Evidence-Based Practice in Nursing and Medicine: A Guide

Introduction to Evidence-Based Practice

The influence of evidence-based practice (EBP) has reverberated across the fields of medical caregiving, academia, and scientific research. The need for evidence-based quality arises from the imperative to provide improved healthcare services that are faster, more accurate, and more effective. Nurses have responded to the emerging guidelines set by national expert groups, reorienting their practices along the lines of evidence-based approaches that have strengthened their services and will continue to add value to their profession. These redesigning activities have touched upon academic background and training as well as field practices. Practitioners also took initiative to redesign their methodology by incorporating scientifically proven methods and updating their knowledge with inputs from colleagues across the country (Stevens, 2013).

The term "evidence-based medicine" was first used in the 1990s by a team of healthcare professionals at McMaster University in Ontario, Canada. In the early days, the idea faced mixed reactions: enthusiasm from academic and research professionals, and doubt and skepticism from practitioners in the field. However, over the following decade, improved communication and the readily available data and diagnostic information on the internet strengthened the feasibility of evidence-based medicine, leading to its widespread acceptance in busy family healthcare settings (White, 2004).

The formal structure of evidence-based medicine was articulated in 1992 in the Journal of the American Medical Association. The model required the physician to study the vast body of literature available for a particular diagnostic question concerning a waiting patient and to analyze that material in order to arrive at the correct course of action. That requirement immediately raised concerns: patients would have to wait interminably. According to John Ely, MD, Associate Professor in the Department of Family Medicine at the University of Iowa College of Medicine, such a model was impossible to implement in day-to-day situations — a view that even the original proponents of the concept have come to share (White, 2004).

"A majority of clinicians want to incorporate evidence-based concepts into their practice," says Ely. "That doesn't, however, mean researching original material from scratch; rather, it means cross-referencing basic guidelines and adapting the theoretical premise concisely when offering services based on available evidence." David Sackett, MD, an original member of the McMaster group, defined EBM as "the holistic, exclusive, and balanced use of practical evidence to arrive at the selected course of action" — in essence, the fine, systematic integration of clinical experience and expertise with research findings to determine the most suitable course of treatment (White, 2004; Sackett et al., 1996).

"The best practitioners make use of both the evidence and their own experience and skills," says Sackett. "Every individual patient needs personal care, and experience and skill are needed to analyze the evidence that may have been consulted. Too much dependence on evidence alone is not advisable. At the same time, experience alone cannot suffice to address newer dimensions in healthcare practice, and the support of evidence goes a long way toward providing better remedies to patients."

Evidence-based medicine has, in some form, been practiced for about five decades even by conventionally trained clinicians and physicians. What has changed is the demand for more rigorous, systematically gathered evidence. As Robert Flaherty, MD, a family physician at Montana State University Student Health Service and an instructor who evaluates medical literature, observes: "There has been widespread — often blind — acceptance of the research evidence portrayed in materials now made available and used in practice. However, many variations and contradictory findings have been recorded in journals, and the best way to approach evidence was still being explored for many years" (White, 2004).

Why We Need EBP

Evidence-based medicine has developed systematic procedures for surveying the vast body of available evidence on any given subject, selecting the most applicable findings, and critically evaluating them for practical use. "In recent times, there has been an exponential rise in well-analyzed and critically evaluated literature that is more pragmatic from the physician's point of view than was traditionally available," said Flaherty. "The medical community now has the advantage of readily accessible material for treatment procedures" (White, 2004).

The dilemma faced by physicians stems from the combination of a vast body of available literature, the complex nature of modern medicine, and the limitations of time and human capacity to absorb and apply information. These factors together contribute to inconsistencies in medical treatment. Ely and colleagues, in a 1999 study, examined how physicians approached critical issues faced by their patients and found that more than 60 percent of the troubling questions that arose were not pursued diligently by the doctors. As a result, at least 3 out of 10 such patients never received an answer to their problems. As Ely notes, "If pursued, at least 80% of the time a satisfactory answer is likely to be found" (White, 2004).

The EBP Movement

The main aim of EBP is to create a strong connection between conventional expertise and evidence in order to support the best possible course of action in healthcare. A disquieting concern that helped drive this movement was the increased prevalence of preventable harm to patients (IOM, 2000). A mapped methodology for approaching healthcare was formulated in the Crossing the Quality Chasm report (IOM, 2001), in which the nation's leading experts emphasized the need to inculcate EBP and sought to narrow the gap between evidence-based and traditional methods (Stevens, 2013).

Evidence-based practices promise better outcomes by extending clinical expertise with research evidence, improving the services provided, and establishing clear goals. This approach rests on the belief that better access to researched material can engender a more effective approach to corrective action in healthcare, ultimately resulting in improved patient well-being. By reducing the inconsistencies inherent in purely experience-based practice, EBP enables clinicians to act from more solid, demonstrable premises (Stevens, 2013).

The birth of EBP was caused by the gap between established knowledge and traditional practices that failed to make use of that knowledge (IOM, 2001). The IOM's declaration in Crossing the Quality Chasm remains relevant today: "there is a huge gap between what could have been done and what is, instead, being done in health care" (IOM, 2001, p. 1). The report called on all professionals in the field to change the system and its procedures radically, with EBP proposed as the bridge to cross that divide. Experts have continued to develop the process through subsequent IOM Chasm reports (IOM, 2003; IOM, 2008a; IOM, 2008b; IOM, 2011a), each of which identifies EBP as central to enhancing healthcare quality. The intended effect is to standardize healthcare services and reduce the inconsistencies that arise from purely experience-based practice. Patient accountability for actions taken by physicians has also been a driving factor in the evolution of EBP toward more standardized, defensible care (Stevens, 2013).

Medical experts define EBP as "the summation of best research evidence combined with clinical skill and valuable patient outcomes" (Sackett et al., 2000, p. ii). As such, EBP integrates research evidence with medical skill and the individual preferences of the patient. This definition has been revised many times but remains useful in integrating nursing with the broader tenets of EBP (Stevens, 2013).

The EBP process has been highly evolutionary, extending well beyond what was recently practiced in nursing and medical caregiving. This paradigm shift introduced new disciplinary streams into the medical arena: new systems for critically reviewing evidence, new professions dedicated to information provision, management teams embedded in healthcare service delivery, new professional cultures in healthcare practice, and new scientific horizons for building the evidence base (Shojania & Grimshaw, 2005). The changes thus brought about fundamentally altered how nurses view the objectives of their work, encouraging them to examine results, evidence, and practices from a radically different perspective (Stevens, 2013).