1. Explain the relationship between research and evidence-based nursing practice.
2. Apply the steps of change used in implementing evidence-based practice.
3. Develop a PICOT question.
4. Summarize the levels of evidence available in the literature.
5. Describe limitations in relying on research as the primary source of evidence for practice.
6. Differentiate the quantitative approach from the qualitative approach in nursing research.
7. Outline the steps of the research process.
8. Describe research-related roles and responsibilities for nurses.
9. Describe the nurse’s role in protecting the rights of human participants in research.
10. Discuss how performance improvement (PI) affects health care.

Current standards of professional performance for nurses include using evidence and research findings in practice.

All nurses are expected to use evidence and research to determine proper nursing actions, to engage in research activities as appropriate to their abilities, and to share knowledge with other nurses.

Nursing research is a ‘‘scientific process that validates and refines existing knowledge and generates new knowledge that directly and indirectly influences nursing practice’’.

Evidence-based practice (EBP) is using the best evidence available to guide clinical decision making.

Nursing has historically acquired knowledge through:

• Traditions: basing practice on customs and past trends
• Authority: crediting another person as the source of information
• Borrowing: using knowledge from other disciplines to guide nursing practice
• Trial and error: using unknown outcomes in a situation of uncertainty
• Personal experience: gaining knowledge by being personally involved in an event, situation, or circumstance
• Role modeling and mentorship: imitating the behaviors of an exemplar

Evidence-based practice (EBP), or evidence-based nursing, occurs when the nurse can “integrate best current evidence with clinical expertise and client/family preferences and values for delivery of optimal health care”.

Model for changing practice as a result of evidence:

1. Cultivate a spirit of inquiry.
2. Ask clinical questions in standard format eg. PICOT
3. Search for the best evidence.
4. Critically appraise the evidence.
5. Integrate the evidence with clinical expertise and client/family preferences and values.
6. Implement and evaluate the outcomes of the intervention.

While evidence includes theories, opinions of recognized experts, clinical expertise, clinical experiences, and findings from client assessments, findings from research studies are often given the most weight in the decision-making process.

This emphasis is because research entails using formal and systematic processes to address problems and answer questions.

The disciplined thinking and the careful planning and execution that characterize research means that the resulting findings should be accurate, dependable, and free from bias.

Concerns about reliance solely on research for EBP:

• Research evidence suggests that there is one best solution to a problem for all clients and this limited perspective stifles creativity.
• Research is often done under very controlled circumstances, which is very different from the real world of health care delivery.
• Not all published research is robust and flawless.
• EBP should promote cost-effective care, but cost is often not included in traditional research studies
• Research may ignore the significance of life events to the individual.

3.1 Developing a PICOT Question

P = Patient/ population of interest

Identify patients by age, gender, ethnicity, and disease or health problem.

I = Intervention or area of interest

Which intervention is worthwhile to use in practice (e.g., a treatment, diagnostic test, prognostic factor)?

What area of interest influences a desired outcome (e.g., complementary therapy, motivational interviewing)?

C = Comparison intervention or area of interest

What is the usual standard of care or current intervention used now in practice?

O = Outcome

What result do you wish to achieve or observe as a result of an intervention (e.g., change in patient behavior, physical finding, or patient perception)?

Make an outcome statement nondirectional. For example: “Does use of chlorhexidine affect incidence of CLABSI?” instead of “Does the use of chlorhexidine reduce incidence of CLABSI?”

A directional outcome may limit the articles in your search.

T = Time

What amount of time is needed for an intervention to achieve an outcome (e.g., the amount of time needed to change quality of life or patient

In some cases, additional components are added to make PICO into PICOD by adding study Design, PICOS by adding Setting or PICOC adding Context.

Nursing insights:

• Proper question formatting allows you to identify key words to use when conducting your literature search
• Note that a well-designed EBP question does not have to follow the sequence of P, I, C, O, and T.
• The aim is to ask a question that contains as many of the PICOT elements as possible to identify knowledge gaps within a clinical situation.

3.2 Levels of Evidence

Once you have a clear and concise PICOT question, you are ready to search for scientific evidence.

A variety of sources will provide the evidence needed to answer your question, such as agency policy and procedure manuals, quality improvement data, existing clinical practice guidelines, and journal articles.

A peer-reviewed article is reviewed for accuracy, validity, and rigor and approved for publication by experts before it is published.

Searchable Scientific Literature Databases and Sources include:

• AHRQ
• CINAHL
• MEDLINE
• EMBASE
• PsycINFO
• Cochrane Database of Systematic Reviews
• PubMed
• World Views on Evidence-Based Nursing

It is important to use the hierarchy of evidence available as depicted in the figure. The level of rigor or amount of confidence you can have in the evidence (e.g., findings from a study) decreases as you move down the pyramid.

Meta-analyses and systematic reviews are the perfect answers to PICOT questions because they rigorously summarize current evidence about a specific topic or intervention.

The use of clinical experts may be at the bottom of the evidence pyramid, but do not consider clinical experts to be poor sources of evidence.

Expert clinicians use evidence frequently as they build their own practices, and they are rich sources of information for clinical problems.

Nursing insights:

• Evidence-based practice, or evidence-based nursing, involves clinical decision making using a variety of sources of evidence modified for use in specific settings and for individual clients.
• Change in practice requires assessing the need for change; locating and analyzing the best evidence; designing, implementing, and evaluating the practice change; and integrating and maintaining the change.