Evidence Based Nursing
What is EBN? Definitions History
Models of EBN Barriers to use of EBN Current national & international projects in EBN
Evaluating quality of nursing research Summary Points Research-based nursing journals
EBN internet resources Teaching EBN Qualitative EB Nursing
1. What's Evidence Based Nursing (EBN)?
Evidence Based Nursing is the process by which nurses make clinical decisions using the
best available research evidence, their clinical expertise and patient preferences. Three
areas of research competence are: interpreting and using research, evaluating practice,
and conducting research. These three competencies are important to EBN.
To carry out EBN the following factors must be considered:
-sufficient research must have been published on the specific topic
-the nurse must have skill in accessing and critically analyzing research
-the nurse's practice must allow her/him to implement changes based on EBN
2. Definitions
Evidence-based Nursing Practice: solves problems encountered by nurses by carrying out
four steps:
Clearly identify the issue or problem based on accurate analysis of current nursing
knowledge and practice
Search the literature for relevant research
Evaluate the research evidence using established criteria regarding scientific merit
Choose interventions and justify the selection with the most valid evidence
Research Utilization: Transfers research findings to nursing practice: Carried out by
individual nurses, groups of nurses working together to solve problems, by
interdisciplinary teams, and by institutions and organizations seeking to make systemwide improvements in care outcomes
Literature review: Scholarly analysis of a body of research about a specific issue or
topic[1]
Integrative literature review: Integration of a body of research findings (including theory,
statistics) which concludes by addressing issues for future research[1]
Systematic literature review: Comprehensive, unbiased analysis of research findings on a
specific topic which uses a strict scientific design to select and assess various related
scientific studies[1]
Meta-analysis: Merged statistical results from a number of related studies which
combines various research studies with the goal of discovering consistencies and
differences between studies[1]
Clinical Decision-making: drawing conclusions based on EBN, clinical expertise, patient
preference, and other factors such as cost-benefit analysis, availability of alternatives, etc.
Reference:
1.Stevens & Cassidy (199) Evidence-based teaching: Current Research in Nursing
Education, 11.
3.History
Nursing research began to focus on clinical issues in the mid 80’s (Stevens & Cassidy,
1999).
The National Institute for Nursing Research (NINR) (http://www.nih.gov/ninr/) was
formed in 1986, greatly increasing the visibility and funding opportunities for nursing
research.
Many new journals emphasize nursing research
In recent years the International Society for Nursing Research, Sigma Theta Tau, has
greatly increased its capacity to support and disseminate nursing scholarships
(http://www.nursingsociety.org/)
McMaster University in Ontario, Canada has developed extensive resources in teaching
and implementing evidence-based practice in nursing and other disciplines
(http://www.fhs.mcmaster.ca/ceb/acts/ebcp.htm)
4. Models
Three models for research utilization in nursing serve as a foundation to understand
evidence-based nursing practice.
(1) The Conduct and Utilization of Research in Nursing (CURN) project.[1, 2, 3] .
The CURN Project was designed to develop and test a model for using research-based
knowledge in clinical practice settings. Research utilization is viewed as an
organizational process. Planned change is integrated throughout the research utilization
process. Systems change is essential to establishing research-based practice on a large
scale.
(2) The Stetler Model of Research Utilization[4,5,6,7]
The Stetler Model of Research Utilization applies research findings at the individual
practitioner level. The model has six phases: (1) preparation, (2) validation, (3)
comparative evaluation, (4) decision making, (5) translation and application, and (6)
evaluation. Critical thinking and decision making are emphasized.
(3) Iowa Model for Research in Practice [8]
The Iowa Model of Research in Practice infuses research into practice to improve the
quality of care [8], and is an outgrowth of the Quality Assurance Model Using Research
(QAMUR)[9] . Research utilization is seen as an organizational process. Planned change
principles are used to integrate research and practice. The model integrates evidencebased healthcare acknowledges and uses a multidisciplinary team approach.[10]
Reference:
1. Haller, K. B., Reynolds, M. A., & Horsley, J.A. (1979). Developing research-based
innovation protocols: Process, criteria and issues. Research in Nursing and Health 2, 4551;
2. Horsley, J.A., Crane, J., & Bingle, J. D. (1978). Research utilization as an
organizational process. Journal of Nursing Administration, July, 4-6;
3. Horsley, J. A., Crane J., , Crabtree, M. K., & Wood, D. J. (1983). Using research to
improve practice. Orlando, FL:Grune & Stratton.
4. Stetler, C. B. (1983):Nurses and research responsibility and involvement. National
Intravenous Therapy Associations, Inc. 6(May/June), 207-212,
5. Stetler, C. B. (1985). Research utilization: Defining the concept. Image: The Journal of
Nursing Scholarship XVII (2), 40-44
6. Stetler, C. B. (1994). Refinement of the Stelter /Marram model for application of
research findings to practice. Nursing Outlook, January/February, 15-25;
7. Stetler, C. B., & Marram, G. (1976). Evaluating research findings for applicability in
practice. Nursing Outlook 24(9), 559-563.
8.Titler, M. G., Kleiber, C., Steelman, V., Goode, C., Rakel, B., Barry-Walker, J., Small,
S., & Buckwalter, K. (1994) Infusing research into practice to promote quality care.
Nursing Research 43(5), 307-313
9.Watson, C. A., Bulecheck, G. M., & McCloskey, J. C. (1987). QAMUR: A quality
assurance model using nursing research. Journal of Nursing Quality Assurance 2(1), 2127.
10.Kleiber, C., & Titler, M. G., (1998). Evidence based practice and the revised Iowa
Model. Fifth national research utilization conference (April 23-24). Iowa City, IA:
University of Iowa hospitals and Clinics.
11. Carroll, D. L., Greenwood, R., Lynch, K. E., Sullivan, J. K., Ready, C. H., &
Fitzmaurice, J. B. (1997). Barriers and facilitators to the utilization of nursing research.
Clin Nurse Spec, 11(5), 207-12.
12. Cronenwett, L. R. (1995). Effective methods for disseminating research findings to
nurses in practice. Nurs Clin North Am, 30(3), 429-38.
13. Estabrooks, C. A. (1998). Will evidence-based nursing practice make practice
perfect? Can J Nurs Res, 30(1), 15-36.
14. Funk, S. G., Champagne, M. T., Tornquist, E. M., & Wiese, R. A. (1995).
Administrators' views on barriers to research utilization. Appl Nurs Res, 8(1), 44-9.
15. Mitchell, G. J. (1997). Questioning evidence-based practice for nursing. Nurs Sci Q,
10(4), 154-5.
16. Peden-McAlpine, C. (1999). Expert thinking in nursing practice: implications for
supporting expertise. Nurs Health Sci, 1(2), 131-7.
17. Stetler, C. B., Brunell, M., Giuliano, K. K., Morsi, D., Prince, L., & Newell-Stokes,
V. (1998). Evidence-based practice and the role of nursing leadership. J Nurs Adm, 28(78), 45-53.
18. Titler, M. G., Kleiber, C., Steelman, V., Goode, C., Rakel, B., Barry-Walker, J.,
Small, S., & Buckwalter, K. (1994). Infusing research into practice to promote quality
care. Nurs Res, 43(5), 307-13.
19. Feninstein, A. R., & Horwitz, R. I. (1997) Problems in the "evidence" of "evidencebased medicine." American Journal of Medicine, 103, 529-535.
5. Barriers to use of EBN
The nursing profession recognized that research is the basis for knowledge development.
Evidence-based nursing practice supports this focus. However, little research has
identified barriers that interfere with the ability of nurses to practice EBN. In one study,
barriers to the use of research evidence in practice described by 400 registered nurses
working in an Australian hospital, were grouped under four main factors. They are:
Factor 1: Accessibility of research findings
Factor 2: Anticipated outcomes of using research
Factor 3: Organizational support to use research
Factor 4 : Support from others to use research.
The most important factor was perceived to be organizational support, particularly in
relation to providing time to use and conduct research.
Link to this reference for another discussion of barriers to EBN:
http://www.clininfo.health.nsw.gov.au/hospolic/stvincents/stvin98/a9.html
Reference:
Retsas A.(2000). Barriers to using research evidence in nursing practice. Journal of
Advanced Nursing 31(3), 599-606
6. Current national and international projects in EBN
Centre for Evidence-Based Nursing (UK)
Evidence-Based Nursing (0nline Journal)
Evidence-Based Nursing and Midwifery (The Joanna Briggs Institute)
Nurse Prescribing (National Prescribing Center, UK)
7. Evaluating quality of nursing research
Evaluating Quality of the Research
Content
Description
Study Design
Random, blind, or repeated measures
Population
Brief description of larger population
Sample
Sample characteristics, randomization
Inclusions/Exclusion Criteria
Criteria described
Time Frame of study
Length of total study
Time Frame of treatment
Length of intervention
Intervention
Intervention description
Data collection
Dependent variables, independent variables
Analysis
Technique used
Results
Results reported in terms of research questions (hypotheses)
Conclusions
Conclusions of study
Limitations
Subjects lost to follow-up
Blinding
Did person giving intervention know whether the subjects were in the experimental or
control groups
8. Summary Points
This module contains many resources to assist nurses to develop and improve their skills
in EBN.
EBN is a way of thinking and practicing that requires discipline and practice to
continually assess, "where is the evidence for this?", and to weigh the validity and
reliability of daily practice activities.
Ongoing skill building is required once a basic understanding of EBN is acquired.
Nurses and other health professions daily confront questions about assessment, treatment,
prevention and cost-effectiveness of care.
As health care costs continue to climb, this emphasis will only increase.
The principles of critical appraisal span health professions and disciplines and overlap
with epidemiology and science in general.
Our patients expect nursing care based on best practice evidence.
The art of nursing, never to be underestimated, also needs to be studied to validate those
contributions to quality care.
In the future, qualitative nursing research will be included in the critical appraisal process
to add essential components to nursing knowledge.
9. Research-based nursing journals
There are a number of journals currently available which are specific or very relevant to
evidence-based nursing. This is a list of such journals. Most of them can be found either
in print and/or online via MNCAT, the University of Minnesota catalog.
NT Research
Biological Research for Nursing
Canadian Journal of Nursing Research
Journal of Nursing Measurement
Western Journal of Nursing Research
Scholarly Inquiry for Nursing Practice
Advances in Nursing Science
Oncology Nursing Forum
Nursing Research
Evidence Based Nursing
Online Journal of Knowledge Synthesis
Clinical Nursing Research
Nurse Researcher
Applied Nursing Research
Research in Nursing and Health
Nursing Science Quarterly
Journal of Nursing Scholarship
Annual Review of Nursing Research
10. EBN internet resources
Evidence-based Clinical Practice Working Group, Department of Clinical Epidemiology
and Biostatistics, University of McMaster, Canada.
http://www.fhs.mcmaster.ca/ceb/acts/ebcp.htm
Books related to EBN:
http://www.astuk.com/products-by-keywords/evidence-based-nursing.html
University of Hertfordshire, UK, has a informative web page to explain evidence-based
medicine.
http://www.herts.ac.uk/lis/subjects/health/ebm.htm
A wonderful EBM website from University of Toronto, Canada, aims to develop,
disseminate, and evaluate resources that can be used to practise and teach EBM for
undergraduate, postgraduate and continuing education for health care professionals from
a variety of clinical disciplines.
http://www.library.utoronto.ca/medicine/ebm/
This is a Nursing Resource Collection from University of Massachusetts – Amherst
http://www.library.umass.edu/subject/business/ebn.html
The unit for Evidence Based Nursing at Malmö University the Department of Nursing
and Public Health, School of Health and Society, recently formed a unit for Evidence
Based Nursing.
http://www.hs.mah.se/Research/Evidenseng.htm
Developing Evidence Based Nursing Practice, Health Care Practice Research and
Development Unit (HCPRDU) University of Salford, UK.
http://www.salford.ac.uk/ihr/hcprdu/complete/ebnp.htm
NHS research and development: center for evidence based medicine. The Center was
established in Oxford University, UK. Its broad aim is to promote evidence-based health
care and provide support and resources to anyone who wants to make use of them.
http://cebm.jr2.ox.ac.uk/
The Western Australian Centre for Evidence Based Nursing and Midwifery, School of
Nursing, Curtin University of Technology, AU.
http://www.curtin.edu.au/curtin/dept/planstats/wacebnm/
Evidence Based Health Care, Saint Louis University, Saint Louis, MO.
http://www.slu.edu/libraries/hsc/wr_ebhc.shtml
Evidence-based Practice websites for nurse researchers, by Mary E. Duffy, the Director
of the Center for Nursing Research at Boston College, School of Nursing
http://www.nursing.uc.edu/nrm/duffy11799.htm
Techniques for Locating Evidence-Based Practice Resources, University of Washington
Health Sciences Libraries
http://healthlinks.washington.edu/ebp/
Evidence-based Medicine resource and information, Duke University medical center
library.
http://www.mclibrary.duke.edu/respub/guides/ebm/index.html
Nursing Informatics and Evidence-Based Nursing, University of Wisconsin Health
Science libraries
http://www.medsch.wisc.edu/chslib/ad/docs/nurfmatc.htm
11. Teaching EBN
Evidence-based teaching is the conscientious, explicit, and judicious use of current best
evidence in making decisions about the education of professional nurses.
An intensive one-week course is offered at McMaster University in Hamilton, Ontario
Canada entitled: How to Teach Evidence-based Clinical Practice. Link to their site. It is
competitive to attend this workshop; it is well-worth the cost. This interdisciplinary group
of health professionals have refined this topic and have excellent resources. Link to their
site: http://www.cche.net/ebcp/
A useful reference for faculty interested in teaching with an evidence-based approach is:
Stevens, K. & Cassidy, V. (1999). Evidence-based teaching. Sudbury MA: National
League for Nursing.
12. Qualitative EB Nursing
Nursing research used qualitative methods quite commonly because they are very
suitable for developing the holistic knowledge of the discipline of nursing. Because most
of the EBP/EBN literature focuses on quantitative methods, it is important to think about
the somewhat different approach needed for critical appraisal of qualitative studies. The
following references were used for this section:
Walker, J. Holloway, I. & sofaer, B. (1999). In the system: The lived experience of
chronic back pain from the perspectives of those seeking help from pain clinics. Pain, 80,
621-8.
Ploeg, J. (1999). Identifying the best research design to fit the question. Part 2.
Qualitative designs. Evidence-based Nursing, 2(2), 36, 37.
Forchuck, C. & Roberts, J. (1993). How to critique qualitative research articles. Canadian
Journal of Nursing Research, 25, 47-56.
Because qualitative research examines concepts and phenomena, their study questions
will be of a descriptive nature, such as "What is the lived experience of an individual
experiencing chronic back pain?" Typically there are smaller sample sizes that are
approached sequentially and in a flexible manner (perhaps using an interview guide or a
series of probing questions). Sampling ceases when the researcher reaches a point of
"saturation" (i.e. further interviews do not uncover new themes). Participant observation,
a technique that has evolved from anthropology, is also commonly used. The analysis
process is extensive and intuitive as the researcher "dwells in the data" uncovering codes,
themes and patterns to produce a rich description of the phenonema. Direct quotyes from
key participants are used in the report to illustrate key themes.
Common types of qualitative research are:
ethnography (describes a culture from an insider perspective)
phenomenology (describes the lived experience of key informants)
grounded theory (develops theory through theoretical sampling and constant comparative
methods)
Criteria for Critical Appraisal of Qualitative Studies:
Are the aims of the study clearly described and appropriate for this methodology?
Is sampling described and conceptually sound for this type of qualitative research?
Are the conditions under which data were collected described and appropriate?
Is the data analysis pathway described in sufficient detail to indicate trustworthiness of
process?
Are the findings clearly stated with rich description included?
Are the results/interpretation of findings logical and clinically useful?