Conceptions of evidence, evidence-based medicine, evidence-based practice and their use in nursing: independent nurse prescribers' views

Aim. The purpose of this study was to explore nurses’ conceptions of evidence and evidence‐based practice, whether there are differences between evidence‐based practice and evidence‐based medicine and to identify the uptake of research evidence in the workplace. Background. The use and comprehension of the term ‘evidence‐based practice’ in relation to nursing shows remarkable variation. Numerous definitions are provided, some tend to be closely related to the concept ‘evidence‐based medicine’. Independent nurse prescribers need to be able to understand the concept of evidence‐based practice to utilize and apply this concept in order to provide adequate medication management of their patients. Method. Data were generated by focus group interview and open question questionnaire and analysed by analytical abstraction. Results. Nurses offered a variety of views on the use and uptake of evidence in the workplace. Some nurses acknowledged that they did not read research papers but were aware that they used a lot of evidence in their practice. Nurses had difficulty differentiating evidence‐based practice from evidence‐based medicine. Conclusions. Nurses were familiar with the research process but not the canons of evidenced‐based practice. The data generated indicate different levels of evidence are used by nurses. This may be a reflection of the level of intrigue of the nurses involved. Relevance to clinical practice. The education and training of independent nurse prescribers should include the exploration of evidence from randomized controlled trials and from naturalistic studies and their contribution to evidenced‐based practice and evidence‐based medicine. Both concepts need to be explored in relation to the medication management of patients.     

Searching the literature for evidence

Nurses are expected to use evidence‐based knowledge when planning and caring for patients and their families. For nurses who practice evidence‐based care, knowing how to effectively search the literature for evidence is an important skill. The objectives of this article are to provide an overview of key sources of evidence and offer instruction on how to do an effective MEDLINE search in PubMed and how to critically review research articles. A sample literature search is performed using the example case study question, “How effective are compression stockings in preventing deep vein thrombosis or pulmonary embolism for thrombotic stroke patients who are on an oral anticoagulant regimen?”     

Evidence-based practice: issues, paradigms, and future pathways

Evidence‐based practice (EBP) has become a real buzz word, not only in the discipline of nursing, but in all healthcare professions. EBP has been identified as the foundation of accountable, professional nursing practice and it would seem that few could argue with the apparent benefits; however, debate does exist in the literature about whether EBP can realistically be attained. As such, a critical discourse regarding the future of EBP for nursing needs to occur. One of the key questions to be addressed through this discourse is, “what counts as evidence?” A review of the nursing literature on the concept of EBP will be presented in this paper along with a discussion of several of the issues associated with EBP within the discipline of nursing. I will also present some ideas about the implications of the EBP movement in nursing and examine the future pathways for nursing.     

A philosophical analysis of evidence‐based practice in mental health nursing

Mental health nurses need to be aware that their knowledge base does not exist in isolation from other cultural practices. They/I/we must become more willing to engage in theoretical problem solving that directly affects clinical practice issues such as the introduction of evidence‐based practice. Critical discussion of evidence‐based practice should be informed by the complex issues that permeate all our socio‐cultural and linguistic practices. This paper examines some of the major philosophical problems in the debate over the use of evidence‐based practice in mental health nursing using both Foucault’s formulation of discourse analysis and Derrida’s construal of deconstruction. The conclusion reached is that postmodern philosophy offers a way to rid nursing of incessant naiive attacks on either quantitative or qualitative research methods which underpin the debate over evidence‐based practice in mental health nursing.     

Translating person-centred care: a case study of preceptor nurses and their teaching practices in acute care areas

Aims and objectives. The research aims to explore how preceptors interpret, operationalize, document and teach person‐centred care as they guide students within an acute surgical environment. Background. Person‐centred care is a term that is widely used in the nursing literature; however, its interpretation in nursing practice remains virtually unexplored. This is of great significance to nurses in general but to Irish nurses in particular on whom this study is focused. As preceptor nurses have been identified as key people in the education of clinical students, it was considered important to explore how clinical preceptors promote person‐centred care to current undergraduate nursing students. Design and method. Using a case study design and a qualitative approach, six preceptors were chosen to participate in this study. Data were collected by means of participant observation, review of nursing care records and semi‐structured interviews. Data were analysed in two stages. The first stage involved the identification of themes. In the second stage data were analysed using a number of propositions to examine and explain what was gleaned from the data in the context of what was originally identified in the literature. Results. Findings highlighted that preceptors had a limited conception of person‐centred care. Measures of care reflected the medical model of nursing. Beyond that, preceptors expressed care in terms of good manners or respectful etiquette. Preceptors also had limited appreciation of what learning entails and were sceptical about classroom theory other than what they considered essential for safe practice. Conclusions. This study highlights that preceptors need both internal and external support to implement the changes advocated by the Commission in Nursing in 1998 , the Nursing Education Forum in 2000 , the Department of Health and Children in 2001 and An Bord Altranais in 2003 . Relevance to clinical practice. Person‐centred care is a relatively new concept in nursing and recommended for practice. Preceptors need facilitation with its implementation. In an effort to promote changes in the delivery of health care, it is suggested that university‐based lecturers empower students to practice evidence‐based nursing as students and subsequently as qualified nurses.     

Factors influencing evidence‐based nursing utilization intention in Korean practice nurses

The purpose of this study was to describe Korean nurses' perceptions, attitudes and utilization intention for evidence‐based nursing (EBN), and to explore what factors influence utilization intention. We conducted a cross‐sectional survey in 2012. Registered nurses directly involved in clinical practice were recruited at a medical centre in Korea. A total of 420 nurses completed a self‐report questionnaire. Results showed that participants reported moderate scores regarding their perceptions and attitudes towards EBN, and rated themselves as higher than the median for utilization intention. Furthermore, this study revealed that perceptions of and attitudes towards EBN, occupational view and previous EBN education were significant factors affecting utilization intention. Nurse educators and managers should encourage nurses to have better attitudes towards EBN, help them be more satisfied with their work and provide them with appropriate education for EBN to establish evidence‐based practice as a part of daily nursing care.     

Exploring the contribution of the Clinical Librarian to facilitating evidence-based nursing

Aim. To examine the potential role of the Clinical Librarian in facilitating evidence‐based practice of nurses in acute hospital settings and develop a model for the role. Background. There is a growing policy and professional expectation that nurses will seek out and apply evidence in their clinical practice. Studies have demonstrated that nurses experience barriers in working with an evidence‐based approach. The role of Clinical Librarian has been used in other countries and within medicine to overcome some of the barriers to evidence‐based practice. There are limitations in the previous work in terms of rigour of evaluation, scope of the Clinical Librarian role and application to nursing in a UK setting. Design. A qualitative consultation of 72 nurses in acute care settings. Methods. Six consultation group interviews of between 4–19 participants. Written records were recorded by the scribe. Content analysis was undertaken to identify the range and frequency of comments. Results. Clinical questions currently go unanswered because of barriers of time, skills deficits and access to resources. Literature searching, skills training and evidence dissemination were the main areas of work the staff requested that a Clinical Librarian should undertake. It was anticipated that the Clinical Librarian could interact and work productively with nursing staff with a limited but regular presence on the ward. Interim communication could be via e‐mail, phone and written suggestions and requests for work. It was seen to be vital that the Clinical Librarian worked in partnership with staff to build evidence‐based practice capacity and ensure clinical relevance of the work. Conclusions. This study has generated the first model for the Clinical Librarian role with an emphasis on nursing. It is derived from the views of clinical nurses. Recommendations are made for the implementation and evaluation of such a role. Relevance to clinical practice. The Clinical Librarian could be an invaluable support to promoting evidence‐based nursing.     

The Effect of Advanced Practice Nurse‐Modulated Education on Rehabilitation Nursing Staff Knowledge

Rehabilitation is a specialty area with defined competencies and discrete nursing knowledge. Nurses need to be educated in the basic competencies of rehabilitation to provide safe, quality care to patients with chronic illnesses and disabilities. A critical appraisal of the literature showed that education increased knowledge in a specialty area and had positive benefits for nurses, organizations, and patients. The purpose of this paper is to describe an evidence‐based educational intervention. Self‐study modules on 15 rehabilitation competencies were developed for 16 nurses working on a new inpatient unit. Outcomes were evaluated using pre and post tests via the online Association of Rehabilitation Nurses (ARN) Competency Assessment Tool (CAT). Data were analyzed using the SPSS14.0 statistical package. Paired t‐tests demonstrated a significant difference between pre and post test scores on 14 of the 15 competencies measured. Findings suggested that education of nursing staff resulted in increased knowledge about rehabilitation nursing competencies.     

Bed articles for nursing care--state of the art in two German hospitals

Background. Bed articles are basic instruments for positioning. Research about this topic has concentrated on evidence for better practice. However, little is known about what practitioners really do. Aims and objectives. This study intended to identify the most common bed articles used for positioning in two German hospitals, and to determine the decision‐maker for their application and the purposes and criteria for their choice. Methods. Nursing experts from 100 wards were interviewed with the help of a structured questionnaire and based on these data a list of the 10 most frequent devices was compiled. Results. Supporting the body position was the most frequent intervention performed by German nurses, mainly with the help of hydraulic beds, pillows and blankets. Nurses were the main decision‐makers for the use of these bed articles. Their choice was mainly based on work experience and patients’ desires. Guidelines and literature played a minor role in this process. Relevance to clinical practice. If nurses, despite the medical doctors’ role as the main decision‐maker in German hospitals, exert significant influence on this aspect of care, they can support their position by evidence‐based practice.     

An observational study on the open-system endotracheal suctioning practices of critical care nurses

Aim and objectives. The purpose of this study was to investigate open system endotracheal suctioning (ETS) practices of critical care nurses. Specific objectives were to examine nurses’ practices prior to, during and post‐ETS and to compare nurses’ ETS practices with current research recommendations. Background. ETS is a potentially harmful procedure that, if performed inappropriately or incorrectly, might result in life‐threatening complications for patients. The literature suggests that critical care nurses vary in their suctioning practices; however, the evidence is predominantly based on retrospective studies that fail to address how ETS is practiced on a daily basis. Design and method. In March 2005, a structured observational study was conducted using a piloted 20‐item observational schedule on two adult intensive‐care units to determine how critical care nurses (n = 45) perform ETS in their daily practice and to establish whether the current best practice recommendations for ETS are being adhered to. Results. The findings indicate that participants varied in their ETS practices; did not adhere to best practice suctioning recommendations; and consequently provided lower‐quality ETS treatment than expected. Significant discrepancies were observed in the participants' respiratory assessment techniques, hyperoxygenation and infection control practices, patient reassurance and the level of negative pressure used to clear secretions. Conclusion. The findings suggest that critical care nurses do not adhere to best practice recommendations when performing ETS. The results of this study offer an Irish/European perspective on critical care nurses’ daily suctioning practices. Relevance to clinical practice. As a matter of urgency, institutional policies and guidelines, which are based on current best practice recommendations, need to be developed and/or reviewed and teaching interventions developed to improve nurses’ ETS practices, particularly in regard to auscultation skills, hyperoxygenation practices, suctioning pressures and infection control measures.     

Evidence based practice and its critics: what is a nurse manager to do?

o'halloran p. , porter s. & blackwood b. (2010) Journal of Nursing Management 18, 90–95
Evidence based practice and its critics: what is a nurse manager to do? Aim(s) The purpose is to discuss the arguments against the evidence based practice (EBP) movement and suggest how nursing management might respond. Background EBP is a pervasive approach to directing and regulating nursing care. There are, however, fierce critics who argue that it is fundamentally flawed and detrimental to patient care. Evaluation We consider some of the more radical criticisms of EBP, weighing the arguments and reflecting on the extent to which alleged short-comings are supported in the literature. Postmodernist critics are amongst the most vocal and are therefore our principal focus. Key issue(s) ‘Best evidence’ implies a hierarchical approach to knowledge which excludes other forms of evidence that are needed to understand the complexity of care. Evidence based guidelines tend to stifle critical thinking amongst nurses. Conclusion(s) While EBP is increasingly open to a range of research methodologies, it still largely subscribes to a hierarchy of evidence, even though this approach to addressing the complexities of healthcare is limiting. Although the EBP approach can be shown to stifle critical thinking, this is not inherent to the approach, which can lend itself to supporting professional nursing practice. Implications for nursing management Nursing managers should neither abandon EBP nor accept it uncritically.     

A review of evidence-based practice, nursing research and reflection: levelling the hierarchy

Aim. This paper examines the evidence‐based practice movement, the hierarchy of evidence and the relationship between evidence‐based practice and reflective practice. Background. Evidence‐based practice is equated with effective decision making, with avoidance of habitual practice and with enhanced clinical performance. The hierarchy of evidence has promoted randomized control trials as the most valid source of evidence. However, this is problematic for practitioners as randomized control trials overlook certain types of knowledge that, through the process of reflection, provide useful information for individualized and effective practice. Method. A literature search was undertaken using CINAHL, medline and Ovid electronic databases in early 2006. The search terms used were: evidence‐based practice, research evidence, evidence for practice, qualitative research, reflective practice, reflection and evidence. Other sources included handpicking of books on evidence‐based practice, reflection and research. Only material written in English was included. Findings. The hierarchy of evidence that has promoted randomized control trials as the most valid form of evidence may actually impede the use of most effective treatment because of practical, political/ideological and epistemological contradictions and limitations. Furthermore, evidence‐based practice appears to share very similar definitions, aims and procedures with reflective practice. Hence, it appears that the evidence‐based practice movement may benefit much more from the use of reflection on practice, rather than the use of the hierarchical structure of evidence. Conclusion. Evidence‐based practice is necessary for nursing, but its’ effective implementation may be hindered by the hierarchy of evidence. Furthermore, evidence‐based practice and reflection are both processes that share very similar aims and procedures. Therefore, to enable the implementation of best evidence in practice, the hierarchy of evidence might need to be abandoned and reflection to become a core component of the evidence‐based practice movement. Relevance to clinical practice. Provides an elaborated analysis for clinical nurses on the definition and implementation of evidence in practice.     

Using theory and evidence to drive measurement of patient,nurse and organizational outcomes of professional nursing practice

An evolving body of literature suggests that the implementation of evidence based clinical and professional guidelines and strategies can improve patient care. However, gaps exist in our understanding of the effect of implementation of guidelines on outcomes, particularly patient outcomes. To address this gap, a measurement framework was developed to assess the impact of an organization‐wide implementation of two nursing‐centric best‐practice guidelines on patient, nurse and organizational level outcomes. From an implementation standpoint, we anticipate that our data will show improvements in the following: (i) patient satisfaction scores and safety outcomes; (ii) nurses ability to value and engage in evidence based practice; and (iii) organizational support for evidence‐informed nursing care that results in quality patient outcomes. Our measurement framework and multifaceted methodological approach outlined in this paper might serve as a blueprint for other organizations in their efforts to evaluate the impacts associated with implementation of clinical and professional guidelines and best practices.     

Implementation of evidence‐based nursing practice for diabetic patients: An Iranian experience

Evidence‐based nursing is recognized as an indicator of quality in nursing practice, a basis for accountability and the gold standard of professional nursing care. The aim of this study was to explore nurses’ experiences and perceptions about evidence‐based nursing practice in giving care to patients with diabetic foot ulcers. A qualitative research design was adopted, and content analysis was used to analyse data. Semistructured interviews were held with 19 bachelor‐degree nurses working in a teaching hospital in an urban area of Iran. During data analysis, two main themes developed: ‘structural backgrounds of the organization’ and ‘empowerment’. Accordingly, it was concluded that successful implementation of evidence‐based nursing requires the reconfiguration of the administrative structure in the hospital. In addition, it requires the support of nurse leaders to facilitate the implementation of evidence‐based nursing in the practice.     

Clinical judgement in the interpretation of evidence: A Bayesian approach

Aim. This paper presents an argument for the use of Bayesian reasoning in considering the value of evidence in making nursing judgements. Background. Nursing has taken on board the drive towards evidence‐based practice. There has been little discussion, however, of how evidence should be interpreted. There is a growing interest in health care in the use of Bayesian reasoning for evidence interpretation, both in research and in clinical practice; as yet, there is a limited discussion in the literature of relevance to nursing. Objectives. To provide a short tutorial in the application of Bayes rule to a clinical judgement. To discuss the implications for practice of adopting a Bayesian perspective. Discussion. The relationship between evidence and clinical judgement is outlined. The need to accept uncertainty, and be equipped to deal adequately with this, is discussed: some basic ideas of probability are rehearsed. An outline of Bayesian reasoning is offered and a demonstration of the application of Bayes rule to a nursing judgement is presented. Relevance to practice. A rationale for adopting a Bayesian perspective on evidence interpretation is offered: namely the changing context of practice, with the blurring of professional boundaries and the need to articulate judgements, the avoidance of error and the opportunity to identify the appropriate areas for investigation in nursing.     

Nursing Sabbatical in the Acute Care Setting: What Is the Evidence?

PURPOSE: To review and examine the literature supporting a professional sabbatical, a potentially viable and innovative change strategy that could renew, revitalize, and retain nursing staff practicing in the acute care setting. METHOD: A literature search was completed using multiple search engines to procure articles that could answer the question: What is the evidence related to professional sabbaticals in nursing? FINDINGS: The search yielded 19 articles: one historical document, eight scholarly business articles, and 10 nursing publications. The literature review revealed most sources described sabbaticals using anecdotal data and 14 of the 19 articles were labeled as expert opinion or consensus. CONCLUSION: Borrowing from the successes in academia and other non‐nursing professions, a human capital investment opportunity exists to design and test nursing sabbaticals. The authors identified a nursing sabbatical as a viable option, which can enhance nursing retention and revitalization.