This is the first article in a new series from the Arizona State University College of Nursing and Health Innovation’s Center for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. When delivered in a context of caring and in a supportive organiza- tional culture, the highest quality of care and best patient outcomes can be achieved.
The purpose of this new series is to give nurses the knowledge and skills they need to implement EBP consistently, one step at a time. Articles will appear every two months to allow you time to incorporate information as you work toward implementing EBP at your institution.
How nurses can build the knowledge and skills they need to implement EBP.
Do you ever wonder why nurses engage in practices that aren’t supported by evidence, while not implementing practices substantiated by a lot of evidence? In the past, nurses changed hospitalized patients’ IV dressings daily, even though no solid evidence supported this prac- tice. When clinical trials finally explored how often to change IV dressings, results indicated that daily changes led to higher rates of phlebitis than did less frequent changes.1 InmanyhospitalEDs across the country, children with asthma are treated with albuterol delivered with a nebulizer, even though substantial evidence shows that when albuterol is delivered with a metered-dose inhaler plus a spacer, children spend less time in the ED and have fewer adverse effects.2 Nurses even disrupt patients’ sleep, which is important for restorative healing, to docu- ment blood pressure and pulse rate because it’s hospital policy to take vital signs every two or four hours, even though no evidence supports that doing so improves the identification of potential complications. In fact, clinicians often follow outdated policies and procedures without questioning their current relevance or accu- racy, or the evidence for them.
When a spirit of inquiry—an ongoing curiosity about the best evidence to guide clinical decision making—and a culture that sup- ports it are lacking, clinicians are unlikely to embrace evidence-based practice (EBP). Every day, nurses across the care continuum perform a multitude of interventions (for example, administering medica- tion, positioning, suctioning) that should stimulate questions about the evidence supporting their use. When a nurse possesses a spirit of inquiry within a sup- portive EBP culture, she or he can routinely ask questions about clinical practice while care is being delivered. For example, in patients with endotracheal tubes, how does use of saline with suctioning compared with suctioning without saline affect oxygen saturation?
In patients with head injury, how does elevating the head of the bed compared with keeping a patient in a supine position affect intracra- nial pressure? In postoperative surgical patients, how does the use of music compared with no use of music affect the frequency of pain medication administration? The Institute of Medicine has set a goal that by 2020, 90% of all health care decisions in the United States will be evidence based,3 but the majority of nurses are still not consistently imple- menting EBP in their clinical set- tings.4 To foster outcomes-driven health care in which decisions are based on evidence, providers and health care systems need a comprehensive approach to ensure that their results are measured.5 Without EBP, patients don’t receive the highest quality of care, health outcomes are seriously jeopar- dized, and health care costs soar.6 Findings from recent studies also indicate that when nurses and other health care providers engage in EBP, they experience greater autonomy in their practices and a higher level of job satisfaction.7 At a time when this country is facing the most serious nursing shortage in its history, empowering nurses to routinely engage in EBP may lead to less turnover and lower vacancy rates, in addition to im- proving the quality of health care and patient outcomes. To accelerate the use of EBP by nurses and other health care providers, some insurers have instituted pay-for-performance programs that offer clinicians incentives to follow evidence- based guidelines. And Medicare no longer reimburses hospitals for treating preventable hospital- acquired injuries or infections (such as falls, pressure ulcers, or ventilator-associated pneumonia). Although these measures should improve the overall quality of care in our hospitals, it’s well known that extrinsic motivators are typically not more successful in facilitating a change in behavior than intrinsic motivators. Therefore, for EBP to accelerate and thrive in the U.S. health care system, nurses must have:
- a never-ending spirit of inquiry and consistently question cur- rent clinical practices.
- strong beliefs in the value of EBP.
- knowledge of and skills in EBP along with the confidence to use it.
- a commitment to deliver the highest quality evidence-based care to patients and their families.
In addition, health care institutions must sustain a culture that embraces EBP, including providing clinicians the support and tools they need to engage in evidence- based care. EBP is a problem-solving ap- proach to the delivery of health care that integrates the best evi- dence from well-designed studies and patient care data, and com- bines it with patient preferences and values and nurse expertise.8, 9 However, there’s no magic for- mula for what percentage of a clinical decision should be based on evidence or patient preferences or nurse expertise. The weight given to each of these three EBP components varies according to the clinical situation. For exam- ple, evidence-based guidelines might indicate that a young child with an ear infection receive amox- icillin and clavulanate (Augmentin) if the infection hasn’t resolved with amoxicillin. However, if the child dislikes the taste and it’s likely that the medication won’t be taken, patient preference should outweigh the best practice guide- line and an alternative antibiotic should be prescribed. Although EBP may be re- ferred to as evidence-based medi- cine, evidence-based nursing, or evidence-based physical therapy within various disciplines, we advocate referring to all of these as evidence-based practice, in order to stimulate transdiscipli- nary evidence-based care and avoid the specialized terminology that can isolate the various health professions. When nurses implement EBP within a context of caring and a supportive organizational cul- ture, the highest quality of care is delivered and the best patient, provider, and system outcomes are achieved (see Figure 1).10 Despite outcomes being substantially better when patients receive evidence-based care, nurses and other health care providers often cite barriers that prevent its delivery, including10, 11
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- • inadequate EBP knowledge and
Case Scenario for E
By Bernadette Mazurek Melnyk, PhD, RN, CPNP/PMHNP, FNAP, FAAN, Ellen Fineout-Overholt, PhD, RN, FNAP, FAAN, Susan B. Stillwell, DNP, RN, CNE, and Kathleen M. Williamson, PhD, RN
Bernadette Mazurek Melnyk is dean and distinguished foundation professor of nursing at Arizona State University in Phoenix, where Ellen Fineout-Overholt is clinical professor and director of the Center for the Advancement of Evidence-Based Practice, Susan B. Stillwell is clinical associate professor and program coordi- nator of the Nurse Educator Evidence- Based Practice Mentorship Program, and Kathleen M. Williamson is associate director of the Center for the Advancement of Evidence-Based Practice. Contact author: Bernadette Mazurek Melnyk, email@example.com.
AJN November 2009 Vol. 109, No. 11
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- 1. Gantz NM, et al. Effects of dressing type and change interval on intra- venous therapy complication rates. Diagn Microbiol Infect Dis 1984;2(4): 325-32.
- Cates CJ, et al. Holding chambers (spacers) versus nebulisers for beta- agonist treatment of acute asthma. Cochrane Database Syst Rev 2006(2): CD000052.
- Olsen L, et al. The learning health- care system: workshop summary. Washington, DC: National Academies Press; 2007. http://www.nap.edu/ catalog.php?record_id=11903.
- Pravikoff DS, et al. Evidence-based practice readiness study supported by academy nursing informatics expert panel. Nurs Outlook 2005;53(1): 49-50.
- Piper K. Results-driven health care: the five steps to higher quality, lower costs. Washington, DC: Health Results Group LLC; 2008.
- Health Research Institute, Pricewater- houseCoopers. What works: healing the healthcare staffing shortage. Dal- las: PricewaterhouseCoopers; 2007. http://www.pwc.com/us/en/healthcare/ publications/what-works-healing- the-healthcare-staffing-shortage. jhtml.
- Maljanian R, et al. Evidence-based nursing practice, Part 2: building skills through research roundtables. J Nurs Adm 2002;32(2):85-90.
- Melnyk BM, et al. The evidence-based practice beliefs and implementation scales: psychometric properties of two new instruments. Worldviews Evid Based Nurs 2008;5(4):208-16.
- Sackett DL, et al. Evidence-based medicine: how to practice and teach EBM. 2nd ed. Edinburgh; New York: Churchill Livingstone; 2000.
- Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing and healthcare: a guide to best practice. Philadelphia: Lippincott Williams and Wilkins; 2005.
- Melnyk BM. Strategies for overcoming barriers in implementing evidence- based practice. Pediatr Nurs 2002; 28(2):159-61.
- French B. Contextual factors influenc- ing research use in nursing. Worldviews Evid Based Nurs 2005;2(4):172-83.
- Melnyk BM. The evidence-based practice mentor: a promising strategy for implementing and sustaining EBP in healthcare systems. Worldviews Evid Based Nurs 2007;4(3):123-5.
- Dacey MJ, et al. The effect of a rapid response team on major clinical out- come measures in a community hos- pital. Crit Care Med 2007;35(9): 2076-82.