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Chapter 1: Nursing’s Commitment to Best Clinical Decisions

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DOI:

10.1891/9780826127594.0001

Authors

  • Christenbery, Thomas L.

Abstract

This chapter helps a reader to draw conclusions about the effectiveness of evidence-based practice (EBP) in a variety of clinical situations among various patient populations and to outline historical and discipline-specific viewpoints on EBP. It also helps to distinguish the similarities and differences among EBP, research, and quality improvement as used in clinical environments. The chapter presents two EBP scenarios which are emblematic of today's healthcare service. Scenario 1 dominates as an example of the more practiced method of healthcare service. In Scenario 2, nurses are actively engaged in the process of EBP by demonstrating standardization of best evidence in practice and reducing illogical variation in care. Understanding essential contextual knowledge about EBP is vital to successfully generating best evidence into practice. The chapter explores background knowledge related to EBP as a foundation for understanding its importance to healthcare and application to a more informed practice of modern nursing.

Objectives

After reading this chapter, learners should be able to:

  1. Draw conclusions about the effectiveness of evidence-based practice (EBP) in a variety of clinical situations among various patient populations

  2. Outline historical and discipline-specific viewpoints on EBP

  3. Distinguish the similarities and differences among EBP, research, and quality improvement as used in clinical environments

EVIDENCE-BASED PRACTICE (EBP) SCENARIOS

Scenario 1

Pediatric clinic nurses in a medically underserved area were concerned when they discovered their patients’ rate of tooth decay, prior to starting kindergarten, surpassed the national average of 40%. To alleviate the tooth decay problem, the nurses contacted a major oral healthcare product distributor and subsequently received a large supply of toothbrushes and toothpaste. At the end of each clinic visit, nurses gave each family a toothbrush and toothpaste for each child. Despite these efforts, the clinic continued to report excessive rates of tooth decay in their pediatric population.

Scenario 2

Pediatric clinic nurses in a medically underserved area were concerned when they discovered their patients’ rate of tooth decay, prior to starting kindergarten, surpassed the national average of 40%. Nurses observed that the American Academy of Pediatric Dentistry (AAPD) Oral Health Risk Assessment guidelines to assess and manage early childhood dental caries were underused by the clinic’s practitioners. In fact, a methodical review of the electronic health records (EHRs) indicated that clinic practitioners were following AAPD assessment and management guidelines 10% of the time. The nurses’ concern led them to inquire, “In patients, between ages 2 and 5 years, would an EHR reminder promote practitioner adherence to AAPD guidelines compared with no use of an EHR reminder?” The nurses reviewed relevant research literature about the efficacy of EHR reminders for clinic populations and found strong evidence supporting the use of EHR reminders. At a monthly team meeting with clinic practitioners, the nurses discussed implementing EHR AAPD guideline reminders for all 2- to 5-year-olds. Clinic practitioners noted that patients’ parents expressed concern about the tooth decay problem, and they agreed on the value of trying the EHR reminder. Thus, the EHR reminder was implemented at the clinic. A chart review, conducted 6 months postimplementation, found AAPD guidelines were incorporated by practitioners into the clinic visits of children 2 to 5 years of age 90% of the time.

Discussion

The preceding scenarios are emblematic of today’s healthcare service. Unfortunately, Scenario 1 dominates as an example of the more practiced method of healthcare service. In Scenario 2, nurses are actively engaged in the process of EBP by demonstrating standardization of best evidence in practice and reducing illogical variation in care (Stevens, 2013). Since 2001, the Institute of Medicine (IOM) has repeatedly recommended EBP as the preferred course to close the gap between what healthcare providers know to be effective healthcare practices and what is actually practiced (Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, 2011; IOM, 2001, 2003, 2008a,2008b). Scenario 2 focuses on the IOM recommendation that nurses lead interprofessional teams to improve both patient care and healthcare delivery systems (Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, 2011).

In Scenario 2, the nurses’ curiosity related to a client-centered care problem led them to question current practice standards. The nurses collected data associated with an identified problem and then searched the research literature for best evidence and evaluated the merit of the evidence. The nurses intentionally integrated research, clinical expertise, and patient/family values to implement an effective practice change. Importantly, the practice change was followed up using an appropriately focused evaluation.

The nurses in Scenario 1, while meaning well, relied on their best inclinations to inform practice. They failed to question whether best or current practices were being used, and whether those practices could bring about desired health outcomes. Critical thinking was insufficient in Scenario 1; therefore, a systematic approach to the evaluation and resolution of a significant health problem was overlooked. Unlike the nurses in Scenario 2, those in Scenario 1 failed to use a formal process with specified steps to change and evaluate clinical practice concerning an important health problem.

COMMITMENT TO BEST CLINICAL PRACTICES

EBP Defined

EBP is defined as the conscientious, explicit, and judicious use of the integration of current best evidence, clinical expertise, and patient values into the decision-making process for patient care (Duke University, 2016; Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996; Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). The key terms within this definition are permanently at the core of nursing care and therefore worthy of review:

  • Conscientious: Being cautious and thorough in the selection and review of all evidence.

  • Explicit: Being open and transparent regarding the detection of flaws and gaps in the evidence.

  • Judicious: Using logic and sound judgment to build compelling cases for practice changes.

  • Current best evidence: “Best” implies a ranking. Typically, nurses engaged in EBP use quantitative or qualitative research from the highest order or level, and that possesses the utmost quality as evidence. However, not all phenomena related to nursing care have been researched; therefore, nurses sometimes rely on the best nonresearch evidence, such as opinions from expert panels or case studies.

  • Clinical expertise: The nurse’s cumulative experience in clinical practice, education, administration, and informatics.

  • Patient values: The patient’s preferences, individual concerns, and expectations related to quality care.

Commitment to Best Clinical Decisions

Nursing, as a profession, seeks to ensure the care nurses deliver is scientifically sound, clinically effective, compassionate, and meets each patient’s needs. Research evidence alone may not always lead to the highest quality care and best practice outcomes. However, integration of best research evidence, clinical experience, and patient values may better determine the provision of optimal nursing care and enhanced patient outcomes. For example, nurses caring for residents in a rural long-term care facility were concerned about the residents’ nighttime restlessness. The nurses reviewed relevant research literature and found evidence to suggest that a daytime social dancing activity decreased nighttime restlessness, and the nurses decided to implement a dance therapy program for residents. After some reflection, the nurses understood dancing would be contraindicated for a number of residents in regard to their religious/cultural heritages. To derive the benefits of movement while respecting all residents’ religious/cultural values, the nurses implemented a low-impact step aerobics social, which was acceptable as a cultural norm. Integrating research, clinical background experience, and resident values/preferences, the nurses were able to initiate a program that decreased nighttime restlessness.

Regardless of academic degree or program type (e.g., ADN, BSN, MSN, DNP), all nurses and nursing students, with direct patient care responsibilities, are expected to use EBP (American Association of Colleges of Nursing, 2017). This directive is based on substantive reasons:

  • EBP helps ensure patients receive nursing care that best addresses their individual needs and, therefore, leads to improved healthcare outcomes (Wells, Pesaro, & McCaffery, 2008).

  • At the point of care, EBP provides sound rationale for clinical decision making and conceptually clarifies the rationale (Scott & McSherry, 2008).

  • Because EBP provides a sound basis for individualized care, risk, and harm are minimized for the patient (Barnsteiner, 2011).

  • Nurses engaged in EBP become proficient in evaluating research evidence and consequently expose gaps and inconsistencies in healthcare knowledge (Fawcett & Garity, 2009).

  • EBP has been associated with lower healthcare-related cost compared with care that remains founded on tradition and dated policies and procedures (Sedwick, Lance-Smith, Reeder, & Nardi, 2012).

  • EBP has demonstrated a relationship with greater job satisfaction and enhanced professional collaboration (Hughes, 2008).

Nurses engaged in EBP typically follow a practice change trajectory from initial nurse inquiry to practice recommendation (see Figure 1.1). Depending on academic degree and role expectations, all nurses have designated levels of responsibility to make significant commitments to patient care along an EBP path to practice change. Commitment means going above and beyond normally expected behaviors. Individuals committed to a profession, such as nursing, generally invest considerable personal involvement in the work of the profession and tend to do the work well (Friss, 1983). Because the decisions nurses make have important patient outcomes, clinical decision making is a hallmark of nursing’s professional work (Benner, Hughes, & Sutphen, 2008). Nurses who are deeply committed to making optimal clinical decisions often share a scholarly commitment to the use of EBP.

FIGURE 1.1
Evidence-based path to practice change
9780826127594_fig1_1

Source: Courtesy of Nancy Wells.

SCHOLARLY CHARACTERISTICS OF NURSES ENGAGED IN EBP

A scholar is someone with a keen focus who delineates an area of inquiry related to his or her work (Tolk, 2012). Nurses who support their practices using EBP seem to share certain scholarly attributes. For example, nurses who use EBP are inquisitive about the current state and standards of patient care and through questioning begin to challenge the status quo (Christenbery, Williamson, Sandlin, & Wells, 2016). Nurses who seek the best current knowledge, in union with clinical expertise and patient values, display mental integration consistent with critical thinking (Profetto-McGrath, Hesketh, Lang, & Estabrooks, 2003). The transference of new knowledge to influence patient care is the essence of disruptive innovation (Christensen, Horn, & Johnson, 2011; Nieva et al., 2005). Nurses engaged in EBP use effective change agent skillsets to modify practice (Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2005). The adoption of best evidence into practice is facilitated by nurses who use constructive interpersonal communication skills (Berry, 2016). By necessity, nurses who implement EBP are context oriented to the patient’s environment (DiCenso, Guyatt, & Ciliska, 2002). Nurses who evaluate outcomes related to the application of new research findings to practice are engaged in validating knowledge creation (Nieva et al., 2005). Importantly, a collaborative spirit is needed when nurses share significant EBP findings and outcomes (Titler & Everett, 2001).

In summary, making evidence-based clinical decisions and practice changes requires an assemblage of scholarly strengths and characteristics (see Table 1.1). An important aim of this book is to help you identify, further develop, and apply these scholarly characteristics so that your commitment to making the best clinical decisions and practice changes may be maximized, befitting a nurse engaged in EBP.

EVIDENCE

Evidence, in healthcare, was traditionally thought of as a body of facts indicating whether a belief (e.g., patients desire pain relief) or proposition (e.g., foot elevation decreases pedal edema) was true. In both medicine and nursing, the “body of facts” was typically derived from the scientific method (see Figure 1.2) and applied to healthcare decision making (Claridge & Fabian, 2005). Nightingale used the scientific method (i.e., research) to great effect in exploring differential mortality among population subgroups (Nightingale, 1863) and excess mortality after childbirth (Nightingale, 1871).

The scientific method consists of a systematic set of skills to investigate phenomena for the purpose of acquiring new knowledge or validating and integrating previously gained knowledge. The scientific method of inquiry is empirical and requires a working hypothesis that can be tested through observation or experiment (Goldhaber & Neito, 2010). Not all nursing research questions are a suitable fit for experimental research designs; thus, nursing research uses multiple other forms of inquiry (e.g., qualitative research, descriptive studies) to study its phenomena.

TABLE 1.1
Scholarly Characteristics of Nurses Engaged in Evidence-Based Practice (EBP)
EBP Scholarly CharacteristicDefinitionDemonstrated Behavior
InquisitiveHaving a desire to learn more about patient care and healthcare systems

  • The nurse wonders if music CDs at bedtime will promote quality of sleep for patients on a cardiac surgery unit.

ChallengerA query regarding the truth or efficacy of healthcare-related phenomena

  • The nurse begins to ask peers if alternative methods of sleep promotion have ever been tried on the unit.

Critical thinkerActively and skillfully analyzing and synthesizing information from a variety of evidence sources

  • The nurse reviews and assesses research literature regarding music therapy relaxation interventions.

  • Using intake admission forms, the nurse begins chart review to assess patients’ preferred bedtime rituals.

Disruptive innovatorCreating or modifying an intervention/procedure that eventually disrupts an old intervention/procedure

  • The nurse seeks support from peers, physicians, and managers to pilot music tape relaxation intervention on selected patients.

Change agentActively engaged in transforming patient care by altering current patient care standards

  • The nurse develops a plan to manage and resolve resistance to change regarding music therapy relaxation.

CommunicatorEffective use of communication skills to convey ideas, innovations, and plans regarding evidence-based intervention

  • The nurse develops a clear vision of a plan for use of music relaxation tapes and clearly articulates that plan to others.

Context orientedAware of the circumstances that form the setting for EBP intervention

  • The nurse is aware of and sensitive to the unit’s established evening care routines.

EvaluatorAn activity to assess the amount or value of EBP implementation

  • The nurse creates a plan to evaluate sleep quantity and quality postintervention.

Knowledge creatorFormation of new ideas regarding EBP implementation

  • The nurse learns that the music CD relaxation intervention is efficacious.

Collaborative spiritWorking with others to accomplish a desired patient outcome

  • The nurse recognizes the contributions of the team effort and shares outcomes with the team and others.

FIGURE 1.2
Representation of the scientific method
9780826127594_fig1_2

Prior to the 1970s, the process by which the scientific method and research were selected and applied in medicine and nursing was highly individualized and subjective. Physicians (DiCenso et al., 2002) and nurses (Beyea & Slattery, 2013) frequently determined independently what research evidence, if any, to consider and how to merge that research with their personal beliefs and contextual factors. There was no formal process in healthcare to determine which research evidence to use, how best to use the research, to what extent to use the research evidence, and on what population. There was an implicit assumption that physicians and nurses would appropriately incorporate research evidence into their practices based on their qualifications as educated, licensed, and altruistic practitioners.

HISTORICAL PERSPECTIVE OF EBP

In 1972, Archibald Cochrane cast doubt on the effectiveness of practitioners independently and arbitrarily applying select scientific knowledge to clinical decision making. Cochrane was especially concerned that practitioners would avoid the results of a single study if the study’s results failed to fit the practitioner’s preconceived ideas. This concern led Cochrane to advocate rigorous and systematic reviews of research (i.e., randomized controlled trials, cohort studies) to provide exhaustive summaries of science related to specific research questions (Beyea & Slattery, 2013; Claridge & Fabian, 2005). Cochrane’s advocacy of systematic reviews of randomized controlled trials led to the development of the Cochrane Library database of systematic reviews (www.cochranelibrary.com). Today, the Cochrane Library is an invaluable resource for nurses and other healthcare providers engaged in EBP.

In 1992, Guyatt introduced the term evidence-based medicine (Evidence-based Medicine Working Group, 1992; Zimerman, 2013). Similar to Cochrane, Guyatt wanted to shift clinical decision making from a position of instinctive, unsystematic clinical experience and pathophysiologic rationale to clinically relevant research. In 1996, Sackett and physician colleagues explained evidence-based clinical decision making as a confluence of systematic research, clinical expertise, and patient preferences (Sackett et al., 1996). Since then, evidence-based clinical decision making has been widely accepted in multiple health disciplines including nursing, social work (Social Work Policy Institute, 2016), and public health (Developing Healthy People 2020, 2010).

Prior to Sackett’s definition of evidence-based clinical decision making, nursing as a profession focused its clinical decision making on research utilization as a method of translating research into practice (Titler & Everett, 2001). Although research utilization incorporates the critical appraisal and application of research to practice, research utilization did not integrate the nurse’s clinical experience or patient’s values.

Current nursing leaders, in the area of EBP, include nursing’s rich tradition of using meaningful research findings in conjunction with best experiential evidence and patient values to inform clinical decision making as the definition of nursing EBP (Dearholt & Dang, 2012; Melnyk & Fineout-Overholt, 2015; Stevens, 2013). This definition of EBP is specific to nursing and at the same time aligns nursing with medicine and other disciplines engaged in providing care in the patient’s best interest.

DIFFERENTIATING EBP, RESEARCH, AND QUALITY IMPROVEMENT

Quality is central to healthcare. The IOM (2001) describes quality as the degree to which healthcare services increase the likelihood of desired health outcomes and are consistent with up-to-date professional knowledge. The Agency for Healthcare Research and Quality (n.d.) explains quality healthcare as doing the right thing, at the right time, in the right way, for the right patient, and having the best possible outcomes. An informed and effective level of quality care is dependent on three key factors: (a) a nursing workforce engaged in EBP, (b) a culture that is amenable to quality improvement practices, and (c) a work environment that supports the use and practice of healthcare-related research. In addition to EBP, this book explores the direct linkages that research and quality improvement (QI) contribute to clinical decision making and, consequently, the richer repertoire of healthcare options and higher quality patient care outcomes.

EBP, research, and QI are three distinct terms that are essential to quality healthcare, yet are frequently used interchangeably and, therefore, used improperly (Hedges, 2009; Newhouse, 2007; Newhouse, Pettit, Poe, & Rocco, 2006; Shirey et al., 2011). The literature is unquestionable in reporting that much misunderstanding exists in how these terms are used improperly.

Misnomers are often harmless; however, using the terms EBP, research, and QI interchangeably in clinical practice leads to unwarranted outcomes such as disregard for Internal Review Board (IRB) protocol, absence or lack of required project oversight, and most importantly, risks (e.g., absence of full disclosure) to participants or subjects. Misusing these three terms may be related, in part, to the nature of their unique and corresponding relationships (Newhouse, 2007). Nevertheless, nurses and other healthcare providers need to make a deliberate effort to use these three terms appropriately.

To assist in the appropriate use of EBP, research, and QI, it is helpful to consider each term in regard to classifications of context, methodology, or scholarly relevance. Context consists of circumstances that form the background for EBP, research, and QI and includes (a) history, (b) definition, (c) and purpose. Methodology refers to various functions and entities that put EBP, research, and QI into action and include (a) rigor, (b) data collection and measures, (c) project oversight, (d) population of interest, (e) funding, (f) interconnections, (g) models and methods, and (h) data analysis. Scholarly relevance demonstrates the intellectual contributions to quality that proper use of EBP, research, and QI provide and is composed of (a) generalizability and transferability and (b) dissemination of findings.

Importantly, the summation in Box 1.1 provides a rationale for remaining vigilant in using EBP, research, and QI as separate terms. Table 1.2 depicts each major classification and related dimensions as a means to help clarify confusion and misuse among EBP, research, and QI.

The EBP nursing movement is in its early decades. Both healthcare organizations and schools of nursing have important roles in assisting nurses to clearly differentiate among EBP, research, and QI. When clarity among these three problem-solving processes is achieved, nurses can more easily begin to develop the necessary skills and appropriate activities to more fully engage in and support EBP, research, and QI.

BOX 1.1
Summary of Evidence-Based Practice, Research, and Quality Improvement

Summation:

Evidence-based practice (EBP): This requires practitioners to ask compelling questions, search for best evidence, evaluate the strength and quality of evidence, and implement practice change if warranted. An EBP project is only as good as the “best evidence” related to research, clinical experience, and patient values. Therefore, EBP is not synonymous with research or quality improvement (QI).

Research: Quantitative research can possibly establish correlation or causality. Qualitative research can provide new understandings of phenomena. The approach to research should be to discover new knowledge, which is not an expected function of EBP or QI.

Quality improvement: This does not establish correlation or causality. Methodologically, QI designs are weak and have poor, if any, internal validity, reliability, and sustainability related to QI projects. Therefore, QI should not be misconstrued as EBP or research enterprises. A commonly held, erroneous belief suggests that generation of QI data signifies nurses are actively engaged in research. QI does not, as a rule, meet federally instructed research design requirements or human participant protection rules.

TABLE 1.2
Distinguishing Characteristics of Evidence-Based Practice (EBP), Research, and Quality Improvement (QI)
ContextEvidence-Based PracticeResearchQuality ImprovementComments
Historical roots

  • Originated with Cochrane, 1972

  • Founded on criticism of lack of reliable evidence to support commonly used interventions

  • Dates to antiquity

  • Heavily influenced by scientific method beginning in 17th century

  • Credited to William Deming, 20th century, as a means to improve product quality

  • EBP, research, and QI have three distinct historical origins underscoring the heterogeneity of each term

Definition

  • Integration of clinical expertise, patient values, and best research evidence into the decision-making process for patient care (Duke, 2016)

  • Systematic inquiry using orderly, disciplined methods to establish facts or achieve new knowledge (Polit & Beck, 2012)

  • Data-driven systematic method with individuals collaborating to improve select internal systems, processes, costs, productivity, and quality outcomes (Shirey et al., 2011)

  • Not within the realms of EBP or QI to generate new knowledge and should not be credited as reliable (i.e., consistently producing the same results under similar circumstances) methods for generating new knowledge

Purpose

  • To rank evidence that will be used to answer clinical or systems questions

  • Describe, explain, or predict phenomena to either verify existing knowledge or create new knowledge

  • Identify organizational or systems problems to improve safety, efficiency, and quality of healthcare

  • EBP and QI use existing knowledge to implement improvement; research creates the knowledge used for EBP and QI

MethodologyEvidence-Based PracticeResearchQuality ImprovementComments
Rigor

  • Rigorous to the extent that certain steps are followed to determine the best evidence for select patient care scenarios

  • Whether quantitative or qualitative, must be extremely rigorous to produce the highest levels of evidence

  • QI is considered least rigorous and produces the lowest level of evidence

  • Level of scientific rigor provides rationale for clear and accurate use of terms

  • Research: most rigorous

  • EBP: Somewhat rigorous

  • QI: Least rigorous

Data collection and measures

  • Data collection usually straightforward and efficient

  • Uses complex measures, requiring precise administration

  • Measurement tools expected to have high estimates of reliability, validity, specificity, and/or sensitivity

  • Data collection usually straightforward and efficient

  • Depending on the scope of the project, resources and cost usually minimal for EBP and QI

  • Research requires well-planned allocation of resources and is often time consuming

Project oversight

  • Regulating body is the home organization

  • Extensive and includes oversight by Institutional Review Board (mandatory) and at times Office of Human Research Protection, Food and Drug Administration, as well as state and local laws

  • Oversight from the home organization

  • May be influenced by Joint Commission on Accreditation of Healthcare Organizations and Centers for Medicare and Medicaid Services

  • EBP and QI require IRB approval if there is possibility of publishing findings or if patients may possibly be exposed to harm

  • IRB approval unquestionably required for qualitative and quantitative research

Population of interest

  • Specific unit (e.g., Renal Dialysis Unit) or a patient population (e.g., children with thalassemia) within a healthcare organization

  • Persons for whom the findings may be generalized (quantitative) to or transferable (qualitative) to

  • Specific unit (e.g., Renal Dialysis Unit) or a patient population (e.g., children with thalassemia) within a healthcare organization

  • Population benefit is usually immediate with EBP and QI

  • Population benefit may be delayed with research populations

Funding

  • Usually internal to organization

  • May be internal or external (e.g., National Institutes of Health) depending on research question and scope of project

  • Usually internal to organization

  • EBP and QI frequently do not require funding

  • Research almost always requires funding

Interconnections

  • Provides insight for potential QI projects

  • May detect gaps in evidence, indicating need for research

  • Informs opportunities for both EBP and QI projects

  • Impetus may be from QI projects that fail to produce quality or gaps found in literature as part of EBP project

  • Research evidence is often essential for the development of interventions to improve patient outcomes in QI endeavors

  • Inform both EBP and research

  • Research may support need for QI projects

  • Corresponding relationships among EBP, research, and QI are beneficial in providing a richer, more informed basis for nursing care

Models and methods usedExamples of frequently used models include:

  • Iowa Model of EBP

  • Academic Center for EBP Star Model of Knowledge Transformation (ACE Model)

  • Rosswurm and Larrabee

  • Uses scientific method or variation of scientific method if quantitative

  • Phenomenology, ethnography, grounded theory if qualitative

Examples of frequently used methods include

  • Six Sigma

  • LEAN Six Sigma

  • FOCUS-Plan Do Study Act (PDSA)

  • FOCUS-Plan Do Check Act (PDCA)

Discrete models and methods to achieve results indicate that EBP, research, and QI are not interchangeable terms
Data analysis

  • Usually descriptive statistics or bivariate analysis

  • Complex inferential statistics are often used with quantitative research, while qualitative analysis requires rich descriptive narrative

  • Usually descriptive statistics or statistical process control charts

 
Scholarly relevanceEvidence-Based PracticeResearchQuality ImprovementComments
Generalizability or transferability

  • Results may be transferable to other similar settings

  • Findings may be generalizable (quantitative) or transferable (qualitative) beyond home organization, depending on design and study rigor

  • Not generalizable beyond home organization

  • External organizations may benefit from lessons learned

  • Lessons learned from EBP and QI projects are often shared with external organizations

  • Results from research findings are often generalizable or transferable to other organizations or populations

Dissemination of findingsDissemination of findings excepted within organization; findings are frequently shared as posters/podiums at nursing conferencesDissemination of findings expected in poster/podium and literature; expected to reach regional, national, and international audiencesDissemination of findings excepted within home organization but not necessarily expected beyond home organizationImportant to keep in mind at outset of EBP and QI projects, if dissemination of findings is expected, IRB approval will be needed

To illustrate the differences among these three processes (i.e., EBP, research, QI), consider the following clinical example. While monitoring (QI) patients on a chronic respiratory unit, nurses found that patient fall rates had increased significantly over the past 6 months. The majority of these falls occurred in patients over 75 years of age and occurred during the night shift. To address this problem, unit nurses conducted an extensive systematic review of the literature related to falls in elderly hospitalized patients (EBP). The systematic literature review found evidence to support the following protocol: Hourly rounds on all high-risk fall patients by direct care staff (to include prompted voiding protocol) between 2400 and 0500 hours. If nurses had detected inconsistencies in the review of literature such as limiting evening fluid intake, the nurses may need to initiate a research study to more fully address prevention of the fall phenomenon (research). If the unit’s patients continue to experience an excessive number of falls following implementation of the fall protocol, additional monitoring may be needed to determine if direct care staff are indeed following the protocol (QI). Using the Agency for Healthcare Research and Quality Falls Management Program Self-Assessment Tool may identify a lack of staff adherence to the protocol and provide opportunity for further staff education on the value of the protocol. The nurses in this example monitored both practice and patient outcomes (QI), systematically reviewed the literature, and recommended a practice change (EBP). They were amenable to further scientific investigation (research) if the literature presented gaps or inconsistences related to relevant implementations.

CLINICAL DECISION MAKING AND EBP

Clinical decision making is the contextual, ongoing, and evolving process, whereby nurses gather, interpret, and evaluate data for the purpose of selecting optimal evidence-based courses of action (Tiffen, Corbridge, & Slimmer, 2014). Clinical decision making is a complex process requiring nurses to make choices far beyond limited, categorical options that lead to a defined course of action. Clinical decisions made by nurses occur within active, goal-shifting, and dynamic contexts. Clinical decisions consist of numerous practice-oriented considerations such as assessment, planning, implementation, and evaluation. External influences such as organizational support and allocated resources greatly impact clinical decisions. Internal factors such as the nurse’s degree of confidence and perceived controllability of clinical outcomes influence clinical decision making. Effective clinical decision making requires the use of a broad and in-depth knowledge base. Additionally, clinical decisions are almost always encumbered by a degree of uncertainty.

The complexities and ambiguities surrounding clinical decision making are frequently numerous and overwhelming. As nurses become increasingly involved in clinical decision making, it becomes more important for them to use EBP to make the most significant and justifiable decisions in the patient’s best interest. Joining the best research evidence, knowledge arising from the nurse’s clinical experience, and patient preferences supports an informed evidence-based clinical decision-making process.

SUMMARY

EBP leads to better patient outcomes; therefore, it is an important aspect of nursing care. EBP is widely encouraged at the organizational, state, and federal levels. Understanding essential contextual knowledge about EBP is vital to successfully generating best evidence into practice. This chapter explores background knowledge related to EBP as a foundation for understanding its importance to healthcare and application to a more informed practice of modern nursing.

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