VOL: 103, ISSUE: 19, PAGE NO: 32-33
Jane Fitzpatrick, DEd, PGCEA, MSc, RGN, RHV, RM
Senior lecturer in the faculty of health and social care, University of the West of England
Fitzpatrick, J. (2007) How to turn research into evidence-based practice.
This is the third in a series of three articles that explores what is involved in developing effective evidence-based practice (EBP) processes. The first article addressed the context of EBP, effective question identification and search strategies. The second introduced critical evaluation of sources. This article addresses summarising evidence and putting together a case following critical evaluation of the evidence. It also examines the factors that will influence the implementation of recommendations for developments in EBP.
The articles aim to facilitate understanding of:
- Effective question identification;
- Search strategies;
- Selecting and retrieving credible sources of evidence;
- The skills required for critical evaluation of sources of evidence;
- The application of research evidence to nursing practice.
Summarising the evidence
Having searched for and reviewed a range of evidence to inform developments in nursing practice, what next? How can the source material lead to a solution to the original question? When putting the ideas together how do nurses construct a case to influence developments in practice in a particular clinical area?
Summarising the evidence is a vast intellectual endeavour. Following the search and critique of sources it requires synthesis of the ideas presented in the evidence. Practitioners need to be able to combine ideas and recommendations from a range of sources to make practical recommendations.
This requires the following:
- Summarising the arguments presented in the range of sources;
- Deciding on the factors to address in relation to the source materials such as rating its validity and relevance in the context;
- Considering the risk implications for the patient group of proceeding with recommendation(s) based on current evidence;
- Considering the feasibility of implementation of the recommendation(s) in practice;
- Considering the development of a protocol to inform the adoption of the recommendation.
The Oncology Nursing Society (www.ons.org/ceCentral/landing.shtml) suggests that it is advisable to adopt a group approach to summarising evidence. This allows nurses to develop a multidisciplinary group that will be able to share different perspectives both on the range of evidence and the proposed changes in the practice setting. A team approach means nurses can draw on the expertise of colleagues to review the efficacy of the source material and to consider the implications for developments in practice. Developing a group approach to EBP requires several skills. According to Harvey et al (2002), effective facilitation is essential for the successful implementation of EBP. For example, the group leader will need facilitation skills to enable group members to:
- Evaluate current practice;
- Engage in question development;
- Devise a search strategy;
- Critically evaluate sources of evidence;
- Organise their results by concepts, setting and variables.
Kitson et al (1998) argued that facilitators have a key role in enabling nurses to appreciate what they need to change and how to bring about change to translate the evidence into practice.
Whether doing an individual project or a group review of a clinical issue, there are several factors that must be addressed regarding the credibility of each source of evidence. For example:
- What is the strength of the research base?
- Does it consist of one or more studies?
- Has the research design met scientific criteria? That is, has each study been critically evaluated with respect to the sample, design, methodology, results and conclusion?
Bearing in mind the differential weighting of the sources of evidence reviewed, it is necessary to consider the potential risks involved in adopting a new approach in practice. For example, Luker et al (2003) (retrieved in the initial search exercise in this series) advocated that district nurses could take on the role of assessing the post-discharge needs of all cancer patients/carers and institute case management if necessary. In contrast, the systematic review of discharge planning (Shepperd et al, 2000, updated in 2004) suggested that a small reduction in length of hospital stay could have an impact on the timeliness of subsequent admissions where there are shortages of acute beds. What this review does not do is offer any indication of how factors - such as the level and quality of nursing services available in the community - affect the patient outcome. Here it is necessary to make a judgement call about the relevance of these recommendations and consider the implications for the clinical setting.
These two articles suggest that several risk factors may emerge in relation to the question and particular nursing context. These may be probed further by exploring issues such as:
- Is there a shortfall in hospital beds in the catchment area?
- What level of nursing support is available in the community?
- What resources are available for patients on discharge?
- What support networks are available for patients and carers?
These questions may lead to seeking out further evidence to either support or refute the proposed changes to clinical practice.
Nurses may also have to ask if they have control over the proposed practice development. If not is there multidisciplinary support for it? It is also worth considering if the evidence supports the proposed development in the specific care setting.
Other factors to consider include resource implications. For example, is there a budget if the change requires new equipment? In addition, does the change require the staff to develop new skills? If so, is there funding available for staff training and development?
These examples illustrate the difficulties in putting forward recommendations for practice developments based on a range of evidence. It is imperative that in making a case nurses are aware of not only the recommendations of a range of sources but also are able to demonstrate they have critically evaluated them. In addition, they need to provide evidence to contextualise the proposed change within clinical practice.
Having decided which of the evidence best suits the issue being addressed, it is worth referring to Sackett et al’s (1996) definition of EBP, which is as follows: ‘The contentious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.’
This suggests nurses should ask questions in light of the specific context of the patient and the care environment and consider the implications for nursing practice. In developing an EBP approach Cluett (2002) suggested asking the following questions:
The context of the patient and the care environment:
- Is the option appropriate for the patient and her or his family?
- Is the option acceptable ethically, culturally and practically?
Is the patient able to understand fully the range of choices available and make an informed choice?
- Is the recommendation within her or his sphere of practice?
- Does the nurse have the education, skills, confidence and resources to offer or facilitate the recommendation in care?
- Is it professionally and personally acceptable to provide such care or to refer to someone who can?
Practitioners need to act and provide care that is based on the best available evidence. This needs to be reviewed in the context of individual circumstances. This leads on to evaluating practice and its impact on the patient’s experience of care. The appropriateness, outcomes, efficiency and effectiveness in relation to patient care should be examined. In addition, it is necessary to review the subjective experience of patients and nurses and evaluate the impact on the service. This will also allow the generating of new ideas and new avenues of enquiry to contribute to the evidence, which in turn will lead to new developments in practice.
Making the case
Having decided on the issue, developed the question, found sources of evidence, developed a critical evaluation of them and summarised the points, the next step is to consider how to present a case to those involved in the development of care within an area of nursing practice.
In some instances, this means presenting a case directly to a patient/client and her or his family based on the evidence currently available. It may also involve making a recommendation to change practice within the team, unit or organisation. Sometimes the recommended changes will also impact on relationships between agencies such as the NHS and the local authority.
When advocating a change to current practice nurses need to consider how they can use the evidence to make a case. This may require not only reviewing the efficacy of the research recommendation but also considering the costs of implementation. This may be minimal and may be offset by the improvement in the patient’s experience of care. In other situations, practice development requires not only consideration of the direct costs in case management but also costs in education and training, and the acquisition of technical resources.
In presenting a case practitioners need to consider to whom it is being made and the format that will be most appropriate. It is important to consider:
- Who the audience is;
- The purpose for making a case:
Addressing weak areas;
New service development;
- The style and format of presentation:
Paper or report;
- The mode of access to information:
Whatever form the case representation takes it must be made in a coherent and competent way. This may involve reviewing skills in oral presentation, writing and using IT. It is important to consider the implications of using the EBP processes in order to put the case competently and answer questions confidently.
Applying an effective EBP process in practice
Gennaro et al (2001) argued that finding the evidence and critiquing it is the relatively easy part of developing an effective EBP process in nursing practice. They suggested that instituting it is more problematic. The authors asserted that organisational norms and rules can either impede or enhance an EBP approach to care. For example, structural changes resulting in cutbacks in staffing and training opportunities (such as recent ones in the NHS) can seem to bring about insurmountable obstacles. However, some may be possible to address by developing new working practices.
Gennaro et al (2001) offered the example of developing flexible practitioners in labour ward settings in Ontario. Their example illustrates how staff who were ‘cross trained’ could be deployed according to workload pressures. In the UK, where nurses have experienced ‘downsizing’, many healthcare providers may believe that it is not possible to engage with EBP. However, Hallas and Melnyk (2003) argued that in such a context it is imperative to rise to the challenge by critically reviewing practice and developing the evidence base in order to provide high-quality nursing care.
The development of an evidence-based culture in the workplace requires a commitment from the organisation concerned, as well as levels of management and clinical staff. In introducing a new innovation based on the evidence it is important to recognise the dynamics of change management if the implementation is to be successful. Drawing on a range of literature Redfern et al (2003) stated that there are several factors that will impinge on the success of an innovation based on EBP. These include:
- Organisational commitment;
- Active support from stakeholders;
- Recognition of the importance of change;
- A credible change agent;
- Face-to-face contact with practitioners to promote enthusiasm;
- Ensuring targeted staff have ownership of the innovation and are empowered to bring about change.
Recommendations using EBP may raise issues for service management and provision. Cluett (2002) argued that these may include:
- Resource implications:
- Staff, equipment, time, funding;
- Health and safety;
- Guideline development;
- Compatibility and coherence with wider service philosophy and provision demands;
- Implications for other service provision.
There may also be barriers to EBP implementation, such as the lack of a learning culture within the organisation or a conflict with priorities for resource allocation. EBP is most often effective in an organisation that has adopted a learning culture in which health and social care management is open to dialogue with practitioners about the efficacy of care.
Hallas and Melnyk (2003) said that if we are to develop an effective EBP process and overcome these barriers it is imperative that there are ‘champions and mechanisms to support its course’. They recommended that academics and practitioners work together to develop a collaborative partnership to enhance the learning culture relating to EBP.
Kitson (2002) observed that the adoption of EBP processes in the clinical area is also affected by agendas within the wider political context - for example those associated with clinical governance, change management, new working practices and professional and inter-professional working agendas. Effective EBP also depends on perceptions held in society about the nature of health and social care provision.
Having decided on the desired outcomes of an EBP initiative it is important to develop an evaluation strategy. This should be done in parallel with the implementation plan, which will demonstrate the effectiveness or otherwise of the implementation of the initiative. Evaluation provides essential data to inform decision-making in the clinical setting. It should include both short- and long-term reporting intervals that indicate why the identified data and timescales were selected.
In order to demonstrate an effective evaluation the outcomes should be measured against established benchmarks. This allows:
- A comparison with data collected and collated prior to the intervention;
- A comparison of data with appropriate clinical areas that have not yet implemented the practice change;
- Consideration of whether external benchmarks exist and will prove to be beneficial for comparison.
Using established benchmarks for comparison between pre- and post-EBP intervention in the clinical area allows the team to make a clear and substantive case for or against the adoption of an EBP initiative.
It is also important to monitor the correct use of the new practice. This will include evaluating the implementation process and reviewing it in light of any unforeseen barriers. For example, this would include reviewing:
- The impact on patient outcomes;
- Staff knowledge level in order to inform the adequacy of education and availability of support for practitioners in developing new skills related to the EBP development. This will include reviewing educational needs and planning for regular educational updates;
- Financial and resource implications.
The evaluation process also offers an opportunity to maintain the momentum of an EBP initiative. For example, members of the team may provide opportunities for discussion in planning sessions or by displaying posters. They may also provide support and information. They can also give regular updates on the progress of the initiative which may enhance staff motivation and morale.
The impact of the involvement of stakeholders, including clinical colleagues, in developing an effective EBP intervention cannot be underestimated. Glasziou and Haynes (2005) asserted that the path from research to improved health outcomes is complex. They suggested that it is dependent not only on the development of an effective EBP process but also on the commitment of stakeholders in making recommendations with respect to its development and implementation.
Implications for continuing professional development
The nature of evidence used to support nursing practice is continually changing. There are new developments ranging from new treatment regimens to organising care delivery. The realms of research and policy development are producing vast amounts of evidence that may support existing practice, suggest some is outmoded and also propose new approaches. Nurses working in clinical practice are required to demonstrate accountability in all aspects of practice. This means being able to justify all aspects of decision-making. However, the volume of evidence is overwhelming. Practitioners need to develop ways of engaging with EBP that allows them to demonstrate competent practice.
The EBP process requires developing a range of skills including:
- Identifying an issue of concern;
- Developing a question;
- Identifying, selecting and retrieving credible sources of evidence;
- Critically evaluating sources of evidence and considering how these should be weighted;
- Synthesising arguments;
- Putting together a case;
- Considering the implications of recommendations in the context of nursing practice.
It also involves considering how organisational factors may impinge on the implementation of effective EBP developments and how effective change management may influence this.
Some continuing education courses such as those that encourage students to develop an independent study or work-based learning project may also offer the opportunity to use an EBP approach to explore an issue relevant to clinical practice.
This third article in this three-part series has introduced the processes involved in synthesising ideas arising from critical evaluation of sources of evidence. It has also considered the implications for introducing the findings of EBP processes into nursing practice, and it tackles the steps needed to bring about change.
In addition, the article has offered an overview weighting the range of evidence and of processes involved in making an informed case to promote practice development based on critical evaluation of the evidence. This has also involved considering how EBP can be embedded in practice. The development of these skills will enable nurses to foster competence in reviewing sources of evidence and presenting a case to influence changes in care. The development of these skills will also enable practitioners to contribute to an EBP culture in the clinical environment.
Cluett, E.R. (2002) Evidence based practice. In: Cluett, E.R., Bluff, R. (eds). Principles and Practice of Research in Midwifery. London: Churchill Livingstone.
Gennaro, S. et al (2001) Making evidence-based practice a reality in your institution: evaluating the evidence using the evidence to change clinical practice. The American Journal of Maternal Child Nursing; 26: 5, 236-244.
Glasziou, P., Haynes, B. (2005) The Paths From Research to Improved Health Outcomes. EBN online:http://ebn.bmj.com/cgi/reprint/8/2/36
Hallas, D.M., Melnyk, B.M. (2003) Evidence-based practice: the paradigm shift. Journal of Pediatric Health Care; 17: 46-49.
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Shepperd, S. et al (2000) Discharge planning from hospital to home. Cochrane Database of Systematic Reviews; 4: CD000313. Review. Updated in 2004: Cochrane Database of Systematic Reviews; 1: CD000313