Evidence-Based Practice in Nursing: Bridging the Gap Between Research and Practice

Article (PDF Available)inJournal of Pediatric Health Care 21(1):53-6 · February 2007with2,015 Reads
DOI: 10.1016/j.pedhc.2006.10.003 · Source: PubMed

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Evidence-Based
Practice in Nursing:
Bridging the Gap
Between Research
and Practice
Noreen Brady, PhD, APRN-BC, LPCC, &
Linda Lewin, PhD, APRN-BC
The concept of evidence-based
practice (EBP) continues to gain
credibility and acceptance in the
health professional community. EBP
is best described as “the integration
of best research evidence with clin-
ical expertise and patient values”
(Sackett, Straus, Richardson, Rosen-
berg, & Haynes, 2000). All three
components of this definition are
equally necessary: evidence from re-
search, clinical expertise, and pa-
tient values. Most experienced
nurses feel quite confident about
their clinical expertise, and to some
extent, patient values. However, sur-
prisingly, research indicates that the
majority of nurses are not aware of
the latest research findings available
to optimize their nursing care
(Bostrum & Suter, 1993; Pravicoff,
Tanner, & Pierce, 2005). Instead of
relying on research findings, nurses
rely on intuition, tradition, and the
authority of policies and procedures
for direction in particular situations.
While not negating the value of our
internal processing or the impor-
tance of following standards of care,
some practice traditions remain unit-
specific and unsupported by evi-
dence. This article will present a
brief discussion of EPB in nursing
and why it is critical that nurses un-
derstand the process of moving to-
ward an evidence base for practice.
TIME GAP BETWEEN
RESEARCH FINDINGS AND
IMPLEMENTATION
EBP is the bridge between re-
search and practice. However, it is
well known that the gap between
research findings and implementa-
tion is far too long. A memorable
example of delayed implementa-
tion of evidence is that of the Brit-
ish Navy (Berwick, 2003). The
benefits of limes and sauerkraut to
prevent scurvy were discovered in
1601, yet rations containing vita-
min C were not required until
1795. In fact, the British Board of
Trade took an additional 70 years
to order that citrus be provided on
merchant ships, a total of 264 years
between evidence and practice!
Nursing is continually strug-
gling to successfully implement
changes in practice. For example,
Bostrum and Suter (1993) found
that only 21% of nurses in their
sample (n 1200) had incorpo-
rated recent research into their pa-
Noreen Brady is Assistant Professor and
Director, Hirsh Institute for Evidence-
Based Practice, Frances Payne Bolton
School of Nursing, Case Western
Reserve University, Cleveland, Ohio.
Linda Lewin is Assistant Professor,
Frances Payne Bolton School of
Nursing, Case Western Reserve
University, Cleveland, Ohio.
Reprints are not available from the
authors.
J Pediatr Health Care. (2007). 21, 53-56.
0891-5245/$32.00
Copyright © 2007 by the National Asso-
ciation of Pediatric Nurse Practitioners.
doi:10.1016/j.pedhc.2006.10.003
Section Editor
Arlene Butz, ScD, RN,
CPNP
The Johns Hopkins
University
Schools of Medicine and
Nursing Division of General
Pediatrics
Baltimore, Maryland
Journal of Pediatric Health Care January/February 2007 53
Department
www.jpedhc.org
Research
Advertisement:
tient care. A review of the literature
by Zeitz and McCutcheon (2003)
about postoperative vital signs
found little evidence to recom-
mend optimal frequency for ob-
taining vital signs. However, there
are historic references dating back
to the late 1800s detailing vital
signs in postoperative patients.
They stated that “unless we have ev-
idence that supports the continua-
tion of such practices, then the basis
for the practice and potential bene-
fits to the patients are questionable”
(p. 276). This is an obvious example
of tradition-based nursing without
evidence.
EVOLUTION OF EVIDENCE-
BASED PRACTICE
The search for evidence is in the
founding heritage of nursing. Flo-
rence Nightingale accessed public
health statistics, and where there
were gaps, she collected new in-
formation. She collected rates of
mortality and disease and con-
ducted a comparison of patient
care outcomes provided by trained
and untrained nurses. Nightingale
even used charts with color-coded
highlights to make her points with
consumers and politicians (Mc-
Donald, 2001). Thus, the roots of
evidence-based nursing have been
present from the outset.
More recent pursuits for EBP are
traced back to Dr. Archie Cochrane
in Britain, who criticized the way
health care decisions were made—
that is, they were not based on rig-
orous review and evidence. Dr. Co-
chrane, an epidemiologist, strongly
believed that these decisions should
be based on results from random-
ized controlled trials. McMaster Uni-
versity became the base for Dr.
Sackett and colleagues, who used
an evidence-based medicine ap-
proach to learning. Evidence-based
nursing centers, such as the Sarah
Cole Hirsh Institute for Best Nursing
Practices at Case Western Reserve
University, was established in 1998
to build a repository of research
findings. Other nursing EBP centers
include the Joanna Briggs Institute
in Australia and the University of
Rochester Center for Research and
Evidence Based Practice.
SOURCES OF EVIDENCE
Many sources of evidence are
available to nurses. Systematic re-
views, meta-analyses, clinical tri-
als, experimental and quasi-exper-
imental studies, qualitative studies,
case studies, and clinical practice
guidelines all are potential sources
of evidence to guide nursing prac-
tice. Systematic reviews are sum-
maries of research literature that
use explicit methods to systemati-
cally search research databases,
critically appraise selected studies,
and integrate research results on a
specific topic. Explicit methods re-
fer to inclusion of a detailed sec-
tion explaining methods used to
examine the literature. To system-
atically search means that descrip-
tions of inclusion and exclusion
criteria for articles selected for re-
view are presented. To critically
appraise refers to explaining the
positive points and possible defi-
cits of the articles prior to inclusion
in the review.
Another source of evidence is
provided by clinical practice guide-
lines. Clinical practice guidelines are
developed by professional organiza-
tions or expert panels convened
specifically to construct evidence-
based guidelines for particular dis-
eases, conditions, or populations.
The National Guideline Clearing-
house (www.ngc.org), which is
sponsored by the U.S. Agency for
Healthcare Research and Quality,
the American Medical Association,
and the American Health Insurance
Plans, presents a searchable data-
base of clinical practice guidelines,
abstracts, and annotated bibliogra-
phies. Specialty evidence-based
journals provide another source
of information for nurses. One of
the earliest evidence-based nurs-
ing journals is Evidence Based
Nursing, available online at www.
evidencebasenursing.com.
POSING AN ANSWERABLE
QUESTION
The complexities of health care
can confound any practitioner’s
choice of clinical actions. Deficits
in current knowledge or the occur-
rence of problem triggers provide
the basis for posing an answerable
question. Posing the right question
is critical in directing the clinician
in the search for best outcomes.
Most nurses find a special interest
niche somewhere in their practice,
and this interest can spark an
investigation of recent research
findings. Interest areas may be
population, age group, illness con-
dition, or level of prevention. In
constructing an answerable clinical
question, Melnyk and Fineout-
Overholt (2005a) suggest includ-
ing “PICO”: patient, intervention,
comparison, and outcome. Let’s
use the sample question, “What is
the effectiveness of second- and
third-generation antibiotics in the
treatment of otitis media in chil-
dren compared with first-genera-
tion antibiotics?” (Berman, Pyrns,
Bondy, Smith, & Lezotte, 1997).
Patient population of interest:
defining the target patient pop-
Most nurses find a special interest niche
somewhere in their practice, and this interest
can spark an investigation of recent research
findings.
54 Volume 21 • Number 1 Journal of Pediatric Health Care
ulation by specifying age, sex,
ethnicity, and specific health
problem of interest. Example:
children who are 13 years and
younger with acute otitis media.
Intervention: defining the nurse
practitioner action including as-
sessment techniques, proce-
dures, and treatments. Example:
use of first-generation antibiotics
(amoxicillin, trimethoprim plus
sulfamethoxazole, or erythromy-
cin plus sulfisoxazole) to treat
acute otitis media.
Comparison: assess the differ-
ences between current practices,
procedures, and health informa-
tion compared with EBPs. Exam-
ple: what is the effectiveness of
first-generation antibiotics com-
pared with second- and third-gen-
eration antibiotics (e.g., cefaclor,
amoxicillin plus clavulanate, or
cefixime)?
Outcome: a nursing action that
results in patient effects; specify-
ing the results may narrow the
focus of the question. Example:
in one randomized clinical trial,
first-generation antibiotics were
more effective than second- and
third-generation antibiotics.
SEARCH STRATEGIES
Introduce yourself to the refer-
ence librarian and make that per-
son your best friend! Staying in-
formed and weeding out massive
volumes of information can be over-
whelming. Just responding to rapid
changes in clinical improvements
in a subspecialty can take substan-
tial effort. Computer searches for
relevant literature can be time-con-
suming, but there are means to ex-
pedite the process. Research data-
bases that are most often used by
nurses include Cumulative Index of
Nursing and Allied Health Literature
(CINAHL), Medline, Embase (bio-
medical/pharmaceutical), ERIC, and
PsychINFO. The greatest challenge
is selecting the key words of the
search—not too broad, not too nar-
row. The use of MeSH headings (the
thesaurus of terms for Medline) may
assist in matching jargon.
To efficiently search for re-
search articles, include meta-ana-
lytic articles and systematic re-
views. In a meta-analysis, the
researchers compare multiple stud-
ies by converting data to a standard-
ized mean difference (d) for com-
parison. Systematic reviews such as
Cochrane Database of Systematic
Reviews (www.cochrance.org) pro-
duce systematic reviews of health
care interventions. No matter how
thorough a search may seem, the
comprehensive inclusion of all evi-
dence (e. g., conference proceed-
ings, expert panel reports, and case
reviews) is not possible.
LEVELS OF EVIDENCE
How does the nurse practitioner
determine the scientific value of
various studies? Appraise the rele-
vance of the evidence: is the prac-
titioner’s population compatible
with the population of the review?
Determine if the potential benefit
of the reviewed intervention
would actually benefit the practi-
tioner’s patient or family. Are the
patient and practitioner clear about
their values and preferences? Ulti-
mately, are the preferences of the
patient and practitioner met by the
practice regimen in the systematic
review? (Melnyk & Fineout-Over-
holt, 2005b).
All research is not equal. Ran-
domized, controlled, multi-site
studies with diverse samples
have the greatest potential for
generalizability. There is general
agreement that a relative hierar-
chy of research evidence exists.
Melnynk and Fineout-Overholt
(2005a) itemize levels ranging
from the lowest level, consisting
of expert opinion, to the highest
level, being multiple randomized
controlled trials.
INTEGRATING EVIDENCE
INTO PRACTICE
It is essential to thoughtfully
prepare before attempting practice
changes. Careful evaluation of the
setting, personalities, and the prac-
tice change itself is needed prior to
action. To enhance success:
1. Plan. Involve those affected by
the change in the change-plan-
ning process. Identify the ex-
pected outcomes. Consider im-
plementing a pilot. Assess pilot
strengths and limitations and
modify accordingly. Identify
motivators for all personnel.
2. Implement. Establish a time-
line designed by those affected
by the practice change. Be real-
istic; most changes take longer
than expected. Build in periodic
evaluation.
3. Correct at mid course. Do not
be rigid; flexibility is an asset.
4. Communicate. Create multi-
ple ways to seek and obtain in-
put. Communicate progress to
practitioners, patients, and fam-
ilies. For example, Virtua Health
of New Jersey has introduced
the use of Translating Research
into Practice to communicate
research information to more
than 2000 nurses. Translating
Research into Practice is an eye-
catching flier that provides evi-
dence-based information and
references (Block & LeGrazie,
2006).
5. Evaluate. Consider focus groups,
brainstorming session, and sur-
veys of patients and professional
staff satisfaction.
Resistance is a factor when planning and
implementing evidence-based changes.
55Journal of Pediatric Health Care January/February 2007
BARRIERS TO PRACTICE
CHANGE
Resistance is a factor when plan-
ning and implementing evidence-
based changes. Individuals and or-
ganizations require congruent goals
and objectives to successfully imple-
ment changes (Winch, Henderson,
& Creedy, 2005). Magnet organiza-
tions promote, develop, and sustain
research as the basis for clinical
practice. Consider potential barriers,
both individual and organizational.
Some people are more open to
change than others, while some
hold fast to traditions.
Organizational barriers include
lack of access to technology, ex-
cessive time demands for clinical
work, lack of peer or administra-
tive support, and, most impor-
tantly, an organizational culture
that does not value inquiry.
Ideally, organizations will provide
computer access, facilitators, dedi-
cated time for EBP activities, com-
mitment to dissemination of re-
search, and practice change
activities (see Box).
CONCLUSION
The science of health care is al-
ways evolving, challenging us to
be progressive. Florence Nightin-
gale reminds us that “Nursing is a
progressive art in which to stand
still is to have gone back.” Practice
routines should be examined to
determine if practitioners are offer-
ing nursing care based on tradi-
tion, intuition, and authority or ev-
idence. The emphasis on EBP
needs to be part of an individual
practitioner’s motivation and col-
lective organizational practice cul-
ture. Bridging research and prac-
tice by designing answerable
questions, utilizing appropriate re-
search databases, implementing
nursing practice changes, and
evaluating outcomes are all strate-
gies that enliven practice and en-
hance patient outcomes.
REFERENCES
Berman, S., Pyrns, P., Bondy, J., Smith, P.,
& Lezotte, D. (1997). Otitis media-re-
lated antibiotic prescribing patterns,
outcomes, and expenditures in a pedi-
atric Medicaid population. Pediatrics,
100, 585-592.
Berwick, D. M. (2003). Disseminating inno-
vations in health care. Journal of the
American Medical Association, 289,
1969-1975.
Block, L., & LeGrazie, B. (2006). Don’t get
lost in translation. Nursing Manage-
ment, 37, 37-40.
Bostrum, J., & Suter, W. (1993). Research
utilization: Making the link to practice.
Journal of Nursing Staff Development,
9, 28-34.
McDonald, L. (2001). Florence Nightingale
and the early origins of evidence-based
nursing. Evidence-Based Nursing, 4,
68-69.
Melnyk, B., & Fineout-Overholt, E. (2005a).
Evidence-based practice in nursing and
healthcare. Philadelphia: Lippincott.
Melnyk, B., & Fineout-Overholt, E. (2005b).
Rapid critical appraisal of randomized
controlled trials (RCTs): An essential
skill for evidence-based practice (EBP).
Pediatric Nursing, 31, 50-52.
Pravicoff, D., Tanner, A., & Pierce, S. (2005).
Readiness of US nurses for evidence-
based practice. American Journal of
Nursing, 105, 40-51.
Sackett, D. L., Straus, S. E., Richardson,
W.S., Rosenberg, W., & Haynes, R, B.
(2000) Evidence-based medicine: How
to practice and teach EBM. Edinburgh:
Churchill Livingston.
Winch, S., Henderson, A., & Creedy, D.
(2005). Read, think, do: A method for
fitting research evidence into practice.
Journal of Advanced Nursing, 50, 20-
26.
Zeitz, K., & McCutcheon, H. (2003). Evi-
dence-based practice: To be or not to
be, this is the question. International
Journal of Nursing Practice,9,
272-279.
Bridging research and practice by designing
answerable questions, utilizing appropriate
research databases, implementing nursing
practice changes, and evaluating outcomes are
all strategies that enliven practice and enhance
patient outcomes.
BOX. Pearls
1. Commit to personal develop-
ment of EBP by frequently
accessing research data-
bases and systemic reviews.
2. Develop and schedule regu-
lar opportunities to dialogue
with colleagues to exchange
ideas and reviews and to
plan for practice changes.
3. Participate and contribute to
a culture of inquiry in
practice.
4. Develop research relation-
ships that foster practice-
based research efforts.
5. Encourage organizational
dissemination of evidence-
based practices.
56 Volume 21 • Number 1 Journal of Pediatric Health Care
    • "The successful implementation of EBP is a dynamic process dependent on a number of variables. Individual experiences, bias and attitudes alongside professional, organisational and workplace factors can act as hurdles or barriers to the translation of empirical knowledge into practice and as such this process can take many years (Brady & Lewin, 2007; Fineout-Overholt et al., 2005; Newman et al., 1998; Retsas, 2000). For individuals to effectively implement EBP, they need to be both motivated and competent (Newman et al., 1998); motivated in that they have a desire to seek out the information that best serves the needs of their patients; and competent in that they need to have the necessary skills and resources available to them to seek out, critically analyse and interpret the data they require (Kajermo et al., 2010; Leasure et al., 2008; Ploeg et al., 2007). "
    [Show abstract] [Hide abstract] ABSTRACT: Background: The responsibility to implement evidence-based practice (EBP) in a health care workplace does not fall solely on the individual health care professional. Organisational barriers relate to the workplace setting, administrational support, infrastructure, and facilities available for the retrieval, critique, summation, utilisation, and integration of research findings in health care practices and settings. Objective: Using a scoping review approach, the organisational barriers to the implementation of EBP in health care settings were sought. Method: This scoping review used the first five of the six stage methodology developed by Levac et al. (2010). The five stages used are: 1) Identify the research question; 2) identify relevant studies; 3) study selection; 4) charting the data; and 5) collating, summarising and reporting the results. The following databases were searched from January 2004 until February 2014: Medline, EMBASE, EBM Reviews, Google Scholar, The Cochrane Library and CINAHL. Results: Of the 49 articles included in this study, there were 29 cross-sectional surveys, six descriptions of specific interventions, seven literature reviews, four narrative reviews, nine qualitative studies, one ethnographic study and one systematic review. The articles were analysed and five broad organisational barriers were identified. Conclusions: This scoping review sought to map the breadth of information available on the organisational barriers to the use of EBP in health care settings. Even for a health care professional who is motivated and competent in the use of EBP; all of these barriers will impact on their ability to increase and maintain their use of EBP in the workplace.
    Full-text · Article · Dec 2014
    • "Such behavior is not consistent with safe care and is not in line with current patient safety law. To ensure patient safety and enhance patient outcomes, bridging research and practice is crucial (Brady and Lewin, 2007). Studies on nursing students' adherence and the development of non-adherence to the VBSC and other medical or nursing guidelines are warranted. "
    [Show abstract] [Hide abstract] ABSTRACT: Despite considerable efforts to increase patient safety by supporting the use of best practice medical and nursing guidelines by healthcare staff, adherence is often suboptimal. Swedish nurses often deviate from venous blood specimen collection (VBSC) guideline adherence. We assessed the adherence to national VBSC guidelines among senior nursing students. We conducted a cross-sectional, self-reported questionnaire survey among 101 out of 177 senior nursing students consisting of web-based students in their fifth semester and campus-based students in their fifth or sixth semester out of six. In regard to the VBSC procedures, we asked about adherence to the patient identification, test request handling, and test tube labelling protocols that the students had learned during their second semester and practiced thereafter. Guideline adherence to patient identification was reported by 81%, test request handling by 74%, and test tube labelling by 2% of the students. Students with no prior healthcare education reported to a higher extent that they operated within the guidelines regarding labelling the test tube before entering the patient's room compared to students with prior healthcare education. Using multiple logistic regression analysis, we found that fifth semester web-based program students adhered better to VBSC guidelines regarding comparing patient ID/test request/tube label compared to campus-based students. Senior nursing students were found to adhere to VBSC guidelines to a similar extent as registered nurses and other hospital ward staff in clinical healthcare. Thus student adherence to VBSC guidelines had deteriorated since their basic training in the second semester, and this can impact patient safety during university/clinical studies. The results of our study have implications for nursing practice education.
    Full-text · Article · Jul 2013
    • "RTs often facilitate other investigators' research. However, to develop independent research capacity, RTs must display professional responsibility toward research within their area of practice (234512,14,16,19,25). RTs expressed a sense of ownership over respiratory therapy research; they believed that RTs are best suited to conduct respiratory therapy research. "
    [Show abstract] [Hide abstract] ABSTRACT: Evidence-based practice (EBP) is increasing in health care services. This means that respiratory therapists (RTs) should be effective consumers, users and producers of scientific research pertaining to respiratory therapy technology and respiratory physiology. However, little is known about RT opinions and attitudes toward research. Survey instruments to measure them are also uncommon. The present article presents the results of a survey of RTs regarding research attitudes including interest, self-perceived skill and barriers. A survey was developed in consultation with practicing RTs and education researchers. It was fielded in six academic hospitals in Toronto, Ontario. Surveys were completed and returned anonymously. Descriptive statistics and associations were examined. Subgroup differences were tested using ANOVA methods. Surveys were completed by 112 RTs (response rate 26.9%). The majority (approximately 80%) of respondents agreed that respiratory therapy research is important, that research can advance the profession and that RTs are suited to performing respiratory therapy research. More than 70% were interested in performing research as long as barriers were eliminated. Among eight potential barriers, lack of time was ranked as the top barrier 59% of the time. Lack of interest in performing research was the least relevant barrier. RTs' educational attainment was positively associated with willingness to perform research and belief in having the skills needed for research. Many RTs want to conduct research. They would need substantial support, including increased research exposure during respiratory therapy training, more time and support from trained researchers.
    Article · Jan 2013
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