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Evidence-Based Practice for Advanced Practice Emergency Nurses

Shapiro, Susan E. PhD, RN, CEN

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Advanced Emergency Nursing Journal: October 2007 - Volume 29 - Issue 4 - p 331-338
doi: 10.1097/01.TME.0000300115.09572.f8
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Abstract

AS we approach toward the end of the first decade of the 21st century, there is no longer any debate over the relevance or importance of evidence-based practice (EBP) as the basis for nursing care. There is now an extensive body of nursing literature on all aspects of EBP, including the role of the advanced practice nurse (APN) as both a role model for implementing EBP and a teacher for staff nurses (Ahrens, 2005; DeBourgh, 2001; Kleinpell & Gawlinski, 2005; Mohide & Coker, 2005; Olade, 2004). It is not entirely clear, however, whether APNs actually understand what EBP is, or how to move smoothly from identifying an opportunity to improve practice, through to implementing and evaluating an EBP change. This is especially true for APNs who finished their graduate education more than 10 years ago, before EBP became a widely accepted model for integrating the best available evidence into practice.

This article defines EBP within the practice of nursing, reviews the history of EBP in nursing, describes the EBP process, and explicates a role for APNs—whether clinical nurse specialists (CNSs), nurse educators (NEs), or nurse practitioners (NPs)—in emergency care. Subsequent articles will provide more details on how to (a) critically review research evidence and synthesize the evidence into a single best practice for a specific practice setting and patient population; and (b) plan, implement, and evaluate an EBP small test of change.

BACKGROUND

Evidence-based practice is defined as the conscientious, explicit, and judicious use of the best available evidence, in combination with the professional's clinical expertise and the patient's preferences, in making decisions about care (Craig & Smyth, 2007; Jennings & Loan, 2001; Melnyk & Fineout-Overhold, 2005; Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). Evidence, in this definition, has traditionally been referred to research evidence. Clinical expertise refers to the education, training, and skills of the provider, and patient preferences refers to the patient's own unique perspectives of health, illness, life, death, family, etc., that so profoundly color the illness experience (Craig & Smyth, 2007). Melnyk and Fineout-Overholt (2005) have expanded the definition of evidence to include not just primary research evidence but also the theories and opinions of clinical leaders and expert panels. They have also included the results of physical examinations and diagnostic studies under their definition of evidence, making visible the role of clinical findings as a component of EBP.

Evidence-based practice grew from a movement that began in the United Kingdom in the early 1970s. The movement was embraced by medicine as a way to synthesize available research to guide practice decisions with the dual goals of better patient outcomes and reduced healthcare expenditures. The first text on EBM appeared in the late 1990s (Sackett, Richardson, Rosenberg, & Haynes, 1997), focusing exclusively on the importance of well-designed research, especially the randomized, controlled trial. This text was quickly updated (Sackett et al., 2000) to add concepts of clinical expertise and patient preferences as considerations in making care decisions. Although nursing is sometimes seen as coming late to the table of EBP, in fact the profession has advocated for research utilization as a basis for nursing practice since the 1970s (Stetler, 2001). Demonstration projects have been undertaken to illustrate the successful translation of research evidence into clinical nursing practice (Donaldson & Rutledge, 1998; Titler et al., 2001), and nursing theorists have derived elegant models that demonstrate the place of EBP in different settings (Olade, 2004; Stetler, 2001; Titler et al., 2001). There are now several textbooks on EBP for nurses, one of which is already in its second edition (Craig & Smyth, 2007), and many schools of nursing are weaving EBP into their curricula, from the undergraduate through doctoral levels. EBP is also an essential component for Magnet status. The American Nurses Credentialing Center (ANCC, 2007) states, “The nursing organization must be able to demonstrate the presence of well-established and operationalized structures and processes for research and evidence-based practice.” Most importantly, institutional support for EBP is growing as more states and the Federal Government are requiring public reporting of clinical outcomes. This movement will force facilities to identify and implement the best practices to maintain the best possible clinical outcomes for patients.

As EBM has become the standard in clinical medical practice, EBP is becoming the standard in nursing practice. Debates about the place of EBP in nursing (Jennings & Loan, 2001) have given way to descriptions of EBP processes and methods to increase the capacity of nurses to participate in EBP programs and projects (Ahrens, 2005; Drenning, 2006; Mohide & Coker, 2005; Thurston & King, 2005). The goal of EBP in nursing is to reduce variability in nursing practice, and in doing so, increase the predictability of results associated with that practice. Barriers to EBP are well known (Melnyk & Fineout-Overhold, 2005) and include a lack of knowledge and training on the part of nurses; a lack of time and resources to engage in the process; and peer pressure to continue with “the way we've always done it” at any given institution. These barriers are as prevalent in the emergency department (ED) as they are in any other clinical setting, and it will fall to advanced practice ED nurses—CNSs, NPs, and NEs alike to move their individual departments and colleagues toward increased evidence-based emergency nursing.

THE EBP PROCESS

There are almost as many descriptions of the EBP process as there are authors of articles and textbooks. Despite some variations in the particulars, the process for implementing EBP changes in an ED will generally follow the steps in Table 1.

Table 1
Table 1:
The steps in the EBP process

Each one of these steps is a multipart process, and knowing and practicing the components of the process will increase the likelihood of success in implementing and sustaining an EBP change.

Identify the Practice That Needs to Change

Identifying the practice that needs to change can be accomplished in many ways. Perhaps the most compelling evidence of the need for a practice change is a dramatic or significant adverse patient outcome, that is, a sentinel event. Less dramatic, but perhaps more critical in preventing adverse outcomes is careful review of routinely collected performance data, including patient complaints. Other sources include information obtained from reading the emergency nursing and related literature, attending clinical conferences, and direct observation of emergency nursing practice.

Search the Available Literature for Evidence Related to the Practice

Once the clinical issue is identified, the next step is to formulate the issue to guide a literature search. Several authors suggest using the Population/Problem, Intervention, Comparison, Outcome, Time (PICOT) format (Craig & Smyth, 2007; Melnyk & Fineout-Overhold, 2005; Table 2) as an organizing framework.

Table 2
Table 2:
Elements of the PICOT format

The use of this format has proven to be helpful, especially for the novice who is learning how to search electronic databases. However, it requires some adaptation when the clinical question does not involve an intervention. Regardless of the details of the clinical practice question, it is important to be clear about the population and outcome of interest as well as the practice being considered. This clarity of purpose will help focus the search on only the most relevant information.

High-speed Internet access is an essential tool for APNs in the 21st century. It is through access to online databases such as Publisher's MEDLINE (PubMed) (“PubMed: A service,” 2007), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (“CINAHL information services,” 2006), and Google Scholar (“Google Scholar,” 2007) that primary research sources can be accessed most readily and these resources form the skeleton of EBP. Other electronic sources of both primary and secondary material (i.e., already-synthesized practice guidelines) include government sources such as the Agency for Healthcare Research and Quality's (AHRQ, 2007)National Guidelines Clearinghouse; academic organizations such as the Cochrane Collaborative (“The Cochrane Collaborative,” 2007); the Joanna Briggs Institute (“The Joanna Briggs Institute,” 2007); and even some professional nursing organizations such as the Oncology Nurses Society (“Oncology Nursing Society: Putting Evidence Into Practice,” 2007). There are many such sources in both medicine and nursing and the emergency APN involved in an EBP initiative needs to be prepared to search through as many as she or he can find to locate the most recent evidence available.

Although absolutely necessary, database search skills may not be sufficient to uncover all that is available to inform practice. It may be necessary to expand the search beyond the resources that are readily available through electronic searches. An expanded search includes classic references not listed in electronic sources, or proceedings from meetings and private communications. The reference lists in primary and secondary sources that have been obtained may also prove to be a rich source of additional evidence.

Performing a thorough evidence review is time-consuming (Jennings & Loan, 2001), and this needs to be considered when undertaking an EBP project. Once acquired, however, all the evidence—regardless of the source—must be critically reviewed and synthesized to identify the best practice.

Critically Appraise the Literature

Critical appraisal of a body of evidence is a fundamentally different process from the in-depth critique of a single research study that many APNs learned in their graduate programs (Melnyk & Fineout-Overhold, 2005). Critical appraisal seeks to answer three basic questions: (a) is the quality of the study/report good enough to consider, that is, are the results and conclusions valid; (b) are the findings applicable to my setting with my patients, my colleagues, and my resources; and (c) what might the results of implementing the described change in practice mean to my patients (Craig & Smyth, 2007)?

Answering the first question will draw on skills learned during graduate education, including some of the skills of research critique. It is important that the APN read research critically, but even the best designed study, one with minimal threats to internal and external validity, may describe an intervention or a practice that is simply inappropriate or impossible to implement in a given emergency care setting. The third question, the meaning of the reported results to one's patients, concerns the clinical significance of the study as opposed to the statistical significance of the study. For example, Nichol et al. (1996) published an elegant meta-analysis on the impact of ambulance arrival time on survival from out-of-hospital cardiac arrest. They reported that a 1-min decrease in mean response time was associated with a 0.4% or 0.7% increase in survival, depending on whether it was a one-tier or two-tier emergency medical services system. This finding was statistically significant, but is it clinically significant? Would it be prudent to recommend incurring the expense associated with reducing ambulance response time based on this report? How many out-of-hospital cardiac arrest patients would have to be treated with the reduced response time before one more patient survived than would have if the response time remained the same? This last question describes a numbers-needed-to-treat analysis (Craig & Smyth, 2007; Melnyk & Fineout-Overhold, 2005), one that is too often missing from even well-designed studies, leaving the reader to assess the clinical impact of proposed practice changes on his or her own.

There are resources available to help APNs through the critical appraisal process, including handbooks and guides such as those published by Crombie (1996) and Davies and Logan (2003); a future article in this series will also describe the process more fully.

Synthesize the Literature to Identify Best Practice

After critically reviewing the literature, the APN must integrate the information from the evidence collected to determine first whether or not a best practice has been identified. The second task is to evaluate the strength of the evidence supporting that practice. This synthesis depends directly on the studies identified for appraisal and the depth and quality of that appraisal. Evidence tables are a good tool for sorting through the various studies that may be gathered during an evidence review, and Table 3 provides an example of one such tool. This is an appropriate way to begin the synthesis process.

Table 3
Table 3:
Example of an evidence table worksheet

The synthesis itself, however, is a thought process, not something that one can write down on paper. Synthesis comes from total immersion in the field, and from deep understanding of the evidence, including a critical appraisal of all studies to identify strengths and weaknesses. Different authors and bodies have recommended various schemes for evaluating the strength of the evidence, both for individual studies and for collections of studies (Craig & Smyth, 2007; Grade Working Group, 2004; Guyatt, Gutterman, et al., 2006; Guyatt, Vist, et al., 2006; McGinn et al., 2000; Melnyk & Fineout-Overhold, 2005). APNs should be familiar with the concepts central to evaluating evidence and be able to apply those concepts when presenting the evidence for practice change.

Implement the Best Practice

Once the best practice has been identified, the next step is to perform a gap analysis to determine the differences between the best practice and current practice, including the policies, procedures, and protocols that describe and govern these practices. It is important to take the time to do a formal gap analysis in order to focus efforts appropriately. It may be possible that the current policy is outdated, or the policy is fine but the actual practice is not consistent with that policy. The form of the EBP change is highly dependent on what the gap analysis indicates is needed. Table 4 provides an example of a Gap Analysis Work Sheet that might assist in this process.

Table 4
Table 4:
Example of a gap analysis worksheet

Implementing an EBP change can be an enormous challenge, given the complexity of the ED work environment and the staff who work there. The ED APN will need to identify key stakeholders and processes likely to be affected by the change and include them in the process, from training through evaluation. It is easy to miss potential stakeholders who are not obviously part of the process under consideration. For example, many ED practice changes affect prehospital providers, yet they are very rarely included among the stakeholders in planning for change. Dartmouth College has developed a microsystem analysis tool (Clinical Microsystems, 2001) for EDs that can be of enormous help in planning for EBP changes. Rogers' (2003) text on diffusing innovations, although not a handbook, provides an evidence-based framework for successfully diffusing change in complex organizations along with excellent practical examples of changes that worked and those that did not.

Evaluate the Effects of the Change in Practice

If the EBP change is one that grew out of a clinical practice issue for which the outcomes have been clearly delineated (e.g., as in the PICOT framework), then evaluating the effects of the change should be relatively straightforward, and the evaluation measures should be presented as part of the proposed practice change. The simplest measures to use are those already being collected, for example, wait times, patient satisfaction, patient complaints, left without being seen, census, sick calls, staff turnover, medication errors, and falls, to name a few. The most difficult measures to obtain are from surveys designed just to evaluate the EBP change. In this case, response rates tend to be low, thereby limiting the validity of the results. It is usually best to consider proposed changes in terms of a time-limited pilot, at which time the evaluation can be conducted and reported, and the decision to continue the practice as is, modify the practice in some way, or discard the practice change entirely, can be made on the basis of predetermined measures.

THE EMERGENCY APN AND EBP

Advanced practice nurses have been identified as being in a unique position to help identify the need for, and then plan, implement, and evaluate EBP changes (Ahrens, 2005; DeBourgh, 2001; Kleinpell & Gawlinski, 2005). Debourgh (2001) suggests that APNs, by virtue of their roles in practice, are ideally situated to assume leadership in EBP efforts by (a) connecting evidence with daily practice; (b) making their own theoretical and experiential knowledge more widely available; and (c) harnessing their informed intuition, clinical judgment, and wisdom to link high-quality, patientand outcomes-focused care throughout their facilities. These responsibilities/opportunities extend beyond the clinical role, however, and include consulting, teaching (both staff and patients/families), expert role modeling, and expert practice. ED APNs are especially important to clinical facilities because they practice at the front door of the hospital, where their knowledge and expertise make a critical difference in the patient's experience.

Practice that is well-grounded in evidence offers two advantages to emergency nursing practice. First, EBPs that are applied consistently throughout the ED will reduce variations in practice. All nurses will apply effective interventions in the same circumstances in the same ways, allowing for minor variations based on patient preferences. Second, practices that are based on a strong body of evidence and implemented consistently should yield predictable results. That is not to say that all patients will respond identically, but rather that ED nurses can assure their patients that under most circumstances, with most patients, the interventions they are applying yield the sought-after results most of the time, with equally predictable untoward effects as well.

Thinking about consistency in practice and predictability of results, it is interesting to try to identify those of our practices/interventions that are truly evidence based. ED APNs can begin simply by reviewing the evidence on which their ED bases its simplest, most routine interventions, for example how is fever managed? What is the current best evidence on fever management for both adults and children? Continuing to think about temperature measurement in the ED, what is the standard for evaluating patient temperatures? Does your unit use oral, tympanic, or rectal temperatures routinely? What is the current best evidence to determine the most accurate readings in various populations of patients?

ED APNs, by virtue of their education, experience, and professional roles, are responsible for recommending, implementing, and evaluating evidence-based nursing practice in their EDs, and for role modeling this behavior for staff nurses. They must be able to identify and critically appraise the evidence, synthesize the evidence and adapt it to their practice environments, implement and evaluate small tests of change where indicated, and lead efforts for widespread adoption of EBP initiatives in their facilities.

SUMMARY

The science of emergency care is changing rapidly; new practices and technologies appear and older practices are reevaluated, providing a constant stream of new evidence. Nursing staff and management in the ED look to the APN to critically appraise the emerging and current evidence and make recommendations for practice changes. This article reviewed the basic steps involved in performing an EBP review, and identifying, implementing, and evaluating an EBP change. Future articles in this series will more thoroughly describe the process of critically appraising and synthesizing the literature; and planning, implementing, and evaluating an EBP change. This information will help prepare emergency APNs to participate fully, and to take leadership roles in implementing EBP in nursing and health care.

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        Keywords:

        advanced practice nurses; EBP in nursing; evidence-based practice

        © 2007 Lippincott Williams & Wilkins, Inc.