Opening Slide: Unit 1: Lecture 2 Evidence Based Practice

Barriers to Evidence Based Practice

Evidence-based nursing practice is the integration of best research evidence with clinical expertise and
patient values to facilitate clinical decision-making.
Slide: Barriers to Evidenced Based Practice
Nurses, physicians, and other health professionals cite a number of barriers to evidence-based practice
that include lack of knowledge and skills, misperceptions or negative attitudes toward research and
evidence-based care, lack of belief that evidence-based practice will result in a more positive outcomes
than traditional care, the tremendous amount of information available in professional journals and the
Internet, lack of time and resources to search for and appraise evidence, overwhelming patient loads,
organizational constraints, such as lack of administrative support or incentives, lack of evidence-based
practice mentors, demand from patients for certain type of treatment, peer pressure to continue with
practices steeped in tradition, resistance to change, lack of consequences for not implementing evidencebased practice, lack of autonomy over practice and incentives, and inadequate evidence-based practice
content and skills building in educational programs.
A fundamental principle of evidence-based nursing practice is that research by itself is never sufficient to
make a clinical decision. Clinicians must always trade the benefits and risks, inconvenience, and cost
associated with alternative management strategies and, in doing so, consider the patients values. The
terms patient values and preferences refer to the underlying assumptions and beliefs that are involved
when clinicians, along with patients, weigh what they will gain or lose, when making a management
decision. The explicit enumeration and balancing of benefits and risks that is central to evidence-based
nursing.
Slide: Misconceptions
There is a misconception that evidence-based nursing practice focuses only on empirical knowing and
even more narrowly on randomized controlled trials as the only legitimate source of knowledge. The
more accurate view of evidence-based nursing is that research use and research-based practice are subsets
within the broader domain of evidence-based nursing. Seen in the context of clinical decision-making
process, evidence-based nursing is consistent with ways of knowing in nursing.
Slide: Formal Inquiry
The purpose of formal inquiry is to build knowledge in a discipline. Inquiry about clinical practice issues
generally takes two paths. One path test hypotheses and leads to quantitative findings numerically
presented for the purpose of generalizing to a population in making predictions. The other path generates
meaning or identifies patterns and leads to qualitative data for the purpose of describing. Both
quantitative and qualitative data build nursing knowledge. Both quantitative and qualitative methods are
crucial to informing nursing practice. Qualitative and quantitative modes of inquiry are complementary.
Qualitative methods can describe phenomena of interest in nursing and can generate theories that propose
relationships between identified concepts. Quantitative methods can then test the relationships in
qualitative develop theories and can suggest whether the theories should be accepted or revised.
Since the concept of evidence-based practice evolved from applying the results of quantitative studies to
clinical practice, there is the erroneous conclusion that evidence-based nursing practice is only about

quantitative research. Evidence-based nursing practice involves the application of best research evidence
and clinical decision-making. The best research evidence can be quantitative or qualitative depending on
the question asked. Quantitative designs are best for evaluating the effectiveness and safety of nursing
interventions, the accuracy and perception of nursing assessment measures, the strength of causal
relationships, and the cost-effectiveness of nursing interventions. Qualitative designs are best for
understanding the meaning of illness or patient experiences, attitudes, and believe. Results of intervention
studies may inform nurses about the optimal effects of an intervention in a sample of patients, but they do
not explore and explain the barriers to patient adherence with the intervention, how the intervention
affects the patient's everyday life, the meaning of illness to the patient, or the adjustment required to
accommodate a lifelong treatment regimen.
Slide: Hierarchy of Evidence
Because misperceptions about evidence-based practice constitute a large barrier to its implementation,
clarifying these perceptions and teaching the basics of evidence-based practice are critical to advancing
evidence-based care. The teaching of evidence-based practice can and should be accomplished with
multiple strategies, including continuing education conferences, interactive workshops, and the
dissemination of educational materials, such as journals, journal articles textbooks, and informational
handouts.
Evidence-based practitioners search out the best available evidence to inform their clinical decisionmaking. The randomized controlled trial is the most appropriate design for evaluating the effectiveness
and safety of a nursing intervention, such as whether protocol directed sedation by nurses reduces the
duration of mechanical ventilation in critically ill patients with acute respiratory failure. The randomized
controlled trial is the most appropriate research design to address this type of question because through
random assignment of patients to comparison groups, known and unknown determinants of outcome are
most likely to be distributed evenly between the groups, ensuring that any difference in outcome is the
result of the intervention being evaluated. Different study designs best address other questions of
importance to nursing practice. For example, observational studies are often best for questions of
prognosis or harm. Qualitative designs are best to understand patient's experiences, attitudes, and beliefs.
Evidence-based nursing is about the application of the best research to practice.
What is the nature of the evidence in evidence-based nursing practice? A broad definition would include
any observation about the apparent relationship between events constitutes potential evidence.
Unsystematic observation can lead to important insights. But unsystematic clinical observations are
limited by small sample size and more importantly by deficiencies in the human processes of making
inferences.
Whenever possible, scientifically sound systematic reviews of the literature should be used instead of
single studies. In a systematic review, all studies that address a specific research question are identified,
relevant studies are critically appraised, data or extracted and summarize either quantitatively or nonquantitatively, and conclusions are drawn. When possible, data from the individual studies included in a
systematic review are statistically combined to create in a fact one large study. This process, known as
meta-analysis, results in a more precise estimate of effect that can be obtained from any individual study
included in the meta-analysis.
The hierarchy is not absolute. If intervention affects are sufficiently large and consistent, for example,
observational studies may provide more compelling evidence than randomized controlled trials. The
hierarchy of evidence indicates there exist some form of evidence about the effect of a particular

treatment or intervention. The evidence may be extremely weak, it may be the unsystematic observation
of a single nurse or generalization from physiologic study data related only indirectly, but there is always
evidence.
Slide: The steps of the evidence-practice Practice Change
The essential environment needed is to cultivate a spirit of inquiry. What is this? This is a consistently
questioning attitude towards practice. It is an environment where practitioners become excited asking
questions regarding their patients care as well as challenging current institutional or healthcare policies. A
culture that supports evidence-based practice promotes the spirit of inquiry and makes it visible to
clinicians. Key elements of an evidence-based practice culture include, a spirit of inquiry where all health
professionals are encouraged to question their current practices; a philosophy, mission, and clinical
promotion system that incorporates evidence-based practice; a cadre of evidence-based practice mentors
who have in-depth knowledge and skills in evidence-based practice, mentor others, and overcome barriers
to individual and organizational change; an infrastructure that provides tools to enhance evidence-based
practice such as computers for searching at the point of care, access to key databases, ongoing evidencebased practice educational and skills building sessions, and evidence-based practice rounds and journal
clubs; administrative support and leadership that values and models evidence-based practice as well as
provides the needed resources to sustain it; and regular recognition of individuals and groups who
consistently implement evidence-based practice.
Slide: Step one; formulate the burning clinical PICOT question
The first step of evidence-based practice involves the clinical question. Clinical questions are asked in the
PICOT format P meaning patient population I the intervention or issue of interest, C is the comparison
intervention or group O outcome and T. is the time or time frame. This clinical question yields the most
relevant and best evidence. When questions are asked in this format, it results in an effective search that
yields the best, relevant information, and saves time. In contrast, an inappropriately formed question
would lead to a search outcome that would likely include non-relevant material.
Slide: Step two; search for the best evidence
The search for best evidence should first begin by considering the elements of the PICOT question. Each
of the key words from the Picot question should be used to begin the search. The type of study that would
provide the best answer to an intervention or treatment question would be systematic reviews or metaanalysis, regarded as the strongest level of evidence on which to-based treatment decisions.
Step three; critical appraisal of evidence.
Step three in the evidence change process is vital, in that it involves critical appraisal of the evidence
obtained from the search process. The steps of critical appraisal can be efficiently accomplish by asking
three key questions as part of the critical appraisal process in which studies are evaluated for their
validity, reliability, and accountability to answer the posed clinical research question.
Are the results of the study valid? Are the results as close to the truth as possible? Did the researchers
conduct the study using the best research methods possible? Number two what are the results? For
example, in an intervention trial, this would include whether the intervention was effective, how large a
treatment effect was obtained, and whether clinicians could expect similar results if they implemented the
intervention in their own clinical practice setting. In the qualitative studies, this would include evaluating
whether the research approach fit the purpose of the study, along with evaluating other aspects of the
study.

Will the results help me in caring for my patients? This third critical appraisal question involves
applicability and asked whether the subjects in the study are similar to the patients whose care is being
delivered, if the benefits are greater than the risk of treatment, if the treatment is feasible to implement in
the practice setting, and if the patient desires the treatment.
Steps four; integrate the evidence with clinical expertise and patient preferences to make the best clinical
decision.
The next step in the evidence base practice process is integrating the best evidence found from the
literature with the healthcare providers expertise and patient preferences and values to implement a
decision. Consumers of healthcare services want to participate in the clinical decision-making process and
it is the ethical responsibility of the health care provider to involve patients in treatment decisions. A
clinicians assessment of healthcare resources that are available to implement a treatment decision is a
critical part of the evidence-based process decision making.
Steps five evaluate the outcome of the practice change based on evidence. Step five in the evidence base
process is evaluating the evidence-based initiative in terms of how the change affected patient outcomes
or how affective the clinical decision was with a particular patient or practice setting. This type of
evaluation is essential in determining whether the change based on evidence resulted in the expected
outcome when implemented in the real world clinical practice setting.
The final step fifth step involves disseminate the outcomes of the evidence-based practice change.
The last step in the evidence-based practice change is disseminating the outcomes of the evidence of the
change. This involves sharing outcomes with others, even colleagues within the same institution. It is
important for clinicians to disseminate outcomes of their practice changes based on evidence through
such things as oral and poster presentations at local, regional, and national conferences; evidence-based
practice rounds within their own institution: Journal and newsletter publications; and lay publications.

Reference
Dicenso, A., Guyatt, G., & Ciliska, D. (2005). Evidenced-based nursing. St.
Louis, MO: Elsevier
Melnyk, B. & Fineout-Overholt, E. (2011). Evidence based practice in nursing
and healthcare: A guide to best practice (2nd ed.). Lippincott Williams and
Wilkins