A little nursing history comment resulting from the "Evidence-based Practice" article

Authors:

Mary Krugman, RN, PhD, FAAN
Mary Krugman, RN, PhD, FAAN, director of professional resources at the University of Colorado Hospital, is responsible for research and evidence-based practice, clinical orientation, training, and continuing education of RNs and ancillary clinical employees, along with other support programs. The author has declared no real or perceived conflicts of interest that relate to this educational activity.

Maureen Habel, RN, MA
Maureen Habel, RN, MA, is an award-winning nurse author residing in Seal Beach, Calif. The planners and author have declared no real or perceived conflicts of interest that relate to this educational activity.

Margi J. Schultz, RN, MSN, PhD, CNE
Margi J. Schultz, RN, MSN, PhD, CNE is the director of the nursing division at GateWay Community College in Phoenix, Ariz. The author has declared no real or perceived conflicts of interest that relate to this educational activity.

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Objectives

The goal of this program is to provide nurses with information about evidence-based practice and strategies to increase evidence-based practice in their clinical work environment. After you study the information presented here, you will be able to —

• Review the concepts of evidence-based practice and the evolution of the field.
• Identify examples of evidence-based practice in clinical nursing practice.
• Examine ways a nurse can incorporate evidence into daily clinical practice.

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Jim, a graduate nurse, is caring for ventilated patients under the guidance of his preceptor. One day, he hears nurses around him talking about a new protocol that requires brushing patients’ teeth. Since the new protocol “suddenly appeared” and requires additional care every two hours, the nurses see it as just one more extra job to do, mandated by administration. But Jim is curious. Having recently graduated with skills enabling him to search for the evidence, he retrieves articles on ventilated patients and learns that brushing patients’ teeth is one of the components of a “ventilator bundle,” an evidence-based group of interventions to help prevent ventilator-associated pneumonia.¹ At first, Jim is hesitant to show the articles to his preceptor. Will she be receptive to learning from a graduate nurse? But Jim is fortunate: His preceptor is pleased to receive the information, and his manager gives him positive feedback, asking him to present the information at a staff meeting.

A few short years ago, evidence-based practice was less well known, and nurses were not as prepared for or open to using data and evidence in professional practice. It’s difficult to keep up with new practice changes. Many nurses learned to function according to procedures, obtaining knowledge and technical skills from nursing instructors and textbooks. Nurses believed these methods of learning provided the most accurate information on how to care for patients. Unfortunately, the nursing profession has sometimes been reluctant to change practice even in light of research that challenges the traditional way of doing things.²

But times have changed dramatically. Now nurses know some of their most widely used techniques and information about nursing practices have been based on tradition, not evidence. All nurses can think of examples of changes in nursing care, such as no longer placing a postpartum patient on bed rest or transferring the care of many surgical patients to the outpatient arena. Evidence provided the basis for these significant practice changes, and this evidence is now available to nurses with a click of a computer mouse. Many nurses, however, still choose to seek information from colleagues rather than use the computer, with research reporting that 67% of nurses surveyed used colleagues rather than evidence in practice, 58% had never used research reports, and 82% had never used library resources for updating practice.³ Gaining knowledge of evidence-based practice and learning strategies for implementation are critical skills for changing practice in your work, whatever the setting. Nurse clinicians have hands-on experience that is invaluable in improving patient care outcomes while reducing cost.⁴

What, When, and Where

Evidence-based practice is the delivery of patient care by a provider who integrates clinical expertise with the best available evidence from systematic research.^2,4 Started by physicians in England and Canada in the 1980s and 1990s, evidence-based medicine reviews and uses the best available evidence so healthcare decisions can be made in a cost-effective way based on valid research. TheCochrane Collaboration, an international nonprofit organization supporting evidence-based practice, develops rigorous reviews of the medical research literature to promote evidence-based medicine decisions. Its reviews are based on criteria that include randomized clinical trials and outcomes evaluation to ensure providers find unbiased recommendations for practice. Evidence-based practice is now considered an essential component of high-quality health care.⁵

In the U.S., the Agency for Healthcare Research and Quality (AHRQ) has been a leader in generating evidence-based standards for healthcare providers, including publishing practice guidelines on outcomes, such as pressure ulcers and pain management. The AHRQ website offers extensive resources to both professionals and consumers.

Over the years, the focus of evidence-based practice has expanded to include not just clinical trial research, but also data on patient preferences and values.⁵ These modifications are important since research-based interventions for a patient problem are not easily implemented if the patient refuses to be treated. Nursing evidence-based practice, generated from the concepts of evidence-based medicine, continues to grow, with journals, models, and books to help nurses understand the concepts and process.

Evidence-based nursing, like evidence-based medicine, emphasizes a systematic approach to examining the evidence rather than relying on tradition and anecdotal opinions. Not all evidence in nursing and patient care practice has been systematically researched, however. Various evidence-based practice models have been developed that incorporate nonresearch sources of evidence, such as the model developed by an academic hospital that depicts current and valid research at the core, then nine other non-research sources of evidence, called practice-based evidence, such as quality data, expert nurse consensus, and benchmark data.⁶Benchmarking is the process of comparing outcomes with national standards.⁵ There continue to be many interpretations of evidence-based nursing practice and some controversy over how this movement impacts the caring, qualitative focus of nursing.⁷ Using evidence enhances caring in practice by providing the nurse with the tools to deliver safe, quality care. Implementing evidence-based practice is a major criterion for organizations seeking to achieve Magnet status for nursing excellence.²

What About Research Utilization?

Experienced nurses may know about research utilization and wonder what the difference is between research utilization and evidence-based practice. Research utilization is a more structured way of using research findings, examining outcomes in a selected area of nursing practice, reviewing the literature, and changing practice based on findings. Evidence-based practice uses a broader focus, including patient preferences and data on the costs of care, among other dimensions.⁶

While nursing now emphasizes evidence-based practice, nursing research utilization was a significant force in moving nursing research from the academic setting into the clinical environment and encouraged nurses to use research at the bedside. Important projects were undertaken to advance research in practice, including the Conduct and Utilization of Research in Nursing (CURN) project.⁸ The CURN project produced 10 research-based nursing care protocols, many of which provided the foundation for how we currently practice. One example of this practice change was the management of urinary catheters. Accepted nursing practice had been to clamp, then disconnect the urinary catheter tubing when the patient ambulated. Research showed that interrupting the closed system by this method increased the likelihood of a urinary tract infection. This landmark CURN protocol promoted change in nursing practice across the country. Research utilization brought a clinical focus to nursing research, involved staff nurses in the process, and increased clinical nursing research publications, all significant advances for our profession. As the evolution of practice-based research continues, the emphasis is now moving to multidisciplinary evidence-based practice teams, recognizing the importance of multiple disciplines working together to determine best practices in patient care.⁹

Evidence-based practice and research utilization both require a nurse to learn to search for and analyze the evidence. Nurses can learn these skills independently, in a classroom, through continuing education, through library services, or in a degree program. Practicing with guidance is an important way to gain confidence when searching and analyzing evidence. Find a peer or a mentor for support and help. A local librarian, a clinical nurse specialist, or a faculty member can serve as a coach to guide learning.

Evidence-Based Practice Examples

Jim, the graduate nurse, learned to search for the evidence in his undergraduate education and quickly located the evidence about brushing teeth of vented patients. Other clinical scenarios show why critical evidence needs to be translated into the practice environment. Translating research into practice can take up to 20 years; delays that mean patient outcomes are not improved.⁵ An example of the gap between evidence and practice, and a delay in moving knowledge to patient care, can be seen in the use of saline vs. heparin in flushing lines. In 1993, a nursing study reported evidence that saline was as effective as heparin in flushing lines, was less expensive, and had better outcomes for patients since heparin is often contraindicated for a patient’s condition.¹⁰ This study was based on original research reported a decade earlier. Even today, some hospitals do not incorporate these findings into practice.

In another example, two care variances had been detected with male catheterized patients even though nurse competencies were verified. Urology physicians were consulted to identify best practices for male catheterization procedures since evidence was limited. This evidence-based project evolved into a research project since there was so little evidence to evaluate.¹¹ Study outcomes revealed that some nursing literature contained outdated facts about male catheterization, including incorrect information on the distance to insert the catheter (6 to 8 inches when it should be 10 to 12 inches) and the incorrect assumption that residual urine return indicates that the catheter is in the bladder.

Increasingly, nursing journals are including an evidence-based or research column to help nurses keep abreast of developments in their field. Some specialty organizations also sponsor grants for members to conduct research. Nurses should keep up their membership in professional organizations to gain access to these excellent evidence-based practice resources.

Starting an Evidence-Based Work Culture

Nurses cannot assume that other healthcare professionals, including physicians, know the most recent evidence since such a large volume of data is now being disseminated. For example, when working on two of our nursing evidence-based practice projects, alcohol withdrawal preprinted order sets and a sedation assessment scale for ICU patients, we discovered that physicians often did not use the same evidence. Nurses initiated the searches for evidence, and after months of journal clubs and the examination of other sources of evidence, including benchmarking data, our collaboration resulted in evidence-based order sets. The practice teams collected pre- and post-data, demonstrating improved outcomes for patients, safer care, and increased satisfaction for staff and providers. These nurse-led evidence-based projects are now collecting follow-up data to measure how the practice changes have been sustained. How did we accomplish these projects? Our work environment fosters evidence-based practice, and nurses are encouraged to question practice. While our environment does have advanced practice nurses to support managing evidence-based practice projects, many of these steps can be carried out in any environment with clinical nurses eager to change practice in their organization.

This type of data collection can and should be done by licensed practical nurses (LPNs) and licensed vocational nurses (LVNs). LPNs, or LVNs as they are known in some areas, work under the supervision of a RN or other healthcare provider. In long-term care (LTC) facilities, the RN is often immersed in managerial tasks while the LPN performs the majority of care for the residents. LPNs/LVNs are a vital part of the healthcare team in an ever-changing healthcare environment, and whether working in LTC, home care, or an acute care facility, the LPN is on the frontline to provide data that contributes to evidence-based practice.¹²

1. Identify a clinical problem or issue bothering you or other nurses. Our projects are examples of good clinical problems to tackle since all team members felt these patients were clinically challenging and exhausting to care for safely. Nurses practicing in all settings have clinical issues they find frustrating. These are often called the burning clinical question.⁷

2. Search for the evidence, using databases applicable to your problem. Some databases are by subscription only, but Medline can be accessed easily and is available at www.nlm.nih.gov/portals/healthcare.html. If you need help to search the literature and don’t have easily accessible resources, try a free online tutorial.

3. Start a journal club to analyze the evidence. Nurses on the University of Colorado Hospital medical ICU held journal club sessions to review articles on alcohol withdrawal and sedation assessment. Journal clubs are essential to keep professional practice current and to sustain the culture of evidence-based practice. Our units/services conduct journal clubs monthly or quarterly to keep up on practice changes, with clinical staff nurses taking turns learning how to lead sessions under the guidance of our CNS/educators and research nurse scientists. We started an e-mail journal to reach our float pool and off-shift nurses. There is always a way to hold a journal club! We have taught nurses about journal clubs through an online program of instruction using PowerPoint, formal classes, grand rounds, and written material.¹³ Journal clubs have the advantage of bringing together nurses from a similar specialty who have multiple views and various years of clinical experience. Participants use quantitative and qualitative critique forms to sharpen their critical thinking skills when reviewing the literature to prepare for journal club discussions. Contact a local nursing college to help conduct journal clubs if this activity seems too challenging to tackle alone in your work setting.

4. Analyze the strength of the literature. Is the evidence sufficiently reliable and valid to change practice? Decisions based on journal club review need to be based on the strength of the evidence. This can be challenging. Five key questions one expert suggests asking are —²

• Is the research relevant?
• Can the research be applied to a broader population?
• Did the intervention do more good than harm?
• What outcomes were studied?
• How large an effect did the study show, using statistical tests of significance? An account of an outcome affecting one patient, such as a case study, will have far less strength than several studies with large sample sizes. A chart (such as the one we use, with fewer levels, below) can help determine the level of evidence.^7,14

Levels of Evidence Chart
Level and Quality of Evidence	Type of Evidence
Level 1	Meta-analysis or a systematic review of multiple controlled studies or clinical trials
Level 2	Individual experimental studies with randomization
Level 3	Quasi-experimental studies, such as nonrandomized, controlled, single group, pre-post cohort, time series, or matched case-controlled studies
Level 4	Nonexperimental studies, such as comparative and correlational descriptive research, as well as qualitative studies
Level 5	Program evaluation, research utilization, quality-improvement projects, case reports (The Joint Commission’s Sentinal Event reports), or benchmarking studies (National Database of Nursing Quality Indicatorsdata, University Health SystemConsortium reports)
Level 6	Opinions of respected authorities or the opinions of expert committees, including their interpretation of nonresearch-based information. This includes textbooks and clinical product guidelines.

5. Use the strength of evidence to determine the next steps. If the evidence clearly supports a practice change, you have to decide the best method for the change process. Who are the stakeholders? Who needs to become involved to “own” the change? If it’s a nursing practice change, such as flushing lines with saline rather than heparin, nurses can initiate change using the quality improvement process in their institutions. Partners would include physicians and pharmacy. If analysis of the evidence indicates insufficient strength exists, you may need to go back and re-review the evidence or consider broadening your scope to find resources to initiate your own institutional study of the problem. We found it helpful to consult an algorithm developed by research experts to help with the next steps.¹⁵

In the case of alcohol withdrawal and the sedation scale, the evidence was clear that these were valid and reliable assessment instruments that could be implemented for safer patient care. In a different example, our nurses were interested in the issue of family presence during resuscitation procedures. The nurses reviewed research articles, but some staff were uncomfortable with having family members present during codes and other emergent procedures. We held journal clubs (many of them multidisciplinary) across our hospital to discuss the evidence. Because of the degree of controversy, we decided to conduct research by surveying nurses, physicians, and families to assess their perceptions of family presence during resuscitation. Based on our internal survey data, one unit then began to initiate the practice change as a pilot project. Our institution decided to implement this initiative as a guideline rather than a policy. Units implementing the guideline have had excellent results.¹⁶ This project demonstrates how the views of leadership influence the readiness to implement evidence, a challenge when creating an evidence-based practice environment.

6. Make the practice change. In the example of the alcohol withdrawal and sedation assessment evidence-based changes, when the preliminary nursing review of the evidence indicated sufficient strength for practice change, we formed a team, including physicians, pharmacists, and nurses, to plan practice changes. These changes included new standards of care, staff education with competency verification, and the development of preprinted medical orders. We used our hospital quality model, FOCUS-PDCA (Plan, Do, Check, Act), to implement and sustain the change.¹⁷ Evidence-based projects enhance nurses’ professional development for they not only learn about evidence-based practice directly, but also exercise leadership skills by co-leading journal clubs, writing new evidence-based nursing standards of care, collaborating with physicians and other disciplines on draft orders, holding in-services to teach peers about the practice changes, coaching staff, and conducting audits. Seeking collaborative partners to make evidence-based practice changes ensures that all team members reach consensus on the evidence and process.

Strategies to Implement Evidence-Based Practice

Activities to support evidence-based practice include forming journal clubs, conducting sessions to teach staff nurses about evidence-based practice, integrating evidence-based practice into the philosophy of nursing care and nursing job descriptions, and building policies and procedures to be evidence-based using both references and levels of evidence to document the strength of the evidence. Orientation on evidence-based practice is provided for new nursing employees, and all professional nurses complete an annual evidence-based practice skill competency. Learning how to examine the evidence is just as important as managing new equipment and deserves education and skill competencies, just like technical updates.¹⁸ We have found that working with our clinical nurses, who represent their units and services, on evidence-based champion teams, such as pain, falls, palliative care, and skin care, leads them to become champions for best practices for these clinical issues. We also disseminate an evidence-based practice newsletter to keep staff updated on evidence-based practice activities and projects.

Research shows that administrative support is key to developing a work environment that supports evidence-based practice.¹⁹ Nurse managers need to provide time and resources to encourage research utilization activities.²⁰While evidence-based activities are critical to transforming the institutional culture, the most important change needs to be your own views about research and evidence. If you think reviewing literature and other sources of evidence to implement evidence-based practice are “add-ons” to your practice, you may never fully understand or accept important practice changes. Many nurses, unfortunately, were taught that research is not part of clinical practice. Practice based on evidence is the foundation for professional nursing practice, not an activity reserved for specialists. Your actions make a difference daily in patient outcomes. Major regulatory agencies and healthcare payer groups are now examining nurse-sensitive indicators, such as pressure ulcers, falls, and restraint use, to benchmark outcomes of nursing care and possibly use this data to determine institutional reimbursement. Consumers expect that nurses will anticipate care problems to keep them safe and prevent adverse outcomes. A growing body of literature documents how nursing interventions rescue, or fail to rescue, the patient and make a difference in patient morbidity and mortality by recognizing pre-arrest conditions.^21,22 Reducing errors and keeping patients safe is a national initiative. Care needs to be delivered using evidence combined with careful patient surveillance.

The role of the LPN/LVN in evidence-based care is especially evident in the examples related to pressure ulcers, fall, and safety issues. The LPN/LVN is often the first to recognize signs of impaired skin integrity, confusion, incontinence, and other issues that affect the safety of the patient. The LPN must observe, record, and report changes that may have a significant impact on patient outcomes. In fact, data collection is one of the primary roles of the LPN/LVN. It’s the responsibility of the LPN/LVN to participate in the development of policy change and new protocols to meet the needs of all patients. LPNs/LVNs are an integral part of the healthcare team and should participate in the change process that occurs with evidence-based nursing care.²³

Patients depend on us to deliver the best care possible. Nurses need to assume accountability for practice by continually learning to fulfill our professional responsibilities. Basing practice on evidence is essential for safe nursing practice and the future of our profession.

Gannett Education guarantees the content of this educational activity is free from bias.

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References

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1. Grap MJ, Munro CL. Preventing ventilator-associated pneumonia: Evidence-based care. Crit Care Nurs Clin North Am.2004;16(3):349-358.

2. Koehn ML, Lehman K. Nurses’ perceptions of evidence-based practice. J Adv Nurs. 2008;62(2):209-215.

3. Pravikoff DS, Tanner AB, Pierce ST. Readiness of U.S. nurses for evidence-based practice. Am J Nurs. 2005;105(9):40-51.

4. Menez JA. Research in evidence-based nursing practice. Acad Medsurg Nurs Official Newslet. 2007;16(4).

5. Burns N, Grove SK. Understanding Nursing Research: Building an Evidence-Based Practice. 4^th ed. St. Louis, MO: Mosby Elsevier; 2007:498-529.

6. Goode CJ. What constitutes the ‘evidence’ in evidence-based practice? Appl Nurs Res. 2000;13(4):222-225.

7. Messear DC, Tanner CA. Evidence-based practice. In: Joel LA. Advanced Practice Nursing: Essentials for Role Development. 2nd ed. Philadelphia: PA Davis; 2009:244-259.

8. Michigan Nurses Association. Conduct and Utilization of Research in Nursing Project. New York, NY: Grune & Stratton;1981-1982.

9. Porter-O’Grady T, Alexander DR, Blaylock J, Minkara N, Surel D. Constructing a team model: creating a foundation for evidence-based teams. Nurs Adm Q. 2006;30(3):211-220.

10. Goode CJ, Kleiber C, Titler M, et al. Improving practice through research: the case of heparin vs. saline for peripheral intermittent infusion devices. Medsurg Nurs. 1993;2(1):23-27.

11. Daneshgari F, Krugman M, Bahn A, Lee RS. Evidence-based multidisciplinary practice: improving the safety and standards of male bladder catheterization. Medsurg Nurs. 2002;11(5):236-241.

12. Crecelius CA. LPNs in long-term care. Licensed practical nurse or least prepared nurse? American Medical Directors Association Web site. http://www.amda.com/publications/caring/october2004/lpns.cfm?printPage=1. Published

October 2004. Accessed June 23, 2010. 

13. Oman KS, Krugman M, Fink R, eds. Nursing Research Secrets. Philadelphia, PA: Hanley & Belfus: 2003.

14. Oman KS, Duran C, Fink R. Evidence-based policy and procedures: an algorithm for success. J Nurs Adm. 2008;38(1):47-51.

15. Titler MG, Kleiber C, Steelman VJ, et al. The Iowa Model of Evidence-Based Practice to Promote Quality Care. Crit Care Nurs Clin North Am. 2001;13(4):497-509.

16. Duran CR, Oman KS, Abel JJ, Koziel VM, Szymanski D. Attitudes toward and beliefs about family presence: a survey of healthcare providers, patients’ families, and patients. Am J Crit Care. 2007;16(3):270-290.

17. Hospital Corporation of America. Continual Improvement Handbook. Nashville, TN: Executive Learning Inc; 1993.

18. Krugman M. Evidence-based practice: the role of staff development. J Nurs Staff Dev. 2003;19(6):279-285.

19. Hutchinson AM, Johnston L. Beyond the BARRIERS scale: commonly reported barriers to research use. J Nurs Adm. 2006;36(4):189-199.

20. McClosky DJ. Nurses’ perceptions of research utilization in a corporate healthcare system. J Nurs Scholarsh. 2008;40(1):39-45.

21. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1987-1993.

22. Ashcraft AS. Differentiating between pre-arrest and failure-to-rescue. Medsurg Nurs. 2004;13(4):211-215.

23. Nursing Practice Standards for the Licensed Practical/Vocation Nurse. National Federation of Licensed Practical Nurses Web site.http://www.nflpn.org/about.html. Published October 2003. Accessed June 23, 2010.

COMMENT:
Being a diploma grad.[1971], who went on for BSN-PHN[1983], with a few courses toward Masters; research was very much a part of my Hospital-based program diploma with hours spent at UCLA Medical Library.

At Mt. St. Mary's College of "The Roy Adaptation Model" of nursing care; unless you read, researched, applied, and evaluated your practice role in every setting; you would not have graduated from the program. This is back in the early '80's.

Another aspect, not recognized is that when a RN recognized a patient-care problem; suchas insertion of a foley catheter in a male patient, and asked urologist for the patient, the physician wasn't a resource for change - even when knowing that change was needed.  Literature searches while readily available and extensive from the 70's, weren't easy to implement clinically...not because of lack of clinical Research and Development information so much, as "if you don't follow the policy and procedure"; then you were 'liable to be written-up'; or the institution might lose their JCHO or JCAHO Accreditation; and it is 'the Policy and Procedure' which is the 'Basis of Law' in malpractice cases.

RN's, especially the group of leaders who taught and lead the 70 through pretty much to date, though many are retiring now; knew exactly what the 5W's and H of their profession.  That #4 question with its answer is very disagreeable to this 38 year practicing, home health nurse! There isn't a good choice among the choices because of the error in the basis of the article.

It is important to separate didactic from clinical in nursing education and thinking, and to not forget - The Art of Patient Care - was also integral, so that nurses learned from instructors and texts is true; but the "67% learn from their peers" is too low a percent for the nursing years, roughly referred to; plus the co-developing of computers and software which did not arrive in 'nursing' until well into the mid-90's. Learning nursing practice in acute and homecare, probably occurred 80 to 95%, via mentor programs, of the time because Art and Science were both involved.

"Accepted nursing practice had been to clamp, then disconnect urine catheter tubing when patients ambulated." dates from before 1978. This distorts nursing history, which in itself parallels some of the most wonderful advances in medicine in history: 1940 through and including the first ICU at Hollywood Presbyterian in 1970 +/- a couple of years.

The hurry-up and wait approach to teaching "evidenced-based practice" was also a bit of Canada and England's (I was in England in '83)answer to 'Continuing Quality Improvement' which had many names, and was part of US Practice before approximately 1988. Adding "patient preference, cost data, + other" doesn't do justice in terms of differentiating nursing research before "evidence-based practice". Many, if not most, thoughtful, practicing profession RN's have always used self-propelled-learning via all the professional journals with peer work - most certainly if they came from Mt. St. Mary's College BSN-PHN Program.