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How to bring evidence-based practice to the bedside

LAWSON, PATRICIA RN, CCRN, BSN

DOING IT BETTER: Putting research into practice
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EVIDENCE-BASED PRACTICE (EBP) means using the best clinical evidence to make patient-care decisions. This practice encourages you to examine nursing rituals and traditions and, if appropriate, replace them with practices grounded in scientific research. Because it improves the quality of patient care, EBP is gaining attention and support in all areas of health care.

To use EBP, you and your colleagues must know how to obtain, interpret, and integrate the best available research into your nursing practice. How can you make this happen? In this article, I'll walk you through six steps that can help you make changes based on EBP a reality at your facility.

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Step 1. Start with a topic

Look at your nursing process and find areas for improvement. You may identify a clinical practice problem in your unit or get an idea from a research article.

At our hospital, we found a research article that showed that removing heparin from arterial line flush solution didn't have a statistical effect on clot formation but did reduce the incidence of heparin-induced thrombocytopenia. We thought that this would be a great project to research and perhaps implement in our facility.

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Step 2. Assemble a work team and evaluate the evidence

To take this step, create a team with diverse clinical and research skills. This team includes staff members or stakeholders (those affected by a decision who are interested in its outcome). In our example, we assembled a team with representatives from critical care, pharmacy, anesthesia, cardiology, and the library (for help with the literature search).

Once selected, the team must first clearly define the problem. Then, your group should gather and assemble relevant research evidence by performing a literature search. Next, locate solid evidence to guide your project plan.

To assess the potential impact of implementing improvements in your own setting, ask yourself these questions:

  • Is the information transferable? For example, how similar are patients in your unit to those in a relevant research study?
  • Is the intervention feasible? Will extra skills, equipment, or staff be needed?
  • What's the cost/benefit ratio; that is, do the expected benefits outweigh the costs and risks? Always consider the potential nonmaterial costs and benefits of implementation. For example, you may be spending more time on research, but you may gain better quality of care and increased patient and staff satisfaction. Your results may also improve staff morale and staff recruitment efforts.

Our group concluded that eliminating heparin in the flush solution would reduce costs, decrease the time needed to assemble an arterial line, and decrease patient exposure to heparin.

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Step 3. Develop an action plan

You can develop a pilot plan using these steps based on the Iowa Model (see Selected references).

  • Determine how you'll collect baseline data so you can assess and document the effectiveness of the new intervention. Our group decided we'd determine what percentage of arterial lines became clotted.
  • Develop written guidelines for implementing the new intervention. Our group decided we'd change our policies and procedures to state that all arterial line flush solution would be maintained by 0.9% sodium chloride solution without additives.
  • Determine how you'll educate the staff about the new guidelines. This step includes “marketing” the new intervention. Our team decided to educate the staff during regular staff meetings and in hospital newsletters. We planned to emphasize cost and time savings.
  • Set a time line for training staff, starting your research, and evaluating the results. For our project, we planned to start 1 month after we received approval and then to monitor results for 6 months to make sure we didn't have an increased incidence of clotting. We also decided to recheck the data at 1 year.
  • Determine how you'll evaluate outcomes. For our example, staff members were instructed to report any clogged arterial lines to their clinical manager.
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Step 4. Implement and promote your plan

Before you implement any changes, you must educate staff members who'll be involved with the new intervention. You can educate them in various ways:

  • staff-development sessions and staff meetings
  • formal lectures, which can be videotaped for later viewing
  • self-learning packets
  • e-mails
  • posters, fliers, or storyboards.

Be sure to inform the staff about all of the steps taken to develop the action plan. This approach will bring them closer to the process and help them understand the reasoning behind the plan. Our project didn't require much education, but we developed posters and hung them in medication rooms, repeated information at staff meetings, sent out more detail in hospital newsletters, and sent reminders via e-mail.

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Step 5. Evaluate your results

Gather outcome measurements for 6 to 12 months to evaluate the effect of your new nursing intervention. Expect some fluctuation of the data as your staff becomes accustomed to the changes. In our project, at the end of 6 months we found we had no reports of clotted arterial lines.

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Step 6. Disseminate project results

Once you begin to obtain outcome measurements, share this information with your staff to maintain your momentum. Keep sharing results to prevent the staff from falling back into old patterns and to bring new staff members up to speed.

When you have positive results from a new intervention, you'll need to update policies and procedures. Publicize these updated policies in your institution—and celebrate a job well done.

Patricia Lawson is a critical care educator in the intensive care and progressive care units of Doylestown (Pa.) Hospital and she's also a student in the MSN education program at Drexel University in Philadelphia, Pa.

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SELECTED WEB SITES

Nursing on the Net: Health Care Resources You Can Use http://www.nnlm.gov/train/nursing/sampler.html

Evidence-Based Practice Tools Summary http://healthlinks.washington.edu/ebp/ebptools.html

National Guideline Clearinghouse http://www.guidelines.gov

Evidence Based Medicine Tool Kit http://www.med.ualberta.ca/ebm/ebm.htm

Last accessed on February 3, 2005.

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SELECTED REFERENCES

Polit DF, Beck CT. Nursing Research: Principles and Methods, 7th edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2004.
    Stetler CB, et al. Evidence-based practice and the role of nursing leadership. The Journal of Nursing Administration. 28(7–8):45–53, July-August 1998.
    Tilter MG, et al. The Iowa model of evidence-based practice to promote quality care. Critical Care Nursing Clinics of North America. 13(4):497–509, December 2001.
    © 2005 Lippincott Williams & Wilkins, Inc.