Evidence-Based Practice in Healthcare: an Overview

Introduction

Evidence-Based Practice (EBP) is a deliberate and thoughtful integration of the best available evidence with clinical expertise, enabling healthcare practitioners to make informed and high-quality decisions. This approach empowers practitioners to address healthcare questions with a qualitative and evaluative perspective. EBP involves assessing current research, clinical guidelines, and various information resources to distinguish between high-quality and low-quality findings.

Background

Evidence-based practices were pioneered by Dr. Ardice Cochrane, a British epidemiologist, who emphasized the importance of evidence from randomized clinical trials as the foundation for clinical decision-making.

EBP has the potential to enhance healthcare across a wide range of conditions, including asthma, smoking cessation, heart failure, and many others. However, despite the availability of evidence-based practices, there are challenges in their implementation and significant variations in healthcare delivery. Recent studies in the United States and the Netherlands have shown that a substantial portion of patients do not receive evidence-based care, while others receive potentially harmful care.

Definition

The most widely accepted definition of Evidence-Based Practice (EBP) comes from Dr.

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David Sackett, who describes it as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of the individual patient, integrating clinical expertise with the best available external clinical evidence from systematic research" (Sackett D, 1996). Muir Gray further defines evidence-based healthcare as "an approach to decision making in which the clinician uses the best evidence available, in consultation with the patient, to decide upon the option which suits the patient best" (Muir Gray, 1997).

Purposes

1. Evidence-based practice aims to guide professionals and decision-makers in making decisions by identifying and evaluating the available evidence for a particular practice, rating its scientific soundness.
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2. Its goal is to eliminate unsound or risky practices in favor of those with better outcomes.
3. Evidence-based practices have significantly contributed to improved patient outcomes.
4. The ultimate objective of evidence-based nursing is to provide the highest quality and most cost-efficient nursing care possible.
5. Evidence-based practice in nursing primarily seeks to enhance the quality of nursing care.

For instance, when caring for a child who has suffered a severe head injury in a motor vehicle accident, healthcare professionals would benefit from knowing and applying empirically supported treatments established through randomized controlled trials to reduce intracranial pressure. In many clinical decision-making situations, empirical evidence plays a crucial role. EBP aims to integrate clinical expertise, external scientific evidence, and patient values to deliver high-quality services aligned with the preferences and needs of individuals.

Steps of Evidence-Based Practice

1. Formulating a Clear Clinical Question

The initial step in evidence-based practice is to formulate a precise clinical question based on a specific clinical problem. Questions may originate from various sources, categorized into problem-focused triggers and knowledge-focused triggers. Problem-focused triggers are identified through quality improvement, risk surveillance, benchmarking data, financial data, or recurrent clinical issues. For instance, an increased incidence of deep vein thrombosis and pulmonary emboli in trauma and neurosurgical patients could prompt a clinical question related to diagnosis and treatment. Knowledge-focused triggers arise from research findings or new practice guidelines.

When selecting a question, nurses should consider its priority, relevance to various clinical areas, and the availability of solid evidence, as these factors influence the willingness of staff to implement it into nursing practice. The PICO model (Patient, Intervention, Comparison, Outcome) is a helpful acronym for formulating clinical questions.

2. Literature Review to Acquire Evidence

Once the topic is chosen, a comprehensive review of relevant research, clinical studies, integrative literature reviews, meta-analyses, and evidence-based practice guidelines is essential. It is crucial to access credible and reliable sources while being cautious of biased or opinionated statements that can compromise the quality of evidence. Time management is vital in information retrieval, and education in research review is necessary to distinguish good research from poorly conducted studies.

Prior to critiquing research, reading theoretical and clinical articles is beneficial for gaining a broader understanding of the topic and related concepts. Existing evidence-based practice guidelines should also be reviewed.

3. Appraising Evidence for Validity and Generalizability

Evaluating the strength and weaknesses of evidence in terms of validity and generalizability is a critical step in evidence-based practice. Rating systems are employed to assess the quality of research. Appraising evidence involves asking questions such as whether the evidence can be trusted and if it is relevant to the clinical practice in question. Different types of evidence may require varying appraisal and interpretation skills.

4. Implementing Evidence in Clinical Practice

After assessing the validity and relevance of evidence, a decision is made regarding its applicability to the initial question. It is crucial to consider aspects related to diagnosis, therapy, harm, and prognosis. When evidence is of high quality, it should be integrated into clinical practice, with consideration of the potential benefits and risks, in collaboration with the patient and the healthcare team.

Interpreting the gathered information according to specific criteria and sharing it with other healthcare professionals is essential for effective implementation.

5. Evaluating Efficacy and Performance

Following the implementation of evidence-based practices, the efficacy and performance are evaluated through self-reflection, internal or external audits, or peer assessments. The evaluation process involves determining whether the actions or decisions have achieved the desired outcomes.

The Steps in the EBP Process:

• ASSESS the patient
• ASK the question
• ACQUIRE the evidence
• APPRAISE the evidence
• APPLY: talk with the patient
• Self-evaluation

Barriers in Evidence-Based Practice

Several barriers hinder the promotion of evidence-based practices, including:

• Lack of professional ability to critically appraise research.
• Time constraints and workload pressures.
• Lack of knowledge of research methods.
• Lack of support from professional organizations.
• Resistance to change in practice environments.
• Values, resources, and evidence influencing decision-making.
• Lack of continuing educational programs.
• Reluctance to suggest new methods.

To overcome these barriers, nurses must be equipped with research evaluation skills, access to journals, and organizational support. Additionally, education in research review is essential to distinguish quality research from poorly conducted studies. Efforts should be made to demonstrate the benefits of evidence-based nursing practices to those resistant to change. Nurses should also improve their ability to assess and apply information to their practice.

Models of the Evidence-Based Practice Process

Several models and theories of evidence-based practice have been developed to guide its implementation in healthcare. These models offer frameworks for understanding the process and implementing evidence-based practice in various settings. Some prominent models include:

• Advancing research and clinical practice through close collaboration (ARCC) model.
• Diffusion of innovations theory.
• Framework for adopting an evidence-based innovation.
• Iowa model of research in practice.
• Johns Hopkins nursing evidence-based practice models.
• Ottawa model of research use.
• Promoting action on research implementation in health services (PARIHS) model.
• Stetler model of research utilization.

Each of these models offers unique perspectives on translating research findings into practice. They provide frameworks for guiding the implementation of evidence-based practice projects in different healthcare settings. The Stetler model of research utilization and the Iowa model of research in practice are among the most prominent models, focusing on various aspects of the evidence-based practice process.

The Stetler Model of Research Utilization

The Stetler model of evidence-based practice assists individual healthcare practitioners in using evidence in daily practice to inform program planning and implementation. It helps practitioners assess how research findings and other evidence can be applied in practice. This model considers three forms of research use: instrumental, conceptual, and symbolic/strategic.

Instrumental use involves the direct application of research findings, while conceptual use leads to changes in understanding. Symbolic or political/strategic use occurs when information is used to justify policies or decisions and influence others' thinking and behavior. The Stetler model acknowledges that various factors, both internal and external, can influence an individual's or group's use of evidence in decision-making.

Phases of the Stetler Model of Research Utilization

The Stetler model consists of five phases:

1. Preparation: Identifying the purpose, context, and sources of research evidence.
2. Validation: Assessing the credibility and applicability of findings and summarizing relevant details.
3. Comparative Evaluation/Decision Making: Organizing and comparing summarized findings and making decisions based on criteria of applicability.
4. Translation/Application: Forming action terms and determining the type, method, and level of research use.
5. Evaluation: Clarifying expected outcomes, conducting formal and informal evaluations, and considering cost-benefit analysis.

Conclusion

Evidence-Based Practice (EBP) in healthcare is the systematic and deliberate use of the best available evidence to inform clinical decision-making. It plays a vital role in improving the quality of clinical nursing practices. EBP integrates clinical expertise with external scientific evidence and patient values to provide high-quality care. The EBP process involves formulating clear clinical questions, acquiring and appraising evidence, implementing evidence in practice, and evaluating the outcomes.

Despite its benefits, several barriers exist, including a lack of research evaluation skills, time constraints, and resistance to change. To overcome these barriers, nurses must enhance their research knowledge and skills, and organizations should support ongoing education and promote the benefits of evidence-based nursing practices.

Various models and theories, such as the Stetler model of research utilization, guide the implementation of evidence-based practice in healthcare settings. These models offer frameworks for understanding the process and translating research findings into practice, ultimately contributing to improved patient care and outcomes.