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Publishing Evidence-Based Practice Projects

Fulton, Janet, S., PhD, RN, ACNS-BC, ANEF, FAAN

doi: 10.1097/NUR.0000000000000365
DEPARTMENTS: Editorial

Author Affiliation: School of Nursing, Indiana University, Indianapolis.

The editor reports no conflicts of interest.

Correspondence: Janet S. Fulton, PhD, RN, ACNS-BC, ANEF, FAAN, School of Nursing, Indiana University, 1111 Middle Dr, Indianapolis, IN 46202 (jasfulto@iu.edu).

Healthcare is evidence based and grounded in knowledge derived from scientific principles and research. True, yet we know from experience that many clinicians and organizations base their care and care policies on opinions and exceptions. Some nurses prefer a unique clinical technique because, in their opinion, it works better than the official unit procedure. Hospital policies reflect practices set in place to years ago to guard against the reoccurrence of a one-off mistake long lost to the institutional memory. Evidence-based practice (EBP) does not remove individual judgment about application of knowledge to practice or the importance of policies. Instead, EBP guides decision making with evidence at every level, from the patient up through the system. Evidence-based practice strives to replace quirky, personal predilections and institutional myths with evidence.

Clinical problems tend to have common elements that are distinctively expressed in individual care settings. Evidence-based practice changes implemented in one setting may not apply to other settings, but the work of EBP can inform others interested in solving the similar problems. For that reason, it is important to publish outcomes of EBP projects. When publishing a report of an EBP project, an author enters a scholarly conversation with a community of like-interested colleagues and contributes to the body of knowledge by creating building blocks for others to use. Even in cases where evidence is weak, identifying gaps lays the groundwork for needed research. With increasing emphasis on publishing clinical scholarship, manuscripts reflecting EBP projects are entering the peer-reviewed literature. Not all journals invite EBP project reports; this journal does. In the interest of receiving high-quality EBP manuscripts, here are some tips for preparing a manuscript report of an EBP project.

Evidence-based practice is a problem-solving approach to clinical decision making. Begin a manuscript with an introduction to the background for the problem. This section should be a succinct summary reflecting the current circumstances of the problem, supported by data from the practice setting, a national database, the scholarly literature, or other sources. Convince the reader that the problem is significant. Write a declarative sentence stating the problem in the context of the clinical setting. State the purpose of the project. Now the reader understands the problem and knows the purpose of the project.

Several methods are available for conducting an evidence review and change implementation, for example, the Star Model (http://nursing.uthscsa.edu/onrs/starmodel/star-model.asp) or the Johns Hopkins Nursing Evidence-Based Practice Model (https://www.hopkinsmedicine.org/evidence-based-practice/ijhn_2017_ebp.html). Select from among many available models. The model should be a good fit for the problem and setting. The steps or phases of the model become the rough outline of the manuscript.

Every EBP project starts with a review of evidence. Provide enough details of the evidence review process to convince the reader that the evidence was adequate to support the practice change. Include details of the literature search, describe other data sources, and review and discuss use of unpublished papers, practice guidelines, and expert opinions.

Summarize the practice change or intervention while providing details. What was done, by whom, when, and for how long. Nursing practice interventions are often a complex cluster of actions as opposed to a singular act, such as switching a medication. Changing practice to include “interdisciplinary rounds” or “early screening” or “postop telephone calls” may be the selected interventions, but they are complex, and the reader needs details. For example, what was discussed during the telephone call, who made the call, what postoperative day the call was made, how problems were followed up, and who trained the telephone callers. Also describe the procedures used for implementing the change. Write the procedures as if it were a recipe for others to follow. Describe resources needed, including staff, equipment, and training. Describe any special considerations, such as starting on one unit before spreading to other units. Include information that would be needed by someone trying to solve a similar problem using this approach.

Describe how outcomes were measured. Make sure the outcome measures address the purpose of the project. The measures provide the answer to the question: Did this project fulfill its purpose? Measures can include clinical indicators (such as laboratory values), staff or patient satisfaction ratings, cost reductions, time (such as waiting), service usage (such as fewer emergency visits), or treatment changes (such as improved medication management), to name a few. Where a psychometric instrument is used as an outcome measure, select one with reliability and validity for the context of the problem.

Conclusion should be supported by the data. Never surprise a reader with conclusions that do not reflect the purpose or the outcome data. The reader wants to know whether the change fixed the problem. What if the problem was not fixed? Discuss the outcomes and identify future recommendations. Perhaps the evidence was not strong, suggesting the need for additional research, or the outcome measures were not sensitive enough to capture the change, or system-level complications interfered with the implementation, such as personnel turnover or unit mergers. Think of this discussion as a conversation with like-interested persons.

The primary reason for rejecting an EBP manuscript is missing information that interrupts the logical flow of the project narrative. Missing or underreported information includes the problem is not clearly stated or supported, the EBP method is not stated or followed, details are missing about the evidence review, the intervention is not explained, change procedures are not stated, the outcome measures are not appropriate, or the conclusions are not supported by the outcome data. A second problem is the misuse of theory, models, and frameworks. An EBP project does not need a “theoretical framework.” Theory is necessary to support research; it grounds studying the unknown in the known, guides what counts as data, and directs how data are interpreted. Research has aims and hypotheses. Research needs theory to discover new knowledge. Evidence-based practice is not discovering new knowledge; EBP is supporting clinical decision making in the here-and-now of practice with existing knowledge. Evidence-based practice uses a PICO (problem-intervention-comparison-outcome) question. Stick with the steps of the EBP model selected and use it as the project frame. A third problem is adding a separate change model to discuss implementation. Use the selected EBP model’s change process as a guide for the discussion. Mixing multiple models and frameworks in one project is confusing. Avoid spending too much of the manuscript space explaining the intricacies of the implementation process. A fourth common mistake with EBP manuscripts is confusing research language with EBP language. An EBP project would not, for example, have a convenience sample of subjects. In an EBP project, comparing one intervention (the current practice) with another intervention (the new EBP) is a step in the PICO format and not a pre-post quasi-experimental design. Although there may be statistically significant differences in a pre-post measure for an EBP project, no P value should be reported, which is the probability that the observed result has nothing to do with what is being tested via a hypothesis. Evidence-based practice is not hypothesis-testing research. Chances of confusing EBP with research are reduced by selecting an EBP model and following its steps.

This journal welcomes manuscripts describing EBP projects and successful implementation of evidence into practice. Clinical nurse specialists are leaders in EBP, and the journal hopes these tips are helpful to future authors. Another important tip: If you are a new author, find a mentor to help interpret the journal’s author guidelines, proofread drafts, guide the submission process, and respond to reviewer comments. Publishing a manuscript is a rewarding journey, but like all journeys, there are challenges. Happy writing! We look forward to receiving excellent manuscripts.

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