Learning Objectives
By the end of this section, you will be able to:
- Describe how nursing research has evolved
- Identify the steps for translating evidence-based research into evidence-based practice
- Understand various models for implementing evidence-based practice
Nurses do not stand alone. They work alongside a wide range of other healthcare providers, ranging from assistive personnel to medical professionals to environmental staff. All these positions, and the organizations that employ them, base decisions regarding their practice on evidence derived from research.
An evidence-based practice (EBP) is an ongoing decision-making strategy that integrates high-quality research with clinical experience and with patients’ preferences and beliefs (American Nurses Association [ANA], 2021; Polit & Beck, 2021). Evidence-based practice is considered one of the five core competencies of healthcare professionals (ANA, 2021). Thus, it is used by nurses and in all other fields of health care. For example, the Trendelenburg position (tilting a patient backward until their head is lower than their feet) was used for generations to manage hypotension immediately. However, studies have proven that while it may work for some patients, it is statistically not beneficial for the general population (Schnur, 2018). Additionally, using the Trendelenburg position has several health risks, including increased pressure on the brain and decreased respiratory ability (due to the pressure of abdominal organs on the lungs). Thus, because of research, current EBP discourages using the Trendelenburg position to manage hypotension.
The many types of research can be organized into two main categories:
- A basic research seeks to answer questions about current conditions without changing them. For example, basic researchers might ask, “What happens when a patient is placed in the Trendelenburg position?” Or, “How does giving patients glucose tablets rather than a cup of juice impact their blood sugar?”
- An applied research uses answers from basic research questions and other sources of current knowledge to evaluate changes to practice. For example, applied researchers might contrast the efficacy of a nurse-driven protocol for managing low blood sugar using glucose tablets (which may require a physician’s order) with the use of juice to manage low blood sugar within the bounds of nursing practice.
Evolution of Nursing Research
Nursing research was in its infancy between Florence Nightingale’s work and the end of World War II, in 1945. The first journal dedicated to nursing research, The American Journal of Nursing, began publication in 1900, and the first doctoral program for nurses opened its doors in 1923 (Polit & Beck, 2021). Most of these early activities focused on nursing education, not patient care. However, in the 1950s, more journals began being published, nursing research centers started opening, and foundations to fund nursing research began to appear.
In the 1960s, as professional nursing organizations recognized the lack of nursing scholarship regarding patient care, they began developing research priorities that included nurses’ viewpoints, which are informed by nurses’ close connection to direct patient care. By the 1970s, quality improvement in patient care had become more important for all healthcare workers, and the expansion of nursing research reflected these needs.
By the early 1980s, at least six major nursing journals were publishing original nursing research, the ANA was holding nursing research conferences, a National Center for Nursing Research (NCNR) operated at the U.S. National Institutes of Health (NIH), and guidelines had been established to assess the quality of research for its usability in practice. Internationally, twenty-five European nurse associations had also joined forces to improve patient care there (Polit & Beck, 2021).
In the 1990s, nursing research continued growing in the United States and abroad. The United States established the Agency for Health Care Policy and Research, now known as the Agency for Healthcare Research and Quality (AHRQ), and the NCNR became the National Institute of Nursing Research. International nursing research groups and journals were also established in Europe, Australia, and Canada. Since the early 2000s, nursing research has come fully into its own, as nurses have become valued partners in the healthcare industry. Nurses have claimed their seats at national and international policy tables, and an army of nurse researchers has conducted and published high-quality research projects.
Clinical Judgment Measurement Model
Generate Solutions: Using ANA Practice Standard 14: Scholarly Inquiry
ANA’s fourteenth practice standard for registered nurses states: “The registered nurse integrates scholarship, evidence, and research findings into practice” (ANA, 2021, p. 100).
Registered nurses should be able to perform several competencies relevant to this standard:
- Identify concerns that may be answered or informed through research.
- Combine evidence-based information with personal experience and patient preferences.
- Engage in evidence-based research.
- Use research to improve their knowledge, skills, abilities, and judgment.
- Share evidence-based knowledge with others to improve everyone’s practice.
- Incorporate research to improve the quality of patient care.
- Explain the value of research to the nursing profession.
- Encourage ethics in research endeavors.
- Review research for appropriateness within given settings and situations.
Today, nursing research is flourishing globally. The World Health Organization (WHO) designated 2020 (the 200th anniversary of Florence Nightingale’s birth) as the International Year of the Nurse and the Midwife (Wakefield et al., 2021). That same year, however, the onset of the COVID-19 pandemic brought to light many issues concerning the nursing workforce and patient care. In 2021, the National Academy of Medicine (NAM) published a report on nursing over the next decade: The Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity. The NAM report explores the unique position of nursing, including nurses’ ability to work with all disciplines and to assist in improving health equity (Wakefield et al., 2021). It also offers research priority suggestions for nurses based on the population’s most pressing needs. These include the following:
- Health equity: How can nursing and nurse-led interventions advance the equality of good health and health care across all patient populations?
- Emergencies: How can nurses better prepare for natural disasters and public health emergencies? Where are the gaps in education? What strategies will enable nurses to respond—and care for themselves—more effectively?
- Paying for health care: How can nurses quantify their value in terms of dollars saved by producing nursing-led interventions that improve patient outcomes versus the dollars spent in performing those interventions?
- Nursing education and workforce development: How can both processes be improved? What changes need to be made to improve workforce retention? What do nursing students need to be fully prepared for?
- Nurse well-being: How can nurses be supported more effectively by their agencies, the community, and each other? How can issues of lateral violence and incivility be managed?
Life-Stage Context
Kangaroo Care for Newborns
Kangaroo care (Figure 15.3) provides an excellent example of EBP in action. Kangaroo care is the use of skin-to-skin contact—typically between an adult’s bare chest (usually that of a parent) and a baby in only a diaper—for babies in neonatal intensive care units. Beginning kangaroo care immediately after the birth of a premature or low-birth-weight baby can dramatically improve their chance of survival, decreasing death rates by over 40 percent. Numerous studies have shown its effectiveness in helping premature babies regulate their body temperature, improving cardiorespiratory stability, decreasing pain and the chances of infection or severe illness, and facilitating bonding. It is cost effective and can be used exclusively in places that do not have available incubators. This practice was studied first in the 1970s but barely used until the late 1990s. Today, at least one hour of kangaroo care a day is considered best practice for premature but stable babies and recommended as a basic standard of care (Campbell-Yeo et al., 2015; WHO, 2021). Instances like these, in which nurses are firsthand witnesses to clinical behaviors that improve patient outcomes, provide a multitude of topics for nursing research.
Protection of Human Rights in Nursing Research
In a position statement about the nurse’s role in ethics and human rights, the ANA highlights the need for nurse researchers to protect the human rights of research participants (ANA, 2016). Nurses taking part in research are specifically expected to do the following things:
- Ensure patients provide uncoerced agreement to participate in research or treatment. This informed consent must clearly explain the purpose, risks, and benefits of the research, as well as the intended use of patients’ personal information.
- Continually evaluate the risks of the research versus the potential benefits of the outcome and stop research that is clearly harmful to the participants.
- Prevent harm to research participants.
- Engage in research that is relevant and will benefit the participants or people like them.
Everyone who seeks to perform research on a human subject, wants to receive grants or funding, or intends to publish their findings in a reputable journal must protect human rights. Per the NIH, a human subject is a living individual whom a researcher wants to interact with to collect information or specimens. Human subjects also include participants with whom the researcher does not interact directly if the researcher nevertheless plans to use their information or specimens in a way that may make them identifiable (NIH, 2018). Consider a case study of a 45-year-old Black man with a communicable disease such as HIV. In a large urban area where many people of all genders and races have the disease, simply removing the patient’s name from the data may well make them unidentifiable to others. However, in a small community, simply removing the name may not be enough, and patients who are at risk of being identified based on the way their information is presented have the right to human subject protections. Figure 15.4 provides more information about how the NIH defines research on human subjects.
Nurse researchers must consider rules for protecting human subjects when developing research questions and proposals. Generally, researchers take some type of education regarding the use of human subjects. The Office for Human Research Protections (part of the U.S. Department of Health and Human Services) offers extensive, web-based educational modules that meet the requirements for human subjects noted in Figure 15.4. Researchers who want to publish or seek funding for their work must also go through their facility’s institutional review board (IRB), a group of people who monitor and approve medical research that will be performed and protect the agency’s employees from engaging in unethical research practices.
Link to Learning
The horrendous treatment of 600 Black men in the Tuskegee Study of Untreated Syphilis in the Negro Male (now called the USPHS Syphilis Study at Tuskegee) was the driving force behind the development of many of today’s rules regarding human participants in research. Check out this video on the Tuskegee syphilis study to learn more about this dark time in medical research and the need for strong protections for human subjects.
Methodology of Nursing Research
When a nurse works with patients on a day-to-day basis, they learn through experiential learning (or learning by doing). This process is not linear or structured; rather, it is based on the lived experience of the practicing nurse. In contrast, nursing research is structured inquiry designed to obtain and evaluate information related to a clear, specific question (Polit & Beck, 2021). The nature of the research question structures the methods used to achieve the answer. The research methods are the strategies and techniques used for gathering and analyzing information. In this context, there are two primary types of research: qualitative and quantitative.
Qualitative Research
A qualitative research is often complex and based on individual experience. It is generally open ended, allowing the participants to guide the research rather than specifying one or two options up front to study. It is descriptive and looks to answer questions about what and how a research participant thinks and feels. The focus is on the participant’s perspective and experience, not the researcher’s. Qualitative research is often basic research rather than applied. However, researchers can use the information obtained from qualitative research to identify questions that can be further studied quantitatively.
In qualitative studies, researchers develop questions based on the desired outcome and narrowed to a specific population, situation, or other relevant characteristic. For example, a researcher might study the factors that influence whether young immigrant mothers choose Western forms of health care for their children or healthcare traditions from their country of origin. The information received from such research will not be clear-cut. Each mother might have a variety of motives, beliefs, and values; individuals immigrating from different places may give completely different reasons for their choices. However, the researcher will look for patterns, relationships, or themes in the data that help deepen their understanding of the situation.
Most of the time, qualitative research in health care is performed through interviews, focus groups, or case studies. An interview is a one-on-one conversation between the researcher and the participant. Interviews can be formal and led by a series of predetermined questions, or informal. For example, a researcher might begin with a few set questions but allow the participant to lead the conversation. Regardless, qualitative research generally uses open-ended questions, which require more information than yes or no responses—often including an explanation of the answer. (An important exception is if the interviewer wants to clarify a point.) A focus group is essentially a group interview, usually ten or fewer people, in which participants interact with each other and the researcher. A case study is an in-depth exploration of all aspects surrounding a complex issue as experienced by one or two individuals.
Qualitative research is an excellent way to explore some issues; indeed, nurses ask their patients qualitative questions daily even when they are not performing research. However, qualitative research has some drawbacks. For example, it is very easy for researchers to introduce bias into the process. A bias is a type of research error that researchers introduce by leading interviewees or suggesting one type of answer over another. Consider again the example study of young immigrant mothers. Suppose one of the interviewers asked, “Please tell me why you do not like pediatricians.” However, this is a leading question: the interviewees may never have said they do not like pediatricians; they may have any number of other reasons for their healthcare choices. Anything they say in response to this question—or even to others that follow—may be invalid because the interviewees may have been influenced by the researcher’s false assumption.
Qualitative research is also immensely time consuming. In general, an interview or focus group lasts one to two hours. The responses must then be transcribed before they can be analyzed. As a result, these studies are generally small. A project that interviews fifty participants is considered very large.
Patient Conversations
Asking Patients Open-Ended Questions
Scenario: Sharon is a 65-year-old White female with a higher weight from a small rural town in Mississippi. She recently moved to Queens, New York; she is at a new doctor’s office for an intake appointment and is speaking with a new nurse. Sharon has a thick accent and low health literacy, and she uses some terminology with which the nurse is unfamiliar. The nurse and Sharon are struggling to understand each other.
Nurse: Do you have any preexisting illnesses or medical conditions?
Patient: I have the sugar.
Nurse: I wasn’t talking about candy. I meant do you have any health concerns the physician should know about, such as hypertension or asthma?
Patient: No.
Nurse: Do you take any medicine?
Patient: Yes, I take shots for the sugar.
[Nurse looks annoyed and frustrated.]
Scenario follow-up: Sharon’s nurse becomes frustrated because they are not communicating, excuses herself briefly, and asks a more experienced coworker for help managing the situation. The older nurse offers to perform Sharon’s intake as the original nurse observes. They begin the assessment over again.
Nurse: Do you have any medical conditions we should know about?
Patient: I told that other nurse that I have the sugar.
Nurse: Can you explain what you mean by “the sugar”?
Patient: You know, the sugar diabetes. I take shots for it.
Scenario follow-up: The more experienced nurse used open-ended questions, did not make assumptions, and identified that Sharon has diabetes. (“The sugar” is a common way of referring to diabetes in the Deep South, though nurses in other parts of the country may be unfamiliar with the term.)
Quantitative Research
A quantitative research tests the validity of a reasonable idea in a given setting. It is based on deductive reasoning, a logical approach that moves from general ideas to specific conclusions and seeks to obtain empirical evidence—evidence that can be measured (Polit & Beck, 2021). As the term suggests, quantitative research is grounded in numerical data, like percentages or rates. It is observational, exploring what can be measured through the senses or quantified in individual responses to questions. Quantitative researchers often use statistical analysis to prevent bias within their research and to evaluate the strength of relationships between variables. A variable is a factor that is measured or studied in research: anything from a subject’s age or level of reported pain to the number of times a patient gets up at night to use the bathroom, the efficacy of a particular pain medication, or the history of illness in a family.
When planning for quantitative studies, nurses and other evidence-based practitioners frequently use the PICOT framework to develop testable questions (Polit & Beck, 2021):
- P: What is the population or patient group? What characteristics bind these individuals together?
- I: What is the intervention that is being tested?
- C: What is the comparison, or the group receiving the current treatment rather than the intervention?
- O: What is the desired or expected outcome?
- T: What is the time frame for the study? How long will subjects be followed?
Here is an example of a potential PICOT question: In adult inpatients, aged 50 to 70 years, with diabetes who experience low blood sugar [Population], how does fruit juice [Intervention] compared to glucose tablets [Comparison] affect patients’ blood sugar levels [Outcome] over the course of a twenty-four-hour period [Time Frame]?
Once the question is defined, the flow of quantitative research generally follows a fairly linear process, as shown in Table 15.1.
| Step | Description |
|---|---|
| Review the literature | Do journal research to see what is known about the question, determine why new research is important, and develop a hypothesis. |
| Develop a research plan | Answer questions such as: How will the research be conducted? How will data be gathered? How will it be analyzed? How will human subjects be protected? How will participants be chosen? How will they provide informed consent? |
| Collect the data | Run the study and gather evidence. Very large studies may be preceded by a sample study to ensure the correct data are being collected. |
| Analyze the data | Perform statistical analysis to compare variables and outcomes. |
| Interpret the results | Make sense of the results and what they mean in relation to the research question. Is there clinical importance to the results? |
| Present the information | This can be done in a group or presentation format or through publication. |
| Evaluate the results | Determine what if anything has been learned that can be used in clinical practice to improve patient care, working conditions, or other outcomes. |
There are several ways to design quantitative research. Here are a few commonly used designs (Winston-Salem State University, 2023):
- A descriptive research approach uses one or more variables. For example, a study might seek to determine what types of pain medications are ordered on a medical-surgical unit, how frequently they are ordered, how often they are given, and what types of patients are most likely to receive them. Most research will include some descriptive statistics.
- A correlational research approach uses statistical analysis to explore relationships between two or more variables. For example, a study might investigate whether different physicians on a medical-surgical unit are more likely to order pain medication to be given as needed or to require patients to adhere to a schedule. Another study might investigate whether there are patterns in the timing of when certain nurses give pain medication.
- A quasi-experimental research approach explores cause-and-effect relationships but does not apply new interventions. For example, a study might investigate how different amounts or types of pain medication affect patients’ length of stay in a facility, chances of acquiring a nosocomial infection, functional ability upon discharge, or overall mortality.
- An experimental research approach studies the effect of a new intervention on a known concern and evaluates its effectiveness. For example, a study might seek to determine the efficacy of alternative therapies—such as trigger point massage, dry needling, or physical therapy—at decreasing the amount of pain medication given on the medical-surgical ward.
Regardless of the design, quantitative researchers should ask close-ended questions, which have a limited range of answers (such as yes/no or 1–5). Each answer should be assigned a value, enabling measurement and comparison. Figure 15.5 gives examples of each type of question: qualitative, or open ended, and quantitative, or close ended.
Quantitative studies are excellent for numerically evaluating the value of interventions and the success of treatments. They can also be easily scaled up to large numbers. Quantitative studies with large data sets may include thousands of participants. However, there are possible issues that can affect the data. For example, if individuals do not use the specified responses, their answers cannot be properly evaluated. Furthermore, because the responses are close ended, important information may be missed. Consider a researcher collecting information regarding insomnia in a particular population. They may ask participants, “How many times do you have difficulty falling asleep or staying asleep in a week?” Answers to this question are limited to 0 through 7. This misses people who perhaps have difficulty falling or staying asleep once every few weeks or only when they are worried about something. If researchers do not find other ways to capture these responses, they will lose an entire segment of the group they want to study.
Mixed Methods Research
Today, many researchers use mixed methods research, combining both qualitative and quantitative components to create more nuanced findings (Polit & Beck, 2021). This approach works well because qualitative and quantitative research are complementary; they help manage the complex phenomena that make up human health and well-being, and they offer greater validity for research. Figure 15.6 offers some examples of how mixed methods research can be achieved.
Understanding the Parts of an Article
Being able to read a research article effectively is an essential piece of being able to evaluate research. Most high-quality articles include several main parts (Polit & Beck, 2021):
- The abstract, placed at the beginning of the article, briefly describes the rest of the paper. Abstracts vary in length depending on the journal but generally range between 200 and 350 words. Some are structured, using specific subject headings; others are narrative, more like a descriptive paragraph of the work.
- The introduction, sometimes called the background, explains why the research was needed and conducted. It usually includes a brief literature review that synthesizes what other researchers have learned about the topic and explores what information still needs to be determined by future research. It may also include definitions of some key terms, an explanation of why the research is needed, and the question(s) the study aims to answer.
- The methods section provides all the details about how the study was conducted, including the patient population, the setting, and the specific variables studied, as well as how those variables were studied and how the data were analyzed. Most methods sections also include the human rights protections used, the way informed consent was obtained, and the approval information from the IRB that evaluated the research plan.
- The results section describes what was learned from analyzing the data. It often includes the demographic statistics of the participants, charts or graphs illustrating the results, and findings from statistical analyses, including how statistically significant the results are. A statistical significance describes the relative chance that results are reliable and would be reproducible with a different group of similar patients. The language used to describe the significance of a specific bit of research might look like this: Given the same parameters, there is an 80 percent likelihood that 75 percent of patients will experience a 5 to 10 percent decrease in their blood pressure.
- In the discussion section, the authors compare their results to other research that has been done related to the question. They should include information regarding the consistency of their results related to other research, the potential clinical importance of their research, any possible implications for clinical practice, suggestions for additional research, and the study’s limitations.
- Some journals require a conclusion separate from the discussion; others add it to the end of the discussion section. Generally, it is a concise statement about the importance of the research and what it brings to the larger research community.
- Articles typically end with a references section that lists all the sources the authors cited when writing the paper.
Other than these central components, an article may present additional information that readers should examine, particularly before considering any of the article’s recommendations. In particular, look for these three pieces of information, which generally appear either in the front matter (everything before the abstract) or the back matter (everything between the conclusion and the references):
- If the Methods section does not provide information about informed consent and human rights protection, it should appear in either the front or back matter. If not, the research may not have been conducted ethically.
- Sometimes, how a study was funded will answer many questions about its potential value. Product manufacturers often fund research, but their biases should be obvious. Making an evidence-based decision to use new products based solely on research paid for by the manufacturer can result in a poor decision.
- One of the values of sharing research is the ability to reproduce that research in various populations. Most journals today require a statement regarding data availability so that other researchers in different places can attempt to reproduce the research to see if the findings will be the same for their population.
Types of Research Articles
Research and research articles come in a variety of formats. For a nurse seeking to expand their knowledge base and improve their practice, the best sources of research are typically peer-reviewed journals. As a condition for publication, these journals require several (usually three) reviewers to thoroughly read the information and evaluate its value. Journal articles come in a variety of formats. Each type of article has value and can be meaningful for practice. Table 15.2 offers a few examples of the types of articles one might find in nursing or other healthcare journals.
| Article Type | Explanation |
|---|---|
| Research | These articles describe original research performed by the authors. |
| Literature review | These articles discuss what other original researchers have said about a topic, attempt to synthesize the information, and explore what information still needs to be determined by future research. They are narrative, do not use statistics, and often do not include a methods section. |
| Systematic review | The authors of these reviews systematically retrieve all research articles written on a given topic. Additionally, they often evaluate individual articles for the quality of the research. |
| Metareview | These systematic reviews include a statistical strategy to analyze and combine the results from many studies and evaluate their usefulness. |
| Guidelines | These are specific statements from large organizations, such as the ANA, that provide standards of practice for specific populations of patients. These are usually based on the most up-to-date and well-validated EBP available. Guidelines may be published in journals when major changes to a discipline’s guidelines are introduced; they may also appear on association websites. |
| Editorials | These are generally short opinion articles, also known as commentaries, written by subject-matter experts to discuss an issue of concern. |
Translating Research into Practice
An evidence-based research (EBR) is incorporated into EBP when healthcare providers use the research findings to improve their day-to-day care of patients, and it can be a dynamic tool for that purpose. However, a large body of EBR has not been implemented into routine patient care because moving from research to practice can be extremely complicated. Translation science is a branch of research dedicated to improving how EBP becomes standard care (Titler, 2018). EBP can be used for individuals or patient groups (Bell, 2023). When an individual patient has a concern, need, or question with which a nurse is unfamiliar, the nurse can use the steps of EBP to seek relevant research and find an answer that aligns with the nurse’s experience and the patient’s preferences and values. Figure 15.7 is a Venn diagram representing these relationships in EBP.
In contrast, a hospital, unit, or clinic may have several patients with similar concerns that could be managed more effectively with alternative interventions. Some nursing staff members may then decide to explore the issue using the steps of EBP to determine whether a practice or policy change should be made at the level of the agency or unit.
Steps of Evidence-Based Practice
There are defined steps for performing EBP that aim to successfully implement a new intervention with patients, while EBR aims to determine the success or failure of an intervention (Titler, 2018). There is some disagreement between researchers regarding the number of steps in EBP. However, most scholars set the number at five or six (Bell, 2023; Capili, 2020). Here is a typical list:
- Ask a question.
- Find information about the topic.
- Evaluate the evidence.
- Align the evidence with clinical experience and patient preferences, determining what specific practice changes to make.
- Make the changes.
- Evaluate the outcomes.
Depending on the situation, additional steps may include planning to make the change sustainable over time, developing or revising policies and procedures, or determining how to share the information within units, hospitals, agencies, or even professional organizations.
Link to Learning
This short video offers a quick introduction to EBP and sets the stage for our continuing inquiry.
Ask a Question
The questions you ask and how you ask them will affect the value of the information you receive. Questions that are too broad will return more results than are needed or desired. Questions that are too narrow may not return the information necessary to evaluate the issue. The first rule of thumb is to ask a searchable question (Bell, 2023), one that uses clear and specific keywords enabling you to find what you are looking for. Consider looking for information about “preterm labor” (early pregnancy delivery). The searcher would receive far more titles and websites than they will be able to review. Here is a more searchable and specific question: “What is the survival rate for preterm labor before twenty weeks in the United States?”
Link to Learning
The Oncology Nursing Society has several excellent resources regarding evidence-based practice. They provide a worksheet with questions that can help staff members generate possible topics and ask questions in a way that facilitates research.
Find Information about the Topic
Several search engines focus specifically on peer-reviewed journal articles on nursing, medical, and allied health topics, including MEDLINE and CINAHL, which can be accessed through most libraries. PubMed and Google Scholar can be accessed through any search engine. Most search engines will bring back many results that must then be explored to ensure they offer appropriate information about the question. The abstract portion of journal articles will generally provide enough information to know if the article pertains to the question and provides quality evidence.
Whether you use journal search engines, Google Scholar, or a general search engine such as Bing or Google, you must use keywords effectively to find the evidence you need. For an individual patient, look for keywords specific to that patient’s situation (Bell, 2023). For example, suppose you were working with a 45-year-old, female, Black patient with prediabetes who wants nutritional guidance to prevent becoming fully diabetic. In that case, you might use these keywords: “female,” “Black,” “prediabetes,” “middle-aged,” “nutrition,” and “patient education.” When working with an individual, even a simple Google search can yield high-quality information from reputable sources, which can frequently be tailored specifically to that individual.
However, suppose you are searching for information that might lead to a practice or policy change for an entire group of patients. In that case, the keywords should be less refined (Bell, 2023). For example, suppose you were working to develop a patient education handout regarding nutrition for patients with prediabetes. In that case, you might search “prediabetes,” “nutrition,” and “patient education” as keywords. The resulting evidence would be less specific for any single patient but more generalizable for all patients.
Evaluate the Evidence
Not all sources are equally reliable, and no search can ensure only high-quality results. Therefore, once a search has been completed, the nurse must assess the quality of the information they received (Bell, 2023). Stricter criteria may be necessary to support a policy change than to treat an individual patient. Consider the following questions when evaluating evidence.
From where did the information come?
High-quality information comes from reputable sources:
- peer-reviewed journals
- practice guidelines from national-level practitioner governing bodies, such as the ANA or the American Association of Critical-Care Nurses
- condition-related organizations, such as the American Diabetes Association or the American Heart Association
- laws and applicable governmental bodies, such as the Centers for Disease Control and Prevention (CDC) or the AHRQ
- reputable websites, which may be more likely to end in .gov, .edu, or .org
Nurses should consider the credentials of the authors of information to determine if it comes from a reliable and reputable source. Lower-quality information typically comes from consumer websites and blogs. It is important to look for references in any article you find. If the authors do not list their sources, you cannot determine the validity of the information. Encyclopedias also do not typically make good sources for research. While they provide excellent overviews of topics, they are usually too broad and may not be current with the most recent data. Even online encyclopedias, such as Wikipedia, which are regularly updated and often supply references, are not necessarily peer reviewed and therefore should not be considered as authoritative sources.
When was the information written?
Research is written and published daily, and the nursing and allied health community is dynamic, constantly changing and continually improving. As a result, when the research was published can be as important as who published it. A general rule of thumb is only to consider research published in the preceding three to five years (if at all possible), unless it is a seminal article meaning it continues to influence research and practice.
Where does the research fall in the hierarchy of evidence?
The hierarchy of evidence is a classification of evidence into categories based on the type of research represented. It is one way to evaluate the strength of research. Examine Figure 15.8. At the bottom of the pyramid (level VII) is the weakest evidence, and at the top (level I) is the strongest. Researchers disagree on how to structure the middle levels, but they generally agree that expert opinion is the lowest quality of evidence, while systematic and metareviews offer the highest quality (Curtis & Keeler, 2022; Oncology Nursing Society, 2023).
Align the Evidence and Determine What Practice Changes to Make
Once the best evidence has been gathered, it must be aligned with the other parts of EBP—the clinical experience of the nurse and the patient’s values—to establish a change moving forward (Capili, 2020; Bell, 2023). This strategy can be straightforward for the individual nurse with a single patient. If the change does not violate current hospital policies or procedures, if the nurse believes in the value of the intervention, and if the patient accepts the intervention, an individual nurse can introduce evidence-based changes to their practice (Bell, 2023).
In contrast, translating knowledge into practice and implementing EBP for more than a few patients require planning and strategies to overcome potential barriers (Curtis et al., 2017). Planning for sustainable change at an agency or even a single unit level may involve multiple disciplines. It can quickly become complicated because the environment in which the EBP will be performed already has a set of rules and procedures that nurses follow, as well as budgetary and other limitations (Titler, 2018). For example, suppose the evidence says that behavioral health therapies could help prevent depression in patients following cardiac surgery; however, if a facility lacks the funds to pay for behavioral health providers, it may be impossible to implement the change there. So, with a group of practitioners or a patient population, it is crucial to initiate evidence-based changes that the agency can sustain over time (Capili, 2020; Titler, 2018).
Make the Changes
Once the decision has been made to implement an evidence-based change, nurses should begin to use the new intervention in daily practice. Depending on the change, it may be used with all patients or only with patients who meet specific parameters (such as age range or condition type). Implementing larger-scale initiatives may require changes to existing policies or procedures or restructuring of resources (Bell, 2023). Proper documentation of the responses to the intervention is necessary for the next stage, evaluation, to take place.
Evaluate the Outcomes
Finally, evaluate the EBP change. Did it work? Was it effective for the individual patient? Did it work for the target population? Is it sustainable for the group? How does it improve patient outcomes and satisfaction? When these questions are answered, nurse scientists can make the thoughtful decision to continue with the practice, change back to the old way, or develop an alternative intervention—always with the foremost goal of improving patient care and outcomes.
Understand Models for Implementing Evidence-Based Practice
When considering EBP initiatives at a facility or unit level, multiple stakeholders (individuals or groups who have some type of interest or concern regarding practice changes in an area), usually from several disciplines, must be engaged in the process and assisting with the initiative. Whereas an individual nurse can make a personal practice change for a specific patient, larger-scale projects take time to develop and implement. Several well-respected models are used to develop EBP initiatives for group or population-level changes, including the Iowa Model, the Joanna Briggs Institute model, and the Evidence-Based Public Health model (Dusin et al., 2023).
To better understand the EBP framework, let’s focus on one model. The Johns Hopkins Evidence-Based Practice (JHEBP) model was developed at the Johns Hopkins Medicine Center for Evidence-Based Practice. It is commonly taught in research courses and used by other large research hospitals and academic institutions such as Vanderbilt University and Medical Center (Dang et al., 2022; Dusin et al., 2023; Vanderbilt University Medical Center, 2018). The JHEBP model includes three core components, known as the PET process: practice question, evidence, and translation (Dang et al., 2022). Each component has several associated steps, with twenty steps for the entire process. The process incorporates agency needs and resources, stakeholder input, best evidence, and information dissemination.
Practice Question
The JHEBP model’s first component involves forming the EBP workgroup and developing the practice question. This happens over seven steps, as follows (Dang et al., 2022):
- Recruit the interprofessional team, using care to involve members who will be impacted by any changes made. These individuals will likely be more invested in the process.
- Decide on the leadership of the project. All projects need a knowledgeable leader to help others stay on track.
- Schedule meetings. The leader should establish a time and quiet place for meetings and ensure that members are involved in keeping minutes, working on a timeline, and managing the project resources and information.
- Clarify and describe the problem. Discuss the differences between what is happening and what participants would like to be happening. Clarify why the current practice is a problem.
- Develop and refine the EBP question. The JHEBP uses the PICOT framework described in Evolution of Nursing Research.
- Determine the need for an EBP project. Before continuing, the group members should explore the literature to determine whether a body of evidence related to the problem exists. The preferred evidence is high-quality systematic reviews published within the last five years. If there is not enough research evidence for an EBP, group members can explore other options, such as initiating quality improvement projects, conducting original research, or verifying that they are using the current standards of their community, agency, or specific disciplines.
- Identify stakeholders who will be impacted by the project and who should be involved or kept informed during the process. Any disciplines that will be directly impacted by any EBP changes should be invited to be team members.
Evidence
Evidence provides support that an intervention is needed and works: for example, data may show that one drug is more effective than another at treating a particular condition. The evidence component of the JHEBP model includes five traditional EBP steps focused on acquiring and evaluating evidence (Dang et al., 2022):
- Search for evidence. Team members should be assigned to various research components, including evidence internal to the agency and external. Journal articles, specifically systematic and metareviews, are essential. Additional evidence will be found in clinical practice guidelines, community standards, position statements from professional organizations, quality improvement data, and safety and regulatory information.
- Evaluate the quality of each piece of evidence. The JHEBP has its own hierarchy of evidence (similar to the evidence pyramid shown in Figure 15.8) that researchers use to rate sources and evidence as high, good, or low. Evidence that is rated as low is not used to make EBP decisions.
- Summarize individual evidence. Each piece of evidence is summarized and documented based on several factors, including quality, evidence level, findings, population, and limitations.
- Synthesize findings. The team examines the entire body of evidence and integrates the findings as a group.
- Develop recommendations. The team determines the value of the overall findings and the evidence level. Then they recommend moving forward, stopping the process, or performing additional investigation.
Translation
The final component of the PET process is translation of the EBP team’s recommendations into practice in the target setting(s). This component involves eight final steps (Dang et al., 2022):
- Identify practice setting–specific recommendations. Work with stakeholders, leaders, and frontline staff to determine if recommendations are actionable and feasible, given the agency’s culture, willingness to change, and resources.
- Create an action plan. Develop any policies or specific procedures reflecting the change, a timeline for implementation, and evaluation processes. Encourage feedback from stakeholders, leaders, and frontline staff.
- Secure stakeholder support and necessary resources. The best projects and interventions can be fumbled if unit and department leadership do not support them.
- Implement the action plan. Ensure everyone impacted receives the education and resources necessary to make the change. The team should be prepared to answer questions and assist with problems.
- Evaluate the change. Has the change created the desired outcomes? Have unexpected outcomes occurred? Evaluate the actual versus expected outcomes and determine if the change should be retained.
- Report the results. Use local presentations to ensure all stakeholders, leaders, and impacted frontline staff know the project’s outcomes.
- Identify the next steps. Review the process and results. Should additional research be undertaken? Are additional changes needed for the process? Have new questions emerged?
- Disseminate the findings. Report the results to the organization, at a minimum. Also, consider other venues for disseminating the results, such as journal articles and conferences.
Link to Learning
The JHEBP model has been used extensively in nursing projects for almost two decades. Read this article about a quality improvement project that used the JHEBP model to decrease surgical site infections. It is an excellent example of translating research into action.