Introduction to evidence-based nursing
"No man, not even a doctor, ever gives any other definition of what a nurse should be than this-'devoted and obedient'. This definition would do just as well for a porter. It might even do for a horse. It would not do for a policeman."
Florence Nightingale, 18601
Florence Nightingale would probably not recognise the nurse of today. As we move into the next millennium, we expect nurses to care with their hearts and minds; identify patients' actual and potential health problems; and develop research-based strategies to prevent, ameliorate, and comfort. We increasingly expect them to undertake work historically done by doctors; we also expect them to be empathic communicators who are highly educated, critical thinkers, and abreast of all the important research findings.
Research makes a difference. In a meta-analysis designed to determine the contribution of research-based practice to patient outcomes, Heater and colleagues reported that patients who receive research-based nursing care make "sizeable gains" in behavioural knowledge, and physiological and psychosocial outcomes compared with those receiving routine nursing care.2
The process of incorporating good quality research findings into nursing practice is, however, not straightforward. Bostrom and Suter found that only 21% of 1200 practising nurses had implemented a new research finding in the previous six months.3 Luker and Kenrick used qualitative techniques in an exploratory study of community nurse decision-making in the United Kingdom and determined that the nurses had an awareness of research but did not perceive it as informing their practice.4 This work also supported previous reports that nurses have difficulty in accessing and appraising published research, either because they do not have access to journals and libraries, or because they have not been taught how to find and appraise research.5, 6, 7
Estabrooks asked staff nurses about the frequency with which they used various sources of knowledge. Most frequently used knowledge sources were found to be experiential, nursing school (even though the average length of time since completing their basic nursing education program was 18 years), workplace sources, physician sources, intuitions, and what has worked for years. Literature (whether in textbook or journal form) was rated in the bottom 5 for frequency. She also asked them to identify the one most common source from which they learned about research findings. While 38.7% identified nursing journals, additional analyses revealed that the primary journals the nurses were reading were not research journals, but rather trade magazines published by nursing professional organisations.8
More than 400 nursing journals are listed in Ulrich's International Periodicals Directory,9 many of which publish original research, and in a range of languages. Nurses working individually cannot hope to find and read even the highest quality research published each year, particularly when much of the research relevant to nursing is published in non-nursing journals.
When clinical nurses have been taught how to identify and appraise research critically they have responded with enthusiasm, but they have had difficulty in learning and applying these skills in practice, partly because of shifting patterns and workloads.10 Nurses who were interviewed in a qualitative study of their information needs said that they needed reference sources to be accurate and concise. This is consistent with a survey of midwives working in the northwest of England, who reported great difficulty in assessing the quality of journal articles. These midwives asked for research reports to be more concise, free from jargon, and self-explanatory.11
Research utilisation has been defined as the use of research findings in any or all aspects of one's work as a registered nurse or at its simplest, the use of research.8 More recently, the term 'evidence-based nursing' (EBN) has emerged. This term has evolved from the initial work done in 'evidence-based medicine' defined as: the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.12 If we use this same definition for 'evidence-based nursing', its meaning is broader than that of 'research utilisation'. The practice of evidence-based nursing involves the following steps: formulation of an answerable question to address a specific patient problem or situation;13 systematic searching for the research evidence that could be used to answer the question;14, 15 appraisal of the validity, relevance and applicability of the research evidence; integration of the research evidence with other information that might influence the management of the patient's problems: clinical expertise, patient preference for alternative forms of care, and available resources;16 implementation of the evidence-based practice decision; and finally, evaluation of the outcome of the decision.
Resources to facilitate evidence-based nursing
During the last decade, major initiatives have been introduced to help clinicians become evidence-based practitioners. The following is a brief description of some of these efforts:
Rather than publishing original research, the objective of these journals is to summarise those studies that are valid and clinically useful. Currently, these journals consist of ACP Journal Club, Evidence-Based Medicine, Evidence-Based Cardiovascular Medicine, Evidence-Based Health Policy and Management, Evidence-Based Mental Health, and Evidence-Based Nursing. While they are all similar in format, we will provide a brief description of Evidence-Based Nursing. The specific purposes of this journal are: to identify, using predefined criteria, the best quantitative and qualitative original and review articles on the meaning, cause, course, assessment, prevention, treatment, or economics of health problems managed by nurses and on quality assurance; to summarise this literature in the form of "structured abstracts" that describe the question, methods, results, and evidence-based conclusions of studies in a reproducible and accurate fashion; and to provide brief commentaries written by practising nurses on the context of each article, its methods, and clinical applications that its findings warrant.
The authors of this module are all involved in the production of Evidence-Based Nursing. Alba DiCenso, Nicky Cullum, and Donna Ciliska are co-editors; Susan Marks and Ann McKibbon are research associates and Carl Thomson is an associate editor. In addition to the abstracts, Evidence-Based Nursing includes an "EBN Notebook" in which we publish short papers about the research process. We have included copies of some of these published to date in this module. Topics include: asking answerable questions; searching for the best evidence, and identifying the best research design to fit the question (Part 1: quantitative designs and Part 2: qualitative designs).
We are now at the point in health care research where important questions have often been addressed by more than one study. A systematic review is a method of summarising the findings of all methodologically sound studies addressing the same research question. In a systematic review, eligible research studies are viewed as a population to be systematically sampled and surveyed. Individual study characteristics and results are then abstracted, quantified, coded, and assembled into a database that, if appropriate, is statistically analysed much like other quantitative data. The statistical combination of the results of more than one study, or meta-analysis, effectively increases the sample size and results in a more precise estimate of effect than can be obtained from any of the individual studies used in the meta-analysis.
The Cochrane Collaboration is an international organisation that aims to help people make informed decisions about health by preparing, maintaining, and ensuring the accessibility of rigorous, systematic, and up-to-date reviews (including meta-analyses where appropriate) of the benefits and risks of health care interventions.17 The Cochrane Library is the product of the Collaboration's work and includes reports and protocols of over 1000 systematic reviews produced within the Collaboration, abstracts of over 1800 reviews summarised and critically appraised by the Centre for Reviews and Dissemination at the University of York, UK, and citations for over 200,000 randomized controlled trials.
Centres for Evidence-Based Nursing
In the past few years, a number of countries, including the UK, Canada, Germany, New Zealand, Australia and others, have created Centres for Evidence-Based Nursing. While the specific goals of these centres vary, most seek to educate nurses through workshops or through formal courses to be evidence-based nurses in practice, education and research; to conduct original research and systematic reviews; and to design and evaluate strategies for disseminating research findings to nurses.
Evidence-based practice guidelines
Clinical practice guidelines are " systematically developed statements to assist practitioner decisions about appropriate health care for specific clinical circumstances"18 Guidelines can be used to reduce inappropriate variations in practice and to promote the delivery of high quality, evidence-based health care. Guidelines should be based on the best available research evidence, should be developed with representation from as many interested parties as possible, should be tested by professionals uninvolved in their development and in the healthcare setting for feasibility, and should be reviewed regularly and modified to incorporate new knowledge.19
These are exciting times in nursing. With the increased emphasis on graduate education for nurses, many important research questions related to the practice of nursing are being addressed using rigorous research methods. There is a strong motivation among nurses to apply the findings of research to their practice through evidence-based nursing. To complement these developments, a variety of resources have emerged to help nurses become evidence-based practitioners.
- Nightingale F. Notes on nursing what it is and is not. London: Churchill Livingstone, 1946. (First published in 1859)
- Heater BS, Becker AM, Olson R. Nursing interventions and patient outcomes. A meta-analysis of studies. Nurs Res 1988;37:303-7.
- Bostrom J, Suter WN. Research utilisation: making the link to practice. Journal of Nursing Staff Development 1993;9:28-34.
- Luker KA, Kenrick M. An exploratory study of the sources of influence on the clinical decisions of community nurses. J Adv Nurs 199217:457-66.
- Ketefian S. Application of selected nursing research findings into nursing practice: a pilot study. Nurs Res 1975;24:89-92.
- Blythe J, Royle JA. Assessing nurses' information needs in the work environment. Bull Med Libr Assoc 1993;81:433-5.
- Pearcey PA. Achieving research-based nursing practice. J Adv Nurs 1995;22:33-9.
- Estabrooks CA. Will evidence-based nursing practice make practice perfect? C J Nurs Res 1998;30:15-36.
- Ulrich's international periodicals directory. New York: Bowker, 1996.
- Royle JA, Blythe J, Ingram C, DiCenso A, Bhatnager N, Potvin C. The research utilization process: the use of guided imagery to reduce anxiety. Canadian Oncology Nursing Journal 1996;6:20-5.
- Meah S, Luker KA, Cullum NA. An exploration of midwives' attitudes to research and perceived barriers to research utilisation. Midwifery 1996;12:73-84.
- Sackett DL, Rosenberg W, Gray JAM, Haynes RB. Evidence-based medicine: What it is and what it isn't. BMJ 1996;312:71-2.
- Flemming K. Asking answerable questions. Evidence-Based Nursing 1998;1:36-7.
- McKibbon KA, Marks S. Searching for the best evidence. Part 1: where to look. Evidence-Based Nursing 1998;1:68-70.
- McKibbon KA, Marks S. Searching for the best evidence. Part 2: searching CINAHL and Medline. Evidence-Based Nursing 1998;1:105-7.
- DiCenso A, Cullum N, Ciliska D. Implementing evidence-based nursing: some misconceptions. Evidence-Based Nursing 1998;1:38-40.
- Jadad AR, Haynes RB. The Cochrane Collaboration - Advances and challenges in improving evidence-based decision making. Medical Decision Making 1998;18:2-9.
- Field MJ, Lohr KN. Clinical practice guidelines: directions for a new program. Washington, DC: National Academy Press, 1990.
- Thomas L. Clinical practice guidelines. Evidence-Based Nursing 1999;2:38-9.