Chapter 5: Evidence-Based Practice in Nursing

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Welcome to the Deep Dive.

We're here to help you get truly well informed, which, let's face it, is crucial in the demanding world of nursing today.

Absolutely.

It's not just what you know anymore.

Right.

It's how you know it and critically how you apply it.

So today, we're going to unpack evidence -based practice, EBP.

And alongside that, nursing research and performance improvement or PI.

Exactly.

We're drawing heavily from Fundamentals of Nursing, the 11th edition by Potter, Perry, Stockert, and Hall.

A foundational text, for sure.

Our mission here is for you to walk away really understanding how nurses use scientific knowledge, sharp critical thinking, and a real spirit of inquiry.

To deliver that high quality, safe, patient -centered care, whether you're in a hospital out in the community or doing home care.

So let's start with why EBP is so necessary.

It wasn't always the standard, was it?

No, not explicitly.

For a long time, nursing relied heavily on tradition, maybe what you learned back in nursing school or just the existing agency policies.

But things change so fast in healthcare.

Precisely.

And relying on tradition just isn't enough.

Policies themselves can sometimes be based on, well, outdated practices, not the current best evidence.

Plus, we're in this age of accountability.

Everything nurses do impacts quality, safety, costs.

And patients are definitely more informed now.

Plus, the reality of medical errors means we absolutely must ground our practice in solid evidence.

The National Quality Forum highlights this constantly.

And isn't there an official mandate for this from the ANA?

Yes, the American Nurses Association.

Their standard 14 is clear.

RNs have to integrate scholarship, evidence, and research findings into practice.

You need to grasp the why behind what you do.

Understanding what works and why it works.

Exactly.

And this drives key research priorities, too.

Things like workforce issues, communication, preventing infections, improving outcomes, all the big challenges.

Okay, so knowing why we need it, let's define EBP.

What is it?

At its core, it feels like more than just using research.

It really is.

Think of EBP as a systematic problem solving approach.

It's about deliberately using the best available evidence.

Like from research studies?

Yes.

Combined with the clinician's own expertise, and crucially, the patient's preferences and values.

Plus, you have to factor in the available healthcare resources.

Oh, okay.

The book uses that model.

Figure 5 .1, right?

Evidence, expertise, patient values.

That's the one.

It's a three -legged stool.

All parts need to be there for solid clinical decision -making.

Makes perfect sense.

Yeah.

So what are the tangible benefits?

Better decisions, obviously.

But the benefits are huge.

EBP genuinely enhances the patient experience, boosts satisfaction, can help decrease costs.

Empowers nurses, too, I bet.

Absolutely.

It gives you a stronger basis for your actions.

And ultimately, it improves patient outcomes.

It's also a core QSNEN competency quality and safety education for nurses.

Equipping nurses with the right knowledge, skills, and attitudes.

For continuous improvement, exactly.

Now, you can find evidence in textbooks and guidelines, sure.

But the gold standard is?

The best scientific evidence.

That comes from well -designed, systematically conducted research studies.

You'll find those in scientific peer -reviewed journals.

Peer -reviewed, meaning other experts have checked it for rigor and accuracy.

Correct.

But even with the best evidence, it's not a rigid formula.

Right.

Your clinical judgment is still paramount, isn't it?

Absolutely critical.

How you apply that evidence depends entirely on the individual patient.

Their physical health, psychological state, their values, their beliefs, their preferences.

Can you give an example?

Sure.

Say, research shows therapeutic touch can reduce pain.

But if your patient's cultural beliefs make them uncomfortable with being touched like that, well, you can't just ignore that.

You'd need to find another evidence -based approach that respects their values.

Exactly.

That's ethical, patient -centered EBP in action.

Okay.

So, EBP is a process.

The book lays out seven steps, starting with step zero.

Step zero.

It sounds funny, but it's foundational.

Cultivate a spirit of inquiry.

Meaning?

It means constantly questioning current practices.

Asking, why do we do it this way?

Believing that EBP actually leads to better care.

And how do healthcare organizations foster this?

Agencies with a strong EBP culture encourage questions, they provide EBP mentors, they have the right infrastructure, their policies are evidence -based, and they, you know, recognize nurses who engage in EBP.

It's about creating that curious learning environment.

So once you have that mindset, you need to focus it.

Step one, ask a clinical question in PCOT format.

Yes, PIC.

This is crucial for making your search for evidence efficient and effective.

Where do these questions usually come from?

They can come from problem -focused triggers.

Remember Kathy and Tom, the ICU nurses?

The ones dealing with the CLAB SI trend.

Exactly.

Their trigger was the monthly quality report showing an increase in central line infections, a serious hospital -acquired condition.

Their unit practice committee saw that problem and decided to investigate.

So a specific problem sparks the question,

what about just wanting to learn more?

That's a knowledge -focused trigger.

Maybe you read about a new guideline from AHRQ or hear something from an expert nurse.

And questions could be broad or specific.

Right.

You have background questions more general, like what's the best way to reduce wandering in dementia patients?

And then foreground questions, which are specific and answerable, like in dementia patients, does using stress reduction techniques actually reduce wandering?

And that's where PCOT comes in to nail down that foreground question, break down PCOT for us.

Okay.

P is the setting.

I is the intervention or issue of interest.

What treatment, test, or approach are you looking at?

C.

C is the comparison intervention.

What's the alternative?

Usually the standard of care or maybe another intervention.

O is the outcome.

What result do you want to measure or achieve?

And T is the time over what period will the intervention take place or the outcome be measured?

So going back to Kathy and Tom's CLAB SI problem, their PCOT question might be.

One of theirs was, does the use of 2 % Gorhexidine compared with alcohol C for cleansing central catheter insertion sites in hospitalized patients affect the incidence of CLAB SI within six months?

T.

Wow.

Yeah, that's incredibly specific.

No ambiguity there.

Exactly.

And that focus makes step two, searching for the best evidence much easier.

Where do you search beyond just the unit's policy manual?

Right.

You definitely check policies, maybe quality improvement data.

But for the literature, you turn to online databases.

Think Medline,

Synet, PubMed, PubMed, Embase, Psych and Photo, and especially the Cochrane database of systematic reviews.

Cochrane is fantastic for high quality systematic reviews, which synthesize lots of studies.

And getting help from librarians or experienced nurses is probably a good idea.

Oh, absolutely.

Librarians, faculty, advanced practice nurses, educators, they can be invaluable in refining your search strategy and keywords,

like Cathy and Tom using catheter associated bloodstream infection, chlorhexidine, etc.

Okay, so you find some studies, how do you know which ones are the strongest?

That's the hierarchy of evidence, right?

Often shown as a pyramid.

Precisely.

Figure 5 .2 in the book shows this pyramid.

It represents the level of rigor, basically, how much confidence you can have in the findings.

And the top is the best.

Yes.

Level 1, at the peak, is a systematic review or a meta -analysis of randomized controlled trials, RCTs.

What's the difference between those two?

A meta -analysis uses statistics to combine results from multiple RCTs to get a powerful overall estimate of the intervention's effect.

A systematic review summarizes all the relevant RCPs on a topic using rigorous methods, but might not involve statistical combination.

Both are top tier evidence summaries.

And just below that, level 2.

Level 2 is a single, well -designed RCT.

An RCT is considered the gold standard for

because it randomly assigns participants to either the treatment group or a control group.

This randomization helps minimize bias.

Okay.

And as you go down the pyramid?

The level of evidence, or the confidence, generally decreases.

You get controlled trials without randomization, then non -experimental studies like cohort or case control studies, then systematic reviews of qualitative studies, single qualitative studies, and finally, at the bottom, level 7 is the opinion of authorities or experts.

Which still has value, but isn't as strong as an RCT.

Exactly.

Expert opinion is important, but it's based on experience rather than rigorous testing.

Alright.

You found the evidence.

Now step 3.

Critically appraise the evidence.

This is where you really scrutinize what you found.

You need to determine its value, its feasibility, can we actually do this here, and its usefulness for your specific practice setting and patients.

What kind of questions are you asking?

Key questions are, what's the level of evidence according to that hierarchy?

How well was the study actually conducted?

Were there flaws?

And how useful are these findings for my patients?

How do you dissect a research article to find those answers?

They can be dense.

They can be.

Look for key sections.

The abstract gives a quick summary.

The introduction sets the stage.

The literature review tells you what was known before the study.

Then the core part, the manuscript narrative.

Right.

Which differs slightly.

A clinical article might describe a patient population or a new technology.

A research article will have specific subsections.

Purpose statement, methods design.

Methods tells you how they did it.

RCT, qualitative, how many people.

Exactly.

Then analysis how they crunched the numbers or identified themes.

For quantitative studies, you look for statistical results, like that p -value.

The p -value again.

Remind us what that means.

The t -value indicates the probability that the results observed in the study occurred purely by chance.

A common threshold is p less than .05.

Meaning less than a 5 % chance it was random luck.

So you're pretty confident the intervention had a real effect.

Correct.

For qualitative studies, the analysis section discusses the major themes that emerged from the data, like interview transcripts.

And finally,

the results or conclusions.

Yep.

Summarizes the findings, whether the hypothesis was supported, answers the research questions, and importantly, discusses the study's limitations.

And then clinical implications.

How might these findings apply in real world practice?

So Cathy and Tom's committee reviewed their articles, the systematic review, the NEJM study, the CDC guidelines.

And based on that critical appraisal, they concluded there was strong evidence supporting the use of chlorhexidine for site care, using full sterile barriers during insertion, and really strict hand hygiene.

Okay.

Evidence appraised.

Next is step four.

Integrate the best evidence.

Putting it into action.

Right.

This can happen at the bedside, maybe trying a new technique with a single patient.

Or it can involve changing formal agency policies and procedures, the PMPs.

Seems like getting buy -in would be crucial for bigger changes.

Absolutely.

You need to involve all the stakeholders, administrators, staff nurses, doctors, pharmacists, everyone involved, and explain why this change is important based on evidence.

And those EVP mentors you mentioned earlier.

They play a huge role here as informal leaders, helping influence staff.

Education is also vital, maybe in -service sessions, newsletters, emails.

Planning has to be meticulous.

Do we need new supplies?

New documentation forms.

How will we communicate this?

Is it smart to test it out first?

Very often, yes.

A pilot study, maybe on one unit for three months, is a great way to test the feasibility and effectiveness of the new practice before a large -scale rollout.

Nurses are way more likely to adopt changes if they see they're useful and feel supported by the organization.

So Kathy and Tom's unit practice committee didn't just decide on the interventions.

No, they then had to integrate them.

They revised the unit's CLABSI PMP, held education sessions, put info in the newsletter, made sure supplies were ready, and then implemented that bundle of interventions.

Which leads right into step five.

Evaluate the outcomes.

Did the change actually work?

You absolutely have to evaluate.

It's non -negotiable.

For an individual patient change, it might be simple observation.

Did the new dressing stay on?

Did the teaching work?

But for a big change, like the CLABSI bundle?

You need a more formal evaluation.

Track the outcome over time, maybe three to six months, and compare the data from before the change to the data after the change, like comparing the monthly CLABSI rates pre - and post -intervention.

See if the rate actually went down.

Exactly.

Was the change effective?

Does it need tweaking?

Or maybe should it be stopped?

You never implement a practice change without evaluating its effects.

Makes sense.

And the final step, step six, communicate the outcomes.

Share what you found.

Yes, dissemination is key.

Why keep good results a secret?

On the unit level, you can share in staff huddles, post results on a bulletin board, maybe use a visual tool like a GEMMA board to track progress.

What about beyond the unit?

Share with nursing practice councils,

EBP councils, research committees, presenting at conferences, doing poster presentations, writing an abstract.

These all help spread the knowledge and promote professional development.

And seeing positive results probably helps keep the change going, right?

Definitely.

Visible benefits make EBP changes much more sustainable.

The book mentions strategies in box 5 .2 for sustainability, things like leadership support,

EBP teams, mentorship, and those visual tools.

Kathy and Tom's team posted their collab SI rates and did audits to make sure staff were sticking to the bundle.

That helps sustain the improvement.

Okay, so that's the EBP process for applying evidence.

But what if the evidence just isn't there?

You hit a gap in knowledge.

That's precisely where nursing research comes in, using the scientific method.

To create new knowledge.

Exactly.

When EBP shows us what we don't know, research steps in.

The scientific method is that objective way to investigate things, aiming for unbiased interpretations and reliable, valid findings.

Validity, meaning the findings apply to similar patients.

Right.

Reliability, meaning you'd get similar results if you repeated the study.

And generalizability, meaning the findings can be applied to a broader population beyond just the study sample.

What are the steps in the scientific method itself?

Is it like the EBP steps?

There's overlap in the thinking, for sure.

It's often seen as five steps.

One, make an observation.

Identify a problem.

Two, ask questions.

Gather information.

That's your literature review.

Three, analyze what you found and form a specific research question or hypothesis.

A hypothesis being a testable prediction.

Exactly.

Four, conduct the study with scientific rigor, collecting empirical data, observable evidence.

And five, analyze that data and draw conclusions.

See if your hypothesis holds up.

The book compares it to the nursing process assessment diagnosis planning.

Yes, there are strong parallels.

Both are systematic, problem -solving processes.

Can you walk us through that peppermint gum example as research?

Sure.

A nurse observes patients after colon surgery seem to have more nausea and slower return of bowel function.

Ileus.

That's step one.

Observation.

Step two, she asks questions, maybe looks up existing info.

Right.

Step three, she forms a research question.

Does chewing peppermint gum postoperatively reduce postoperative Ileus in patients undergoing colon surgery?

Maybe a hypothesis.

Patients chewing gum will have less nausea and faster return of bowel function than those who don't.

Step four, conduct the study.

She works with a team to design a pilot study, maybe an experimental design.

They get 60 eligible patients, randomly assigned 30 to chew gum, 30 to be the control group.

They collect data on nausea scores and time to first bowel movement.

But before starting with patients.

Crucially, they must get approval from the Institutional Review Board, the IRB, Human Subjects Committee, and every single patient must give informed consent.

Meaning they fully understand the risks, benefits, alternatives,

and freely agree to participate, knowing their information will be kept confidential.

Absolutely.

Ethics are paramount in research.

And step five, analyze the data.

Did the gum help?

They analyze the nausea scores and bowel function times.

Maybe they find the gum group did significantly better.

They draw conclusions, noting any limitations.

Like if it was a small pilot study.

Exactly.

A small sample size limits generalizability.

Maybe it was only done at one hospital.

These limitations don't negate the findings, but they point towards needing larger multi -site studies.

And the implications for practice might be.

Based on this pilot, perhaps recommending offering peppermint gum is a low -cost, low -risk intervention for eligible post -op colon surgery patients, while also calling for more research.

So research generates that new knowledge.

Are different types of research?

Yes.

Broadly quantitative and qualitative.

Quantitative is about numbers.

Right.

It precisely measures variables, uses numerical data, statistical analysis.

It tries to control bias.

This includes experimental research like RCTs, which test interventions under controlled conditions.

And non -experimental quantitative research.

That describes, explains, or predicts things without intervening.

Think of case control studies, comparing groups with and without condition.

Or correlational studies, looking for relationships between variables, like RN education level and job satisfaction.

Surveys also fall here, gathering data from large groups.

Okay.

And qualitative research.

Qualitative explores phenomena that are hard to quantify experiences, perceptions, quality of life.

It uses non -numeric data, like interviews or observations.

Instead of statistics, it looks for themes.

Exactly.

It uses inductive reasoning, developing theories from the observations.

Examples might be understanding patients' perceptions of caring in palliative care, or exploring the stress families feel when a loved one is critically ill.

So we have an EBP and we have research generating knowledge.

What's the role of specific nursing research?

Nursing research, often supported by the National Institute of Nursing Research, NINR, at NIH,

focuses on areas vital to nursing practice, symptom science, wellness, self -management of chronic conditions, end -of -life care.

It's impact.

It directly improves patient health and welfare,

generates knowledge specific to nursing scope, improves education,

helps us use resources wisely and crucially, validates the effectiveness of nursing interventions.

It provides that scientific basis for practice.

Now, I've heard the term translation research or implementation science.

How does that fit in?

Good question.

Translation research focuses specifically on how to get evidence -based practices actually used effectively in real -world settings.

It tests implementation strategies.

So EBP uses the evidence,

research creates the evidence.

And translation research figures out the best way to implement the evidence across diverse settings and populations.

It bridges that gap between knowing what works and actually getting it done consistently.

Can you give an example?

Sure.

The transitional care model is proven to help prevent rehospitalizations for older adults, but it's complex and not widely adopted.

Translation research would study how to best implement this model in different types of hospitals or communities.

Which strategies work best?

Interesting.

And what about outcomes research?

Outcomes research looks at the end results of care, the benefits, risks, costs, and holistic effects of different treatments or services.

It helps everyone.

Patients, providers, policymakers make informed decisions.

And the focus is on the patient's results.

Yes.

Primarily on care delivery outcomes.

Measurable results experienced by the patient, family, or community.

Like, can the patient self -administer their insulin correctly?

Not just, did the nurse teach them well?

And you mentioned nurse -sensitive indicators.

Right.

These are outcomes directly influenced by nursing care.

Think pressure injuries, falls, clapped asses.

Measuring these helps demonstrate the specific impact nurses have on patient safety and quality.

Okay.

That covers EBP and research.

What about the third piece?

Performance improvement or PI?

Yeah.

How is it different?

PI is a formal approach to analyze and improve existing processes.

But it's done at a local level, like within a specific hospital unit or clinic.

So its findings aren't usually generalizable elsewhere.

Correct.

The goal is the triple aim.

Improve quality, enhance the patient experience, and lower costs within that specific setting.

Unlike EBP, PI typically doesn't involve introducing brand new practices based on external research.

It's about optimizing what's already being done.

Exactly.

How do existing processes function?

Where are the bottlenecks or problems?

PI is usually an ongoing effort, often quicker than formal EBP or research projects.

It might be triggered by monthly data trends, rising infection rates, medication errors, patient complaints.

What kinds of problems does PI tackle?

Could be system issues, like supply delivery problems.

Could be people issues, like staffing or communication breakdowns.

Or clinical problems, like infection rates or falls.

Interprofessional teams are key here.

Is it connected to things like Joint Commission Standards?

Very much so.

The Joint Commission's National Patient Safety Goals are often a focus for PI initiatives.

And if a serious sentinel event occurs, like unexpected death or serious injury, a specific PI tool called Root Cause Analysis, RCA, is used.

RCA digs deep to find out why it happened.

Yes.

Looking for both active errors, mistakes made by people, and, more importantly, latent errors, flaws in the system or processes that allowed the error to happen.

Models like PDSA Plan Doe Study Act are commonly used frameworks for PI projects.

And having a just culture helps this.

Immensely.

A just culture encourages reporting errors without fear of blame, focusing instead on learning from mistakes and fixing the underlying system issues.

It promotes critical thinking.

So EBP, research, PI,

they seem related but distinct.

How do they all fit together?

They're definitely closely interrelated.

Think of them on a continuum of clinical scholarship.

All three share the goal of using the best information to deliver high quality care.

But different focuses.

Right.

EBP uses existing evidence to improve outcomes.

Research generates new knowledge when evidence is lacking.

PI improves local work processes and measures effects within a specific setting.

And who does what?

EBP and PI are often done by practicing nurses and health care teams as part of their regular Formal research is typically conducted by dedicated researchers, often with external funding, and always requires IRB approval.

EBP and PI might sometimes need IRB oversight, depending on the project.

So they influence each other.

Constantly.

EBP uses findings from research and data from PI.

Both EBP and PI can highlight gaps in knowledge that then spark new research questions.

It's a dynamic interplay.

Can you give an example of how they might merge?

Let's say a unit's patient satisfaction scores for pain management are dropping.

First, they might use PI methods to analyze their current process and collect local data.

What are the specific issues here?

Okay, local analysis first.

Then the team might use EBP.

They search the literature for the best evidence on pain management protocols, appraise it, and integrate a new or revised evidence -based protocol into their practice.

They evaluate the results.

And if satisfaction still doesn't improve?

If EBP doesn't solve it, maybe there's a deeper knowledge gap.

That's when they might initiate a formal research study to investigate persistent factors affecting pain management on their unit, generating new knowledge.

Ah, I see.

PI identifies a local problem.

EBP applies known solutions.

And if that fails, research seeks new answers.

That's a great way to summarize the potential flow.

They're interconnected tools in the nurse's toolkit.

It really paints a clear picture.

These aren't just abstract concepts.

They're fundamental pillars supporting everything nurses do.

Absolutely.

Understanding and using EBP research and PI empowers you, as a nurse, to be a powerful advocate for patient safety and quality.

To constantly refine your practice and contribute to the science of nursing.

Precisely.

So our final thought for you.

As nurses, you are right there at the forefront of healthcare innovation.

Our challenge to you is to always cultivate that spirit of inquiry we talked about.

Keep asking why.

Challenge the status quo when needed.

And always leverage evidence to make a real difference in your patient's lives and help shape the future of care.

Well said.

Thank you so much for joining us on this Deep Drive today.

We really appreciate you being part of our learning community and your commitment to your own growth.