Chapter 10

Evidence-Based Practice

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 Objectives
 Define evidence-based practice.
 Understand the history of evidence-based
practice in health care.
 Assess the relationship between evidence-
based practice and the practice of nursing in the
community.
 Provide examples of evidence-based practice in
the community.
 Identify barriers to evidence-based practice.
 Identify resources for evidence-based practice.

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 Introduction
 Research evidence provides a scientific basis for
practice, thus using research to support practice
will result in better client outcomes and more
efficient practice.
 Nurses at all levels can be involved in the
development, implementation, and evaluation of
the effects of evidence-based practice (EBP).
 Need for more evidence-based guidelines in
public health.

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 Definition of Evidence-Based
Practice
 Evidence-based medicine
 Evidence-based public health
 Evidence-based nursing
 Evidence-based practice

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History of Evidence-Based Practice
 Mid to late 1970s:
 Growing consensus among nursing leaders that scientific
knowledge should be used as a basis for nursing practice
 Division of Nursing began funding research utilization
projects
 Three Divisions of Nursing Projects: NCAST, WICHEN,
CURN
 1990s
 Paradigm shift
 Evidence-based practice term created
 Current literature
 Focus is on applications in the acute and primary care
setting

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 Types of Evidence
 Hierarchy of evidence
 Randomized controlled trials ranked as the highest
level of evidence
 Some include ways to judge that incorporate clinical
experience, i.e., professional guidelines

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 Factors to Implementation of EBP
 Knowledge of research and current evidence
 Ability to interpret the meaning of the evidence
 Individual professional’s characteristics
 Time restraints
 The hierarchy of the practice environment and the level of
support of managers and the ability to engage in
autonomous practice
 Philosophy of the practice environment
 Availability of resources
 Practice characteristics
 Links to outside supports
 Political constraints
 Lack of relevant and timely public health practice research

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 Steps in EBP Process
 Step Zero: Curiosity about the interventions that
are being applied
1. PICOT question
2. Literature search
3. Critical appraisal of the evidence
4. Found evidence integrated with clinical expertise and
client values
5. Evaluation of outcomes of practice decisions and
changes based on step 4
6. Disseminating outcomes

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 Approaches to Finding Evidence
 Systematic review
 Guide to Community Preventive Services
 Cochrane Public Health Group
 Center for Reviews and Dissemination
 Campbell Collaboration

 Meta-analysis
 Integrative review
 Narrative review

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 Evaluating Evidence
 Sample selection
 Randomization
 Blinding
 Sample size
 Description of intervention
 Outcomes
 Length of follow-up
 Attrition
 Confounding variables
 Statistical analysis

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Approaches to Evaluating Evidence
 The evidence is assigned a “grade” based on:
 Quality of the evidence
 Number of well-designed studies
 Presence of similar findings in all of the studies

 Three domains for evaluation systems:

 Quality
 Quantity
 Consistency
 Patient oriented evidence that matters (POEM)

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 Approaches to Implementing EBP
 Recognize current status of your own practice
 Believe that EBP care will lead to improved
client outcomes

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 Current Perspectives
 Cost versus quality
 Individual differences
 Appropriate EBP methods for community-
oriented nursing practice

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 Current Perspectives
 Rising costs of health care = continued
challenge of finding resources to implement EBP
 Emphasis on quality care, equal distribution of
health care resources, and cost control will
continue
 Use of internet for evidence data

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 Healthy People 2020 Objectives
 Offer a systematic approach to health
improvement.
 Provide general direction and focus for
measuring progress of improving health status
within a specific amount of time.
 Objectives for improving clients’ understanding
for EBP

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 The Minnesota Model
 1994: The Minnesota Department of Health
nursing staff aimed to develop a model of public
health nursing interventions.
 The model received input from public health
nurses, clinicians and educators, and a national
expert panel.
 Final model defines the scope of public health
nursing practice by type of intervention and the
client level of practice.
 17 interventions were identified.

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 Minnesota Model:
17 Interventions
1. Surveillance 10. Counseling
2. Disease and health event 11. Consultation
investigation
3. Outreach 12. Collaboration
4. Screening 13. Coalition building
5. Case finding 14. Community organizing
6. Referral and follow-up 15. Advocacy
7. Case management 16. Social marketing
8. Delegated functions 17. Policy development and
9. Health teaching enforcement

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 Minnesota Model: Actions
 For each intervention listed in the previous slide, the
following actions are taken:
 The intervention is defined.
 Assumptions about the intervention are given.
 Practice examples are given for type of client.
 How the intervention relates to other interventions is
explained.
 Basic steps are given for implementing the intervention.
 Best practices are explained.
 The evidence used to develop the intervention is given.

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