EVIDENCE BASED PRACTICE

Introduction: The concept of EBP in nursing is till in a very primitive stage in many parts of the world.
Nursing practice in most parts in India is based on experience, tradition, intuition, common sense and
untested theories. Nursing is gradually building its base of knowledge. More and more clinical
intervention studies are being conducted and published in the literature. The strength of evidence was
categorized by five levels when the first Clinical Practice Guideline was published by the Agency for
Health Care Policy and Research (1992). From most to least strength of evidence, these levels are

1) meta-analysis of multiple studies

2) Experimental studies

3) Quasi experimental studies

4) Non experimental studies

5) Case reports and clinical examples.

The past century has witnessed spectacular changes in the way we live and think. Human brilliance
and technology have come together to propose solutions we dared not imagine fifty years ago. Many
diseases have been conquered, millions of people have been saved from premature death and disability and
the search for better solutions to health care is on.Like most disciplines, nursing consists of both scientific
knowledge and conventional wisdom (knowledge that has not been empirically tested). Traditionally only
what stands the test of repeated measures constitutes truth or knowledge. Classical scientific process
however are net suitable for creating and describing all types of knowledge for the caring profession of
nursing.Evidence based nursing is closely aligned to the development of evidence based medicine. The
origins of contemporary Evidence Based medicine can be traced to the work of A.L. Cochrane, Ian
Chalmers and David Sackett. Cochrane drew attention to the lack of information about the effects of health
care, with particular reference to medicine, and suggested that:

"[It] is surely a great criticism of our profession that we have not organized a critical summary by
specialty or subspecialty adapted periodically of all relevant randomized controlled trials"

He argued that, as resources for health care are limited, they should be used effectively to provide care that
has been shown, in valid evaluations, to result in desirable outcomes. He emphasized the importance of
randomized controlled trials in providing reliable information on the effectiveness of medical interventions.

Basing practice in the best available evidence has become a highly valued aspiration for nurses and
nursing leaders have been exhorting nurses to engage in “research based practice” for at least 50 years.

Definition:

Evidence based practice is the melding of individual clinical judgment and expertise with the best
available external evidence to generate the kind of practice that is most likely to lead to a positive outcome
for a client or patient. Evidence Based Nursing Practice: Evidence based Nursing practice is nursing
practice that is characterized by these attributes takes into account the context within which care takes place;

the preferences of the client

the clinical judgment of the health professional

The best available evidence

Evidence based nursing practice can also be considered as:

1. An approach to clinical practice 2. A way to keep current with new developments

Aim of Evidence Based Practice:

The aim of evidence based health care is to provide the means by which current best evidence from
research can be judiciously and conscientiously applied in the prevention, detection, and care of health
disorders by nurses.

This aim is decidedly ambitious given how slowly important new treatments and procedures are
disseminated into practice and how resistant nurses are to withdrawing established treatments from practice
even once their utility has been disproved.

Goal of EBN

To provide the highest quality and most cost-efficient nursing care possible.

History and development

Evidence based nursing started in the 1800s with Florence Nightingale. Her concepts of promoting
health, prevention of disease, and care of the sick were central ideas of her system (LoBiondo-Wood, Haber
pg. 11). Nightingale served in the Crimean War during the 1850s in which she organized a unit of 38 nurses.
In 1856, when she returned to London, she spread the word of how important sanitation was in nursing care.
Florence Nightingale believed that infection arose spontaneously in dirty and poorly ventilated places. This
mistaken belief nevertheless led to improvements in hygiene, healthier living, and working environments.
Nightingale did not know the scientific facts of germs and bacteria, though she knew that if materials used to
treat the patients were clean, patients healed faster. Therefore if doctors and nurses washed their hands,
patient deaths decreased dramatically. She fought the established medical practices of the day, insisting that
it was not enough to rest on ungrounded theories, even if their proponents were prominent physicians of the
time. She stated, "What you want are facts, not opinions...The most important practical lesson that can be
given to nurses is to teach them what to observe-how to observe-what symptoms indicate improvement-
which are of none-which are the evidence of neglect-and what kind of neglect." This is evidence based
nursing.

In the 1960s, research priorities began to be reordered and practice-oriented research was targeted.
These priorities were supported by nursing's major organizations. Nurses soon were attaining educational
preparation in research design in order to teach research and conduct their own research courses. Nurses
primarily worked with others from related disciplines that had the expertise to teach these courses
(LoBiondo-Wood, Haber pg. 12-14). Today, the definition of evidenced based nursing came as a response to
the push for efficiency in the 1970s and 1980s. While efficiency was certainly a worthy goal, the decision
makers who impacted health-care policy were managers and businessmen rather than nurses or doctors who
actually interacted with patients. What these managers and businessmen lacked was the ability to evaluate
nursing and medical diagnosis, interventions, and clients' plans of care.

Critical Features of EBP

 It is problem based approach.

 It considers the context of the practitioner's current experience.

 It brings together the best available evidence and current practice by combining research with
knowledge and theory.

 It facilitates the application of research findings by incorporating first and second hand
knowledge into practice.
 EBP is still in its infancy in nursing. EBP is similar to research based practice and has been called an
approach to problem solving in clinical practice. In nursing Practice Evidence Based Practice have
underlined clinical features:

1. It involves identifying a clinical problem.

2. Searching the literature.

3. Critically evaluating the research evidence.

4. Determining appropriate interventions (Upton, 19

It is believed that EBP will fill the gap between research theory and practice.

Uses of Evidence Based Practice:

 Advances quality of care provided by nurses.

 Increases satisfaction of patients

 Refocuses nursing practice away from habits and tradition to evidence and research

Core of Evidence Based Practice:

The core of evidence based practice is the systematic review of the literature on a particular condition,
intervention or issue. The systematic review is essentially an analysis of all of the available literature (that is,
evidence) and a judgment of the effectiveness or otherwise of a practice. Currently, the systematic review
involves the following steps:

1. The development of a rigorous proposal or protocol. The review protocol provides a predetermined
plan to ensure scientific rigor and minimize potential bias. It also allows for periodic updating of the
review if necessary. All of the stages of the review (as listed below) are described fully in the
protocol, and it is usually subjected to peer review before the review commences.
2. Stating the questions or hypotheses which will be pursued in the review. Questions should be specific
regarding the patients, setting, interventions and outcomes to be investigated.
3. Identifying the criteria that will be used to select the literature. The inclusion criteria should address
the participants of the primary studies, the intervention and the outcomes. In addition to this, it
should also specify what research methodologies will be considered for inclusion in the review (e.g.
randomized controlled trials, clinical trials, case studies etc).
4. Detailing a strategy that will be used to identify all relevant literature within an agreed time frame.
This should include databases and bibliographies that will be searched, and the search terms that will
be used.
5. Establishing how the quality of primary studies will be assessed or critically appraised and any
exclusion criteria based on quality considerations.
6. Detailing how data will be extracted from the primary research regarding the participants, the
intervention, the outcome measures and the results.
7. Setting out a plan of how the data extracted will be pooled. Statistical analysis (Meta analysis) may
or may not be used in pooling numerical data and this will depend on the nature and quality of
studies included in the review. Where possible, odds ratio (for categorical outcome data) or
standardized mean differences (for continuous data) and their 95% confidence intervals are
calculated for each included study. If appropriate with available data, results from comparable groups
of studies are then pooled in statistical meta-analysis using Review Manager Software from the
Cochrane Collaboration, which also tests the heterogeneity between the combined results using
standard chi-square test. For textual data, the current convention is to develop a narrative summary.
While it may not be possible to state exactly what analysis will be undertaken, the general approach
should be included in the protocol.
 Users of Evidence-Based Practice:Nurses (RN, LVN, NP),Nursing assistants,Physicians, Respiratory
Therapists, Physical Therapists, Pharmacists ,Others

Need of EBP:

 Advances quality of care provided by nurses.

 Increases satisfaction of patients

 Refocuses nursing practice away from habits and tradition to evidence and research

Source: Specialty organizations, Government publications, Commercial organizations, Bibliographic

databases, Journals, Message services

The Cochrane Collaboration

The Cochrane Collaboration has played a leading role in developing and promoting evidence based
health care and continues to be pre-eminent in developing methodology related to the systematic review of
evidence of effectiveness. The Cochrane Collaboration focuses on the systematic review of randomized
controlled trials for specific medical conditions, client groups or specific health professional interventions.
The collaboration links review groups internationally and offers training and support to such groups. Review
groups commit to an ongoing process of systematic review in a specific area, and this involves:

 determining the objectives and eligibility criteria for including trials;

 identifying studies that are likely to meet the eligibility criteria;
 tabulating the characteristics and assessing the methodological quality of each study identified;
 excluding studies that do not meet the eligibility criteria;
 compiling the most complete set of data feasible, involving the investigators if possible;
 analyzing the results of eligible studies, using a meta-analysis or statistical synthesis of data if
appropriate and possible;
 performing sensitivity analyses if appropriate and possible; and
 Preparing a structured report of the review that states the aims of the review, describes the materials
and methods used and reports the results.

Review groups also engage in a continual process of updating reviews. The Cochrane Collaboration
caters for other interests (including non-medical groups) such as certain categories of health service users,
groups of health professionals, settings for health care, or classes of intervention.

Joanna Briggs Institute (JBI) and Evidence Based Nursing:

The Joanna Briggs Institute is an interdisciplinary, not-for-profit; international research and development
agency linked to an international collaboration of autonomous specialty, country or state based collaborating
centers – The Joanna Briggs Collaboration. There are 26 collaborating centre’s incorporating the disciplines
of nursing, medicine, midwifery, physiotherapy, rural health, multi-professional practice, nutrition and
dietetics, podiatry, occupational therapy, complementary therapies, aged care and medical radiation. Since
its establishment, the Joanna Briggs Institute has sought to impact on health improvement internationally
through advancing Evidence Based Care in health care.

The role of the Joanna Briggs Institute is too improve the feasibility, appropriateness, meaningfulness and
effectiveness of health care practices and health care outcomes by facilitating international collaboration
between collaborating centre’s, groups, expert researchers and clinicians through:

 Developing methods to appraise and synthesize evidence and conducting systematic reviews and
analyses of the research literature (evidence translation);
  Globally disseminating information in diverse formats to inform health systems, health professionals
and consumers (evidence transfer);
 Facilitating the effective implementation of evidence and the evaluation of its impact on health care
practice(evidence utilization)
 Contributing to clinical cost effective health care through the promotion of Evidence Based health
care practice(evidence utilization).

The 5 steps of EBN

Select a Topic

The first step is to select a topic. Ideas come from different sources but are categorized in two areas:
Problem-focused triggers and Knowledge focused triggers.

When selecting a topic, nurses should formulate questions that are likely to gain support from people
within the organization. An interdisciplinary medical team should work together to come up with an
agreement about the topic selection. The priority of the topic should be considered as well as the severity of
the problem. Nurses should consider whether the topic would apply to many or few clinical areas. Also, the
availability of solid evidence should be considered because providing proof of the research will increase
staffs' willingness to implement into nursing practice.

Problem & Knowledge Focused Triggers Problem focused triggers are identified by health
care staff through quality improvement, risk surveillance, benchmarking data, financial data, or recurrent
clinical problems. Problem focused triggers could be clinical problems, or risk management issues.
Example: Increased incidence of Deep Vein thrombosis and Pulmonary Emboli in trauma and neurosurgical
patients.

Diagnosis and proper treatment of a DVT (Deep Vein Thrombosis) is a very important task for health care
professionals and is meant to prevent pulmonary embolism. This is an example of an important area that
more research can be conducted to add into Evidence Based Practice.

Knowledge focused triggers are created when health care staff read research, listen to scientific papers at
research conferences or encounter EBP guidelines published by federal agencies or organizations.
Knowledge based triggers could be new research findings that further enhance nursing, or new practice
guidelines.
Example: Pain management, prevention of skin breakdown, assessing placement of nasogastric and naso
intestinal tubes, and use of saline maintain patency of arterial lines.

It is important that individuals work closely together to reach the optimum outcome for the chosen
topic. Some things that would ensure collaboration are working in groups to review performance
improvement data, brainstorming about ideas, and achieving consensus about the final selection.1

ii. Form a Team

Some might become overwhelmed when they first learn about EBP and apply it for reasons other than
improvement of patient care. Forming a team increases the chance of EBP being adopted. A team becomes
paramount in implementation, and evaluation of the EBP. It is important to have representatives of the team
from authority members of the organization and also grass root members. It is also important to consider
interdisciplinary involvement to decrease rejection, and for all to have an understanding of the project. All
these individuals have a great impact on the possibility of successful implementation. Other factors to put
into consideration include power figures in the organization who may directly or indirectly sabotage the
efforts if they are not consulted, and fully included in EBP implementation. The EBP team should have
explanations that clearly define the types of patients, setting, outcomes, interventions and exposures. This
should be in simplified language that is comprehensible to a lay person.
The role of the practitioners is remarkable in any meaningful gains, they are therefore inevitable and their
role becomes pivotal. The approach they adopt and their ability to educate the coworkers, answer their
questions, and clarify any misconceptions greatly improves the outcomes.

iii. Evidence Retrieval

One of the most challenging issues in using EBP in the clinical setting is learning how to adequately frame a
clinical question so that an appropriate literature review can be performed. When forming a clinical question
the following should be included: the disorder or disease of the patient, the intervention or finding being
reviewed, possibly a comparison intervention, and the outcome. An acronym used to remember this is called
the "PICO" model:

P = who is the Patient Population?

I = what is the potential Intervention or area of Interest?
C = is there a Comparison intervention or Control group?
O = what is the desired Outcome?
Illustration and example of PICO is as below:

 Patient, Age, sex, ethnicity, etc., Condition, diseases, general health status, Intervention,
Education, diagnostics, treatment plan, self-care, etc.

Comparison Intervention, Placebo, etc., Outcome, Expected and actual effects on patient

Example: Do nurse led tobacco cessation interventions result in decreased smoking rates after
hospital admission for coronary heart disease? Once the topic is selected, the research relevant to the
topic must be reviewed, in addition to other relevant literature. It is important that clinical studies,
integrative literature reviews, meta-analysis and well-known and reliable existing EBP guidelines are
accessed in the literature retrieval process. With the internet at one’s fingertips, a plethora of research is
just a few clicks away. However, just because you found it in a respectable journal does not signify high
quality research. When reviewing any article for evidence retrieval read it very closely. Articles can
appear to be precise and factual on the surface but with further and much closer examination, flaws can
be found. The article can be loaded with opinionated and/or biased statements that would clearly taint the
findings, thus lowering the creditability and quality of the article. Use of rating systems to determine the
quality of the research is crucial to the development of EBP.

Time management is crucial to information retrieval. Nurses making their way through the vast amount of
research available may find it helpful to read research articles or critical reviews instead of clinical journals.
To maintain high standards for EBP implementation, education in research review is necessary to distinguish
good research from poorly conducted research. Equally important is that the materials being reviewed,
consider if they are current.

Once the literature is located, it is helpful to classify the articles as either conceptual (theory and clinical
articles) or data-based (systematic research reviews). Before reading and critiquing the research, it is useful
to read theoretical and clinical articles to have a broad view of the nature of the topic and related concepts,
and to then review existing EBP guidelines.

iv. Apply the Evidence

After determining the internal and external validity of the study , a decision is arrived at whether the
information gathered does apply to your initial question. It’s important to address questions related to
diagnosis, therapy, harm, and prognosis. The information gathered should be interpreted according to many
criteria and should always be shared with other nurses and/or fellow researcher.

v. Decision to Change the Practice

When the studies are completed, and the EBP outcomes are evaluated, a decision is reached on whether to
use this in practice. Several factors are put into consideration. First the relevance of evidence for practice
and second the consistency in findings across studies and/or guidelines; a significant number of studies
and/or EBP guidelines with sample characteristics similar to those to which the findings will be used;
consistency among evidence from research and other nonresearch evidence; feasibility for use in practice;
the risk/benefit ratio risk (risk of harm; potential benefit for the patient). Putting together results from other
studies may end up supporting what is currently in practice rather than changing practice. Using a focus
group is a great way to provide discussion about the EBP standard and to point out key areas that may cause
problems during the implementation phase.

What Evidence Based practice is and what it is not?

 Evidence-based practice is not "cook-book” practice. Because it requires a bottom-up approach that
integrates the best external evidence with individual clinical expertise and patient-choice, it cannot
result in slavish, cook-book approaches to individual patient care.

 Evidence-based practice is not cost-cutting practice. Some fear that evidence-based practice will be
hijacked by purchasers and managers to cut the costs of health care.

 Evidence-based practice is not restricted to randomized trials and meta-analyses. It involves tracking
down the best external evidence with which to answer our clinical questions. To find out about the
accuracy of a diagnostic test, we need to find proper cross-sectional studies of patients clinically
suspected of harboring the relevant disorder, not a randomized trial. Because the randomized trial,
and especially the systematic review of several randomized trials, is so much more likely to inform
us and so much less likely to mislead us, it has become the “gold standard” for judging whether a
treatment does more good than harm. However, some questions about therapy do not require
randomized trials (successful interventions for otherwise fatal conditions) or cannot wait for the trials
to be conducted. And if no randomized trial has been carried out for our patient’s predicament, we
follow the trail to the next best external evidence and work from there.

 Does not eliminate clinical judgment/reasoning

 Does not ignore patient preferences

 Is not rigid, unchangeable

Despite its ancient origins, evidence-based practice remains a relatively young discipline whose positive
impacts are just beginning to be validated, and it will continue to evolve. This evolution will be enhanced as
several undergraduate, post-graduate, and continuing education programmes adopt and adapt it to their
learners’ needs. These programmes, and their evaluation, will provide further information and understanding
about what evidence-based practice is, and what it is not.

Barriers to promoting Evidence Based Practice

The use of evidence based practice depends a great deal on the nursing student's proficiency at
understanding and critiquing the research articles and the associated literature that will be presented to them
in the clinical setting. According to, Blythe Royal, author of Promoting Research Utilization in nursing: The
Role of the Individual, Organization, and Environment, a large amount of the preparation requirements of
nursing students consists of creating care plans for patients, covering in depth processes of pathophysiology,
and retaining the complex information of pharmacology. These are indeed very important for the future of
patient care, but their knowledge must consist of more when they begin to practice. Evidence based nursing
in an attempt to facilitate the management of the growing literature and technology accessible to healthcare
providers that can potentially improve patient care and their outcomes. Nancy Dickenson-Hazard states,
"Nurses have the capacity to serve as caregivers and change agents in creating and implementing community
and population-focused health systems. There is also a need to overcome the barriers to encourage the use of
research by new graduates in an attempt to ensure familiarity with the process. This will help nurses to feel
more confident and be more willing to engage in evidence based nursing. A survey that was established by
the Honor Society of Nursing and completed by registered nurses proved that 69% have only a low to
moderate knowledge of EBP and only half of those that responded did not feel sure of the steps the process
consists of. Many responded, "Lack of time during their shift is the primary challenge to researching and
applying EBP." There is always and will always be a desire to improve the care of our patients. The ever
increasing cost of healthcare and the need for more accuracy in the field proves a cycle in need of evidence
based healthcare. The necessity to overcome the current issues is to gain knowledge from a variety of
literature not just the basics. There is a definite need for nurses, and all practitioners, to have an open mind
when dealing with the modern inventions of the future because these could potentially improve the health of
patients.

There are many barriers to promoting evidence based practice. The first of which would be the:

1. Practitioner’s ability to critically appraise research: This includes having a considerable amount of
research evaluation skills, access to journals, and clinic/hospital support to spend time on EPN. Time,
workload pressures, and competing priorities can impede research and development. The causes of
these barriers include nurses and other professional practitioner’s lack of knowledge of research
methods, lack of support from professional colleagues and organizations, and lack of confidence and
authority in the research arena.
2. The practice environment can be resistant to changing tried and true conventional methods of
practice: This can be caused because of reluctance to believe results of research study over safe,
traditional practices, cost of adopting new practices, or gaining momentum to rewrite existing
protocols. It is important to show nurses who may be resistant to changes in nursing practice the
benefits that nurses, their patients, and their institutions can reap from the implementation of
evidence-based nursing practice, which is to provide better nursing care. Values, resources and
evidence are the three factors that influence decision-making with regard to health care. All
registered nurses and health care professionals should be taught to read and critically interpret
research and know where to find articles which relate to their field of care. In addition, nurses need
to be more aware of how to assess the information and determine its applicability to their practice.

3. Lack of continuing education programs: Practices do not have the means to provide workshops to
teach new skills due to lack of funding, staff, and time; therefore, the research may be tossed
dismissed. If this occurs, valuable treatments may never be utilized in patient care. Not only will the
patients suffer but the staff will not have the opportunity to learn a new skill. Also, the practitioners
may not be willing to implement change regardless of the benefits to patient care.

4. Fear of "stepping on one's toes”: New nurses might feel it is not their place to suggest or even tell a
superior nurse that newer, more efficient methods and/or practices are available.

The perceived threat to clinical freedom offered by evidence-based practice is neither logical nor surprising.
Resistance to change and to authority is part of human nature. When we make decisions based upon good
quality information we are inconsistent and biased. Human nature offers many challenges to evidence-based
practice. Can we do a better job of promoting evidence-based practice? And even if we find and use the
evidence, will we make consistent unbiased decisions?

Role of Nurse in evidence Based Practice:

Nurses should be encouraged to recognize the theoretical basis for practice and see ways to enhance
the knowledge base that supports practice right in the beginning of their practice. There needs to be an
increased emphasis on increasing reciprocal interaction among theory, research and practice with bridging
the gap between practices. The nurses should take care of following points to enhance evidence Based Care:

 Do nothing … and get out of date

  Depend solely on courses/conferences

 Choose the main professional journal(s) and read them cover to cover every month

 Learn how to find and appraise the evidence to answer questions that come from clinical practice

Essential Qualities of the Nurse in the 21st Century

1. Critical thinker.

2. Culturally competent.

3. Knowledgeable coordinator of community resources.

4. Politically aware.

5. Ethically and legally grounded.

6. Effective communication.

7. Competent provider of health care.

8. Responsible manager of human fiscal and material resources.

9. Understands relationship amongst healing, wellbeing and transcendence.

Research report on Evidence Based Practice:

Evidence-based practice has been recognized by the healthcare community as the gold standard for
the provision of safe and compassionate healthcare. Barriers and facilitators for the adoption of evidence-
based practice in nursing have been identified by researchers. Healthcare organizations have been
challenged to foster an environment conducive to providing care based on evidence and not steeped in
ritualized  practice.
Methods:
A descriptive, cross-sectional research study was conducted in 2006-2007 with a convenience sample
of 458 nurses at an academic medical center in California (response rate 44·68%). Two reliable and valid
questionnaires were electronically formatted and administered using a secured website. Relationships
between responses to the two instruments were examined and results  compared with previously published
data.
Results:
Organizational barriers (lack of time and lack of nursing autonomy) were the top perceived barriers.
Facilitators were learning opportunities, culture building, and availability and simplicity of resources.
Statistically significant correlations were found between barriers and practice, knowledge and attitudes
related to evidence-based practice.  
Conclusion of Study:
Similar barriers to the adoption of evidence-based practice have been identified internationally. Educators
must work with managers to address organizational barriers and proactively support evidence-based
practice.

Inferences:

Ingersoll (2000) suggested that EBP for nursing is the conscientious, explicit and judicious use of
theory derived; research based nursing information in making decisions about care delivery to individuals or
groups of patients and in consideration of individual’s needs and preferences.
 EBP de-emphasizes ritual, isolated and unsystematic clinical experiences ungrounded opinions and
tradition as a basis of practice. It stresses the use of research findings. Other measures e.g. quality
improvement and consensus among recognized experts are also incorporated as appropriate.

Best Practice in Nursing

Introduction:

Use of the phrase “Best Practice in Nursing” has become increasingly popular over the last few
years. At the same time, a clear and consistently used definition of what “Best Practice” really constitutes
remains unavailable to many practicing nurses.

Definition:

“Best Practice” refers to nursing practices that are based on the “best evidence” available from nursing
research.

Goal:

The goal of “best practices” is to apply the most recent, relevant, and helpful nursing interventions, based on
research, in real-life practice. Although other terms for infusing day-to-day nursing practice with research-
based interventions have been used in the past (e.g., research utilization, research-based practice), the phrase
“best practices in nursing” is the most popular today.

The concept “Best Practice in nursing” is an important one. New knowledge based on nursing and
related interdisciplinary research is rapidly expanding. Provision of high quality care depends on translating
research-based knowledge into real-life nursing practice. Regrettably, methods used by many nurses in the
past, such as attending conferences, networking with colleagues, and reading professional journals, can
barely keep pace with the array of potentially valuable practice-related reports released.

Evidence-Based Practice in Nursing and Best Practice:

Although ‘Best Practice” and “evidence-based Practice” are sometimes used interchangeably, the
two are different in some important respects. In simple terms, best practice is a generic or general phrase for
a process of infusing nursing practice with research-based knowledge. Evidence-based practice (EBP), on
the other hand, emerges from evidence-based medicine (EBM), which Sackett et al. (1996) defined as

“Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in
making decisions about the care of individual patients. The practice of evidence based medicine means
integrating individual clinical expertise with the best available external clinical evidence from systematic
research.”

The words “systematic research” is key to the distinguishing between evidence-based and best
practice. Systematic research implies a number of things. First, it connotes use of research that is rigorous
and well designed. Systematic research also suggests use of findings that have been supported in a series of
studies. Although nurses have long valued reviews of nursing research, like those provided in the Annals of
Nursing Research, the methods of EBP add additional requirements.

Systematic reviews are distinct from traditional literature reviews in some important ways.
Systematic reviews are more comprehensive in scope, use pre-set criteria to grade the quality of research
reviewed, and, for the most part, use randomized clinical trials as the gold standard by which evidence is
judged. The process of grading research using preset criteria means that all evidence from research is not
considered of equal value, and some may not be admissible at all. Decisions are guided by the hierarchy
used by the organization or person to evaluate the evidence.