What Is Evidence-Based Practice in Nursing?

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A nurse consults with a patient in an ER bed.

 

Tens of thousands of people die from influenza each year. Around 20,000 lost their lives during the 2019-2020 flu season, while 52,000 died during the 2017-2018 flu season, according to the Centers for Disease Control and Prevention (CDC). However, with a flu vaccine, people can avoid getting sick from the flu altogether. What does it take to raise vaccination rates and save lives? One evidence-based intervention program managed to raise vaccination rates by 597%, according to a recent study published in the Journal of the American Association of Nurse Practitioners. This speaks to the powerful impact evidence-based practice can have in achieving positive health outcomes.

Aspiring nurses can learn to integrate this approach into their practice by pursuing an online Bachelor of Science in Nursing (BSN) to Doctor of Nursing Practice (DNP) at Hawai‘i Pacific University. Health care professionals have used evidence and data to lower risk for heart disease, raise success rates for smoking cessation, and improve patient care in various other areas. What is evidence-based practice in nursing? To best understand evidence-based practice, it is useful to explore its definition, as well as discuss its benefits and the steps involved.

What Is Evidence-Based Practice?

The term “evidence-based practice” refers to an approach to health care delivery that focuses on integrating proven research from studies into clinical decisions and problem-solving. This helps improve accountability and the effectiveness of care.

Health care disciplines, from nursing to physical therapy to urology, have often relied on the historical treatment approach in which practitioners make treatment decisions based on what was done in the past, not based on clear evidence of what works.

However, evidence-based practice strives to move beyond the mentality of justifying treatment decisions by saying, “This is how we’ve always done it.” Instead, evidence-based practice incorporates clinical expertise, evidence from scientific literature and observations of the patient, and the cultural perspective and priorities of the patient when making decisions.

Clinical Expertise

Clinical expertise serves as an important component of evidence-based practice. It refers to a health care provider’s clinical skills, experience, and education. Health care providers develop clinical expertise and judgment from their interactions with patients. Over time, clinicians begin to see patterns and learn to better recognize and interpret the signs and symptoms that patients exhibit. This can increase a health care provider’s proficiency in making accurate diagnoses. It can also improve a clinician’s ability to identify and empathize with a patient’s predicaments and preferences.

The training that clinicians undergo plays an instrumental role in their ability to interpret patient histories and external evidence, such as research and studies published in medical journals. Additionally, health care providers’ knowledge and skills allow them to appropriately apply their education to actual clinical situations.

Evidence from Scientific Literature

Along with clinical expertise, health care providers using an evidence-based practice approach consider scientific literature. Scientific literature comprises empirical studies published in peer-reviewed medical journals.

These studies have undergone critical examinations by other experts in the field. This helps ensure the studies’ accuracy and relevance. Scientific literature aims to provide health care providers with accurate and unbiased medical information about health conditions and effective treatments.

To get the most out of scientific literature and maintain objectivity, health care providers appraise it critically, methodically, and with clear criteria for evaluating the quality of the research findings. This helps weed out irrelevant studies.

Meta-Analyses

Clinicians rely on various types of studies to inform their medical decisions. Systematic reviews, or meta-analyses, rank at the top of the hierarchy of evidence. They offer surveys of many scholarly articles or scientific studies on a specific research topic.

Using statistical analysis, these systematic reviews combine the results of numerous individual studies to arrive at the most accurate approximation of all their overall findings. This survey of published literature on a particular medical issue gives health care providers data on which to base their decisions.

Randomized Controlled Studies

When meta-analyses are not available, clinicians can turn to primary randomized controlled studies. These studies, considered the gold standard for studying the effectiveness of medical interventions, compare two or more treatment methods randomly assigned to study participants. This helps researchers evaluate the impact of the intervention under study.

Cultural Perspectives and Priorities of Patients

Integrating patients’ cultural perspectives and priorities makes up another element of what evidence-based practice is. Patients have their own individual preferences when it comes to their health care. Personal values, cultural backgrounds, health goals, and other factors influence these preferences.

Delivering evidence-based practice means recognizing and appreciating the differences between patients. This involves designing treatment plans that take into account the specific concerns, desires, and needs of each patient. Often, patients and health care providers differ in their assessments of the harms and benefits of a treatment.

A clinician may view a particular treatment with little chance of success as inadvisable, while a patient may want to proceed with the treatment if it has any chance of working. For example, patients with fertility issues may want to try in vitro fertilization even if their chance of conception is in the single digits and the cost is very high.

In evidence-based practice, health care providers weigh a treatment’s side effects, risks, and effectiveness with a patient. This offers patients an accurate understanding of a particular treatment, and it gives clinicians’ insight into patient priorities.

Evidence-Based Practice in Nursing

Florence Nightingale, considered the founder of modern nursing, first applied a simple form of evidence-based practice to nursing in the 1850s. Though Nightingale did not have scientific literature to refer to, she used her observation of patients as evidence on which to base certain medical decisions.

Specifically, she connected the poor sanitary conditions in the hospital where she worked with greater loss of life among soldiers. By examining medical statistics and gathering data of her own, she made connections between mortality rates and their causes. She responded by implementing sanitation measures that lowered the patient death rate. This early example of evidence-based practice in nursing helped shape current approaches to health care delivery.

Provisions in the American Nurses Association’s Code of Ethics state that nurses must demonstrate authority and accountability in their practice and make decisions that promote optimal care. The integration of scientific research, clinical expertise and observations, and patient preferences central to evidence-based practice certainly aligns with this professional obligation.

Evidence-based practice allows nurses to ensure that they are using the most effective and safest interventions while simultaneously respecting patient values and expectations. Sometimes, optimal treatments stand in conflict with a patient’s beliefs or preferences. In these cases, clinicians present the evidence but allow patients to make their own choices.

By accessing scientific research, nurses can stay current on the latest medical protocols and build their knowledge of the most effective treatment options. This also helps nurses learn about the risks and benefits of diagnostic tests and clinical interventions.

Research Used by Nurses

Nurses benefit from examining both quantitative and qualitative research. Each has its own strengths, supporting different components of the evidence-based practice model. Quantitative research, for example, helps nurses understand how well different treatment methods work. Qualitative research, however, can provide insights into patient preferences.

Quantitative Research

Quantitative research looks at measurable variables that scientists or study investigators can analyze. This produces reliable information about the effects of a medication or the procedures that can most effectively treat a health condition or disease. By measuring the statistics of patient outcomes, quantitative research provides results that can inform nurses and other clinicians of the most impactful interventions.

Qualitative Research

Not all information lends itself to numerical values and measurements. Researchers cannot apply quantitative tools to many phenomena valuable to medical practitioners. For example, nurses can benefit from understanding how culture can influence patient experiences of childbirth or how hope can affect the experience of cancer patients. However, researchers cannot offer precise measurements about such topics, even though they can collect and analyze data about them in ways that offer important insights.

While qualitative research offers more subjective results, it often builds understanding about patient preferences and priorities, making it a useful tool for those engaged in evidence-based practice.

How Nurses Locate Research

Nurses can retrieve most peer-reviewed research online via databases. Databases vary, with different search settings and requirements. To find high-quality relevant materials quickly, nurses familiarize themselves with the specific characteristics of various databases and modify their search strategies accordingly.

Some databases especially relevant to nurses include the following:

  • PubMed — a database of biomedical literature
  • Cumulative Index to Nursing and Allied Health Literature (CINAHL) — an index of nursing and allied health journals
  • Cochrane Database of Systematic Reviews (CDSR) — a database for systematic reviews in health care

Inputting carefully selected keywords related to specific research questions can help ensure that nurses find what they are looking for. Users can filter their search results by subject, publication date, and other criteria.

Why Is Evidence-Based Practice Important?

Evidence-based practice strives to ensure that patients have access to the best available care by strategically using resources and prioritizing the use of relevant evidence in health care decision-making. Additionally, it helps replace outdated methods that are more subject to bias and error, while encouraging clinicians to ask questions and look for new evidence that guides them to more effective practices.

Putting Research Into Practice

Bringing scientific research into clinical practice can be a long process. Many studies suggest that the implementation of research findings into clinical settings can lag 17 years. While research may have proven that an intervention improves patient outcomes, that does not necessarily mean that health care systems have adapted that intervention as a standard of care.

For example, numerous research studies found that the Creating Opportunities for Parent Empowerment (COPE) program, which trains parents in how to care for their preterm baby in a neonatal intensive care unit (NICU), improved the health outcomes for preterm infants and their parents. However, it took more than 20 years before NICUs implemented the program as a standard of care across the country, ultimately leading to shortened stays in NICUs and considerable cost savings.

Conversely, the health care profession engages in many practices steeped in tradition but backed by limited evidence showing they are beneficial. Such practices tend to yield poorer outcomes. They also waste money and get in the way of optimal care.

Evidence-based practice helps put research into practice, so treatments reflect the most recent scientific knowledge. How? The steps of evidence-based practice direct clinicians to collect, appraise, and then incorporate scientific evidence into their clinical decisions.

Promoting an Inquiry Mindset

Evidence-based practice promotes an inquiry mindset and values critical thinking. This helps nurses solve problems and encourages them to question current practices, how they benefit or potentially harm patients, and if better alternatives exist.

Asking the right questions can identify problems and help uncover important solutions. An openness to reflect on information and review evidence to determine if it indeed indicates the necessity of an intervention allows nurses to both grow and discover ways to improve patient care. Evidence-based practice in nursing prioritizes an approach of curiosity that values evidence to determine best practices, instead of simply relying on existing practices out of habit.

Saving Time While Providing High-Quality Care

The support of a continual questioning and evaluation process found in evidence-based care leads to innovation. It can also empower nurses to let go of time-consuming practices with no proven benefit to patients. When nurses have evidence on their side, they make better decisions that save time. They engage in practices that can result in fewer infections and lead to faster recovery.

For example, by using an evidence-based practice approach, a team of nurses at Mississippi Baptist Health Systems found that by removing urinary catheters earlier than what had been standard practice, they could reduce the number of catheter-associated urinary tract infections (CAUTIs) by around a third.

Benefits of Evidence-Based Practice in Nursing

The concept of the quadruple aim of health care, a widely accepted idea in the field, espouses that to improve the performance of a health care delivery system, models must focus on:

  • Improving patients’ experience of care
  • Improving the health of patient populations
  • Lowering health care costs
  • Improving the work experience of clinicians to reduce burnout

Evidence-based practice in nursing offers many noteworthy benefits, and it can play an instrumental role in achieving these health care goals. Additionally, evidence-based practice can improve the consistency of care and reduce inefficiencies.

Enhancing Patient Experience

Evidence-based practice emphasizes the importance of including patients in the decision-making process and strengthening communication about treatment options, diagnosis, and prognosis. It also focuses on honoring the diversity of patient needs and preferences. This fosters an improved patient-nurse relationship that can improve patient satisfaction.

Improving Patient Health

A great deal of evidence has shown that evidence-based practice improves health outcomes for patients.

When nurses consult evidence, they can better identify risk factors for health conditions such as stroke or diabetes. They can also make more accurate assessments and select the most effective interventions, which deliver the best results.

Numerous studies attest to this. For example, a recent study published in the Journal of the American Heart Association found that stroke patients receiving evidence-based stroke care had higher survival rates and overall improved outcomes.

Lowering Health Care Costs

Better patient care typically lowers health care costs. Evidence-based care reduces the rate of unnecessary procedures and increases patient safety. For example, research-backed treatment approaches can reduce the number of patient falls, cases of ventilator associated pneumonia, and return visits, all of which generate huge expenses.

The more effective treatment delivered as a result of evidence-based practice can also reduce the length of hospital stays, as well as lower the number of incorrect diagnoses and other clinical mistakes.

Reducing Nurse Burnout

A recent study published in JAMA Network Open found that more than 30% of nurses who leave the profession do so because of burnout. This serious issue in the profession needs attention. Fortunately, evidence-based practice in nursing helps address the problem. By increasing autonomy and improving patient-nurse relationships, it can lower nurses’ stress levels.

Research has shown that evidence-based practice positively affects the work experience of clinicians. A study published in Worldviews on Evidence Based Nursing, for example, found that evidence-based practice improves nurse retention and increases job satisfaction.

Steps of Evidence-Based Practice

Nurses and other clinicians follow five essential steps when engaging in evidence-based practice.

Forming a Clinical Question

Well-formed clinical questions start the process of evidence-based practice. They help nurses focus clearly on specific health problems that need solutions. Typically, these questions originate from encounters with patients that encourage nurses to consider ways to improve treatment methods, diagnosis, etc.

Nurses use the PICOT format when framing their clinical questions. This ensures that nurses create searchable and answerable questions. PICOT stands for:

Patient Population

A patient population means the group of patients the question concerns. When defining the patient population, nurses may consider specific characteristics, including demographic factors, such as age or gender. Additionally, nurses may consider setting. Pediatric patients in a critical care unit, for example, may serve as the patient population focus of a clinical question.

Intervention

An intervention means the treatment under consideration. When defining an intervention, nurses first describe it and then consider how its administration may vary in dosage, delivery mode, or delivery frequency.

Comparison Intervention

To measure an intervention’s efficacy, it is helpful to compare it with an alternative intervention. Comparison interventions may include a placebo, the absence of a risk factor, or no intervention.

Outcome

An outcome means the results or consequences of the intervention. Outcomes include both actual and possible harmful effects and should focus on the characteristics of the outcome important to the patient.

Time

Nurses have the option of including a time frame in their questions. In this way, they may form the following PICOT question: In female adults with fertility problems (P), how does Femara (I) compared with Clomid (C) affect ovulation (O) within a single menstrual cycle (T)?

Gathering Research Literature

With a carefully constructed PICOT question in hand, nurses can begin their search for evidence-based answers. One strategy to find relevant information is to enter the most significant terms and phrases from the PICOT question into a database’s search engine. Nurses may also conduct searches on each individual section of their PICOT question.

These methods help nurses locate randomized controlled studies, systematic reviews, and other scientific work related to their question.

Critically Assessing Evidence

After gathering research literature, nurses evaluate it to eliminate unreliable or inapplicable studies. Only studies conducted using rigorous, reliable, reproducible methods will prove useful. To help their patients, nurses must be able to produce results in their own practice similar to those reported in the study.

The process of critically appraising research literature involves:

  • Assessing the question that the study addresses
  • Determining the validity of the study’s methods
  • Evaluating the study’s results
  • Reviewing how or if the study’s results apply to the situation in question

To draw useful conclusions from the scientific literature, nurses may create tables to organize information. They can then compare findings, as well as develop a broader understanding of the body of evidence. This also allows nurses to locate patterns across the studies and better interpret the researchers’ recommendations.

Making a Clinical Decision Based on Evidence, Patient Preferences, and Clinical Expertise

The next step of evidence-based practice involves making a clinical decision based on the evidence, patient preferences, and the nurse’s clinical expertise. This may involve consulting with patients and presenting them with evidence about a specific intervention. It may also involve creating an action plan that details how nurses will implement the practice change as well as evaluate it.

Evaluating the Results of the Decision

The final step of evidence-based practice involves evaluating whether implemented changes produced the intended results. Nurses must consider the overall effect the practice change had on the quality of health care delivered, patient health, and patient satisfaction. They must also consider any unexpected adverse effects, such as complications and extra costs.

Nurses can evaluate the results of their decision through comparison. They may contrast the outcomes of patients receiving the updated clinical practice with the outcomes of patients who received the replaced clinical practice to determine what, if any, gains were made.

Using Evidence-Based Practice to Drive Better Care Delivery

Evidence-based practice in nursing both empowers clinicians and improves patient health. Bringing research findings into clinical practices helps ensure that patients receive the best and most up-to-date care.

Hawai‘i Pacific University offers aspiring nurses a comprehensive BSN to DNP program that teaches evidence-based practice. Students have three concentrations to choose from:

  • Family Nurse Practitioner
  • Psychiatric Mental Health Nurse Practitioner
  • Adult-Gerontology Acute Care Nurse Practitioner

Learn more about how Hawai‘i Pacific University’s online BSN to DNP program prepares nurses to use evidence-based practice that drives better care.

Recommended Readings

Nursing Advocacy: The Role of Nurses Advocating for Patients

Patient Rights and the Essential Role of Nurses

Which Nurse Practitioner Specialty Is Right for Me?

Sources:

Agency for Healthcare Research and Quality, EvidenceNOW in Action

AHA Journals, “Impact of Evidence‐Based Stroke Care on Patient Outcomes: A Multilevel Analysis of an International Study”

American Association of Nurse Anesthesiology, Evidence-Based Practice

American Association of Nurse Practitioners, “Why Choose Evidence-Based Practice?”

American Nurse, “Introduction to Qualitative Nursing Research”

American Nurses Association, Code of Ethics for Nurses with Interpretive Statements

American Physical Therapy Association, Components of Evidence-Based Practice

American Speech-Language-Hearing Association, Evidence-Based Practice (EBP)

American Speech-Language-Hearing Association, How to Search for External Evidence in Communication Sciences and Disorders (CSD)

American Speech-Language-Hearing Association, The EBP Process

Canadian Nurses Association, Evidence-Based Practice

Career Trend, “What Are the Benefits of Quantitative Research in Health Care?”

Centers for Disease Control and Prevention, Estimated Influenza Illnesses, Medical Visits, Hospitalizations, and Deaths in the United States — 2019-2020 Influenza Season”

Centers for Disease Control and Prevention, What Are the Benefits of Flu Vaccination?

Harvard Business Review, “4 Ways to Make Evidence-Based Practice the Norm in Health Care”

Health Systems and Policy Research, “Evidence Based Practice: A Concept Analysis”

Journal of the American Association of Nurse Practitioners, “Evidence-Based Interventions Cause Multifold Increase of Influenza Immunization Rates in a Free Clinic”

Nursing Centered, “Improving Healthcare Quality, Patient Outcomes, and Costs With Evidence-Based Practice”

The O&P Edge, “The Role of Expertise in Clinical Decision-Making: Is Experience Evidence?”

Physiopedia, Evidence Based Practice (EBP)

Wiley Online Library, “Evidence-Based Practice Culture and Mentorship Predict EBP Implementation, Nurse Job Satisfaction, and Intent to Stay: Support for the ARCC Model”