In the past 15–20 years, the principles of evidence-based practice (EBP) have been embraced and integrated into the lexicons of both nursing and medicine. Unfortunately, not all who use the term evidence-based practice understand what it really means and it is often used interchangeably with the phrases “best practice” and “standard of practice” (Proehl, 2011). As advanced practice nurses (APNs), it is important to understand the differences in these terms.
First of all, nursing practice has always been based on some sort of “evidence.” It just was not necessarily good evidence. If your fundamentals of nursing instructor told you to position pillows so that the opening of the pillowcase faced away from the door because it helped prevent infection, you did it because an “authority” told you to do it. (Not to mention that your grade might have depended on it.) But, there were never any scientific data provided to justify this practice. Authority opinion is one type, albeit a low level, of evidence. In one tongue-in-cheek look at the basis for clinical decisions in medicine, this would be referred to as “eminence-based” practice wherein experienced practitioners' opinions transcend the need for scientific evidence (Isaacs & Fitzgerald, 1999). “Evidence-based practice,” as referred to in current parlance, refers to the formulation of practice recommendations based on a rigorous appraisal of scientific evidence that demonstrates statistically significant differences in outcome.
“Standard of care” is doing what reasonable, similarly qualified persons in similar circumstances would do. It is a legal term with important ramifications in litigation. However, the standard of care is rarely 100% evidence-based, nor is it always explicitly stated. In fact, most nursing and medical interventions and many medications have never been examined in prospective, randomized controlled trials (a very high level of evidence) or meta-analyses (the highest level of scientific evidence). As a result, experts testify to the standard of care in malpractice cases and frequently different experts opine different standards of care. A rare example of an explicit standard of care that is evidence-based is the use of continuous waveform capnography to verify and monitor endotracheal tube placement. This is a Class I recommendation from the American Heart Association based on high-quality evidence (Level A), demonstrating that the benefits of using continuous waveform capnography significantly exceed the risks (Neumar et al., 2010). If all standards were so explicit and solidly based on evidence, our jobs would be much easier.
“Best practice” is an ambiguous term that does not necessarily imply that the practice is based on data. Best practice is often used to indicate what esteemed and highly regarded institutions or practitioners are doing. It may be a method or practice that, conventional wisdom suggests, is effective in achieving desired outcomes. However, “conventional wisdom” is a phrase that by definition does not mean that the practice is based on scientific data. In fact, some things that make sense from a conventional wisdom perspective and may be recognized as long-standing standards of care are eventually discredited by evidence. Remember in the old days (2010 and prior) when we ventilated patients with cardiac arrest before we started chest compressions? In the absence of data, best practice may simply be a matter of authority or expert opinion.
Evidence-based practice involves critical appraisal of the available research, the formulation of recommendations based on the findings of well-designed and executed studies, and an indication of how solid the evidence is to support the practice. Many professional associations, including the Emergency Nurses Association (ENA) and the American College of Emergency Physicians, have committees that evaluate the evidence related to specific clinical questions and create EBP documents. The ENA documents, known as Emergency Nursing Resources, are available online at http://www.ena.org/IENR/ENR/ and address topics such as capnography during procedural sedation, difficult intravenous access, and needle-related pain in pediatric patients. The American College of Emergency Physicians clinical policies address conditions such as abdominal trauma, seizures, and headache. They are available at http://www.acep.org/clinicalpolicies/. There is also a repository of EBP guidelines administrated by the Agency for Healthcare Research and Quality freely available at www.guidelines.gov.
That APNs are interested in EBP is reflected in the fact that one of the most popular features in AENJ is the Research to Practice column. The purpose of the column is to assist APNs in the evaluation of evidence and, ultimately, the translation of that evidence into clinical practice. One of the most important roles APNs play in emergency care is the identification and implementation of practice changes based on solid evidence. So, keep your terminology straight and help others move toward the goal of EBP as the standard of care. And, the next time someone tells you that a practice change is needed, ask them to show you the data.
—Jean A. Proehl, RN, MN, CEN, CPEN, FAEN
Emergency Clinical Nurse Specialist
Proehl PRN, LLC
—Karen Sue Hoyt, PhD, RN, FNP-BC, CEN, FAEN, FAANP
Emergency Nurse Practitioner
St. Mary Medical Center
Long Beach, CA
Note: Jean A. Proehl expressed many of these thoughts on the ENA Educators ListServ on Tuesday, September 6, 2011.
Isaacs D., Fitzgerald D. (1999). Seven alternatives to evidence-based medicine. British Medical Journal, 319, 1618.
Neumar R. W., Otto C. W., Link M. S., Kronick S. L., Shuster M., Callaway C. W., Morrison L. J. (2010). Part 8: Adult advanced cardiovascular life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 122(Suppl. 3), S729–S767.
Proehl J. A. (2011). EBP, ENA, and ENRs. Journal of Emergency Nursing, 37, 217.