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Overview Donate to Wikibin
Evidenced-based nursing/evidence-based practice
(EBN/EBP) is a nursing process that entails reviewing
and instilling the most reliable and updated research in
patient care. The goal of EBN is to provide the highest
quality and most cost efficient nursing care possible.
EBN is a process founded on the collection,
interpretation, and integration of valid, important, and
applicable patient-reported, clinician-observed, and
research-derived evidence. The best available evidence,
moderated by patient circumstances and preferences, is
applied to improve the quality of clinical judgments."
Some define EBN as "the synthesis and use of scientific
findings from randomized clinical trials only." Others
see it as "the use of information from case reports and
expert opinion" . EBN must use the best research
evidence with clinical expertise and patient values.
Nurses want to use EBN to improve the quality of care
and create new and exciting questions to be addressed
through the research. EBN is not easily achieved and
requires a conscious effort to practice and participate. In
order to practice evidence based nursing one must
understand the concept of research, know how to
accurately evaluate research and decide which research
is measurably valid and reliable.
EBP Meets Nursing
"Registered Nurses are expected to access, appraise, and
incorporate research evidence into their professional
judgment and decision-making as well as to consider
preferences and values of their patient population."
Associate degree graduates will demonstrate an
awareness of the value or relevance of research in
nursing. Registered nurses help identify problem areas in
nursing practice within an established structured format,
assist in data-collection activities, and , in conjunction
with the professional nurse, appropriately use research
findings in practice (Geri LoBiondo-Wood, Judith Haber
pg.9) Thus, incorporating EBP into their nursing careers.
"When enough research evidence is available, it is
recommended that the evidence base for practice be
based on the research." EBP is a growing trend in
nursing. As more research is done in a specific area, the
research evidence can be used to update and refine
guidelines. "As we are exposed to new scientific
knowledge, we need to use integrative review of
literature, formulation of a new theory, or generate new
hypotheses. Use of knowledge in this way is referred to
as cognitive application" . It is not to be overlooked
however, that the nursing approach to evidence based
practice may differ from the standard medical approach.
This is typically due to nurses' commitment to providing
holistic care; treating and working with patients rather
than working on them.
The difficulties associated with EBP in nursing is due to
the wide range of meanings and uses associated with the
term and the failure to clarify them in the context of a
nursing discussion. "The science of nursing is based on a
critical thinking framework, known as the nursing
process, composed of assessment, diagnosis, outcomes
identification, planning, implementation, and evaluation.
These steps serve as the foundation of clinical decision-
making and are used to provide evidence- based
practice."
Because EBP originated in medicine, the
assumptions associated with it may or may not apply to
nursing and must be identified and
addressed. Specifically, the assumptions equate practice
decisions
with medical interventions and evidence with
quantitative
research. Is the definition of EBP—along with these
underlying
assumptions—congruent with nursing practice?
Prior to adopting EBP in nursing, clinicians must
determine
what constitutes evidence and what an effective nursing
intervention is. It is important to distinguish how these
concepts of evidence and intervention differ when
applied
in fields other than medicine. Any discussion of the
application
of EBP within nursing must be accompanied by a
clarification
of these terms and consideration of how they fit into
the nursing discipline.
According to Sackett et al.', evidence-based
practice is the "conscientious, explicit, and judicious
use of current best evidence in making
decisions about the care of individual patients."
Gibbs- takes this idea further, stating, "Placing
the client's benefits first, evidence-based practitioners
adopt a process of lifelong learning
that involves continually posing specific questions
of direct practical importance to clients,
searching objectively and efficiently for the current
best evidence relative to each question, and
taking appropriate action guided by evidence."
Challenges of EBN for Nurses
Professional nurses are constantly challenged to be
aware of new information to provide the highest quality
of patient care (Barnsteiner and Prevost, 2002; IOM,
2001). Nurses are challenged to expand their "comfort
zone" by offering creative approaches to old and new
health problems and designing new and innovative
programs. Nursing research provides a specialized
scientific knowledge base that empowers the nursing
profession to anticipate and meet these shifting
challenges and maintain our societal relevance. The best
available evidence—moderated by patient circumstances
and preferences—is applied to improve the quality of
clinical judgements and facilitate cost-effective health
care (Sackett, Straus, Richardson, Rosenberg, and
Haynes, 2000)
In order to be the best possible patient advocate, a nurse
must be willing to continually evaluate and change his or
her practice methods. Health care is constantly changing.
New information on how to provide better care for
patients is discovered every day; and old practices are
being improved. Now, health care practices are being
implemented after research is done to prove their
effectiveness. Accurate research provides health care
workers with the evidence needed to change their
practice. However, not all research is valid. Many
studies are biased or have low external and internal
validity. These studies cannot be trusted because nurses
cannot be sure if the intervention is really beneficial.
Therefore, these new methods should not be put into
practice. That is how research, theory, and practice all
come together. Nurses must realize how important
research is in patient care. He or she must then learn to
become a wise interpreter and evaluator of research, and
continually evaluate current research to provide the
highest quality patient care.
History
Evidence based nursing started in the 1800s with
Florence Nightingale. Her concepts of promoting health,
prevention of disease, and care of the sick were central
ideas of her system (LoBiondo-Wood, Haber pg. 11).
Nightingale served in the Crimean War during the 1850s
in which she organized a unit of 38 nurses. In 1856,
when she returned to London, she spread the word of
how important sanitation was in nursing care. Florence
Nightingale believed that infection arose spontaneously
in dirty and poorly ventilated places. This mistaken
belief nevertheless led to improvements in hygiene,
healthier living, and working environments. Nightingale
did not know the scientific facts of germs and bacteria,
though she knew that if materials used to treat the
patients were clean, patients healed faster. Therefore if
doctors and nurses washed their hands, patient deaths
decreased dramatically. She fought the established
medical practices of the day, insisting that it was not
enough to rest on ungrounded theories, even if their
proponents were prominent physicians of the time. She
stated, "What you want are facts, not opinions...The
most important practical lesson that can be given to
nurses is to teach them what to observe-how to observe-
what symptoms indicate improvement-which are of
none-which are the evidence of neglect-and what kind of
neglect." This is evidence based nursing.
In the 1960s, research priorities began to be reordered
and practice-oriented research was targeted. These
priorities were supported by nursing's major
organizations. Nurses soon were attaining educational
preparation in research design in order to teach research
and conduct their own research courses. Nurses
primarily worked with others from related disciplines
that had the expertise to teach these courses (LoBiondo-
Wood, Haber pg. 12-14).
Today, the definition of evidenced based nursing came
as a response to the push for efficiency in the 1970s and
1980's. While efficiency was certainly a worthy goal, the
decision makers who impacted health-care policy were
managers and businessmen rather than nurses or doctors
who actually interacted with patients. What these
managers and businessmen lacked was the ability to
evaluate nursing and medical diagnosis, interventions,
and clients' plans of care. We are striving to do this with
EBN.
Future
The continuation of nursing knowledge provides various
opportunities for a nurse to study research questions
while promoting health, preventing illness, and
optimizing patient outcomes. The increasing
number of doctoral level programs in and outside of the
United States will contribute to a large number of nurse
researchers who are prepared to bring research-based
knowledge to life. Nurse researchers are focused on
developing
programs that incorporate quantitative and qualitative
study outcomes to form a foundation for evidence based
practice. This practice is being incorporated in order for
the nurses to give patients the best care.
In the near future, information may be available online
through electronic communications such as a dedicated
list server, a Virtual Hospital System, or another form of
electronic media. Such a center could facilitate
networking among health care professionals working on
similar EB topics and provide helpful consultants and
educational materials. This center also would provide
data regarding the interventions/strategies that have been
tested to translate research into practice and provide a
"tool kit" of these interventions for use by all types of
health care agencies.
Education of Nurses must include knowledge and skills
in using research evidence in practice. Nurses are
increasingly being held accountable for practices based
on scientific evidence and tradition. Therefore, we must
communicate and integrate into our profession the
expectation that it is the professional responsibility of
every nurse to communicate with nurse scientists the
numerous clinical problems for which we do not yet
have scientific base. Nursing has risen to the challenge
of improving health care, and will continue to research
and implement new nursing
based practices in the future.
The 5 steps of EBN
Step 1: Select a Topic
The first step is to select a topic. Ideas come from
different sources but are categorized in two areas:
Problem-focused triggers and Knowledge focused
triggers(see below). When selecting a topic, nurses
should formulate questions that are likely to gain support
from people within the organization. An
interdisciplinary medical team should work together to
come up with an agreement about the topic selection.
The priority of the topic should be considered as well as
the severity of the problem. Nurses should consider
whether the topic would apply to many or few clinical
areas. Also, the availability of solid evidence should be
considered because providing proof of the research will
increase staffs' willingness to implement into nursing
practice.
Problem & Knowledge Focused Triggers
Problem focused triggers are identified by health care
staff through quality improvement, risk surveillance,
benchmarking data, financial data, or recurrent clinical
problems. Problem focused triggers could be clinical
problems, or risk management issues.
Example: Increased incidence of deep vein thrombosis
and pulmonary emboli in trauma and neurosurgical
patients.

Deep Vein Thrombosis (DVT) is a blood clot in the deep

venous system in the legs. Many things can contribute to
a clot forming in the legs such as impaired mobility and
bed rest. A thrombosis in the leg is not a huge problem
but becomes a very dangerous situation when a piece of
the clot breaks off and is free to travel in the
bloodstream. In most situations, the thrombosis will
travel into the right heart and then into the pulmonary
circulation and become wedged in the lungs. This
creates a pulmonary embolism which is a very serious
situation.
Diagnosis and proper treatment of a DVT (Deep Vein
Thrombosis) is a very important task for health care
professionals and is meant to prevent pulmonary
embolism. This is an example of an important area that
more research can be conducted to add into Evidence
Based Practice.
Knowledge focused triggers are created when health
care staff read research, listen to scientific papers at
research conferences or encounter EBP guidelines
published by federal agencies or organizations.
Knowledge based triggers could be new research
findings that further enhance nursing, or new practice
guidelines.
Example: Pain management, prevention of skin
breakdown, assessing placement of nasogastric and
nasointestinal tubes, and use of saline to maintain
patency of arterial lines.
It is important that individuals work closely together to
reach the optimum outcome for the chosen topic. Some
things that would ensure collaboration are working in
groups to review performance improvement data,
brainstorming about ideas, and achieving consensus
about the final selection.
Step 2: Form a Team
Some might become overwhelmed when they first learn
about EBP and apply it for reasons other than
improvement of patient care. Forming a team increases
the chance of EBP being adopted. A team becomes
paramount in implementation, and evaluation of the
EBP. It is important to have representatives of the team
from authority members of the organization and also
grassroot members. It is also important to consider
interdiscipline involvement to decrease rejection, and for
all to have an understanding of the project. All these
individuals have a great impact on the possibility of
successful implementation.
Other factors to put into consideration include power
figures in the organization who may directly or
indirectly sabortage the efforts if they are not consulted,
and fully included in EBP implementation. The EBP
team should have explanations that clearly define the
types of patients, setting, outcomes, interventions and
exposures. This should be in simplified language that is
comprehensible to a lay person.
The role of the practitioners is remarkable in any
meaningful gains, they are therefore inevitable and their
role becomes pivotal. The approach they adopt and their
ability to educate the coworkers, answer their questions,
and clarify any misconceptions greatly improves the
outcomes.
Step 3: Evidence Retrieval
One of the most challenging issues in using EBP in the
clinical setting is learning how to adequately frame a
clinical question so that an appropriate literature review
can be performed. When forming a clinical question the
following should be included: the disorder or disease of
the patient, the intervention or finding being reviewed,
possibly a comparison intervention, and the outcome. An
acronym used to remember this is called the "PICO"
model:
P = Who is the Patient Population?
I = What is the potential Intervention or area of Interest?
C = Is there a Comparison intervention or Control
group?
O = What is the desired Outcome?
Once the topic is selected, the research relevant to the
topic must be reviewed, in addition to other relevant
literature. It is important that clinical studies, integrative
literature reviews, meta-analyses and well-known and
reliable existing EBP guidelines are accessed in the
literature retrieval process. With the internet at one’s
fingertips, a plethora of research is just a few clicks
away. However, just because you found it in a
respectable journal does not signify high quality
research. When reviewing any article for evidence
retrieval read it very closely. Articles can appear to be
precise and factual on the surface but with further and
much closer examination, flaws can be found. The
article can be loaded with opinionated and/or biased
statements that would clearly taint the findings, thus
lowering the creditability and quality of the article. Use
of rating systems to determine the quality of the research
is crucial to the development of EBP. There are several
rating systems available online. The National Guideline
Clearinghouse is a database of published EBP guideline
abstracts at (http://www.guideline.gov). These and
others will help to guide your way through the perils of
research review.
Time management is crucial to information retrieval.
Nurses making their way through the vast amount of
research available may find it helpful to read research
articles or critical reviews instead of clinical journals. To
maintain high standards for EBP implementation,
education in research review is necessary to distinguish
good research from poorly conducted research. Equally
important is that the materials being reviewed, consider
if they are current.
Links to article sources
# Cinahl Information Systems Home Page
# British Medical Journal
# Medline Industries, Inc
# Pubmed
To learn more about the PICO go to
<http://healthlinks.washington.edu/ebp/pico.html> this is
an excellent resource.
Once the literature is located, it is helpful to classify the
articles as either conceptual (theory and clinical articles)
or data-based (systematic research reviews). Before
reading and critiquing the research, it is useful to read
theoretical and clinical articles to have a broad view of
the nature of the topic and related concepts, and to then
review existing EBP guidelines.
Step 4: Apply the Evidence
After determining the internal and external validity of
the study , a decision is arrived at whether the
information gathered does apply to your initial question.
Its important to address questions related to diagnosis,
therapy, harm, and prognosis. The information gathered
should be interpreted according to many criteria and
should always be shared with other nurses and/or fellow
researchers.
Step 5: Decision to Change the Practice
When the studies are completed, and the EBP outcomes
are evaluated, a decision is reached on whether to use
this in practice. Several factors are put into
consideration. First the relevance of evidence for
practice and second the consistency in findings across
studies and/or guidelines; a significant number of studies
and/or EBP guidelines with sample characteristics
similar to those to which the findings will be used;
consistency among evidence from research and other
nonresearch evidence; feasibility for use in practice; the
risk/benefit ratio risk (risk of harm;potential benefit for
the patient). Putting together results from other studies
may end up supporting what is currently in practice
rather than changing practice. Using a focus group is a
great way to provide discussion about the EBP standard
and to point out key areas that may cause problems
during the implementation phase.
Qualitative Research Process
One method of research for Evidence based practice in
nursing is Qualitative Research. "The word implies a
focus on qualities of a process or entity and meanings
that are not experimentally examined or measured in
terms of quantity, amount, frequency, or intensity."
With qualitative research, researchers learn about patient
experiences through discussions and interviews. The
point of qualitative research is to provide beneficial
descriptions that allow insight into patient experiences.
"Hierarchies if research evidence traditionally categorize
evidence from weakest to strongest, with an emphasis
on support for the effectiveness of interventions. That
this perspective tends to dominate the evidence-based
practice literature makes the merit of qualitative research
unclear;" Some people view qualitative research as less
beneficial and effective, with its lack of numbers, the
fact that it is "feeling-based" research, makes the
opponents associate it with bias. Nevertheless, the
ability to empathetically understand an individual's
experience (whether it be with cancer, pressure ulcers,
trauma, etc.), can benefit not only other patients, but the
health care workers providing care. For qualitative
research to be reliable, the testing must be unbiased. To
achieve this, researchers must use random and non-
random samples to obtain concise information about the
topic being studied. If available, a control group should
be in use, if possible with the qualitative studies that are
done. Evidence should be gathered from every available
subject within the sample to create balance and dissolve
any bias. There should also be several researchers doing
the interviewing to obtain different perspectives about
the subject. Researchers must also obtain negative
information as well as the positive information gathered
to support the data. This will help to show the
researchers were unbiased and were not trying to hide
negative results from readers, and actually makes it
posible to objectively understand the phenomenon under
investigation. The inclusion of this negative information
will strengthen the researchers initial study, and may
actually work in favor to support the hypothesis. Any
data that has been gathered must be appropriately
documented. If the data collected was obtained from
interviews or observation, it must all be included. Dates,
times and gender of the sample may be needed,
providing background on subjects, such as breast cancer
in women over thirty-five. Any pertinent information
pertaining to the sample must be included for the reader
to judge the study as worthy.In addition, the current
evidence-based practice (EBP) movement in healthcare
emphasizes that clinical decision making should be
based on the "best evidence" available, preferably the
findings of randomized clinical trials. Within this
context qualitative research findings are considered to
have little value and the old debate in nursing has been
re-ignited related as to whether qualitative versus
quantitative research findings provides the best empirical
evidence for nursing practice. In response to this crisis
qualitative scholars have been called upon by leaders in
the field to clarify for outsiders what qualitative research
is and to be more explicit in pointing out the utility of
qualitative research findings. In addition, attention to
"quality" in qualitative research has been identified as an
area worthy of renewed focus. Within this paper two key
problems related to addressing these issues are reviewed:
disagreement not only among "outsiders" but also some
nursing scholars related to the definition of "qualitative
research", and a lack of consensus related how to best
address "rigor" in this type of inquiry. Based on this
review a set of standard requirements for qualitative
research published in nursing journals is proposed that
reflects a uniform definition of qualitative research and
an enlarged yet clearly articulated conceptualization of
quality. The approach suggested provides a framework
for developing and evaluating qualitative research that
would have both defensible scholarly merit and heuristic
value. This will help solidify the argument in favor of
incorporating qualitative research findings as part of the
empirical "evidence" upon which evidence-based
nursing is founded.
How to Critique a Research Article
The critiquing process is the building block and
foundation for the multiple steps that are to follow in the
successful implementation of EBP. This is so because
you must first ensure that the material and research that
you are trying to convince others to accept is reliable and
accurate. By taking the time to thoroughly critique a
study you can point out both the strengths and
weaknesses of the findings and weigh them accordingly.
Successful completion of this vital step will help "weed
out" the material lacking the needed proof of
effectiveness, therefore minimizing useless, or even
harmful, implementation of new practices in the
healthcare field.

Critiquing criteria are the standards, evaluation guides,

or questions used to judge (critique) an article. In
analyzing a research report, the reader must evaluate
each step of the research process and ask questions about
whether each step of the process meets the criteria.
Remember when you are doing a critique, you are
pointing out strengths, as well as the weaknesses. To
critique an article you must have some knowledge on the
subject matter. There is no replacement for reading the
article many times. The reader must search the article for
contradictions, illogical statements, and faulty reasoning.
It is important to evaluate every section of the research
article. Each section has different criteria to meet, in
order to be considered a well-written addition to the
article.
Sometimes the harder you try the harder something
becomes, locating hard core evidence that people will
relate to may be a difficult task that you may face in
future situations. The attached web site is an excellent
tool that can help diminish your uncertainty about the
decision making process. This handy little tool kit will
make you a "connoisseur of evidence" and will give you
the insight into how to focus and prepare to approach
EBP research and to express yourself to the public
accurately and be heard.
<http://www.ebm.med.ualberta.ca/ebmintro.htm>
Another site to check out would be
<http://www.ahrq.gov/clinic/epcsums/strengthsum.htm>
Very interesting reading if the Research field is in your
heart.
Keys to critiquing a research article
In order to correctly critique a research paper you have
to have
some idea of what you are looking for in the article.
Articles can be very deceiving at first glance, filled with
persuasive wording,
unneeded information, or downright false claims. In
order to
successfully decipher through the fog of deception you
must take on the persona of an investigator. It is solely
up to you to deem the material worthy of your seal of
approval. The following paragraphs contain criteria that
you as the reader want to be watchful for. These criteria
will help guide you in knowing exactly what it is you are
looking to examine. It is recommended that you read the
article several times, each time looking for more answers
to the criteria listed below. It is helpful to write out notes
as you go. 1.The first section of the article to be
analyzed is the problem statement and purpose. The
following are questions that must be answered by you
the reader. The first question that you must ask yourself
is whether or not the purpose of the research is made
clear. Then you need to keep an eye out for a
relationship between two or more testable variables.
Next, you need to see if the article specifies the nature of
the population being studied, and if a problem has been
identified. 2. The next section of the article to be
analyzed is the review of the literature and the
theoretical framework. You must ask yourself what
concepts are included in the review. You must separate
the concepts that belong to the independent variable, and
the dependent variable. Next, ask yourself if the
literature review makes the relationship among the
variables clear. Identify any gaps, or conflicts in the
knowledge, if so read to see how this study intends to fill
those gaps, or resolve those conflicts. You will want to
focus on the references, noting whether they are primary
or secondary sources. 3. The next section of the article to
be analyzed is the hypothesis, or research question. The
first question that needs answering is whether or not the
hypothesis, or research question is appropriately stated.
If research questions were used, are they in addition to a
hypothesis, or are they used to guide an exploratory
study? Next, it needs to be determined whether or not
the hypothesis is null or research, and last it needs to be
determined if the hypothesis is testable. 4.The next
section for analysis is the sample. It is here where you
want to figure out how the sample was selected, what
type of sampling method was used, if it reflects the
population as stated in the study, if it is appropriate, and
if it can br generalized.
5.The next section to be analyzed is research design. In
this section you will want to determine what type of
method was used, and whether or not the design fits the
research problem, theoretical framework, literature
review, and hypothesis. 6.The last section for analysis is
the internal and external validity. You will want to note
if the threats to internal validity are discussed, and if
there are controls for the threats to internal validity.
When it comes to external validity you will want to note
any threats to external validity.
Introduction, Purpose, and Hypothesis
Introductions need to at least include a literature review
and a purpose statement, but they may also contain a
theoretical framework, a research question, and a
hypothesis. The research question presents the idea that
is to be examined in the study and is the foundation of
the research study. A well developed research question
guides a focused search for scientific evidence about
assessing, diagnosing, treating, or assisting patients with
understanding of their prognosis related to a specific
health problem. The hypothesis attempts to answer the
research question. A hypothesis is a declarative
statement about the relationship between two or more
variables that predicts an expected outcome.
Characteristics of a hypothesis include a relationship
statement, implications regarding testability, and
consistency with a defined theory base. They can be
formed by either a directional or nondirectional method.
The literature review needs to explain the reason the
study was conducted and why it was important for the
study to be conducted now. The theoretical framework
and the literature review should also work together. The
purpose statement needs to explain what the study wants
to accomplish. The purpose, aims, or objectives often
provide the most information about the intent of the
research question and hypothesis and suggest the level of
evidence to be obtained from the findings of the study.
The introduction should cover these topics, and should
not throw in a lot of excess, useless knowledge. The
research question, hypothesis, and the study should all
correlate together. You have to be careful when
critiquing research articles because sometimes
researchers will try to cover up a poor study with lots of
information that does not belong. It may look good to
the reader at first glance so it is always a good idea to
reread the articles a few times to fully understand it and
to see if there are any discrepancies.
Methodology
The methodology section must start off by gathering a
sample. There are a few definitions you must understand
first. 'Population' is the group that you want you study
findings to apply to. A 'sample frame' is the target
population, in which the study will affect. There are
three different ways to select a population. The
researchers can choose who they want in the study, the
participants can choose if they want to be in the study, or
it can be a random selection in which neither the
researcher or the participant chooses. The study must
either have external validity or internal validity. If the
study has external validity then the study's findings have
different settings, procedures, and participants. External
validity will also question what types of subjects and
conditions in which the same results can be expected to
occur. If the study has internal validity then the findings
are held true within the sample. The researchers will rule
out factors or threats as rival explanations of the
relationship between the variables that are present. Be
careful with internal validity and external validity
because there are a number of threats for both that can
affect the outcome of the study. These should be
considered by the researchers who are planning the study
and by consumers before implementing the results into
practice.
Phenomenological method
In qualitative research phenomenological methods are
used to learn and construct the meaning of the human
experience through intensive dialogue with persons who
are living the experience. The researcher's goal is to
explain the meaning of the experience to the participant.
This is achieved through a dialogic process, which is
more than a simple interview.
Results and Discussion
The results section puts forth the findings of a study in a
clear, logical, and unbiased manner. It presents the
findings according to the variables studied without
extrapolating beyond what those variables yielded.
Qualitative studies do not contain statistical tests.
Therefore, the themes, concepts, observational or print
data are described in the "Methods" or "Data Collection"
subtitles and are reported in the "Results" or "Findings"
section.
A good results section should also make use of
descriptive statistics. Descriptive statistics are used to
summarize, reduce, and organize the data and
characteristics of the data into an easily understood,
manageable format. Finding data's mode, median, and
mean are three techniques used to easily recognize
central tendency. Techniques such as range and standard
deviation are used to measure variability and scatter
plots are used to measure correlation. After analyzing
the data and finding central tendency, variability, and
correlation, this information should be worked into an
easily understood format such as a frequency
distribution table, chart, or graph. The reader should be
able to easily recognize and interpret the data. However,
the reader must be on alert to recognize that this may yet
be another opportunity for the author of the study to
make the results appear more grandiose than they are.
Always look at what the actual numbers amount to
instead of just looking at how significant the graph or
chart makes the data look. In a good results section, the
author will not try to make insignificant data look
significant, but simply show the results. If the numerical
data of a study does not show the same claims that the
researcher stated then this is a major flaw in the study
and raises significant concerns about the study's validity
and reliability; therefore, a nurse and other healthcare
providers should not only stay current on new research
but should be able to decipher the research in order to
determine its true value to the medical practice.
Inferential Statistics
The very last section of a research study is known as the
discussion section. Here, the researchers draw all the
pieces from the study together to present the whole
picture. The researchers review the literature and discuss
how the results compare and contrast previously
completed studies. The researchers often present biased
opinions in the discussion section but these should
always be supported by the research and not just the
interpretation of the researchers. This overview of the
study serves to make a comparison with the background
literature. The results and discussion sections can
sometimes be combined into one by the researcher, but
normally, the researcher will report the findings into
separate "results" and "discussion" sections. One way is
not better than the other when it comes to combining or
dividing the findings into sections. Any new or
unexpected results are usually described in the
discussion section as well.
Evaluating The Conclusion
A conclusion can be identified as paragraphs that state
the main claims that came out of the findings that were
read earlier in the article. It should have a summary of
the findings (strengths and weaknesses), status of the
hypothesis, limitations, and recommendations,
implications, or applications. In each section the best and
worst needs to brought forth. In a quality conclusion
section the author will only state what has been found, or
not, without adding anything extra. The hypothesis will
be proven true or false and nothing in between.
Limitations will be discussed such as the statistical
framework or design errors made in the beginning. The
researcher should also present the limitations or
weaknesses of the study. This presentation is important
because it effect's the studies generalizability. The
generalizations or inferences about similar findings in
other samples also are presented in light of the findings.
Recommendations will be few in quality research. If no
loop holes or oversights are made at the beginning then
these will not have to be expressed at the end. When all
of these come together in a simplified manner then a
conclusion can be considered strong.
A limitation is an admission of how certain aspects of
the study, such as the sampling, were not as unbiased as
they should have been. This lets the reader know that
improvements can be made from what was
accomplished in the article.
The last thing the conclusion should do is give the reader
a recommendation. This recommendation should be
derived from the results gathered earlier in the article.
Based on the results, the reader will be able to judge
whether the data and hypothesis should be applied to
nursing practice.
Legal and Ethical Issues of Research
The big issues concerning research today are the legal
and ethical issues surrounding it. The American Nurses
Association (ANA) has set up five basic human rights
for patient protection which are:
1. Right to self determination
2. Right to privacy and dignity
3. Right to anonymity and confidentiality
4. Right to fair treatment
5. Right to protection from discomfort and harm.

You must also ask yourself questions such as: Were the
study participants subjected to any physical harm,
discomfort, or psychological distress? Did the
researchers take appropriate steps to remove or prevent
the harm?
Did the benefits to participants outweigh any potential
risks or actual discomfort they experienced? Did the
benefits to society outweigh the costs to participants?
Was any type of coercion or undue influence used in
recruiting participants? Were vulnerable subjects used?
Were participants deceived in any way? Were they fully
aware of participating in a study, and did they
understand the purpose of the research? Were
appropriate consent procedures implemented?
Were appropriate steps taken to safeguard the privacy of
participants?
Was the research approved and monitored by an
Institutional Review Board or other similar ethics review
committee? (Polit, Beck and Hungler: Essentials of
Nursing Research (5th Edition).
These rights apply to both researchers and participants.
Informed consent is one area that nurses must be
familiar with in order to complete research. Informed
consent is "the legal principle that governs the patients
ability to accept or reject individual medical
interventions designed to diagnose or treat an illness".
Without informed consent research is at a halt and
informed consent can only be obtained after the entire
procedure and potential risks have been explained to the
participant. Only then can the participant decide if they
still want to participate. When dealing with the ethical
portion of Evidence based practice, the Institutional
Review Boards (IRB) review research projects to assess
that ethical standards are being followed. The
institutional review board is responsible for protecting
subjects from risk and loss of personal rights and
dignity. The IRB also come into play when deciding on
which populations can be included in research.
Vulnerable groups such as children, pregnant women,
physically disabled or elderly maybe excluded from the
process. Fraud is also a problem that has been associated
with research. These days just about anyone could
publish falsified information causing millions of people
to be misinformed and any practices that decide to
follow this incorrect information could be causing harm
to their patients. Nurses must keep a watch out for
articles that may look suspicious and notify the IRB to
make sure that these individuals receive the appropriate
attention and review.
It is important to be up to date on all the appropriate
state laws and regulations regarding vulnerable
populations. This may mean consulting with lawyers,
clinicians, ethicists, as well as the affiliatedd IRB. It is
imperative that researchers act as advocates for these
vulnerable persons that cannot do so for themselves.
In order for Evidenced Based Nursing to continue to
improve, all of these issues must be addressed and these
problems must be resolved.
Barriers to promoting Evidence Based Practice
The use of evidence based practice depends a great deal
on the nursing student's proficiency at understanding and
critiquing the research articles and the associated
literature that will be presented to them in the clinical
setting. According to, Blythe Royal, author of Promoting
Research Utilization in nursing: The Role of the
Individual, Organization, and Environment, a large
amount of the preparation requirements of nursing
students consists of creating care plans for patients,
covering in depth processes of pathophysiology, and
retaining the complex information of pharmacology.
These are indeed very important for the future of patient
care, but their knowledge must consist of more when
they begin to practice. Evidence based nursing in an
attempt to facilitate the management of the growing
literature and technology accessible to healthcare
providers that can potentially improve patient care and
their outcomes. Nancy Dickenson-Hazard states,
"Nurses have the capacity to serve as caregivers and
change agents in creating and implementing community
and population-focused health systems." There is also a
need to overcome the barriers to encourage the use of
research by new graduates in an attempt to ensure
familiarity with the process. This will help nurses to feel
more confident and be more willing to engage in
evidence based nursing. A survey that was established
by the Honor Society of Nursing and completed by
registered nurses proved that 69% have only a low to
moderate knowledge of EBP and only half of those that
responded did not feel sure of the steps the process
consists of. Many responded, "lack of time during their
shift is the primary challenge to researching and
applying EBP." There is always and will always be a
desire to improve the care of our patients. The ever
increasing cost of healthcare and the need for more
accuracy in the field proves a cycle in need of evidence
based healthcare. The necessity to overcome the current
issues is to gain knowledge from a variety of literature
not just the basics. There is a definite need for nurses,
and all practitioners, to have an open mind when dealing
with the modern inventions of the future because these
could potentially improve the health of patients.

There are many barriers to promoting evidence based

practice. The first of which would be the practitioner's
ability to critically appraise research. This includes
having a considerable amount of research evaluation
skills, access to journals, and clinic/hospital support to
spend time on EPN. Time, workload pressures, and
competing priorities can impede research and
development. The causes of these barriers include
nurse's and other professional practitioners lack of
knowledge of research methods, lack of support from
professional colleagues and organizations, and lack of
confidence and authority in the research arena.
Another barrier is that the practice environment can be
resistant to changing tried and true conventional
methods of practice. This can be caused because of
reluctance to believe results of research study over safe,
traditional practices, cost of adopting new practices, or
gaining momentum to rewrite existing protocols.. It is
important to show nurses who may be resistant to
changes in nursing practice the benefits that nurses, their
patients, and their institutions can reap from the
implementation of evidence-based nursing practice,
which is to provide better nursing care.
Values, resources and evidence are the three factors that
influence decision-making with regard to health care. All
registered nurses and health care professionals should be
taught to read and critically interpret research and know
where to find articles which relate to their field of care.
In addition, nurses need to be more aware of how to
assess the information and determine its applicability to
their practice.
Another barrier to implementing EBN into practice is
lack of continuing education programs. Practices do not
have the means to provide workshops to teach new skills
due to lack of funding, staff, and time; therefore, the
research may be tossed dismissed. If this occurs,
valuable treatments may never be utilized in patient care.
Not only will the patients suffer but the staff will not
have the opportunity to learn a new skill. Also, the
practitioners may not be willing to implement change
regardless of the benefits to patient care.
Another barrier to introducing newly learned methods
for improving treatments or
patients' health is the fear of "stepping on one's toes".
New nurses might feel
it is not their place to suggest or even tell a superior
nurse that newer, more
efficient methods and/or practices are available.
The perceived threat to clinical freedom offered by
evidence-based practice is neither logical nor surprising.
Resistance to change and to authority is part of human
nature. When we make decisions based upon good
quality information we are inconsistent and biased.
Human nature offers many challenges to evidence-based
practice. Can we do a better job of promoting evidence-
based practice? And even if we find and use the
evidence, will we make consistent unbiased decisions?
Even if clinicians do act consistently it is possible that
their decisions are consistently biased. People put
different values on gains and losses. Tversky and
Kahneman gave people the two identical problems (with
the same probabilities of life and death outcomes - see
fig 1) but framed the outcome choices as either lives
saved or as deaths.10 Most people wanted to avoid
taking risks with gains which could be safeguarded, but
would take risks with losses which might be avoided;
this is a framing effect. If people are given identical
options but different words are used to emphasize a gain
rather than a loss, then a different response is given by a
large proportion of the population under study. Such a
change in response appears to be inconsistent. (Health
Education Authority. Oral Health Effectiveness Review
No 7. Effectiveness of oral health promotion. London:
HEA, 1998).
How is an EBP sample population chosen:
Nonprobability Sampling vs. Probability Sampling
The sampling strategies are grouped into two main
categories: nonprobability sampling and probability
sampling. The difference between nonprobability and
probability sampling is that nonprobability sampling
does not involve random selection and probability
sampling does. Does that mean that nonprobability
samples aren't representative of the population? Not
necessarily. But it does mean that nonprobability
samples cannot depend upon the rationale of probability
theory. At least with a probabilistic sample, we know the
odds or probability that we have represented the
population well. The major drawback to nonprobability
sampling is there is no way of estimating each element's
probability of being included in the samples; there is NO
way of ensuring that every element has a chance of
being included in the nonprobability sampling.
Nonprobability sampling tends to produce less
representative samples unless the researcher thoroughly
thought through the inclusions and exclusions of the
study.
Nonprobability sampling
The three major nonprobability sampling methods that
are used are: convenience, quota and purposive.
The convenience sample is when the researcher chooses
the sample population at his/her convenience.
Convenience sampling has the largest risk of bias due to
the sample population being self selected by the
researcher.
Quota sampling is easy to draw a sample population as
well and does contain an unknown source of bias which
greatly affects the external validity of the study.
In a purposive sampling, the risk of bias increases with
greater heterogeneity of the population; conscious bias is
also a danger with this study.
All three samples are not fully representative of the
population because of small generalizability. Bias is a
major problem with nonprobability sampling.
Probability sampling
Probability sampling consists of four major sampling
strategies: simple random, stratified random, cluster, and
systematic sampling.
* Random sampling has a significant lower risk of bias
than nonprobability sampling, but the ease of drawing
the sample population is much more difficult.
* Simple random sampling is constructed when the
researcher defines a specific population (i.e. sampling
frame) and then selects a sample to be studied within the
population through randomization (i.e.: assigning each
person of a population with a specific number then
randomly choosing 100 of those numbers).
* Stratified random sampling is done by dividing the
population into subgroups. An example: 5000 registered
nurses are split up into three different groups depending
on the type of degree that was received (group1: diploma
school graduates, group2: Associate degree graduates,
and group3: baccalaureate graduates). As one can
determine these three groups were composed of random
factors.
* Cluster sampling involves a successive random
sampling of clusters that progress from large to small
and meet sample eligibility criteria. An example: if a
sample of nurse practitioners is desired, the first
sampling unit would be a random sample of hospitals.
The second step consist of a list of pediatric nurse
practitioners practicing at each hospital from the
hospitals selected in the first group. The third stage
consist of inclusion or exclusion criteria that the NPs had
to meet to be eligible for the study.
* systematic sampling refers to a sampling strategy that
involves the section of every "kth" case drawn from a
population list at fixed intervals. An example: every 15th
person from the phone book is chosen to participate.
Conclusion
In conclusion it is very important to know how the
sample population was chosen in a study in order to
determine the reliability and validity of a study. Without
accurate sampling, EBP is botched from the beginning.
The Star Model of Knowledge Transformation
The Star Model of Knowledge Transformation uses a
five point model to explain the major steps of
“knowledge transformation” Those are: 1. Discovery
2.Evidence summary 3.Translation into practice
recommendations 4.Integration into practice
5.Evaluation
These guidelines were developed in 2005 to fill in the
missing pieces of EBP. Until this time, there were no
national competencies for EBP in nursing. The
researchers at the University of Texas Health Science
Center at San Antonio, who developed the Star Model,
define Knowledge Transformation as the “conversion of
actual findings from research studies, through a series of
stages, to impact on health outcomes.” They are sure to
mention that before integration into practice can happen,
changes must occur at the individual, organizational, and
environmental levels. It is not enough to just change our
own beliefs and practices. It is the individuals
responsibility to present the knowledge to others for
changes to happen on all levels.
EBP Example and Graph
When healthcare providers are considering adopting a
new practice they want to clearly see the results. Charts
and graphs are a good way to show statistical results of a
study. In 1997 an article was published about a study
performed by Professor Richard Gray, a distinguished
epidemiologist. Professor Gray studied and documented
the effects of aspirin on mortality related to acute
myocardial infarctions. Professor Gray made a graph
using the results he obtained from the study. By looking
at the graph, one can see immediately that mortality rates
are much lower when patients were given aspirin as
opposed to a placebo.
Nurses are more likely to catch the attention and gain
support from other healthcare providers when they have
statistical graphs. Other nurses may not have time to sit
and read about results from a study. The researching
nurse needs to present the evidence in a simple, concise
manner. This is not to say, however that the evidence
should not be backed up. All charts and graphs used in
research should be accompanied with enough
information to fully explain how the researchers arrived
at those particular numbers and figures. Charts and
graphs can also contain hidden information and the nurse
must then dig deeper into the text to uncover things the
researchers may not have wanted anyone to notice.
Therefore, visual charts and graphs can have a profound
influence on the acceptance of a new intervention, but
must first be carefully screened for any faulty claims.
Further Information
If you would like to learn more about evidence based
nursing practice, and see some real-life examples of its
use and importance, please check out these websites.
They are all excellent sources for nurses, other health
professionals, instructors, or anyone interested in
evidence based nursing and its application to practice.
* "Indiana Center for Evidence Based Nursing Practice",
a collaborating center of The Joanna Briggs Institute,
located at Perdue University Calumet’s School of
Nursing: http://www.ebnp.org/
* "University of Minnesota Libraries", a tutorial on
evidence based nursing:
http://www.biomed.lib.umn.edu/learn/ebp/
* "Centre for Evidence Based Medicine", University
Health Network:
http://www.cebm.utoronto.ca/syllabi/nur/intro.htm
* "Academic Center for Evidence Based Practice", The
University of Texas Health Science Center at San
Antonio: http://www.acestar.uthscsa.edu/
* "Medscape Today", online nursing resource and a
source of CEU credit articles:
http://www.medscape.com/viewarticle/514532
See Also

• Chiropractic care: Research and Criticism

• Council for Refractive Surgery Quality
Assurance
• Divorce and Children: An Annotated
Bibliography
• Pharmacology Weekly

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