, et al.: The Iowa Model of Evidence-Based Practice to Promote Quality Care. Crit Care Nurs Clin North Am. 13(4), 2001, 497. RE Watkins, et al.: Perceptions of infection control practices among health professionals. Contemp Nurse. 22(1), 2006, 109. T Werawatganon, S Charuluxanum: Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intra-abdominal surgery. The Cochrane Database Rev. 2005, 1. C Winfield, et al.: Evidence: the first word in safe I.V. practice. Am Nurse Today. 2(5), 2007, 31.

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