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Nursing Science Quarterly
26(2) 152155
Historical Perspectives on
The Author(s) 2013
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Suzanne C. Beyea, RN; PhD; FAAN1 and Mary Jo Slattery, RN; MS2
Abstract
The authors of this article offer a review and historical perspective on research utilization and evidence-based practice
in nursing. They present the evolution of research utilization to the more contemporary framework of evidence-based
nursing practice. The authors address the role of qualitative research in the context of evidence-based practice. Finally, some
approaches and resources for learning more about the fundamentals of evidence-based healthcare are provided.
Keywords
clinical practice guideline, evidence-based nursing, evidence-based practice, research utilization
Evidence-based practice requires identifying a specific Nursing Child Assessment Satellite Training Projects (King,
clinical question, finding the evidence, conducting a critical Barnard, & Hoehn, 1981). These initiatives focused on
review of the research literature, appraising the evidence, retrieving and reviewing research findings, disseminating
and then applying the evidence to a clinical patient situation. results, and evaluating any changes in practice.
The concept of evidence-based practice is most frequently Other research utilization approaches included the
linked to Cochrane (1972), whereas the term evidence-based University of North Carolina model (Funk, Tornquist, &
emerged from a research group led by Guyatt (Evidence- Champagne, 1989), which placed an emphasis on the dis-
Based Medicine Working Group, 1992). Sackett, Rosenberg, semination of research findings. This model provided a
Haynes, and Richardson (1996) defined evidence-based series of annual research conferences and thus supported
medicine as the conscientious, explicit and judicious use of research-based nursing practice as an approach to improve
the best evidence in making decisions about the care of indi- patient care outcomes. The Stetler model (Stetler, 1994;
vidual patients (p. 71). Subsequently, Ingersoll (2000) pro- Stetler & Marram, 1976) provided an organizing framework
posed that evidence-based nursing is the conscientious, and approach to assist clinicians make decisions about using
explicit, and judicious use of theory-derived, research-based research findings. This model consists of six steps: a) prepa-
information in making decisions about care delivery to indi- ration, b) validation, c) evaluation of comparative findings,
viduals or groups of patients reflective of individual needs d) decision-making, e) translating the findings to practice,
and preferences (p. 152). This definition of evidence-based and f) evaluation. Stetler (Stetler, 1994; Stetler & Marram,
nursing emerged from various perspectives and a rich tradi- 1976) advanced this model, published extensively, first
tion of using research findings for conducting research utili- describing models of research utilization in nursing practice,
zation activities in nursing. subsequently evidence-based practice, and most recently the
Nursing research utilization focused on approaches to Promoting Action on Research Implementation in Health
apply knowledge derived from research studies in clinical Services (PARIHS) framework (Helfrich et al., 2010).
practice. In contrast to evidence-based practice, research uti- The Stetler model shared similar processes and outcomes
lization focused more on translating the extant research to to other approaches, such as the Iowa model of research in
practice instead of systematically determining the worthi- practice (Titler et al., 1994), the Goode research utilization
ness of the research findings prior to implementing it in prac- model (Goode, Lovett, Hayes, & Butcher, 1987), and the
tice. Starting in the 1970s, various models for research research utilization frameworks adopted by various nursing
utilization in nursing were proposed and applied in various specialty practices (such as the American Association of
clinical situations. These models focused on the adoption or Critical Care Nurses). Most of these models focused on
dissemination of new knowledge and integrating it in clinical
practice. Early efforts included the Western Interstate 1
Director, Center for Nursing Excellence, Mission Hospital, Asheville, NC
Commission on Higher Education, the Conduct and 2
Clinical Program Coordinator, Nursing Research, Dartmouth-Hitchcock
Utilization of Research in Nursing (Krueger, 1978), and the Medical Center, Lebanon, NH
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Beyea and Slattery 153
changing nursing practice within organizations, such as In nursing, research utilization evolved into evidence-
healthcare institutions or professional nursing organizations. based practice during a time when nursing research utiliza-
Staff nurses often joined nursing research committees. tion efforts were well established within healthcare
Through a systematic and organization-wide process they organizations and specialty organizations. For example, the
critiqued nursing research specific to a topic. Using pre- American Association of Critical Care Nurses (1993)
established criteria, the committee members determined launched its now renowned, Thunder Projects, involving
whether the research was adequate to make a practice change organizations and nurses from across the country in nursing
and then they monitored the outcomes. research efforts. This project examined the effects of hepa-
The success of these efforts was limited in part due to the rinized and non-heparinized flush solutions on the patency of
scope and dissemination of the research utilization initia- arterial pressure monitoring lines. Projects such as this pro-
tives, the number and quality of the published research vided clinical nurses with an opportunity to participate in
papers on a specific topic, and the ongoing challenge of nursing research and then utilize the findings in practice.
closing research and practice gaps. Despite highly success- This resulted in a growing interest in practice-focused nurs-
ful projects and promising results, clinicians at the bedside ing research and an increasing focus on evidence-based prac-
were often simply unaware of the findings. A gap also tice in nursing.
existed between research utilization efforts and the nursing The shift from a focus on research utilization to evidence-
textbooks used to educate the next generation of clinicians. based practice in nursing could be described as an increasing
Faculty members and administrators did not recognize the focus on achieving high-quality health outcomes by using
value of nursing research or research utilization. Other bar- research findings. Journals and articles pertinent to clinical
riers included the fact that many practicing nurses had not nursing research expanded in number, and the Internet pro-
had formal research or statistics courses, and research utili- vided additional access to the published literature and
zation was not a performance expectation. It was not until research. Concurrently, researchers no longer used paper-
the late 1970s that most baccalaureate nursing programs based indexes and could easily search and access published
included a formal research course or at least integrated articles using personal computers. This occurred at a time
research concepts in curricular materials (Funk, Tornquist, when there was increased value for evidence-based practice
& Champagne, 1995). within the disciplines of medicine.
Despite various barriers related to research utilization and Increasingly, healthcare insurers and regulators have
subsequently evidence-based practice, a number of factors placed an emphasis on providing evidence-based care that is
began to create more interest in evidence-based nursing care. cost-effective. This approach intended to improve care,
During this period, schools of nursing focused additional decrease costs, and promote high quality care. Payers do not
attention on advanced education in nursing at both the mas- want to provide costly, ineffective treatments that do not pro-
ters and doctoral level. Advanced education programs in vide a return on investment. Furthermore, healthcare sys-
nursing incorporated research education and addressed nurs- tems have focused more on engaging frontline clinicians in
ing knowledge development. Increasingly, nurses engaged in performing evidence-based interventions, such as hand
efforts to improve the quality of care through research find- washing, that reduces the risk of infections and protects
ings. Additionally, the United States Agency for Healthcare patients from unnecessary harm.
Research and Quality (AHRQ, formerly the Agency for As the importance of evidence-based care has emerged,
Health Care Policy and Research) began to publish practice some clinicians have resisted this approach suggesting
guidelines starting in 1992 (http://www.ahrq.gov/clinic/ that the system would be tyrannized by the evidence and
cpgonline.htm) that specifically addressed phenomena of somehow result in cookbook medicine. Other clinicians
interest to nurses. were unaware that much of medicine and nursing were
One of the first of these practice guidelines offered guid- either opinion-based or evidence-free due to a lack of high
ance on strategies to prevent pressure ulcer formation. This quality research on various topics. Others were unclear
guideline relied on Level 3 evidence (lacking direct patient about how to engage the patient as an active participant in
outcome data), expert opinion, and the consensus of an inter- the decision-making process and how clinical expertise
disciplinary expert committee. This and similar documents played a critical role in the process. But during the past
placed ever-increasing attention on evidence-based health- decade, there has been growing support for and movement
care and improving healthcare outcomes and services. These toward implementing a wide variety of evidence-based
guideline publications provided a national model for dis- practices in a more systematic manner. Initiatives such as
seminating research findings and establishing interdisciplin- the Institute for Healthcare Improvements efforts to
ary care standards. Guidelines of interest to nurses included embed evidence-based safety practices in acute care set-
acute pain management, management of cancer pain, pres- tings have increased the awareness of the relationship
sure ulcer treatment, and urinary incontinence in adults between evidence-based practices and patient outcomes
(http://www.ahrq.gov/clinic/cpgarchv.htm). (www.IHI.org).
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154 Nursing Science Quarterly 26(2)
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Beyea and Slattery 155
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