Nursing: Evidence-Based Nursing

What is Evidence-Based Nursing?

Definitions of evidence based nursing have varied in scholarly literature.  Scott & McSherry's extensive literature review looked at commonalities between EBN definitions and synthesized them to come up with the following definition: 

"An ongoing process by which evidence, nursing theory and the practitioners’ clinical expertise are critically evaluated and considered, in conjunction with patient involvement, to provide delivery of optimum nursing care for the individual."

Why Evidence Based Nursing?

Evidence-based nursing is one approach that may enable nurses to manage the explosion of new literature and technology and ultimately may result in improved patient outcomes.

Nursing students spend a great deal of preclinical preparation time designing care plans, reviewing pathophysiology, and memorizing pharmacologic interactions. Although these activities are useful, they cannot be the only methods of preparing students for nursing practice.

Sole reliance on textbooks and expert faculty knowledge does not promote the critical thinking skills that nurses must have to survive in the current fast paced clinical settings. Students must learn to develop independent, evidence-based methods of clinical decision making. Both medical and nursing professionals have explored this change in healthcare practice, research and knowledge development, a paradigm shift called "evidence based practice".

Evidence based practice (EBP) "involves an ability to access, summarize, and apply information from the literature to day-to-day clinical problems". Evidence based practice "requires an emphasis on systematic observation and experience and a reliance on the research literature to substantiate nursing decisions." Evidence based practice allows practitioners to meet a daily need for valid information about clinical situations.

Evidence based practice allows nurses to enrich their clinical training and experience with up to date research. With the large amount of research and information that exists in nursing, learning the skills of evidence based practice allows nurses to search for, assess, and apply the literature to their clinical situations.

Quotations from: Kessenich CR, "Teaching nursing students evidence-based nursing." Nurse Educator, Nov/Dec 1997, 22(6): 25-29.

Further Reading: 
Royal J, Blythe J. "Promoting research utilisation in nursing: the role of the individual, organisation, and environment." Evidence-Based Nursing July 1, 1998; 1(3): 71-72.

How is EBN different from Evidence Based Medicine?

Evidence based medicine is defined as "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."

Quotation from: Sackett, David L, et al. "Evidence Based Medicine: What It Is and What It Isn't." BMJ 1996; 312: 71-72.

Both EBM and EBN fall under the umbrella of evidence based practice.  However, nurses' approach to evidence based practice may differ from the standard biomedical model. Typically, nurses are committed to providing holistic care; treating and working with patients rather than working on them. Effectiveness of treatment is only one part of the clinical decision-making process: in deciding on therapeutic interventions, acceptability to the patient and cost-effectiveness are considered.

McSherry, Robert, (ed.) Evidence-informed nursing : a guide for clinical nurses. London ; New York : Routledge, 2002. pg.7

Evidence Based Nursing is a Five-Step Process

The 5 "A's" will help you to remember the EBN process:

1. ASK:  Information needs from practice are converted into focused, structured questions.
2. ACQUIRE:  The focused questions are used as a basis for literature searching in order to identify relevant external evidence from research.
3. APPRAISE:  The research evidence is critically appraised for validity.
4. APPLY: The best available evidence is used alongside clinical expertise and the patient's perspective to plan care.
5. ASSESS:  Performance is evaluated through a process of self reflection, audit, or peer assessment.

Step One: Ask

Defining the Question:  Issues or questions can arise in a variety of situations.  The use of the evidence based process is not limited to the clinical situation, but can also be useful in the management environment. With such an overwhelming (and rapidly growing) amount of medical information, but a limited amount of time available to search, this step can be one of the most important ones. The creation of a focused and clearly defined question can make efficient use of your time to find a manageable amount of literature to address the information need.

There are generally four parts to question building:  the patient/problem, the intervention, the comparison and the outcome. You may have heard of the acronym PICO to refer to this question building process.

Step Two: Acquire

Selecting Resources and Conducting the Search:  In this step, you will locate the highest quality, relevant information from the medical literature to answer your question. To do this, you need to select the databases and journals you will use to find the answer to your question. Information about these databases and journals is available in the EBN Databases and Journals section.

Some resources, such as the Cochrane databases are "prefiltered". This means that the authors of the database have already systematically reviewed the articles to make sure that they are relevant and of high quality. Systematic reviews are an overview of all of the evidence addressing a focused clinical question. Other resources, such as PubMed and CINAHL, are "unfiltered". This means that you conduct a search based on your question and filter through the results yourself.

You should examine your search strategy based on the tool you are using. Some databases, such as PubMed, have a controlled vocabulary. For example, instead of classifying "cancer", they classify "neoplasm". When using their controlled vocabulary, you may receive greater accuracy in terms or the topic on which you are searching. See our suggested PubMed Tutorials for assistance and more information.

PubMed (MEDLINE) search:

Let's perform a PubMed (MEDLINE) search to find articles related to the following situation:

You are a nursing administrator responsible for cutting the personnel budget with the least amount of impact on patient care.  The question you are asking yourself is, "Will decreasing the number of RNs (versus unlicensed assistive personnel) have a low impact on patient care?"

To access PubMed, go to the Health Sciences Library website http://www.hsl.unc.edu.  From there, click on the PubMed (MEDLINE) link.  Accessing through this link both on campus and off campus (if connected through the proxy server) will allow you to access any of UNC's electronic journals and resources.

A possible set of search terms that could be used include: nurses' aides AND staffing AND patient outcomes   Three of the resulting articles are listed below. 

Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K.
Nurse-staffing levels and the quality of care in hospitals.
N Engl J Med. 2002 May 30;346(22):1715-22.

Sovie MD, Jawad AF.
Hospital restructuring and its impact on outcomes: nursing staff regulations are premature.
J Nurs Adm. 2001 Dec;31(12):588-600.

Blegen MA, Vaughn T.
A multisite study of nurse staffing and patient occurrences.
Nurs Econ. 1998 Jul-Aug;16(4):196-203.

Step 3: Appraise

Critical Appraisal / Evaluation of the Literature:  In this step you critically appraise the evidence for its validity, impact, and usefulness in clinical practice. If you do not use a systematic reviews database, you will have to appraise whether or not the research is clinically sound. There are many different types of research studies, including prognosis, diagnosis, harm/etiology, and therapy. You will need to examine the articles on the basis of validity by examining potential sources of bias, as well as looking at the type of methodology used in the study. For more information about these, see UNC's HSL Evidence Based Medicine tutorial and the readings below. Regardless of whether you use CINAHL or Cochrane, you will need to assess whether the articles you are reading are appropriate to your clinical situation and patient's needs.

Read the following articles, looking for potential sources of bias, examining the methodology, and validity. Compare the usefulness of the articles to your question: Will decreasing the number of RNs (versus UAPs) have a low impact on patient care? 

Sovie MD, Jawad AF.
Hospital restructuring and its impact on outcomes: nursing staff regulations are premature.
J Nurs Adm. 2001 Dec;31(12):588-600.

Blegen MA, Vaughn T.
A multisite study of nurse staffing and patient occurrences.
Nurs Econ. 1998 Jul-Aug;16(4):196-203.

Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K.
Nurse-staffing levels and the quality of care in hospitals.
N Engl J Med. 2002 May 30;346(22):1715-22.

Step 4: Apply

This is the step where you integrate the evidence with your clinical expertise and the unique needs and values of your patient/situation.

From the literature search, you've found that the articles you've read do not state specific guidelines or staff ratio suggestions, but do discuss that cuts in RNs have lead to decreases in patient outcomes.  Initially, you considered cutting some of your RN staff because of cost purposes.  After assessing your current situation, you remember that your most recent personnel cuts have been to the RN staff.  After considering the literature and your current situation, you believe that any further RN cuts may provide too much of a risk to quality of care and not enough of a benefit to the budget.  You decide on having cutbacks in the number of UAPs and to reorganize the staff in order to have a more effective combination of RNs to UAPs. 

Step 5: Assess

After applying what you've learned from the literature to your situation, you will need to evaluate outcomes in shorter-term and longer-term intervals.  In assessing the situation, you regard feedback from all staff and from patients.  You notice changes and statistics of patient care and outcomes, as mentioned in the articles.  You personally will need to decide after what period of positive or negative feedback you decide to consider the changes a success or choose alternative plans. 

You should not only assess the outcomes in your situation, but also the effectiveness and efficiency of the evidence based process and consider avenues for improvement.  

Exercises and Scenarios

Sample scenarios, searches, completed worksheets, and CATs for Evidence Based Nursing  Topics include diagnosis, prognosis , therapy, harm, systematic reviews, and qualitative research.

From the University of Toronto Centre for Evidence Based Medicine, Mount Sinai Hospital

From the Johns Hopkins Center for Evidence Based Practice

From Health Libraries in Lincolnshire Online

Critical Appraisal Skills Programme Checklists for Evaluation

From the Cincinnati Children's Hospital

Slideshows with Scenarios from JAMAEvidence

BMJ's Clinical Review series (topics with search strategies and analysis)

Ask: What is the question or problem? Frame practice question(s) into a structured format such as PICOT

Acquire: Search for evidence from multiple, trustworthy sources: online resources and databases, content experts, peer-reviewed publications, policies, literature searches. 

Appraise: Evaluate the evidence. Does the evidence address your question? Develop a review table to help in evaluating your findings. Points to consider include:

• is the information reasonably well-suited for your setting?
• are the findings from the different sources concordant?
• do some sources present conflicting information/recommendations?
• how credible are the sources?

Aggregate: In this step determine what is known or unknown about your problem or question. Take the acquired and appraised information and consider it in light of your, and your colleagues', clinical expertise. Prioritize and synthesize relevant information. Translate the synthesized evidence into an actionable plan.

Apply: Pilot interventions on your unit.

• recommend practice change(s) based upon overwhelming evidence
• if the evidence is inconsistent or has conflicting outcomes, or if insufficient evidence exists to confidently change practice - propose research study.

Assess & Spread: Assess the results of any change - monitor and measure outcomes.

• survey stakeholders
• audit
• solicit peer feedback

EBN Databases

Below are databases that focus specifically on Evidence Based Practice that you may find helpful.

• Cochrane Library

  Leading source for full-text systematic reviews in health care. Searches a collection of six databases that includes the CDSR, DARE, CENTRAL, CMR, HTA, NHS EED. Click on "Search Limits" or the Browse tab to select content from a specific database.
• TRIP Database : the Search Engine for Evidence-Based Medicine

  Open access clinical search engine designed to allow users to quickly and easily find and use high-quality research evidence to support their practice and/or care.
• UpToDate

  Clinical resource specifically designed to answer the clinical questions that arise in daily practice and to do so quickly and easily so that it can be used right at the point of care for a broad range of hospital and medical specialties.

EBN in Other Databases

EBN Journals

UNC-CH Libraries Catalog
Not all journals that you will want to read will have online access.  Fortunately, UNC has access to many of both online and print journals related to nursing. To find out whether UNC-CH carries a particular journal, print or electronic, visit the UNC-CH Libraries Catalog. Type the title of the journal in the box. Select "Journal Title" from the "Search for words:" dropdown menu.

Electronic Journals Finder
The Electronic Journals Finder includes all of the journals to which UNC-CH has online access. 

Specific Evidence Based Practice Journals to Look For
The following journals use predefined criteria to publish evaluated abstracts of the literature and comment on the methodology of each published study. In other words, these journals perform systematic reviews of the literature, performing the critical appraisal and assessment of the literature mentioned in the "steps" of evidence based practice.

AJN Evidence-Based Practice Step by Step

This series is a good place to start when thinking about Evidence Based Practice.  Articles are in sequence order.

Melnyk, B. M., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. M. (2009). Evidence-based practice: Step by step: Igniting a spirit of inquiry: An essential foundation for evidence-based practice. The American Journal of Nursing, 109(11), 49-52. doi:10.1097/01.NAJ.0000363354.53883.58

Melnyk, B. M., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. M. (2010). Evidence-based practice: Step by step: The seven steps of evidence-based practice. The American Journal of Nursing, 110(1), 51-53. doi:10.1097/01.NAJ.0000366056.06605.d2

Stillwell, S. B., Fineout-Overholt, E., Melnyk, B. M., & Williamson, K. M. (2010). Evidence-based practice, step by step: Asking the clinical question: A key step in evidence-based practice. The American Journal of Nursing, 110(3), 58-61. doi:10.1097/01.NAJ.0000368959.11129.79

Stillwell, S. B., Fineout-Overholt, E., Melnyk, B. M., & Williamson, K. M. (2010). Evidence-based practice, step by step: Searching for the evidence. The American Journal of Nursing, 110(5), 41-47. doi:10.1097/01.NAJ.0000372071.24134.7e

Fineout-Overholt, E., Melnyk, B. M., Stillwell, S. B., & Williamson, K. M. (2010). Evidence-based practice step by step: Critical appraisal of the evidence: Part I. The American Journal of Nursing, 110(7), 47-52. doi:10.1097/01.NAJ.0000383935.22721.9c

Fineout-Overholt, E., Melnyk, B. M., Stillwell, S. B., & Williamson, K. M. (2010). Evidence-based practice, step by step: Critical appraisal of the evidence: Part II: Digging deeper--examining the "keeper" studies. The American Journal of Nursing, 110(9), 41-48. doi:10.1097/01.NAJ.0000388264.49427.f9

Fineout-Overholt, E., Melnyk, B. M., Stillwell, S. B., & Williamson, K. M. (2010). Evidence-based practice, step by step: Critical appraisal of the evidence: Part III. The American Journal of Nursing, 110(11), 43-51. doi:10.1097/01.NAJ.0000390523.99066.b5

Fineout-Overholt, E., Williamson, K. M., Gallagher-Ford, L., Melnyk, B. M., & Stillwell, S. B. (2011). Following the evidence: Planning for sustainable change. The American Journal of Nursing, 111(1), 54-60. doi:10.1097/01.NAJ.0000393062.83761.c0