477140

Nursing Science QuarterlyBeyea and Slattery

NSQXXX10.1177/0894318413477140

Article
Nursing Science Quarterly
26(2) 152155

Historical Perspectives on
The Author(s) 2013
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Evidence-Based Nursing DOI: 10.1177/0894318413477140

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Suzanne C. Beyea, RN; PhD; FAAN1 and Mary Jo Slattery, RN; MS2

Abstract
The authors of this article offer a review and historical perspective on research utilization and evidence-based practice
in nursing. They present the evolution of research utilization to the more contemporary framework of evidence-based
nursing practice. The authors address the role of qualitative research in the context of evidence-based practice. Finally, some
approaches and resources for learning more about the fundamentals of evidence-based healthcare are provided.

Keywords
clinical practice guideline, evidence-based nursing, evidence-based practice, research utilization

Evidence-based practice requires identifying a specific
clinical question, finding the evidence, conducting a critical
review of the research literature, appraising the evidence,
and then applying the evidence to a clinical patient situation.
The concept of evidence-based practice is most frequently
linked to Cochrane (1972), whereas the term evidence-based
emerged from a research group led by Guyatt (Evidence-
Based Medicine Working Group, 1992). Sackett, Rosenberg,
Haynes, and Richardson (1996) defined evidence-based
medicine as the conscientious, explicit and judicious use of
the best evidence in making decisions about the care of indi-
vidual patients (p. 71). Subsequently, Ingersoll (2000) pro-
posed that evidence-based nursing is the conscientious,
explicit, and judicious use of theory-derived, research-based
information in making decisions about care delivery to indi-
viduals or groups of patients reflective of individual needs
and preferences (p. 152). This definition of evidence-based
nursing emerged from various perspectives and a rich tradi-
tion of using research findings for conducting research utili-
zation activities in nursing.
Nursing research utilization focused on approaches to
apply knowledge derived from research studies in clinical
practice. In contrast to evidence-based practice, research uti-
lization focused more on translating the extant research to
practice instead of systematically determining the worthi-
ness of the research findings prior to implementing it in prac-
tice. Starting in the 1970s, various models for research
utilization in nursing were proposed and applied in various
clinical situations. These models focused on the adoption or
dissemination of new knowledge and integrating it in clinical
practice. Early efforts included the Western Interstate
Commission on Higher Education, the Conduct and
Utilization of Research in Nursing (Krueger, 1978), and the
Nursing Child Assessment Satellite Training Projects (King,
Barnard, & Hoehn, 1981). These initiatives focused on
retrieving and reviewing research findings, disseminating
results, and evaluating any changes in practice.
Other research utilization approaches included the
University of North Carolina model (Funk, Tornquist, &
Champagne, 1989), which placed an emphasis on the dis-
semination of research findings. This model provided a
series of annual research conferences and thus supported
research-based nursing practice as an approach to improve
patient care outcomes. The Stetler model (Stetler, 1994;
Stetler & Marram, 1976) provided an organizing framework
and approach to assist clinicians make decisions about using
research findings. This model consists of six steps: a) prepa-
ration, b) validation, c) evaluation of comparative findings,
d) decision-making, e) translating the findings to practice,
and f) evaluation. Stetler (Stetler, 1994; Stetler & Marram,
1976) advanced this model, published extensively, first
describing models of research utilization in nursing practice,
subsequently evidence-based practice, and most recently the
Promoting Action on Research Implementation in Health
Services (PARIHS) framework (Helfrich et al., 2010).
The Stetler model shared similar processes and outcomes
to other approaches, such as the Iowa model of research in
practice (Titler et al., 1994), the Goode research utilization
model (Goode, Lovett, Hayes, & Butcher, 1987), and the
research utilization frameworks adopted by various nursing
specialty practices (such as the American Association of
Critical Care Nurses). Most of these models focused on
1
Director, Center for Nursing Excellence, Mission Hospital, Asheville, NC
2
Clinical Program Coordinator, Nursing Research, Dartmouth-Hitchcock
Medical Center, Lebanon, NH

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Beyea and Slattery 153
changing nursing practice within organizations, such as
healthcare institutions or professional nursing organizations.
Staff nurses often joined nursing research committees.
Through a systematic and organization-wide process they
critiqued nursing research specific to a topic. Using pre-
established criteria, the committee members determined
whether the research was adequate to make a practice change
and then they monitored the outcomes.
The success of these efforts was limited in part due to the
scope and dissemination of the research utilization initia-
tives, the number and quality of the published research
papers on a specific topic, and the ongoing challenge of
closing research and practice gaps. Despite highly success-
ful projects and promising results, clinicians at the bedside
were often simply unaware of the findings. A gap also
existed between research utilization efforts and the nursing
textbooks used to educate the next generation of clinicians.
Faculty members and administrators did not recognize the
value of nursing research or research utilization. Other bar-
riers included the fact that many practicing nurses had not
had formal research or statistics courses, and research utili-
zation was not a performance expectation. It was not until
the late 1970s that most baccalaureate nursing programs
included a formal research course or at least integrated
research concepts in curricular materials (Funk, Tornquist,
& Champagne, 1995).
Despite various barriers related to research utilization and
subsequently evidence-based practice, a number of factors
began to create more interest in evidence-based nursing care.
During this period, schools of nursing focused additional
attention on advanced education in nursing at both the mas-
ters and doctoral level. Advanced education programs in
nursing incorporated research education and addressed nurs-
ing knowledge development. Increasingly, nurses engaged in
efforts to improve the quality of care through research find-
ings. Additionally, the United States Agency for Healthcare
Research and Quality (AHRQ, formerly the Agency for
Health Care Policy and Research) began to publish practice
guidelines starting in 1992 (http://www.ahrq.gov/clinic/
cpgonline.htm) that specifically addressed phenomena of
interest to nurses.
One of the first of these practice guidelines offered guid-
ance on strategies to prevent pressure ulcer formation. This
guideline relied on Level 3 evidence (lacking direct patient
outcome data), expert opinion, and the consensus of an inter-
disciplinary expert committee. This and similar documents
placed ever-increasing attention on evidence-based health-
care and improving healthcare outcomes and services. These
guideline publications provided a national model for dis-
seminating research findings and establishing interdisciplin-
ary care standards. Guidelines of interest to nurses included
acute pain management, management of cancer pain, pres-
sure ulcer treatment, and urinary incontinence in adults
(http://www.ahrq.gov/clinic/cpgarchv.htm).
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In nursing, research utilization evolved into evidence-
based practice during a time when nursing research utiliza-
tion efforts were well established within healthcare
organizations and specialty organizations. For example, the
American Association of Critical Care Nurses (1993)
launched its now renowned, Thunder Projects, involving
organizations and nurses from across the country in nursing
research efforts. This project examined the effects of hepa-
rinized and non-heparinized flush solutions on the patency of
arterial pressure monitoring lines. Projects such as this pro-
vided clinical nurses with an opportunity to participate in
nursing research and then utilize the findings in practice.
This resulted in a growing interest in practice-focused nurs-
ing research and an increasing focus on evidence-based prac-
tice in nursing.
The shift from a focus on research utilization to evidence-
based practice in nursing could be described as an increasing
focus on achieving high-quality health outcomes by using
research findings. Journals and articles pertinent to clinical
nursing research expanded in number, and the Internet pro-
vided additional access to the published literature and
research. Concurrently, researchers no longer used paper-
based indexes and could easily search and access published
articles using personal computers. This occurred at a time
when there was increased value for evidence-based practice
within the disciplines of medicine.
Increasingly, healthcare insurers and regulators have
placed an emphasis on providing evidence-based care that is
cost-effective. This approach intended to improve care,
decrease costs, and promote high quality care. Payers do not
want to provide costly, ineffective treatments that do not pro-
vide a return on investment. Furthermore, healthcare sys-
tems have focused more on engaging frontline clinicians in
performing evidence-based interventions, such as hand
washing, that reduces the risk of infections and protects
patients from unnecessary harm.
As the importance of evidence-based care has emerged,
some clinicians have resisted this approach suggesting
that the system would be tyrannized by the evidence and
somehow result in cookbook medicine. Other clinicians
were unaware that much of medicine and nursing were
either opinion-based or evidence-free due to a lack of high
quality research on various topics. Others were unclear
about how to engage the patient as an active participant in
the decision-making process and how clinical expertise
played a critical role in the process. But during the past
decade, there has been growing support for and movement
toward implementing a wide variety of evidence-based
practices in a more systematic manner. Initiatives such as
the Institute for Healthcare Improvements efforts to
embed evidence-based safety practices in acute care set-
tings have increased the awareness of the relationship
between evidence-based practices and patient outcomes
(www.IHI.org).
154 Nursing Science Quarterly 26(2)
Current Perspectives and the Role
of Qualitative Research
The currently accepted definition of evidence-based practice
requires the inclusion of the perspective and values of the
patient. The goal is to integrate the best research evidence
with clinical expertise and patient values (Sackett, Strauss,
Richardson, Rosenberg, & Haynes, 2000). Qualitative
researchers are in the unique role of identifying patients
experiences with healthcare conditions and treatments.
Scientifically sound individual qualitative studies, as well as
qualitative metasynthesis can provide patients with a voice
in evidence-based healthcare (Beck, 2009; Thorne, 2008).
Regardless of the research methods, findings must be
trustworthy and systematically evaluated for use in clinical
practice. Then, the evidence must be presented in an unbi-
ased manner to the patient and family fully recognizing that
each situation is unique. An ideal framework for evidence-
based practice consists of a clinicians expertise, the best evi-
dence in context of the patients values and preferences.
Resources for Evidence-based
Practice
Many resources exist to assist nurses in finding and evaluat-
ing research for evidence-based practice. Several web-based
search engines are available for rapid and comprehensive
literature searching. Numerous evidence-based guidelines
are published by professional specialty organizations and
collected in the National Guideline Clearinghouse (www.
ngc.gov).
Various groups, including the AHRQ, the United States
Preventive Services Task Force (USPSTF), and the Centre
for Evidence-Based Medicine, rate research findings accord-
ing to their strength and stability and then assign a level of
evidence using a consistent framework. Some are intended
for use with diagnosis, prognosis, and therapies or interven-
tions. Although many of these have been developed for
quantitative findings, rating scales have been identified for
use with findings from qualitative research (Treadwell,
Tregear, Reston, & Turkelson, 2006). In addition, another
helpful tool for use with metasynthesis is the Qualitative
Assessment and Review Instrument (QARI), which is avail-
able through the Joanna Briggs Institute at http://www.joan-
nabriggs.edu.au (Beck, 2009).
Evidence-based practice provides a framework by which
clinicians and patients can participate in a shared decision-
making process about care decisions. Evidence-based practice
supports a decision-making process that is based on research
findings instead of just expert opinion. An evidence-based
approach integrates valid and reliable findings from both quali-
tative and quantitative research findings. It requires that the
evidence is applied in the context of patients specific situations
and consistent with patients unique values and preferences.
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Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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