INTRODUCTION

Evidence Based Practice is a process involving the examination and application of

research findings or other reliable evidence that has been integrated with scientific
theories. For nurses to participate in this process, they must use their critical thinking
skills to review research publications and other sources of information. After the
information is evaluated, nurses use their clinical decision making skills to apply
evidence to patient care. As in all nursing care, patient preference and needs are the basis
of care decisions and therefore essential to EBP
Evidence based practice represents both an ideology and a method. The ideology springs
from the ethical principle that clients deserve to be provided with most effective
interventions. The method of EBP is the way we go about finding and then implementing
those interventions.

DEFINITION OF EVIDENCE BASED NURSING PRACTICE:

Evidence Based Practice (EBP) can be defined as ‘the conscientious, explicit, and
judicious use of the current best evidence in making decisions about the care of
individual patients.’
Evidence Based Practice alternatively known as Empirically Supported Treatment (EST)
is the preferential use of mental and behavioral health interventions for which systematic
empirical research has provided evidence of statically significant effectiveness as
treatment for specific problems.

AIMS OF EVIDENCE BASED PRACTICE:

• To do the right thing at the right time, for the right person, ensure quality care for the
individual client.
• Resolve problem in clinical setting.
• Achieve excellence in care delivery.
• Reduces the variations in nursing care and assist with efficient and effective decision
making.

FEATURES OF EVIDENCE BASED PRACTICE:

1. Integration of Research Evidence:

EBP involves systematically searching for and critically appraising current research
literature to identify the most relevant and reliable evidence related to a clinical
question or problem.

2. Clinical Expertise:

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Nursing practice is informed not only by research evidence but also by the clinical
expertise and experience of nurses. Clinical expertise is used to interpret and apply
research findings to individual patient situations.

3. Patient-Centered Care:

EBP emphasizes the importance of considering individual patient preferences,

values, and unique circumstances when making clinical decisions. It encourages
shared decision-making with patients and their families.
Critical Thinking and Problem Solving:

Nurses are encouraged to engage in critical thinking and problem-solving processes

to evaluate evidence, apply it to practice, and adapt interventions as needed based on
patient responses.

4. Systematic Approach:

EBP follows a systematic and structured approach, often involving a series of steps,
including formulating clinical questions, searching for evidence, critically appraising
evidence, integrating findings with clinical expertise and patient values, and
evaluating outcomes.

5. Applicability to Practice:

EBP aims to translate research evidence into practice by developing guidelines,

protocols, and standards of care that can be implemented in clinical settings.
Continuous Improvement:

EBP is dynamic and promotes ongoing learning and improvement. Nurses are
encouraged to stay updated with the latest evidence and to continually evaluate and
refine their practice based on new findings.
Interdisciplinary Collaboration:

EBP encourages collaboration among healthcare professionals, including nurses,

physicians, pharmacists, and others, to ensure that the best available evidence is
used to guide patient care.

6. Use of Technology:

EBP often involves the use of electronic resources, databases, and clinical decision
support tools to access and apply evidence in real-time clinical situations.

7. Evaluation of Outcomes:

The effectiveness of EBP interventions is regularly evaluated to assess their impact

on patient outcomes, safety, and quality of care. This evaluation informs further
refinements in practice.
Ethical Considerations:
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 Ethical principles are integrated into EBP to ensure that decisions align with ethical
standards and promote the well-being of patients while respecting their autonomy
and rights.

8. Education and Training:

Healthcare institutions provide education and training to nurses to develop their EBP
skills, ensuring they can effectively apply evidence to their practice.

9. Leadership Support:

Leadership within healthcare organizations plays a crucial role in fostering a culture

of EBP by providing resources, mentorship, and support for nurses.
By incorporating these features, evidence-based practice in nursing strives to deliver
the highest quality of care, improve patient outcomes, enhance patient satisfaction,
and drive continuous improvement in healthcare delivery.

STEPS IN EBP PROCESS:

I) Formulating a well built question [Ask].
II) Finding evidence [Acquire].
III) Appraising the evidence [Appraise].
IV) Applying the evidence\make clinical decision [Apply].
V) Re evaluation [Audit\ Assess].

RESOURCESS OF EVIDENCE BASED PRACTICE:

Research evidence has assumed priority over other source of evidence in the
delivery of evidence based health care. It includes:

• Background Information\Expert Opinion or Books (Preappraised Evidence).

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 Research evidence comes in various forms, the most basic of which is in individual
studies. Clinical experts and subjects specialist pose a question and then synthesize
evidence to state conclusion based on available research,These sources are helpful
because the literature has been searched and results evaluate to provide an answer to
clinical question

• Systematic Reviews and Meta Analysis:

Evidence-based practice relies on meticulous inte- gration of research evidence on a

topic. The emphasis on best evidence in EBP implies that evi- dence about a clinical
problem has been gathered, evaluated, and synthesized so that conclusions can be
drawn about the most effective practices. Sys- tematic reviews are a pivotal
component of EBP: their "bottom line" is a summary of what the best evidence is at
the time the review was written.

A systematic review is not just a literature review, A systematic review is in itself a

methodical, scholarly inquiry that follows many of the same steps as those for
primary studies. Systematic reviews can take various forms. Until recently, the most
common type of systematic review was a traditional narrative integration of research
findings. Narrative reviews of quantitative studies are still common, but a type of
systematic review called a meta-analysis has emerged as an important EBP tool.

Meta-analysis is a method of integrating quan- titative findings statistically. In

essence, meta- analysis treats the findings from a study as one piece of information.
The findings from multiple studies on the same topic are combined and ana- lyzed
statistically. Instead of people being the unit of analysis (the basic entity of the
analysis), indi- vidual studies are the unit of analysis in a meta- analysis. Meta-
analysis provides a convenient, objective method of integrating a large body of
findings and of observing patterns that might other- wise have gone undetected

Some systematic reviews are published in pro- fessional journals that can be
accessed using standard literature search procedures; others are available in
dedicated databases. In particular, the Cochrane Database of Systematic Reviews
contains thousands of systematic reviews (mostly meta- analyses) relating to health
care interventions. Cochrane reviews are done with great rigor, and have the
advantage of being checked and updated regularly.

• Clinical Practice Guidelines and Care Bundles:

Evidence-based clinical practice guidelines, like systematic reviews, represent an

effort to distill a large body of evidence into a manageable form, but guidelines are
different in a number of respects. First, clinical practice guidelines, which are
usually based on systematic reviews, give specific recommendations’ for evidence-
based decision making. Their intent is to influence what clinicians do. Second,
guidelines attempt to address all of the issues relevant to a clinical decision,
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 including the balancing of of benefits and risks. Third, systematic reviews are
evidence-driven-that is, they are undertaken when a body of evidence has been
produced and needs to be synthesized. Guidelines, by contrast, are "necessity-
driven" (Sackett et al., 2000), meaning that guidelines are developed to guide
clinical practice-even when available evidence is limited or of unexceptional quality.
Fourth, systematic reviews are done by researchers, but guideline development
typically involves the consensus of a group of researchers, experts, and clinicians.
For this reason, guidelines based on the same evidence may result in different
recommendations that take into account contextual factors

Also, organizations are developing and adopting care bundles a concept developed
by the Institute for Healthcare Initiatives-that encompass a set of interventions to
treat or prevent a specific cluster of symptoms .There is growing evidence that a
combination or bundle of strategies produces better outcomes than a single
intervention.

• Latest Research Articles And Journals:

It provides most recent information. Evidence summaries and abstracts uploaded in

internet through various websites will give updated reports of various evidenced
base studies with examples.

HIERARCHY OF EBP:

I) Systematic reviews and meta analysis

II) Randomized controlled trials with definitive results
III) Randomized controlled trials with non definitive results
IV) Cohort studies
V) Case control studies
VI) Cross sectional studies
VII) Case reports

Evidence hierarchy: levels of evidence regarding the effectiveness of an intervention.

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MODELS OF EBP IN CLINICAL SETTING:
Evidence-based practice (EBP) is an approach to healthcare, education, and various other fields that
emphasizes the use of the best available evidence from research, clinical expertise, and patient or
stakeholder preferences to inform decision-making and improve outcomes. There are several models
and frameworks used to guide the implementation of evidence-based practice. Here are a few
prominent ones:
The Iowa Model of Evidence-Based Practice to Promote Quality Care: This model is widely used
in nursing and healthcare. It includes a series of steps, including problem identification, literature
review, critical appraisal of evidence, and implementation of changes in practice.
This model consists of seven steps:
Step 1: Recruit and organize an EBP team.
Step 2: Ask the clinical question.
Step 3: Collect and evaluate the evidence.
Step 4: Integrate the evidence with clinical expertise and patient preferences.
Step 5: Implement the practice change.
Step 6: Evaluate the outcomes.
Step 7: Disseminate the results.

The ACE Star Model of Knowledge Transformation: Developed by the Academic Center for
Evidence-Based Practice, this model consists of five stages: Discovery, Evidence Summary,
Translation, Integration, and Evaluation. It emphasizes the importance of integrating evidence into
clinical practice.
Discovery: Generating new knowledge through research.
Evidence Summary: Systematic review and synthesis of evidence.
Translation into Guidelines: Developing practice guidelines based on the evidence.
Integration into Practice: Implementing evidence-based guidelines into clinical practice.
Evaluation and Feedback: Continuously assessing outcomes and improving practice.
The PICO(T) Framework: While not a full model on its own, the PICO(T) framework is often used
as a starting point for EBP. It helps in formulating clinical questions by considering the
Patient/Population, Intervention, Comparison, Outcome, and Timeframe.
The Johns Hopkins Nursing Evidence-Based Practice Model: This model focuses on asking
clinical questions, finding evidence, appraising and synthesizing evidence, and integrating the
evidence into practice.
The Stetler Model: This model includes a series of phases, from preparation to evaluation, and
provides a structured approach to incorporating evidence into practice. It is particularly useful in
nursing and healthcare settings.
The Stetler Model:
This model includes five stages:
Stage I: Preparation.
Stage II: Validation.
Stage III: Comparative Evaluation and Decision Making.
Stage IV: Translation/Application.
Stage V: Evaluation.

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The Ottawa Model of Research Use: This model emphasizes the dynamic nature of EBP and
includes several stages such as assessing the practice environment, acquiring and assessing the
evidence, adapting the evidence to the local context, assessing barriers, and monitoring the use of
evidence.
The Ottawa Model of Research Use (OMRU):
This model involves six steps:
Assess the practice environment.
Linking research to practice.
Adapt knowledge to the local context.
Assess potential barriers and facilitators.
Select, tailor, and implement interventions.
Monitor knowledge use and evaluate outcomes
The Advancing Research and Clinical Practice Through Close Collaboration (ARCC) Model:
Developed by Dr. Bernadette Melnyk, this model emphasizes the collaboration between researchers
and practitioners to promote the use of evidence in clinical practice.
The Translating Research into Practice (TRIP) Model: This model focuses on translating research
findings into practice through a series of steps, including problem identification, evidence synthesis,
and implementation.
These models provide structured approaches to evidence-based practice, but they all share a common
goal: improving the quality of care or services by integrating the best available evidence with
clinical expertise and considering patient preferences and values. The choice of model may depend
on the specific field, context, and resources available.
The 5A's Model:
Ask: Formulate a clear and focused clinical question.
Acquire: Search for and access the best available evidence.
Appraise: Critically evaluate the evidence for its validity and relevance.
Apply: Integrate the evidence with clinical expertise and patient values.
Assess: Continuously evaluate the outcomes and make adjustments as needed.
The PARIHS Framework:This framework focuses on three key elements: Evidence, Context, and
Facilitation.
Evidence: The quality and type of evidence available.
Context: The local context and culture within whicTh the evidence will be implemented.
Facilitation: The process of enabling and supporting individuals and teams to apply evidence in
practice.
.
These models and frameworks provide structured approaches to integrating evidence-based practices
into various settings, helping to ensure that decisions and actions are based on the best available
evidence, clinical expertise, and the values and preferences of patients or stakeholders. The choice of
model may depend on the specific context and goals of the EBP implementation.
Although each model offers different perspectives on how to translate research findings into practice,
several of the steps and procedures are similar across the models .The most prominent of these
models have been the diffusion of Innovations Theory, the settler model and the Iowa model.

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 • Individual Clinical Expertise.
• Patient Values & Expectations.
• Best External Evidence.

EVIDENCE BASED PRACTICE IN INDIVIDUAL NURSING PRACTICE:

The EBP movement has both advocates and critics. Supporters argue that EBP offers a solution to improving health
care quality in cost-constrained environments. EBP is viewed as a rational approach to providing the best possible
care with the most cost-effective use of resources. Advocates also note that EBP provides a framework for self-
directed lifelong learning that is essential in an era of rapid clinical advances and the information explosion. Critics
worry that the advantages of EBP are exaggerated and that individual clinical judgments and patient inputs are
being devalued. They are also concerned that, in the current EBP environment, insufficient attention is being paid
to the role of qualitative research. Although there is a need for close scrutiny of how the EBP journey unfolds, an
EBP path is the one that health care professions will almost surely follow in the years ahead.

For individual-level EBP efforts, the major steps in EBP include the following:

1. Asking clinical questions that can be answered with research evidence.

2. Searching for and retrieving relevant evidence.
3. Appraising and synthesizing the evidence.
4. Integrating the evidence with your own clinical expertise, patient preferences,
And local context.
5. Assessing the effectiveness of the decision, intervention, or advice.

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 FEATURES OF EVIDENCE BASED PRACTICE
Integration of Research Evidence: EBP involves systematically searching for and
critically appraising current research literature to identify the most relevant and reliable
evidence related to a clinical question or problem.
Clinical Expertise: Nursing practice is informed not only by research evidence but
also by the clinical expertise and experience of nurses. Clinical expertise is used to
interpret and apply research findings to individual patient situations.
Patient-Centered Care: EBP emphasizes the importance of considering individual
patient preferences, values, and unique circumstances when making clinical decisions. It
encourages shared decision-making with patients and their families.
Critical Thinking and Problem Solving:Nurses are encouraged to engage in critical
thinking and problem-solving processes to evaluate evidence, apply it to practice, and
adapt interventions as needed based on patient responses.
Systematic Approach :EBP follows a systematic and structured approach, often
involving a series of steps, including formulating clinical questions, searching for
evidence, critically appraising evidence, integrating findings with clinical expertise and
patient values, and evaluating outcomes.
Applicability to Practice:EBP aims to translate research evidence into practice by
developing guidelines, protocols, and standards of care that can be implemented in
clinical settings.
Continuous Improvement:EBP is dynamic and promotes ongoing learning and
improvement. Nurses are encouraged to stay updated with the latest evidence and to
continually evaluate and refine their practice based on new findings.
Interdisciplinary Collaboration: EBP encourages collaboration among healthcare
professionals, including nurses, physicians, pharmacists, and others, to ensure that the
best available evidence is used to guide patient care.
Use of Technology:EBP often involves the use of electronic resources, databases,
and clinical decision support tools to access and apply evidence in real-time clinical
situations.
Evaluation of Outcomes:The effectiveness of EBP interventions is regularly
evaluated to assess their impact on patient outcomes, safety, and quality of care. This
evaluation informs further refinements in practice.
Ethical Considerations:Ethical principles are integrated into EBP to ensure that
decisions align with ethical standards and promote the well-being of patients while
respecting their autonomy and rights.
Education and Training:Healthcare institutions provide education and training to
nurses to develop their EBP skills, ensuring they can effectively apply evidence to their
practice.
Leadership Support:Leadership within healthcare organizations plays a crucial role
in fostering a culture of EBP by providing resources, mentorship, and support for nurses.
By incorporating these features, evidence-based practice in nursing strives to deliver
the highest quality of care, improve patient outcomes, enhance patient satisfaction, and
drive continuous improvement in healthcare delivery.
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 BARRIERS OF EVIDENCE BASED PRACTICE:
• Lack of value for research in practice.
• Difficulty in bringing changes.
• Lack of administrative supports.
• Lack of knowledge mentors.
• Lack of time for research.
• Lack of knowledge about research.
• Research reports not easily available.
• Complexity of research reports.
• Lack of knowledge about EBP.

HOW TO OVERCOME BARRIERS

Overcoming barriers to evidence-based practice (EBP) in nursing is essential to
ensure that healthcare providers are delivering the best possible care based on the
latest research and evidence. Here are some strategies to help address these barriers:

Education and Training:

Continuous Learning: Keep nurses updated with the latest EBP through
workshops,
seminars, webinars, and online courses.
Skill Development: Offer training on critical appraisal skills, research methodology,
and data analysis to empower nurses to evaluate and apply evidence effectively.
Access to Journals and Databases: Provide nurses with access to relevan journals,
databases, and online resources to search for the latest evidence.
Library Support: Collaborate with hospital or university libraries to ensure nurses
can access research materials.
Time Constraints:

Workload Management: Streamline nursing workflows to allocate time for EBP

activities.
Prioritization: Emphasize the importance of EBP in patient care and encourage
nurses to prioritize EBP activities.
Leadership Support: Ensure that nurse managers and leaders actively support and
Promote EBP within the organization.
Change Management: Implement change management strategies to facilitate the
transition to EBP, including clear communication and involving frontline nurses in
decision-making.

Mentoring and Support: Provide mentorship programs where experienced EBP

nurses can guide and support those who are less confident.
Peer Learning: Encourage nurses to learn from their peers through regular
discussions and sharing of experiences.
Language and Terminology:

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 Simplify Communication: Use plain language when discussing research findings to
make it more accessible to all nurses.
Provide Resources: Offer glossaries and reference materials to help nurses
understand complex terminology.
Resource Constraints:

Advocate for Resources: Nurse leaders can advocate for funding and resources to
support EBP initiatives within the organization.
Collaboration: Collaborate with other departments and institutions to share resources
and reduce duplication of efforts.
Cultural and Organizational Barriers:

Cultural Change: Promote a culture of continuous improvement and EBP within

the organization.
Leadership Alignment: Ensure that the organizational mission and values align
with the principles of EBP.
Documentation and Integration:
Electronic Health Records (EHRs): Integrate EBP guidelines and protocols into
EHR systems for easy access and documentation.
Regular Review: Periodically review and update EBP protocols to ensure they
reflect the latest evidence.
Measurement and Evaluation:
Outcome Tracking: Establish key performance indicators (KPIs) to measure the
impact of EBP initiatives on patient outcomes.
Feedback Mechanism: Use feedback to continuously improve EBP processes and
address any challenges.
Overcoming barriers to EBP in nursing requires a multifaceted approach that
involves education, resources, leadership support, and a commitment to fostering a
culture of evidence-based practice within the healthcare organization.

ADVANTAGES OF EVIDENCE BASED PRACTICE:

• Provide better information to practitioner
• Enable consistency of care
• Better patient outcome
• Provide client focused care
• Structured process
• Increases confidence in decision making
• Generalize information
• Contribute to science of nursing
• Provide guidelines for further research
• Help nurses to provide high quality care

DISADVANTAGES:

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• Not enough evidence of EBP.
• Time consuming.
• Reduced client choice.
• Reduced professional judgment or autonomy.
• Suppress creativity.
• Influence legal proceedings.
• Publication bias.

ROLE OF A NURSE IN EVIDENCE BASED PRACTICE

Evidence-based nursing, also more broadly known as evidence-based practice

(EBP), is the process by which nurses and other clinical experts determine best
practices in healthcare based on research and studies. The promise of EBP is that it
combines clinical rigor informed by science with the understanding of individual
patient needs. It can also be scaled up to the community level for population-health
initiatives. The goal of EBP is to improve patient outcomes and lower healthcare
costs.Nurses are in an excellent position to practice evidence-based care, since they
have the most contact with patients and understand their mental, physical, and
emotional conditions.Rather than take a one-size-fits-all patients approach, EBP
empowers nurses to use their scientific knowledge to identify the best care models.It
is essential for nurses to build their body of knowledge, standardize practice, and
improve patient outcomes.
Some examples are

Pressure Ulcer Prevention: Nurses follow evidence-based guidelines for turning and
repositioning patients regularly to prevent pressure ulcers.
Pain Management: Nurses use evidence-based pain assessment tools and follow
protocols for administering pain medication based on patient needs and pain
severity.
Hand Hygiene Practices: Following evidence-based protocols for hand hygiene to
reduce the risk of healthcare-associated infections.
Fall Prevention: Implementing evidence-based fall risk assessments and
interventions to prevent patient falls in healthcare settings.
MedicationAdministration: Following evidence-based medication administration
procedures, including double-checking medications, verifying patient identities, and
checking for allergies.
Infection Control:Using evidence-based guidelines for the prevention and
management of infections, including catheter-associated urinary tract infections
(CAUTIs) and central line-associated bloodstream infections (CLABSIs).
Providing patients with evidence-based information and resources to help them
understand their health conditions, treatment options, and self-care measures.
These examples illustrate how evidence-based practice in nursing encompasses a
wide range of clinical activities, from routine tasks like hand hygiene to complex
interventions like managing chronic diseases and providing specialized care. The
goal is to ensure that nursing care is based on the best available evidence to promote
optimal patient outcomes and safety.

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CONCLUSION:
Evidence base nursing care is a lifelong approach to clinical decision making and
excellence in practice. Evidence based nursing care is informed by research findings.
Clinical expertise and patients values and its use can improve patient’s outcomes. Use of
research evidence in clinical practice is an expected standard of practice for nurses and
health care organizations. But numerous barriers exist that create gap between new
knowledge to improve patient care.

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