Nursing evidence-based practice: principles and applications

Nursing

Evidence-based practice is a crucial component of quality of care. Nursing is a holistic profession that depends on caring and compassion but also on research and science. As both art and science, nursing must not neglect the role of evidence when making decisions related to patient care. The proposed research outlines the importance of evidence-based practice on quality of care as well as cutting costs in a health care institution. Evidence-based practice has been shown experimentally to increase quality of care and to reduce costs. Therefore, employing more evidence-based practice at the bedside should be a primary concern of nurse leaders. To encourage greater reliance on evidence-based practice, nurses need time, mentors, and access to avenues of professional advancement. When these elements are in place, nurses are more likely to consult scientific journals for recent best practices in areas such as catheter treatment, anesthesia, and other routine health care services. The research therefore works with the hypothesis that evidence-based practice is directly dependent on an organizational culture that supports it.

Chapter One: Nature of Project and Problem Identification

a. Introductory materials with an abbreviated literature review to substantiate the choice of this problem

As Staffileno & Carlson (2009) point out, many nurses have difficulty incorporating research into daily practice because of insufficient time, lack of quality nursing leadership, and a lack of education on what the research process entails. Yet "using evidence-based research to drive practice is suggested to both improve the quality of health care as well as contain costs," (Artinian, West & Conger 2011). Research also shows a disconcerting pattern in health care: few nurses are actually using evidence-based research to guide their daily practice. This research elucidates the problem and proposes a comprehensive solution for transforming nursing care into the middle of the 21st century.

b. Identify significance of problem.

Ironically, the efficacy and practical results of evidence-based practice must itself be rooted in empirical research. This research will show that incorporating evidence-based practice into the daily practice of all nurses will be qualitatively and quantitatively beneficial for the health care industry. The problem of insufficient evidence-based practice in daily nursing care is an extensive one, cutting straight to the core of what it means to be an effective nurse and an effective health care organization. Delivering quality of care to patients within time and budgetary constraints are among the primary objectives of health care institutions. If evidence-based practice is shown to "both improve the quality of health care as well as contain costs," as Artinian, West & Conger (2011) point out, then it only makes sense to bolster evidence-based practice. To bolster evidence-based practice, nurses must learn to embrace research by incorporating empiricism into their daily practice. As Staffileno & Carlson (2009) show, three factors are shown to be the most important to increasing evidence-based practice in health care: time, leadership, and education.

The Problem: Evidence-based practice is necessary to improving quality of care and lowering health care costs overall. However, evidence-based practice is not being sufficiently used by current nursing staff at Mary Martha Hoffman Healthcare Center (MMH) in rural northern Mississippi. As a result, quality of care is diminishing, and in some cases patient health is being seriously compromised. The health care institution risks not only moral dilemmas but also financial ones, as malpractice suits will be inevitable.

c. Hypotheses or list of research questions that further expand the problem

How can evidence-based practice become an integral part of the nursing care repertoire at MMH?

What factors are empirically shown to increase the prevalence of evidence-based practice in the health care industry in general? These factors will be used as independent variables in the current research with MMH.

How can empirical research enhance nursing leadership practices, so that nurses (a) have more time to devote toward reading journals, attending seminars, and boosting knowledge of their areas of specialization; (b) trust nurse leaders and use mentoring as a means of improving evidence-based practice methods; (c) receive nursing education that promotes evidence-based practice as normative? The answers to these research questions will also impact the selection of independent variables in the proposed research.

Hypothesis: An organizational commitment to evidence-based practice will lead to patient care that is safe, cost-effective, and consistent with empirical research, without sacrificing a culture of caring and compassion.

Chapter 2: Review of Literature and Theoretical Framework

The following review of literature includes definitions of terms and overview of prior research on the importance of evidence-based practice. A theoretical framework within which the research will be conducted follows.

According to Burns and Grove, (2009) "evidence-based practice is the conscientious integration of best research evidence with clinical expertise, patient needs and values in the delivery of quality cost-effective care," (p. 699). Evidence-based practice is the application of science to the daily job of nursing: from washing hands to safely maintaining catheters. Evidence-based practice is "explores the empiric way of knowing, focusing on methods of critically appraising and applying available data and research to understand and inform clinical decision-making better," (Pipe, Wellik, Hansen & Martyn 2005, section 2). Moreover, evidence-based practice is a "problem-based learning approach" that "synthesizes clinical expertise, with the best evidence available from systematic research, and the values and preferences of patients," (Bennett & Bennett 2000, p. 172). The concept of evidence-based practice "emerged from evidence-based medicine (EBM), which has been defined as the conscientious and judicious use of current best evidence from clinical care research in the management of individual patients," (Egerod & Hansen, 2005, p. 466).

Evidence-based practice is not, and need not be, the only factor impacting decision-making in health care. In fact, evidence-based practice is only one component of health care delivery and in some cases is insufficient for providing for the total needs of patients. Pipe, et al. (2005) outlines at least four different ways of knowing that impact health care decisions, including empiricism, ethics, personal inclinations, and aesthetic patterns. Being a fundamentally empirical pursuit, evidence-based practice is an important but not singular part of health care. As Bennett & Bennett (2000) put it, "research evidence is just one factor informing clinical decision making." Ultimately nurses need to integrate empirical with other ways of knowing, in order to deliver the best quality of care. Because evidence-based practice is the implementation of scientific literature into the daily decision-making and praxis of nurses, "it has been debated whether EBP represents a new paradigm, or whether it is a neologism for known phenomena, such as research utilization or quality improvement," (Egerod & Hansen, 2005, p. 466).

Evidence-based practice is crucial in all aspects of health care and is not limited to one specific type of nursing. Bennett & Bennett (2000) define evidence-based practice in terms of its application to the field of occupational therapy. Chwalisz (2003) provides a framework for evidence-based practice in the psychological counseling field. The type of evidence might change depending on the specific health care field, but the relevance and role of evidence-based practice remains the same.

Evidence-based practice in health care has come to light "because of troubling gaps between available knowledge and what is used by professionals" in their actual daily practice (Gambrill, 2005, p. 254). This problem is evident in health care centers such as Mary Martha Hoffman Healthcare Center (MMH) in rural northern Mississippi. Moreover, research reveals several problems related to designing and implementing a comprehensive means by which to encourage evidence-based practice. For one, "the relevant research-based databases are not comprehensive in many areas," (Pipe et al. 2005, section 2). This means most nurses do not have access to credible scientific data regarding best practices. Another problem revealed in the research is that many nurses underestimate the raw importance of scientific data. Scott & Pollock (2008) found that the hierarchical organizational structure inhibited nurse initiative during the decision-making process because "nurses perceived that the behaviors expected of them were arbitrarily determined by physicians and managers in charge," (p. 298). This means that changing the very organizational structure of a health care institution can be one of the best ways of increasing evidence-based practice.

Other important barriers to implementing evidence-based practice are related to time constraints, leadership weaknesses, and failings in the nursing education sector. As Gambrill (2005) points out, some health care workers view research as a "waste of time" and even believe that research" will diminish the quality of service because it interferes with the creative, spontaneous flow that is the heart of effective helping," (p. 24). Yet combining the art of caring with the science that underlies best practices is the only way to deliver quality care to patients (Gambrill 2005).

The possible consequences of not using evidence-based practice in a health care institution are grave. Gambrill (2005) outlines some of the potential risks that health care institutions take when they deny the relevance of research in daily practice. First, the health care administrators might adopt policies or intervention methods that are unproven, or even those that have "proven ineffectiveness," (Gambrill, 2005, p. 254). Second, administrators and nurses both might fail to adopt interventions that would cut costs and improve health and safety. Third, lack of attention to evidence-based practice can lead to inconsistent delivery of care services.

Evidence-based practice relates to almost every aspect of health care at every stage of a client's relationship with the institution. For example, evidence-based practice informs the types of questions asked during the diagnostic procedures and might even impact the diagnosis itself (Bennett & Bennett, 2000). Evidence-based practice impacts the methods by which infections are prevented (Cantrell, 2009). Evidence-based practices impact the extent to which nurses are empowered to make sound, safe, and effective decisions (Scott & Pollock 2008). Evidence-based practice has the potential to transform the structure of a health care organization like MMH. This is because evidence-based practice changes the hierarchical structure in the organization due to the increased responsibility of nurses for conducting their own research. Alternatively, evidence-based practice can be an extension of organizational change. Health care organizations reducing the hierarchical nature of health care will be more likely to support evidence-based practice because of the inherent ways the method empowers nurses as opposed to empowering only managers.

The process of implementing evidence-based practice in a health care setting like that of MMH involves a series of steps. Those steps include the following, based on a review of literature. First, the nurse formulates the appropriate question based on the parameters of the scenario (Bennett & Bennett, 2000; Egerod & Hansen, 2005). For example, a nurse might need to know whether it would be appropriate to cut in half the dose of a given antibiotic due to the lower body mass of the patient vs. The norm. Second, the nurse searches the literature for evidence. This is one of the most important steps in the evidence-based practice. The nurse requires access to academic and professional databases of literature. Here is where the administration of the health care organization comes in: management must encourage access to nursing and health care databases. To promote evidence-based practice, the health care organization would have on hand terminals with free access to professional and academic databases. Then, nurses would apply their critical thinking skills regarding the accuracy, relevance, validity, and applicability of any given research study.

The third step in implementing evidence-based practice according to Egerod & Hansen (2005) is to integrate the empirical research evidence with clinical experience. Although this step is not included in Bennett & Bennett's (2000) list, it is implied as the past experiences of the nurse are to be taken seriously. The next step in integrating evidence-based practice is to implement the decision, using the evidence gathered from research in the clinical setting (Bennett & Bennett, 2000; Egerod & Hansen, 2005). The choice of method or technique to implement will be based on the review of literature and also on patient preferences (Egerod & Hansen, 2005; Gambrill, 2005). Finally, the nurse evaluates the outcome as systematically as possible. There are a number of ways a nurse may do this. From a managerial perspective, sharing the results with coworkers in staff meetings may be fruitful. Pipe et al. (2005) point out that "incorporating evidence-based research into an organization's policies and procedures" may be one of the most effective ways of improving patient care (Section 2).

According to Bennett & Bennett (2000), implementing evidence-based practice in a health care organization requires an ongoing commitment by individual nurses, nurse leaders, and administrators. Nurses need to "seek continuing education to develop skills for accessing information resources, understanding research methodologies and summary statistics, and critical appraisal," (Bennett & Bennett 2000). However, management and administration need also to make such opportunities for personal and professional development available and affordable to nurses. Nurses also need to be dedicated to using databases and reliable sources of evidence rather than assuming best practices based on habit or coworker advice. Even the authority of managers and doctors must be continually questioned in a genuine evidence-based practice paradigm. To implement evidence-based practice, nurses do need to participate in the creation of new research and in the development of their area of specialization. In other words, evidence-based practice is a means by which to improve the existing canon of knowledge. It is also up to the individual nurse to reconstruct priorities to account for evidence-based practice. The myth that time prohibits evidence-based practice must be discarded in favor of the truth that evidence-based practice is necessary for providing quality of care and for reducing health care costs. Time constraints are indeed a concern for nurses, though, especially given the current staffing shortage. As Pipe et al. (2005) note, "Evaluating studies for scientific merit can be a large task" calling for intensive organizational support for individual efforts (Section 2).

Theoretical Framework

Evidence-based practice itself has no one theoretical framework. Rather, each evidence-based practice reflects a particular theory in action. The Iowa Consortium for Substance Abuse Research and Evaluation's report (2003) distinguishes between clinical practice guidelines and evidence-based practice as being a reflection of theoretical frameworks. Whereas practice guidelines reflect "a wide variety of research literature, representing an eclectic collection" of best practice concepts, evidence-based practices "are generally based on one theoretical approach and provide detailed descriptions of how to carry out the approach," (Iowa Consortium for Substance Abuse Research and Evaluation 2003).

The theoretical framework for the proposed research is in fact eclectic, but also proven in research. Following the research of Kitson, Harvey & McCormack (1998), the current project will employ the "multidimensional framework for implementing research into practice." The multidimensional framework for implementing research into practice is based on the equation SI = f (E, C, F), "where SI=successful implementation, E=evidence, C=context, F=facilitation, and f=function of," (Kitson, et al., 1998, p. 150). The successful implementation of evidence-based practice in a specific health care institution like MMH is therefore "is a function of the relation between the nature of the evidence, the context in which the proposed change is to be implemented, and the mechanisms by which the change is facilitated," (Kitson et al. 1998, p. 150).

Chapter 3: Design and Methodology

a. Design

The research will be exploratory in nature, and the research design will be a quasi-experiment. Although not necessarily lauded for their external validity, a quasi-experimental design is a very useful method for measuring social variables," (Shuttleworth, 2008). A quasi-experiment can be an important first step in initiating the type of organizational and individual-level change that this research calls for. After a review of literature outlining the definition of evidence-based practice, its role in a holistic vision of nursing, and its intended application in clinical settings, a quasi-experiment will take place at the Mary Martha Hoffman Healthcare Center (MMH) in Mississippi. One benefit of using a quasi-experimental research design is that it may be "integrated with individual case studies," (Shuttleworth, 2008). Integrating the proposed research with future case studies can be a valuable tool for notifying the administration of a health care organization as to the specific ways of improving quality of care while also cutting costs.