Evidence-Based Practice and Nursing Theory
Helen Soderstrom was stricken with changes in her vision, disturbances of gait, and occasional periods of severe fatigue during her senior year of nursing school. She experienced intermittent periods of normality as well as illness, and the periods when she had no symptoms lasted many months. During a time when her symptoms were unusually active, she sought medical help, and her physician determined that her symptoms were related to stress. Despite the periods of weakness and fatigue, she was able to complete the nursing program and graduated with honors. Evidence-Based Practice and Nursing Theory
During Helen’s first year of practice, she experienced two periods of symptom exacerbation, but each was short-lived. With full insurance, she was able to see a neurologist who concluded that she was experiencing the beginning stages of a neuromuscular disease. Because there was no “cure,” the neurologist worked with Helen to find interventions that helped her manage the symptoms when they became problematic.
After a few years in practice, Helen enrolled in a graduate program to work toward a career in nursing education. During her first year of graduate studies, she seldom experienced neurologic symptoms, but during her practice teaching course, they returned. Evidence-Based Practice and Nursing Theory
The recurrence of symptoms, along with a new understanding of evidence-based practice from her graduate courses, led Helen to make her personal health experience the topic of her final paper. To learn more, she sought resources that would help her gain better control of the neuromuscular symptoms as well as assist her in her studies. To that end, she contacted her University’s neuroscience department and joined a research team. As she learned more about EBP, she considered what system she would use to develop guidelines on symptom management and selected the Iowa Model because of its extensive use in research.
The idea of evidence-based practice (EBP) was introduced in the 1970s by Dr. Archie Cochrane, an Englishman who wrote a dynamic book questioning the efficacy of non–research-based practices in medicine (Melnyk & Fineout-Overholt, 2011). In particular, Dr. Cochrane emphasized the critical review of research, largely focusing on randomized control trials (RCTs) to support medical practice. His influence eventually led to development of the Cochrane Collaboration, an organization charged with developing, maintaining, and updating systematic reviews of health care interventions (Cochrane Collaboration, 2013). Although the notion of EBP was somewhat delayed in being recognized and implemented in nursing, over the past two decades, EBP has appeared with increasing frequency in the nursing literature and now has essentially become the standard for research-based, informed decision making for nursing care. Evidence-Based Practice and Nursing Theory
EBP is similar to research-based practice and has been called an approach to problem solving that conscientiously uses the current “best” evidence in the care of patients (LoBiondo-Wood & Haber, 2010). EBP involves identifying a clinical problem, searching the literature, critically evaluating the research evidence, and determining appropriate interventions. Nursing scholars note that EBP relies on integrating research, theory, and practice and is equivalent to theory-based practice as the objective of both is the highest level of safety and efficacy for patients (Fawcett & Garity, 2009). Evidence-Based Practice and Nursing Theory
Overview of Evidence-Based Practice
The concept of EBP is widely accepted as a requisite in health care. EBP is based on the premise that health professionals should not center practice on tradition and belief but on sound information grounded in research findings and scientific development (Melnyk & Fineout-Overholt, 2011; Schmidt & Brown, 2012). Until the early part of the 21st century, the concept of EBP was more common in Canadian and English nursing literature than in U.S. nursing literature. Over the last decade, however, the term has become ubiquitous. This is attributed in part to the guideline initiatives of the Agency for Health Care Quality, the Institute of Medicine, and the U.S. Preventative Services Task Force, among others (Hudson, Duke, Haas, & Varnell, 2008; Melnyk & Fineout-Overholt, 2011).
Many nursing scholars (DiCenso, Guyatt, & Ciliska, 2005; Ingersoll, 2000; LoBiondo-Wood & Haber, 2010; Melnyk & Fineout-Overholt, 2011; Rycroft-Malone, 2004) have pointed out that EBP and research are not synonymous. They are both scholarly processes but focus on different phases of knowledge development—application versus discovery. In general, EBP refers to the integration of individual clinical expertise with the best available external clinical evidence from systematic research. It is largely based on research studies, particularly studies using clinical trials, meta-analysis, and studies of client outcomes, and it is more likely to be applied in practice settings that value the use of new knowledge and in settings that provide resources to access that knowledge. Evidence-Based Practice and Nursing Theory
Definition and Characteristics of Evidence-Based Practice
In medicine, EBP has been defined as the conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). It is an approach to health care practice in which the clinician is aware of the evidence that relates to clinical practice and the strength of that evidence (Jennings & Loan, 2001; Tod, Palfreyman, & Burke, 2004).
To distinguish nursing from medicine in discussing EBP, a number of definitions have been presented in the literature. Sigma Theta Tau International (2005, para. 4) defined “evidence-based nursing” as “an integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families, and communities who are served.” Similarly, DiCenso and colleagues (2005) defined EBP as “the integration of best research evidence with clinical expertise and patient values to facilitate clinical decision making” (p. 4). Both of these definitions use similar terms (e.g., best evidence, expertise, patient values). Ingersoll (2000) used slightly different terms when she suggested that evidence-based nursing practice “is the conscientious, explicit, and judicious use of theory-derived, research-based information in making decisions about care delivery to individuals or groups of patients and in consideration of individual needs and preferences” (p. 152). Evidence-Based Practice and Nursing Theory
In nursing, EBP generally includes careful review of research findings according to guidelines that nurse scholars have used to measure the merit of a study or group of studies. Evidence-based nursing de-emphasizes ritual, isolated, and unsystematic clinical experiences; ungrounded opinions; and tradition as a basis for practice and stresses the use of research findings. Other measures or factors, including nursing expertise, health resources, patient/family preferences, quality improvement efforts, and the consensus of recognized experts, are also incorporated as appropriate (Melnyk & Fineout-Overholt, 2011; Schmidt & Brown, 2012).
In summary, EBP has several critical features. First, it is a problem-based approach and considers the context of the practitioner’s current experience. In addition, EBP brings together the best available evidence and current practice by combining research with tacit knowledge and theory. Third, it incorporates values, beliefs, and desires of the patients and their families. Finally, EBP facilitates the application of research findings by incorporating first- and second-hand knowledge into practice. Link to Practice 12-1 presents information on databases that nurses and others can access to find specific information on current guidelines and other collections of “evidence” that can be used to improve health care.
Link to Practice 12-1: Key Resources for Evidence-Based Practice
Several important databases have been set up over the last 20 years to promote integration of “evidence” in health care. Information on three of the most influential are presented here.
Cochrane Collaboration – http://www.cochrane.org/
The Cochrane Collaboration is an international network that helps health care practitioners, policy makers, patients, and their advocates make informed decisions about health care. The Cochrane Library prepares, updates, and promotes the accessibility of the Cochrane Database of Systematic Reviews.
Joanna Briggs Institute – http://www.joannabriggs.edu.au/
The Joanna Briggs Institute is an international research and development organization from the School of Translational Science at the University of Adelaide, South Australia. The Institute and its collaborating entities promote and support the synthesis, transfer, and utilization of evidence through identifying feasible, appropriate, meaningful, and effective health care practices to assist in the improvement of health care outcomes.
Agency for Healthcare Research and Quality (U.S. Preventative Services Task Force/National Guideline Clearinghouse) http://www.guideline.gov/
The National Guideline Clearinghouse (NGC) is a database of evidence-based clinical practice guidelines. It is intended to be used by health professionals, practitioners, patients, and others to obtain objective, detailed information on clinical practice guidelines and to further their dissemination, implementation, and use.
Concerns Related to Evidence-Based Practice in Nursing
Despite growing acceptance of application of EBP in nursing, some criticisms and concerns have been voiced in the nursing literature. For example, there is the concern that EBP is more focused on the science of nursing than on the art of nursing. Some authors have expressed concern that strict concentration on empirically based knowledge will lead to the failure to capture the uniqueness of nursing and the importance of holistic care in contemporary practice (Fawcett, Watson, Neuman, Walker, & Fitzpatrick, 2001; Hudson et al., 2008; Upton, 1999). Evidence-Based Practice and Nursing Theory
Another concern is that strict reliance on EBP will place nurses in the role of medical extender or medical technician, where nursing will be reduced to a technical practice. This concern was voiced as equating EBP with “cookbook care” and a disregard for individualized patient care (Finkelman & Kenner, 2013; Melnyk & Fineout-Overholt, 2011). Indeed, although evidence may provide direction for development of procedures, techniques, and protocols for nursing, it has been established that these are not the only knowledge that informs the nursing practice and that consideration of individual needs and values is essential (Hudson et al., 2008; Mitchell, 2013).
Third, because research involving humans is complex, findings may be open to interpretation and therefore should not be the sole basis for practice. Research must be considered within the context of the practice prescribed by theory, and it must integrate the values and beliefs of nursing philosophy (Chinn & Kramer, 2011; McKenna & Slevin, 2008; Walker & Avant, 2011).
A fourth concern relates to promoting a link with evidence-based medicine and its emphasis on positivist thinking and the dominance of randomized clinical trials as the major evidence. This concern is related to the absence of consideration of evidence gathered through qualitative research and theory development (Fawcett et al., 2001; Jennings & Loan, 2001; Stevens, 2001) Evidence-Based Practice and Nursing Theory
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