CONNECTING KNOWLEDGE TO PRACTICE
Increased emphasis on efficiency, cost containment, and quality in a health care delivery system that is rapidly changing, and the advancement of science and technology have led to the need for reliable, up-to-date evidence about effective healthcare interventions.
The movement of evidence-based healthcare has evolved over time. Dominant themes for the decades of 1970-1980 were “doing things cheaper” (efficiency) and “doing things better” (quality improvement). These two themes together were considered “doing things right.” During 1980-1990, “doing the right things” (increasing effectiveness) was the major theme and this, in combination with “doing things right” was considered “doing right things right” in the 21st century (Gray, 1997, p. 17).
These days, practitioners have come to expect evidences for their interventions, some to the point of saying, “In God we trust: All others bring data” (Cornelia Beck, as cited in Tanner, 1999).
The history of evidence-based nursing is closely related to the evolution of evidence-based health practice and evidence-based medicine. This article presents a brief overview of the essential features of these, related criticisms/issues, and responses to the criticisms. Selected resources providing summaries of effective interventions and/or high quality evidence are provided for those who may be interested in learning more about the topics.
EVIDENCE-BASED PRACTICE DEFINED
Evidence-based practice refers to a decision-making approach based on integrating clinical expertise with the best available evidence from systematic research. This is in contrast to opinion-based decision-making that is based primarily on values and resources (Gray, 1997). Five steps are involved in evidence-based healthcare: 1) defining the question; 2) collecting evidence; 3) critical appraisal; 4) integration of the evidence and patient factors to make and carry out the decision; and 5) evaluation of the whole process (McKibbon, 1999).
The major purpose of evidence-based medicine is the elimination of the use of expensive, ineffective, or dangerous medical decision-making (Rosenberg and Donald, 1995). Sackett, et al. (as cited in Ingersoll, 2000) defined that “evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research” (p. 151-152).
This definition spurred criticisms by concerned practitioners and scholars. Major concerns expressed by some nursing scholars were the failure to mention theory and patient input into clinical decision-making, and the explicit requirement of “systematic” research in the definition. Addressing these concerns, Ingersoll (2000) proposed the following definition. “Evidence-based nursing practice is the conscientious, explicit and judicious use of theory-derived, research based information in making decisions about care delivery to individuals or groups of patients and in consideration of individual needs and preferences” (p. 152).
The notion of evidence-based nursing practice is not new. Gortner, et al. (1976) made a plea for implementation of research findings in nursing practice, and Roper (1977) pointed out that nursing practice was relying on a traditional base that is primarily opinion-based and not within a framework of scientific verifications.
Emphasis on applying research findings to clinical practice has continued throughout recent decades by many researchers and practitioners alike who have identified several barriers to using evidence in practice. Major barriers include lack of time, poor access to the literature, and lack of ability to judge the quality of the research (Ciliska and DiCenso, 1999).
RESOURCES FOR IMPLEMENTING EVIDENCE-BASED NURSING PRACTICE
In order to facilitate the implementation of evidence-based nursing while addressing some of these barriers, government, professional organizations and others have created numerous resources such as the following, which are by no means exhaustive:
The Agency for Health Care Policy and Research (now called Agency for Healthcare Research and Quality, AHRQ) has produced 697 “evidence-based” guidelines for various health problems (www.guideline.gov).
The Agency for Healthcare Research and Quality began an initiative, “Translating Research Into Practice (TRIP)” in fiscal year 1999. The aim of this initiative was to implement evidence-based tools and information in diverse health care settings among practitioners caring for diverse populations. To date they have issued two rounds of Requests for Applications. The first round was aimed at generating new knowledge about effective and cost-effective approaches for some select health problem areas and the second round on continued development of partnerships between researchers and health care systems and organizations (AHRQ Profile, Pub. No. 00p005, March 2000).
The practice guidelines for the diagnosis and management of allergic diseases, “Allergic Disorders, Promoting Best Practice” were written by multi-disciplinary health care professionals representing 23 national health care associations and the federal government. Relative to the development of the guidelines, Nativio (2000) cautioned, “we must guard against the guidelines becoming more important than the clinician” (p. 58). The guidelines are not intended to substitute for decisions based on clinician expertise or the patient’s individual needs and preferences.
The Critical Care Nurse journal added a new feature in the February 1998 issue called “Protocols for Practice: Applying Research at the Bedside” (p. 94). These protocols are written by a team of experts led by the executive editor of the journal and are offered as a clinical resource developed by the American Association of Critical Care Nurses (Fontaine, 1998).
In 1997, a new journal, Evidence-based Nursing (EBA) was launched by colleagues in the United Kingdom and Canada. The general purpose of the journal is to “select from the health related literature those articles reporting studies and reviews that warrant immediate attention by nurses attempting to keep pace with important advances in their profession.” (Evidence-Based Nursing, January 1999, p. 2). One recent issue (January 1999) of EBN listed 132 journals reviewed for that issue. These journals were in the areas of medicine, surgery, psychology, epidemiology, and nursing; and they were published in the USA, UK, Canada and Australia. As best as one can see, 19, or 14 percent of these journals were nursing journals. This wide net of literature used for EBN illustrates how nursing has come to embrace scientific evidence for nursing practice with disregard to the origin of the evidence (i.e., source of discipline) as long as the evidence is judged relevant to nursing practice and beneficial to patient care. Important to note here is the fact that increasing numbers of nurse researchers are publishing in non-nursing journals worldwide including those listed in the January 1999 issue of EBN.
RESPONSES TO CRITICISMS OF EVIDENCE-BASED PRACTICE
Evidence-based nursing is not without criticism. Some of the major criticism and issues regarding the applicability of evidence-based practice to nursing are outlined here with corresponding responses:
“Evidence-based healthcare overemphasizes randomized controlled trials (RCT) and systematic reviews.” RCT is the most appropriate design for evaluating the effectiveness of a nursing intervention. This is because through random assignment of patients to comparison groups, known and unknown confounders are distributed evenly between the groups ensuring that any difference in outcome is due to the intervention. Systematic overviews of the research literature, the statistical combination of the results of more than one study, or meta-analysis, effectively increase the sample size and results in a more precise estimate of treatment effect than can be obtained from any of the individual studies used in the meta-analysis. However, qualitative studies are also the best designs to better understand patients’ experiences, attitudes, and beliefs. Rigorous qualitative research is based on explicit purposive strategies, in-depth analysis of data, and a commitment to examining alternative explanation. (Dicenso and Cullum, 1998). In essence, both randomized clinical trials and qualitative research are important for evidence-based nursing as they produce evidences that can be used by nurses and other healthcare practitioners. It is the nature of health problems clinicians confront that will determine which evidences to use.
– “Emphasis on ‘routinization’ of evidence-based nursing may work against strategies of professional authority and autonomy embedded in the new nursing” (Bonell et al., 1999). No one supports the routine practice (“routinization”) of evidence-based nursing without nurses’ critical appraisal of individual patients and their unique needs. In fact, nursing knowledge and judgement implicit in the use of evidence-based nursing strengthen professional authority and autonomy.
Third party payers may ask, “should we pay for care that has not been validated as the best way to improve the patient’s health status?” Not all interventions lend themselves to randomized clinical trials for external validity. Hence, developing a payment system on the “validated” interventions only would be unreasonably restrictive, and antithetical to the spirit of evidence-based practice.
– “Evidence-based nursing isn’t `new.”‘ The concept itself is not new, as evidence-based practice provides clinicians with scientific evidences to solve the patients’ problems they confront. However, systematic approach and resources available for implementation of evidence-based nursing are new. Current approach facilitates the “access” to research findings (Discenso and Cullum, 1998) and helps clinicians to use them with ease.
– “Evidence-based nursing leads to “cookbook” nursing and a disregard for individualized patient care.” In practicing evidence-based nursing, a nurse has to decide whether the evidence is relevant for the particular patient, including the patient’s unique clinical circumstances such as co morbid conditions and preferences. Evidencebased clinical decisions have four major components: (1) clinical experuse, (2) patients’ preferences for alternative forms of care, (3) clinical research evidence, and (4) available resources. For a given decision, clinical expertise and patient preference may override the other components (Dicenso and Cullum, 1998).
– “Emphasis on ‘current’ best care practice. This is because `today’s golden truth may easily be tomorrow’s inaccurate, or even inappropriate information.’ (McKibbon, 1999).” Nurses in practice should monitor the validity of current evidences as they apply to their patient care, and this continuous formative evaluation may lead to other research that may change the evidences that are currently available.
“Is evidence-based nursing the same as research utilization?” As Stetler et al. (1998) stated, evidence-based practice encompasses more than research utilization. The authors recognized that evidence on which practice is based can include performance data from quality improvement initiatives, consensus recommendations of recognized experts, and affirmed experience, as well as research findings.
In conclusion, evidence-based nursing practice will continue to play a significant role in everyday practice of nurses. Comprehensive definition of evidence-based nursing by Ingersoll (2000) and evidencebased practice guidelines for various health problems/needs provide a good start for nurses to practice evidence-based nursing. Our patients stand to gain the most as nurses and other health professionals make evidence-based practice the norm of their everyday practice.
EVIDENCE-BASED PRACTICE RESOURCES
For more information about evidence-based practice, please refer to the following list of selected resources of high quality evidence:
– The Cochrane Library (For details: Update Software, Summertown Pavillion, Middle Way, Summertown, Oxford OX2 7LG; and for internet access: URLs: http://www.medlib.com and http:// www.hcn.net.au/
Cochrane Collaboration (http://hiru.mcmaster.ca/ COCHRANE)
The Agency for Healthcare Research and Quality for National Guideline Clearinghouse (http:// www.ngc.gov)
American College of Physicians, ACP Journal Club (ACP Journal Club on CD-ROM: http:// www.acponline.org)
Best Evidence data base (CD-ROM available from BMJ Publishing, BMA House, Tavistock Square, London WC1H 9JR and URL: http:// hiru.hirunet.mcmaster.ca/acpjc)
Agency for Healthcare Research and Quality (March 2000). AHRQ profile: Quality research for quality healthcare. AHRQ Pub. No. 00-p005.
Bonell, C. (1999). Evidence-based nursing: a stereotyped view of quantitative and experimental research could work against professional autonomy and authority. Journal of Advanced Nursing, 30 (1), 18-23.
Ciliska, D. & DiCenso, A. (1999). Centres of evidence-based nursing: directions and challenges. Evidence-Based Nursing, 2 (4), 102-104.
Copyright Illinois Nurses Association Nov 2000
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