Evidence Based Practice in Nursing
NRSG 354
1-EVIDENCE BASED PRACTICE(EBP)
OBJECTIVES
At the end of session, each student should be able to:
1. Define Evidence Based Practice
2. Enumerate the Quadruple (four) Aims of Evidence
Based Practice.
3. Describe the Differences of Evidence Based Practice,
Research and Quality improvements
4. List the importance of evidence based practice
5. Explain the barriers and facilitators for EBP
6. Clarify rating system for the hierarchy of evidence
Evidence Based Practice
Definition evidence-based practice (EBP)
Evidence-based practice (EBP) is defined as "the
integration of clinical expertise, patient values and the
best research evidence into the decision-making process
for patient care.“
EBP strategies allow nurse practitioners (NPs) and other
health care providers to translate research findings into
clinical practice.
Definition and evolution of evidence-based practice
In 2000, Sackett et al. defined EBP as the careful use of
current best evidence in making decisions about patient
care.
Since then, the definition of EBP has broadened in scope
and is referred to as a lifelong problem-solving approach
to clinical practice that integrates the following steps:
Definition and evolution of evidence-based (cont..)
A systematic search of the most relevant and best research (i.e.,
external evidence) to answer a burning clinical question;
One’s own clinical expertise, including use of internal evidence
generated from outcomes management or evidence-based
quality improvement projects, a thorough patient assessment,
and evaluation and use of available resources necessary to
achieve desired patient outcomes;
Patient/family preferences and values
Types of evidence-based practice
1. External evidence - is generated through rigorous research
(e.g., RCTs or predictive studies) and is intended to be generalized
and used in other settings.
An important question when implementing external evidence is
whether clinicians can achieve the same results with their
patients that were obtained in the studies they reviewed (i.e., can
the findings from research be translated to the real-world clinical
setting with the same outcomes?).
This question of transferability is why measurement of key
outcomes is necessary when implementing practice changes
based on evidence.
Types of evidence-based practice
2. Internal evidence - is typically generated through practice
initiatives, such as outcomes management or evidence-based
QI projects.
Researchers generate new knowledge through rigorous
research (i.e., external evidence), and EBP provides clinicians
the process and tools to translate the external evidence into
clinical practice and integrate it with internal evidence to
improve quality of healthcare, patient outcomes, and cost
reductions
Aims of evidence-based practice (EBP)
“Evidence-based practice is key to achieving the quadruple
aim in health care.”
1- Healthcare quality,
2- Improves patient outcomes,
3- Reduces costs,
4- Empowers clinicians
(Bodenheimer & Sinsky, 2014; Melnyk & Fineout-Overholt,
2015; Tucker, 2014).
DIFFERENCES AMONG EBP, RESEARCH, AND QUALITY
IMPROVEMENT
RESEARCH EVIDENCE BASED PRACTICE QUALITY IMPROVEMENT
Uses scientific Involves critical appraisal A systematic process that
process to generate including synthesis and
new recommendations for often uses the plan, do,
knowledge/external practice, of a body of study, act (PDSA) model, is
evidence and evidence comprised of
research utilization multiple studies and used by healthcare systems
frequently combines it with the to improve their processes
operationalized as expertise of the clinician as
the use of well as patient/family or outcomes for a specific
knowledge typically preferences and values to population once a problem
based on a single make the best decisions
study about patient care. is identified.
Often confused with EBP
DIFFERENCES AMONG EBP,
RESEARCH,AND QUALITY IMPROVEMENT
WHY EVIDENCE-BASED PRACTICE?
To the highest quality of care
To the best patient outcomes
Reduces healthcare costs
Reduce geographic variation in the delivery of care
Clinicians report feeling more empowered and have higher
job satisfaction when they engage in EBP
WHY EVIDENCE-BASED PRACTICE?
To the highest quality of care
To the best patient outcomes
Reduces healthcare costs
Reduce geographic variation in the delivery of care
Clinicians report feeling more empowered and have higher
job satisfaction when they engage in EBP
WHY EVIDENCE-BASED PRACTICE?
With recent reports of pervasive “burnout” and depression
among healthcare professionals
The use and teaching of EBP may be key not only to
providing outstanding care to patients and saving healthcare
dollars, but also to reducing the escalating turnover rate in
certain healthcare professions
Barriers to Evidence-Based Practice
Lack of EBP knowledge and skills
Cultures steeped in tradition
Misperceptions or negative attitudes about research and
evidence-based care
Lack of belief that EBP will result in more positive outcomes than
traditional care
Voluminous amounts of information in professional journals
Lack of time and resources to search
Lack of EBP mentors
Barriers to Evidence-Based Practice
Organizational constraints, such as lack of administrative support
Demands from patients for a certain type of treatment
Peer pressure to continue with practices steeped in tradition
Resistance to change
Lack of consequences for not implementing EBP
Peer and leader/manager resistance
Lack of autonomy and power to change practice
Inadequate EBP content and behavioral skills building in
educational programs
Facilitators of Evidence-Based Practice
Support and encouragement from leadership/administration
Alignment of stakeholders
Time to critically appraise studies and implement findings
Clearly written research reports
EBP mentors with excellent EBP skills
Proper tools to assist with EBP at the point of care (e.g.,
computers dedicated to EBP; computer based educational
programs)
Facilitators of Evidence-Based Practice
Integrating EBP into health professions curricula
Clinical promotion systems and performance evaluations that
incorporate the EBP competencies;
Evidence-based clinical practice policies and procedures
EBP models that can guide implementation and sustainability of
EBP
Journal clubs and EBP rounds
A certification credential and high level of education.
Rating System for the hierarchy of evidence
Level I .Evidence obtained from a systematic review or
meta-analysis of all relevant, randomized clinical trials
(RCTs), or clinical practice guidelines based on
systematic reviews of RCTs
Level II. Evidence obtained from at least one well-
designed RCT/Random Clinical Trial.
Level III. Evidence obtained from well-designed controlled
trials without randomization (quasi-experimental).
Rating System for the hierarchy of evidence
…(con’t)
Level IV.Evidence from well designed case-control and
cohort studies.
Level V.Evidence from Systematic Reviews of descriptive
and qualitative studies.
Level VI.Evidence from a single descriptive or qualitative
study.
Level VII.Evidence from opinion of authorities and/or
reports of expert committees.
Definition of evidence synthesis
1. Randomized Controlled Trial (RCT): A true experiment
(i.e., one that delivers an intervention or treatment in which
participants are randomly assigned to control and
experimental groups); the strongest design to support
cause-and-effect relationships.
2. Systematic review: A summary of evidence, typically
conducted by an expert or expert panel on a particular
topic, that uses a rigorous process (to minimize bias) for
identifying, appraising, and synthesizing studies to answer
a specific clinical question and draw conclusions about the
data gathered.
Definition… (con’t)
3- Meta-analysis: A process of using quantitative methods to
summarize the results from the multiple studies, obtained and
critically reviewed using a rigorous process (to minimize bias)
for identifying, appraising, and synthesizing studies to answer
a specific question and draw conclusions about the data
gathered.
4. Clinical Practice Guidelines: Systematically developed
statements to assist clinicians and patients in making decisions
about care; ideally, the guidelines consist of a systematic review
of the literature, in conjunction with consensus of a group of
expert decision makers, including administrators, policy makers,
clinicians, and consumers who consider the evidence and make
recommendations.
Definition… (con’t)
5. Quasi-experiments: A type of experimental design that
tests the effects of an intervention or treatment but lacks
one or more characteristics of a true experiment (e.g.,
random assignment; a control or comparison group).
6.Case–control study: A type of research that
retrospectively compares characteristics of an individual
who has a certain condition (e.g., hypertension) with one
who does not (i.e., a matched control or similar person
without hypertension); often conducted for the purpose
of identifying variables that might predict the condition
(e.g., stressful lifestyle, sodium intake).
Definition… (con’t)
7. Cohort study: A longitudinal study that begins with
the gathering of two groups of patients (the cohorts),
one who received the exposure (e.g., to a disease)
and one who does not, and then following these
groups over time (prospective) to measure the
development of different outcomes (diseases); an
observational study.
Definition… (con’t)
8. Descriptive studies: Those studies that are
conducted for the purpose of describing the
characteristics of certain phenomena or selected
variables.
9.Qualitative research: Research that involves the
collection of data in non-numeric form, such as
personal interviews, usually with the intention of
describing a phenomenon or experience seeking an in-
depth understanding within a natural setting.
Question
Which of the following is NOT considered to be a key
concept of EBP?
A. Best evidence
B. Patient values
C. Provider expertise
D. Traditional practices
Question
• Which of the following sources of evidence is best able
to inform a nurse’s clinical practice?
a. A well-designed randomized controlled trial (RCT)
b. A systematic review that encompasses multiple studies
c. Expert opinion of experienced and educated nurses
d. A case study that addresses an unique clinical scenario
