A problem-solving approach to clinical decision making, evidence-based practice (EBP) integrates the best available scientific evidence with the best available experiential evidence. Its goal: to ensure that practice is evidence-based.
EBP is a new competency now required for professional nurse clinicians. Although EBP models began emerging in the mid-1990s, the average age of a registered nurse (RN) is 47. So for many RNs in the current workforce, EBP wasn’t part of their basic nursing education curriculum, and their knowledge of EBP may be limited.
Integrating EPB into the workplace culture
Healthcare leaders agree on the importance of integrating EBP into an organization’s culture. Successful implementation requires a systematic plan. An EBP forum provides a creative venue for nurses with diverse educational backgrounds, clinical expertise, and years of experience to improve both the practice of nursing and the practice environment.
At York Hospital in York, Pennsylvania, we use the Johns Hopkins Nursing EBP (JHNEBP) model as an organizational perspective for conducting hospital-wide EBP projects. Each month, nurses from varied backgrounds meet in a council setting for a forum on EBP.
A shared decision-making governance philosophy created the six councils that operate at York Hospital; the EBP/nursing research council is the most recent addition. The others are the coordinating council, education council, leadership council, performance improvement council, and practice council.
Only the EBP council has a voluntary membership; the others have mandated service-line representation. EBP council members include staff RNs, clinical nurse specialists, RNs in various specialty roles (such as infection control or lactation consultant), and PhD/RN research advisors. (See Shared decision-making councils by clicking on the PDF icon above.)
All councils meet monthly, with participation supported by the hospital budget. The EBP council meets for 4 hours, with each meeting covering:
- business related to the council’s basic functioning
- open consultation for project managers or principal investigators
- EBP forum.During the education portion, topics include introduction to EBP; how to identify practice questions, search the literature, critique research, and translate evidence into practice; and common statistical tests. More complex issues also have been presented—for example, parametric and nonparametric analyses, how to write for publication, and experimental and nonexperimental research. Presentations are balanced to include both beginning and advanced levels of understanding about EBP and research. Although some topics are repeated, many are fresh new ideas. All nurses in the hospital are invited to attend the education hour.
Evolution of the EBP forum
The EBP forum grew from council members’ desire to put their knowledge of EBP to use. Council members identify practice questions that pertain to all nurses in the hospital; one question becomes the EBP project.
To date, the forum has completed four projects, which have addressed the following practice questions:
- What are the best strategies for identifying, managing, and preventing workplace violence? (workplace violence project)
- What are the best nonpharmacologic practices for preventing deep vein thrombosis (DVT) and venous thromboembolism? (DVT project)
- Does oral or temporal artery temperature most accurately reflect core temperature? (core temperature project)
- What are the best practices for storing and using equipment in the rooms of patients with contact precautions?
Three phases of EBP projects
EBP council members have identified a three-phase process—planning, meeting operations, and follow-up—that leads to successful project completion. This process was modified based on our experience in completing the first two projects (workplace violence and DVT). Input regarding distribution of materials, project timelines, feasibility, and satisfaction has improved the EBP forum format. (See Elements crucial to project success by clicking on the PDF icon above.)
During the planning phase, the EBP council identifies and prioritizes topics of broad interest and a member volunteers to be project leader. The chairperson invites all RNs in the hospital to participate in the EBP forum via an e-mail blast distributed 3 months before the first meeting. This memo specifies the required time commitment and states that participants must attend four 2-hour meetings.
Working with the hospital librarian and PhD nurse researchers, the project leader identifies appropriate databases and conducts the search for evidence. Initially, the leader reviews abstracts to determine the most appropriate literature. For the workplace violence project, 187 abstracts were reviewed, with 57 articles chosen for the final critique. Articles are distributed electronically at least 1 month before the first meeting. A handout explaining how to read and evaluate research is sent with the articles, and an educational session is offered to first-time participants.
Small work groups are formed according to specialty, with each group including both EBP-experienced nurses and EBP novices. For the DVT project, articles pertaining to DVT incidence in critical care patients were assigned to nurses from intensive care units. Each group gets approximately five to seven articles to read and evaluate; each nurse is expected to read the articles before the first meeting.
Appraisal guidelines and organizational tools from the JHNEBP model are available on the hospital EBP website for easy access by all staff. At meetings, group members discuss their assigned articles. At the first meeting, the group determines which articles are good or excellent and which are of poor quality; the latter are excluded from summary recommendations.
At the second meeting, the group reviews the selected articles a second time and categorizes the results and recommendations from each article according to the evidence level, creating a summary table. Different EBP models use different evidence rating systems. The JHNEBP model uses five levels of evidence. (See JHNEBP levels of evidence by clicking on the PDF icon above.)
At the third meeting, groups are reassigned and practice recommendations for each level of evidence are identified. At the fourth meeting, all participants meet to review final practice recommendations and develop an action plan.
The council uses various methods to successfully translate practice recommendations to nursing practice. The project leader serves as the champion, driving the process from start to end. For example, for the workplace violence project, the project leader reported the action plan to a hospital-wide safety committee. The EBP council invited three senior vice-presidents to hear the report and discuss how to implement the action plan.
Translating evidence into practice can be the most challenging aspect of the EBP process. Depending on the nature of the practice recommendations, translation may take many forms. For instance, for the core temperature project, the group’s recommendation was to conduct research. A research team and principal investigator were identified from EBP forum participants. This research has been approved by the hospital’s institutional review board and currently is in process.
Engagement, enthusiasm, and energy
At York Hospital, our EBP forum has involved approximately 150 nurses in four projects. Participants are engaged throughout the entire process. Participation is recognized within the clinical advancement program.
We’ve created enthusiasm and energy for using evidence in making clinical decisions. As a result, unit-based EBP/nursing research committees are developing, promoting a scholarly approach to clinical practice. The bottom line—improved patient care with improved outcomes.
Newhouse R, Dearholt S, Poe S, Pugh LC, White K. Johns Hopkins Nursing Evidence-based Practice Model and Guidelines. Indianapolis, IN: Sigma Theta Tau International; 2007.
The Registered Nurse Population: Findings from the 2008 National Sample Survey of Registered Nurses. http://bhpr.hrsa.gov/healthworkforce/rnsurvey/2008/nssrn2008.pdf. Accessed October 22, 2010.
The authors work at York Hospital in York, Pennsylvania. Sheree Seben is a clinical nurse educator and staff nurse in the coronary care unit. Karen S. March is a nurse researcher. Linda C. Pugh is the director of EBP and nursing research.