1

FACULTY OF NURSING AND ALLIED HEALTH SCIENCE

NMND5103 –CLINICAL DECISION MAKING

ASSIGNMENT 2

Topic: A Critical Reflection on Clinical Practice, and Evaluation of the Effectiveness of

Clinical Decision Making Using the Three Elements of Evidence- based Practice: Best
Available Research Evidence; Clinical Expertise; and Patient Preferences.

Name of the Student : J.A.D.S.Tharangani

Matrix Number :

NIC : 787440878V

Telephone Number : +96891454682/0717620231

E-mail Address : sitharajayatunga@gmail.com

Facilitator’s Name : Mrs. Rupa Pathmini

International Institute of Health Sciences

Learning Centre :
– IIHS Sri Lanka

Current Semester : May 2018 Semester

Date of submission : 01.09.2018

 2

Acknowledgement

First of all, I would like to owe my deepest gratitude to my facilitator, Ms. Rupa Pathmini, who
guided me through the path of knowledge of the subject of Clinical Decision Making in nursing
to complete this assignment successfully.

And also, I sincerely remind my course coordinator and the rest of the staff in the IIHS- Sri-
Lanka, for offering their timely important assistance during the course.

My parents and the family has become an important and immeasurable part of my life, and they
are hopefully looking forward to see my success in education as a nurse, and, I must remind
them with the deepest gratitude.

Lastly, it is my duty to give my thanks to all of my friends for their immense love and
encouragement throughout my journey.

J.A.D.S.Tharangani.
 3

Preface

Evidence-based research involves collecting, evaluating and implementing evidence to improve

patient care and outcomes. Clinicians rely on experience and expertise to evaluate research
findings that can benefit patients. Evidence-based practice (EBP) respects the patient’s unique
situation, preferences and values. It is not a static model; rather, evidence-based practice
continually incorporates updated research. (Colorado Mesa University, 2016).

Evidence-based practice attempts to cover gaps in patient care for better outcomes and a
healthier population by blending clinical experience and evidence. Further, it takes into account
patient values to promote better patient experiences. Evidence-based research offers nurses a
unique opportunity to expand their roles and transform patient care. (Colorado Mesa University,
2016).

The principles of EBP first appeared formally in 1992 in the Journal of the American Medical
Association. The practice tries to bridge what the Institute of Medicine (IOM) once called a
chasm between what is known and what is done in patient care. The IOM, renamed the National
Academy of Medicine in July 2015, identified glaring shortcomings. Evidence-based practice
can, and does, resolve these issues. (Colorado Mesa University, 2016).

As demand increases for the improved outcomes of evidence-based practice, the need for more
educated nurses will follow. This practice requires nurses to utilize critical thinking-, appraisal-
and decision-making skills. Nurses must learn to efficiently analyze research to determine its
relevance to a particular patient .The benefits of EBP have prompted the American Nurses
Association (ANA) to mirror the IOM’s recommendation. The ANA predicts that 90 percent of
all nursing practices will use evidence-based practices and principles by 2020. (Colorado Mesa
University, 2016).

In this assignment, the author will be discussed critically a reflection on clinical practice and
evaluation the effectiveness of clinical decision making by using the three elements of evidence-
based practice such as; best available research evidence; clinical expertise; and patient
preferences. First of all, will be introduced brief background information of EBP. Secondly,
elaborates the importance of EBP in Nursing Clinical decision making .In addition, illustrates a
clinical practice issues and barrios to EBP.
 4

Table of Content

Title Page No.

Acknowledgement 2

Preface 3

Chapter 1 Introduction 5

1.1 What is Evidence-Based Practice (EBP)? 5

1.2 Defining Evidence 7
1.3 The Seven Steps of Evidence-Based Practice 9

Chapter 2 Evidence –based Practice with Health Sector 21

2.1 Benefits of EBP 21

2.2Responsibilities at different levels of health-care systems for developing consistent EBP 22

2.3 Implementing EBP in Nursing and Midwifery 24

2.4 Main Types of Barriers to EBP 29

Chapter 3 Clinical Practice and Effectiveness of Clinical Decision Making with EBP 30

3.1 Best available Research Evidence with Clinical Practice 30

3.2 Clinical Expertise with Clinical Practice 31

3.3 Patient Preferences with Clinical Practice 35

Chapter 4 Case Study 42

Conclusion 48

References 49
 5

Chapter 1

Introduction

1.1 What is Evidence-Based Practice (EBP)?

The most common definition of Evidence-Based Practice (EBP) is from Dr. David Sackett. EBP
is “the conscientious, explicit and judicious use of current best evidence in making decisions
about the care of the individual patient. It means integrating individual clinical expertise with the
best available external clinical evidence from systematic research.” (Sackett, D., 1996) .EBP is
the integration of clinical expertise, patient values, and the best research evidence into the
decision making process for patient care. Clinical expertise refers to the clinician’s cumulated
experience, education and clinical skills. The patient brings to the encounter his or her own
personal preferences and unique concerns, expectations, and values. As cited by Dr. David
Sackett in 2002, the best research evidence is usually found in clinically relevant research that
has been conducted using sound methodology. (Introduction to Evidence-based Practice, 2018).

Aspects of evidence-based decision-making

Figure 1
 6

The four aspects of evidence-based decision-making are (see Figure 1):

1. Integration of the best available evidence generated by quality research;

2. Clinical evidence and expertise;

3. Patient values and preferences; and

4. Relevant contextual knowledge, which includes available resources and acknowledges

potential resource barriers and enablers within the context of care. (Jylhä,V.,
Oikarainen,A., Perälä,M-L., & Holopainen,A., 2017)

The evidence, by itself, does not make the decision, but it can help support the patient care
process. The full integration of these three components into clinical decisions enhances the
opportunity for optimal clinical outcomes and quality of life. The practice of EBP is usually
triggered by patient encounters which generate questions about the effects of therapy, the utility
of diagnostic tests, the prognosis of diseases, and/or the etiology of disorders. (Introduction to
Evidence-based Practice, 2018).

Evidence-Based Practice requires new skills of the clinician, including efficient literature
searching, and the application of formal rules of evidence in evaluating the clinical literature.
(Introduction to Evidence-based Practice, 2018).

What happened before Evidence-Based Practice?

Before EBP health professionals relied on the advice of more experienced colleagues, often
taken at face value, their intuition, and on what they were taught as students. Experience is
subject to flaws of bias and what we learn as students can quickly become outdated. Relying on
older, more knowledgeable colleagues as a sole information source can provide dated, biased and
incorrect information. This is not to say that clinical experience is not important, it is in fact part
of the definition of EBP. However, rather than relying on clinical experience alone for decision
making, health professionals need to use clinical experience together with other types of
evidence-based information. (Introduction to Evidence-based Practice, 2018).
 7

1.2 Defining Evidence

Evidence is a fundamental concept of the EBP paradigm. Even so, there is little agreement
between practitioners, academics and professional bodies as to the meaning of evidence. Indeed,
the insufficient definition of evidence and the different methodological positions of clinicians
and academics might all contribute to these discrepant viewpoints. From the broadest sense,
evidence is defined as ‘any empirical observation about the apparent relation between events’.
Whereas this definition suggests that most forms of knowledge could be considered evidence,
Romyn et al. asserts that the evidence used to guide practice should be ‘subjected to historic or
scientific evaluation’. Hence, not all evidence is considered the same. These differences in the
quality of information are known as the hierarchy of evidence. (Matthew ,J .L., 2006).

The hierarchy of evidence

 Level I Systematic reviews

 Level II Well-designed randomized controlled trials
 Level III-1 Pseudo-randomized controlled trials
 Level III-2 Comparative studies with concurrent controls, such as cohort studies, case–
control studies or interrupted time series studies
 Level III-3 Comparative studies with historical control, two or more single-arm studies,
or interrupted time series without a parallel control group
 Level IV Case series and pretest/post-test studies (Matthew ,J .L., 2006).

The hierarchy of evidence informs practitioners which information is likely to provide the
greatest impact on clinical decisions. According to this, decisions based on findings from
randomized controlled trials (RCTs) might therefore be sounder than those guided by case series
results. However, when findings from controlled trials are unavailable or insufficient, decisions
should be guided by the next best available evidence. The hierarchy of evidence can also be used
to identify research findings that supersede and invalidate previously accepted treatments and
replace them with interventions that are safer, efficacious and cost-effective. For these reasons,
clinical decision-making might benefit from using EBP and the hierarchy of evidence. (Matthew
,J .L., 2006).
 8

The EBP Framework

The EBP paradigm consists of a series of steps that assist the practitioner in finding a solution to
a clinical problem (see Table 1.). The five-stage process begins with the identification of a
clinical problem and the subsequent formation of a structured and answerable question.
Following the problem stage, the literature is searched for the best available evidence to answer
the proposed question. The evidence is then critically appraised for its validity, quality and
generalizability. Once evaluated, the best available evidence is integrated into clinical practice in
conjunction with clinical expertise and available resources. (Matthew ,J .L., 2006).

 Assess patient situation

 Formulate an answerable clinical question
 Search and acquire evidence
 Critically appraise evidence
 Apply the evidence

Table 1: The evidence-based practice paradigm (modified from Leung). (Matthew ,J

.L., 2006)

In addition to considering the availability of resources, the EBP paradigm also ‘requires the
judicious application of research findings in the patient context and an understanding of the
values of persons involved in clinical decisions’. Hence, studies only investigating the clinical
efficacy of an intervention might not meet all the requirements of the EBP framework. This is
because clinical evidence provides only one element of the decision-making process. Clinical
decisions should therefore take into account client’s preferences, values and expectations. In
other words, effective decision-making depends on the provision of professional expertise,
clinical evidence, economic justification and consumer perspective. (Matthew ,J .L., 2006).
 9

1.3 The Seven Steps of Evidence-Based Practice

Step Explanation

0 Cultivate a spirit of inquiry within an EBP culture and environment.

1 Ask the burning clinical question in PICOT format.

2 Search for and collect the most relevant best evidence.

3 Critically appraise the evidence (i.e., rapid critical appraisal, evaluation, synthesis, and
recommendations).

4 Integrate the best evidence with one’s clinical expertise and patient preferences and values
in making a practice decision or change.

5 Evaluate outcomes of the practice decision or change based on evidence.

6 Disseminate the outcomes of the EBP decision or change. ( Melnyk,B.M., 2016).

Step #0: Cultivate a spirit of inquiry within an EBP culture and environment
The first step in EBP is to cultivate a spirit of inquiry, which is a continual questioning of clinical
practices. When delivering care to patients, it is important to consistently question current
practices: For example, is Prozac or Zoloft more effective in treating adolescents with
depression? Does use of bronchodilators with metered dose inhalers (MDIs) and spacers versus
nebulizers in the emergency department (ED) with asthmatic children lead to better oxygenation
levels? Does a double-checking pediatric medication lead to fewer medication errors?

Cultures and environments that support a spirit of inquiry are more likely to facilitate and sustain
a questioning spirit in clinicians. Some key components of an EBP culture and environment
include (Melnyk, 2014; Melnyk & Fineout-Overholt, 2015; Melnyk et al., 2012a, 2016):

 An organizational vision, mission, and goals that include EBP.

 An infrastructure with EBP tools and resources.

 10

 Orientation sessions for new clinicians that communicate an expectation of delivering

evidence-based care and meeting the EBP competencies for practicing registered nurses
(RNs) and advanced practice nurses (APNs).

 Leaders and managers who “walk the talk” and support their clinicians to deliver
evidence-based care.

 A critical mass of EBP mentors to work with point-of-care clinicians in facilitating

evidence-based care.

 Evidence-based policies and procedures.

 Orientations and ongoing professional development seminars that provide EBP

knowledge and skills-building along with an expectation for EBP.

 Integration of the EBP competencies in performance evaluations and clinical ladders.

 Recognition programs that reward evidence-based care. ( Melnyk,B.M., 2016).

Step #1: Ask the burning clinical question in PICOT format

After a clinician asks a clinical question, it is important to place that question in PICOT format to
facilitate an evidence search that is effective in getting to the best evidence in an efficient
manner. Sometimes, there is not a time element; therefore you see PICO rather than PICOT. (
Melnyk,B.M., 2016).

PICOT represents:

 P: Patient population

 I: Intervention or Interest area

 C: Comparison intervention or group

 O: Outcome

 T: Time (if relevant)

 11

For example, the clinical questions asked in Step #0 that all involve interventions or treatments
should be rephrased in the following PICOT format to result in the most efficient and effective
database searches:

 In depressed adolescents (P), how does Prozac (I) compared to Zoloft (C) affect
depressive symptoms (O) 3 months after starting treatment (T)?

 In asthmatic children seen in the ED (P), how do bronchodilators delivered with MDIs
with spacers (I) compared to nebulizers (C) affect oxygenation levels (O) 1 hour after
treatment (T)?

 In hospitalized children (P), how does double-checking pediatric medications with a

second nurse (I) compared to not double-checking (C) affect medication errors (O) during
a 30-day time period (T)?

Step #2: Search for and collect the most relevant best evidence
After the clinical question is placed in PICOT format with the proper template, each keyword in
the PICOT question should be used to systematically search for the best evidence; this strategy is
referred to as keyword searching. For example, to gather the evidence to answer the intervention
PICOT questions in Step #1, you would first search databases for systematic reviews and
randomized controlled trials given that they are the strongest levels of evidence to guide practice
decisions.

However, the search should extend to include all evidence that answers the clinical question.
Each keyword or phrase from the PICOT question (For example, depressed adolescents, Prozac,
Zoloft, depressive symptoms) should be entered individually and searched. Searching controlled
vocabulary that matches the keywords is the next step in a systematic approach to searching.

In the final step, combine each keyword and controlled vocabulary previously searched, which
typically yields a small number of studies that should answer the PICOT question. This
systematic approach to searching for evidence typically yields a small number of studies to
answer the clinical question versus a less systematic approach, which usually produces a large
number of irrelevant studies. ( Melnyk,B.M., 2016).
 12

The type of question is important and can help lead you to the best study design:

Most common type of questions: Most common type of questions:

Diagnosis prospective, blind comparison to a gold
how to select and interpret diagnostic tests standard or cross-sectional
Therapy randomized controlled trial > cohort study
how to select treatments that do more good
than harm and that are worth the efforts and
costs of using them
Prognosis cohort study > case control > case series
how to estimate the patient’s likely clinical
course over time (based on factors other than
the intervention) and anticipate likely
complications of disease
Harm/Etiology cohort > case control > case series
how to identify causes for disease (including
iatrogenic forms)
Table 2 (Introduction to Evidence-based Practice, 2018)

Type of Study

Figure 2 (Introduction to Evidence-based Practice, 2018)

 13

As you move up the pyramid the study designs are more rigorous and allow for less bias or
systematic error that may distract you from the truth. (Introduction to Evidence-based Practice,
2018).

Case series and Case reports consist of collections of reports on the treatment of individual
patients or a report on a single patient. Because they are reports of cases and use no control
groups to compare outcomes, they have little statistical validity. (Introduction to Evidence-based
Practice, 2018).

Case control studies are studies in which patients who already have a specific condition are
compared with people who do not have the condition. The researcher looks back to identify
factors or exposures that might be associated with the illness. They often rely on medical
records and patient recall for data collection. These types of studies are often less reliable than
randomized controlled trials and cohort studies because showing a statistical relationship does
not mean than one factor necessarily caused the other. (Introduction to Evidence-based Practice,
2018).

Cohort studies identify a group of patients who are already taking a particular treatment or have
an exposure, follow them forward over time, and then compare their outcomes with a similar
group that has not been affected by the treatment or exposure being studied. Cohort studies are
observational and not as reliable as randomized controlled studies, since the two groups may
differ in ways other than in the variable under study. (Introduction to Evidence-based Practice,
2018).

Randomized controlled clinical trials are carefully planned experiments that introduce a
treatment or exposure to study its effect on real patients. They include methodologies that reduce
the potential for bias (randomization and blinding) and that allow for comparison between
intervention groups and control (no intervention) groups. A randomized controlled trial is a
planned experiment and can provide sound evidence of cause and effect. (Introduction to
Evidence-based Practice, 2018).

Systematic Reviews focus on a clinical topic and answer a specific question. An extensive
literature search is conducted to identify studies with sound methodology. The studies are
 14

reviewed, assessed for quality, and the results summarized according to the predetermined
criteria of the review question. (Introduction to Evidence-based Practice, 2018).

A Meta-analysis will thoroughly examine a number of valid studies on a topic and

mathematically combine the results using accepted statistical methodology to report the results as
if it were one large study. (Introduction to Evidence-based Practice, 2018).

Cross-sectional studies describe the relationship between diseases and other factors at one point
in time in a defined population. Cross sectional studies lack any information on timing of
exposure and outcome relationships and include only prevalent cases. They are often used for
comparing diagnostic tests. Studies that show the efficacy of a diagnostic test are also
called prospective, blind comparison to a gold standard study. This is a controlled trial that
looks at patients with varying degrees of an illness and administers both diagnostic tests — the
test under investigation and the “gold standard” test to all of the patients in the study group. The
sensitivity and specificity of the new test are compared to that of the gold standard to determine
potential usefulness. (Introduction to Evidence-based Practice, 2018).

Qualitative Research answers a wide variety of questions related to human responses to actual
or potential health problems. The purpose of qualitative research is to describe, explore and
explain the health-related phenomena being studied. (Introduction to Evidence-based Practice,
2018).

Retrospective cohort (or historical cohort) follows the same direction of inquiry as a cohort
study. Subjects begin with the presence or absence of an exposure or risk factor and are
followed until the outcome of interest is observed. However, this study design uses information
that has been collected in the past and kept in files or databases. Patients are identified for
exposure or non-exposures and the data is followed forward to an effect or outcome of interest.
(Introduction to Evidence-based Practice, 2018).

How to Do the Literature Search?

For example, the clinical question is: In patients with type 2 diabetes and obesity, is bariatric
surgery more effective than standard medical therapy at increasing the probability of remission
 15

of diabetes? It is a therapy question and the best evidence would be a randomized controlled trial
(RCT). If we found numerous RCTs, then we might want to look for a systematic review.

Constructing a well-built clinical question can lead directly to a well-built search strategy. Note
that you may not use all the information in PICO or well-built clinical question in your
MEDLINE strategy. In the following example we did not use the term “male.” We also did not
include the word therapy. Instead we used the Clinical Query for Therapy or the publication
type, randomized controlled trial, to get at the concept of treatment. However, you may
consider the issue of gender later when you review the articles for applicability to your patient
(see Table 3).

PICO Clinical Question Search Strategy

Patient / Problem obese, diabetes type 2, male diabetes type 2, obesity

Intervention stomach stapling (gastric bariatric surgery
bypass surgery; bariatric
surgery)
Comparison (if any) standard medical care
Outcome remission of diabetes; weight
loss; mortality
Type of Question therapy (see below)
Type of Study RCT Clinical Query –
Therapy/narrow
or
Limit to randomized
controlled trial as
publication type
Table 3 (Introduction to Evidence-based Practice, 2018)

Selecting the Resources

Evidence-Based Practice requires that clinicians search the literature to find answers to their
clinical questions. There are literally millions of published reports, journal articles,
 16

correspondence and studies available to clinicians. Choosing the best resource to search is an
important decision. Large databases such as PubMed/MEDLINE will give you access to the
primary literature. Secondary resources such as ACP Journal Club, Essential Evidence, FPIN
Clinical Inquiries, and Clinical Evidence will provide you with an assessment of the original
study. The Cochrane Library provides access to systematic reviews which help summarize the
results from a number of studies. These are often called “pre-appraised” or EBP resources.

To quickly find an answer, we might first look at an appraised resource, such as ACP Journal
Club. ACP Journal Club’s general purpose is to select from the biomedical literature articles that
report original studies and systematic reviews that warrant immediate attention by physicians
attempting to keep pace with important advances in internal medicine. These articles are
summarized in value-added abstracts and commented on by clinical experts. Studies included in
this small database are relevant, newsworthy and critically appraised for study methodology.
(Introduction to Evidence-based Practice, 2018).

A search of diabetes and bariatric surgery identified this citation: Mingrone, G., Panunzi S., De
Gaetano, A., et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N
Engl J Med. 2012;366:1577-85. This trial found that for severely obese patients with type 2
diabetes, bariatric surgery resulted in reduced levels of HbA1c, glucose and BMI than did
medical therapy. (Introduction to Evidence-based Practice, 2018).

If you do not have access to ACP Journal Club or other EBP resources you will need to do the
search in PubMed or MEDLINE. PubMed/MEDLINE is a very large database with over 22
million citations. You will need your focused question and search strategy for this database.
(Introduction to Evidence-based Practice, 2018).

EBP Resources:

 ACP Journal Club

Part of Annals of Internal Medicine, ACPJC offers critical appraisals of important articles from
over 100 different journals.

 Clinical Evidence
 17

Clinical Evidence describes the best available evidence from systematic reviews, RCTs, and
observational studies when appropriate for assessing the benefits and harms of treatments.

 Dynamed

Dynamed is a point-of-care reference resource designed to provide clinicians with current,

evidence-based information to support clinical decision-making.

 Essential Evidence

Essential Evidence is a one-stop reference that includes evidence-based answers to clinical

questions concerning symptoms, diseases, and treatment.

 FPIN Clinical Inquiries

Clinical Inquiries provides answers to clinical questions by using a structured search, critical
appraisal, clinical perspective, and rigorous peer review. FPIN Clinical Inquiries deliver
evidence for point of care use.

 Up-to-date

Up-to-date is an evidence-based, peer reviewed information resource available via the Web,
desktop/laptop computer, and PDA/mobile device. (Introduction to Evidence-based Practice,
2018).

Article Databases:

 PubMed (MEDLINE)

PubMed comprises more than 22 million citations for biomedical articles from MEDLINE and
life science journals. Access to titles / abstracts is free. Citations may include links to full-text
articles from PubMed Central or publisher web sites.

 Cochrane Library.

The Cochrane Library contains high-quality, independent evidence to inform healthcare

decision-making. It includes reliable evidence from Cochrane systematic reviews and a registry
 18

of published clinical trials. The methodology used to create the Cochrane reviews is recognized
as the gold standard for developing systematic reviews.

 Center for Reviews and Dissemination (DARE).

The databases DARE, NHS, EED and HTA assist decision-makers by identifying and describing
systematic reviews and economic evaluations, appraising their quality, and highlighting their
relative strengths and weaknesses. (Introduction to Evidence-based Practice, 2018).

E-Books and Libraries:

 Access Medicine

Numerous e-books available to subscribers.

 ClinicalKey

Online search tool for e-books, journals, Procedures Consult, First Consult, surgical Vitals and
other clinical information.
To access PDF files for E-books, you must register for and login to a personal account. If you get
a session time out message while searching ClinicalKey, please close or refresh your browser
and try your search again.

 Scientific American Surgery

Scientific American Surgery, formerly ACS Surgery, contains authoritative recommendations on

current surgical care from master surgeons. Includes drawings, graphs, photos, and decision-
making algorithms. Please note: This resource has a limited number of simultaneous users.
Try again later if unable to access. (Introduction to Evidence-based Practice, 2018).

Meta / Cross Search Engines:

 TRIP (Turning Research into Practice)

The TRIP Database searches across multiple internet sites for evidence-based content. It covers
key medical journals, Cochrane Systematic reviews, clinical guidelines, and other highly relevant
 19

websites to help health professionals find high quality clinical evidence for clinical practice.
(Introduction to Evidence-based Practice, 2018).

Step #3: Critically appraise the evidence

After relevant evidence has been found, critical appraisal begins. First, it is important to conduct
a rapid critical appraisal (RCA) of each study from the data search to determine whether they are
keeper studies: that is, they indeed answer the clinical question. This process includes answering
the following questions:

 Are the results of the study valid? Did the researchers use the best methods to conduct the
study (study validity)? For example, assessment of a study’s validity determines whether
the methods used to conduct the study were rigorous.
 What are the results? Do the results matter, and can I get similar results in my practice
(study reliability)?
 Will the results help me in caring for my patients? Is the treatment feasible to use with
my patients (study applicability)?

Rapid critical appraisal checklists can assist clinicians in evaluating validity, reliability, and
applicability of a study in a time-efficient way. ( Melnyk,B.M., 2016).

Step #4: Integrate the best evidence with one’s clinical expertise and patient preferences
and values in making a practice decision or change

After the body of evidence from the search is critically appraised, evaluated, and synthesized, it
should be integrated with a clinician’s expertise and also a patient’s preferences and values to
determine whether the practice change should be conducted. Providing the patient with evidence-
based information and involving him or her in the decision regarding whether he or she should
receive a certain intervention is an important step in EBP. To facilitate greater involvement of
patients in making decisions about their care in collaboration with healthcare providers, there has
been an accelerated movement in creating and testing patient-decision support tools, which
provide evidence-based information in a relatable understandable format. ( Melnyk,B.M., 2016).
 20

Step #5: Evaluate outcomes of the practice decision or change based on evidence

After making a practice change based on the best evidence, it is critical to evaluate outcomes—
the consequences of an intervention or treatment. For example, an outcome of providing a baby
with a pacifier might be a decrease in crying. Outcomes evaluation is essential to determine the
impact of the practice changes on healthcare quality and health outcomes. It is important to target
“so-what” outcomes that the current healthcare system considers important, such as complication
rates, length of stay, re-hospitalization rates, and costs given that hospitals are currently being
reimbursed based on their performance on these outcomes . ( Melnyk,B.M., 2016).

Step #6: Disseminate the outcomes of the EBP decision or change

Silos often exist, even within the same healthcare organization. So that others can benefit from
the positive changes resulting from EBP, it is important to disseminate the findings. Various
avenues for dissemination include institutional EBP rounds; poster and podium presentations at
local, regional, and national conferences; and publications. (Melnyk, B.M., 2016).
 21

Chapter 2

Evidence –based Practice with Health Sector

2.1 Benefits of EBP

Beneficiary Benefits

General population • Improved conditions for patient-centred care

• Patient preferences included in decision-

making

• Consistent health services leading to better

equity

• Reduction in geographic variation

• Reduction in patients’ length of stay

• Better patient outcomes

• Quality health-care services

• Increased patient safety

Nurses and midwives • Increased job satisfaction

• Empowerment

• Improved skills to integrate patient

preferences into practice

• Support for professional growth

• Continuous career development through

expert roles

Health-care systems • Improvement in the quality of care

 22

• Better outcomes for patients

• Increased patient safety

• Reduced costs

• Stronger basis for health-care investment

decisions

• Capacity-building through collaboration

Research and education • Increased need for production and synthesis

of robust evidence

• Competence development

• Integration of nursing and midwifery expert

roles in health

systems

Table 4: Source: Nursing Research Foundation. (Jylhä,V., Oikarainen,A., Perälä,M-L., &

Holopainen,A., 2017).

2.2 Responsibilities at different levels of health-care systems for developing consistent EBP

CONTENT National level Local level Organizational Individual

level nurse/midwife
Producing, Policy and Plans for Plans for Evidence-based
disseminating strategies implementation implementation nursing/
and for EBP: and and development midwifery
implementing • research development of of practice:
knowledge policy systematic systematic • evidence-based
 23

(important reviews and reviews and decision-making

research guidelines: guidelines:
topics are • local networks • local networks
described) • structures for • structures for
• databases for evidence evidence
synthesized dissemination dissemination
evidence
• responsibility
to
produce
synthesized
evidence
• national
guidelines
for nursing and
midwifery
Developing Support for Responsibilities Development of Commitment to
consistent evidence for evidence-based evidence-based
practice synthesis: consistent consistent consistent
• research and practices: practices: practice:
education • guideline • evaluation and •
• development implementation follow-up of EBP nursing/midwifery
projects • evaluation and • participation in documentation
• evaluation follow-up of development • evaluation of
and EBP projects patient
follow-up of • benchmarking care
EBP
Ensuring Competence Plans to Methods to Development and
competence needed for strengthen evaluate evaluation of own
EBP: competence for nurses’/midwives’ expertise and
• support for EBP: competence for competence
 24

competence • collaboration EBP:

development with • collaboration
• model for local research with
using and local educational
different kinds educational institutions: e.g.,
of institutions curriculum
expertise in development,
practice continuing
education
Table 5: Source: Holopainen et al. Reproduced by permission of Fioca Ltd. (Jylhä,V.,
Oikarainen,A., Perälä,M-L., & Holopainen,A., 2017)

2.3 Implementing EBP in Nursing and Midwifery

New innovations and practices are presented to improve outcomes in nursing and midwifery.
Health-care innovation can include the introduction of a new concept, idea, service, process or
product that aims to improve treatment, diagnosis, education, outreach, prevention and research,
with the long-term goal of improving quality, safety, outcomes, efficiency and costs. (Jylhä,V.,
Oikarainen,A., Perälä,M-L., & Holopainen,A., 2017).

Innovations in health care can be divided into products, processes and structures. Products
typically consist of technology or services, such as clinical procedures. A process refers to a new
change to the production or delivery of care. Structures usually affect the internal and external
infrastructure of health-care organizations and create new structural models. To be called an
innovation, an idea must be replicable and satisfy a specific need. Innovations must have sound
scientific justification to be facilitators of EBP. In other words, careful consideration of expected
and unexpected outcomes and effectiveness based on current evidence is required when
presenting new innovations, such as technology, in nursing and midwifery practice.
Implementation should be encouraged for innovations that have proven feasible, appropriate,
effective and meaningful. (Jylhä,V., Oikarainen,A., Perälä,M-L., & Holopainen,A., 2017).
 25

Several models have been developed to facilitate the implementation of change in health care.
Models and frameworks are used to illustrate EBHC and EBP. Models can be targeted towards
specific phases of EBP, focusing on the organization or practitioner. Some (such as Jordan et al
are generic models that describe the whole process of EBP from research to practice. Others
focus on organizational features that support EBP or implementation of evidence throughout the
system. The models are not the main point in the development process, but are facilitators of
change. Models that support organizational change are particularly useful tools for improving
and developing EBP. (Jylhä,V., Oikarainen,A., Perälä,M-L., & Holopainen,A., 2017).

Currently, an abundance of scientific knowledge is communicated through journals, databases

and so-called grey literature. Cooperation is therefore needed to critically evaluate and
synthesize current research into systematic reviews and clinical practice guidelines. International
collaborators such as Cochrane and the JBI have developed methodologies for evidence
synthesis of different types of research to support the implementation and dissemination of
evidence. In addition, multiple national organizations produce systematic reviews, clinical-
practice guidelines and methodological guidance for evidence synthesis. (Jylhä,V.,
Oikarainen,A., Perälä,M-L., & Holopainen,A., 2017).

International cooperation, along with national improvements, creates structures that support the
development of EBHC and make evidence available for transfer and implementation. There is
nevertheless a need to reform management practices in healthcare services at national, regional
and local levels towards supporting the development of evidence-based nursing and midwifery.
This requires the creation of specific national, regional and local structures in the following areas
to:

 Produce, disseminate and implement knowledge

 Develop consistent practices
 Ensure the continuing development of nurses’ and midwives’ competence. (Jylhä,V.,
Oikarainen,A., Perälä,M-L., & Holopainen,A., 2017).
 26

Why is EBP important to nursing practice?

• It results in better patient outcomes.

• It contributes to the science of nursing.

• It keeps practice current and relevant

• It increases confidence in decision-making

• Policies and procedures are current and include the latest research, thus supporting to better
practice.

• Integration of EBP into nursing practice is essential for high-quality patient care and
achievement of ANCC Magnet Recognition Program (MRP) designation. (Beyea, S.C., &
Slattery, F.M.J., 2006).

Often, nurses feel that they are using “evidence” to guide practice, but their sources of evidence
are not research-based. In a study conducted by Thompson, et al., (2003), nurses reported that the
most helpful knowledge source was experience or advice from colleagues or patients. Of concern
were reports that up-to-date electronic resources that included evidence-based materials were not
useful to nurses in clinical practice. This barrier contributes to significant gaps in clinician’s
applying research findings to practice and dissemination of innovations. (Berwick, 2003). The
failure to use evidence results in care that is of lower quality, less effective, and more expensive.
(Beyea, S.C., & Slattery, F.M.J., 2006).

Evidence-based practice can be easier for nurses to use if they refer to already-developed
evidence based or clinical practice guidelines. Numerous expert groups have already undertaken
systematic efforts to develop guidelines to help both healthcare providers and patients make
informed decisions about care interventions. Guideline developers use a systematic approach to
critique the existing research, rate the strength of the evidence, and establish practice guidelines.
The overall goal of these types of efforts focuses on guiding practice and minimizing the
variability in care. (Beyea, S.C., & Slattery, F.M.J., 2006).
 27

The Action Model of Expertise (AME)

Experts’ roles Nurses in Specialized Clinical nurse Specialists in

in clinical care nurses specialists* clinical
EBP in clinical care nursing science
Core • Advanced • Advanced • Advanced • Expertise in
competencies clinical specialized clinical conducting
competency clinical competency in a scientific
• Skills to apply competency certain clinical research
evidence into • Skills to apply area • Can organize
practice evidence into • Advanced clinical research
• Acquainted practice developmental and
with the and utilize it in skills development
context (unit a • Research skills projects
level) specialized area • Acquainted • Leader of
• with the clinical
Developmental context research
skills (department • Acquainted
acquainted with or hospital level) with the
the context
context (several (department,
units hospital, national
and department and
level) international
level)
Emphasis of Competencies Competencies Competencies in Competencies in
competency in clinical in clinical development and development and
nursing and nursing and research research
patient or patient or in generation and in generation and
client-oriented client-oriented dissemination of dissemination of
implementation implementation EBP EBP
 28

of EB of EB
Actions in • Utilize EBP • Utilize EBP • Apply scientific • Search, appraise
implementation knowledge knowledge knowledge and
of EBP in patient or in patient or • Develop synthesize
client client consistency evidence,
care care and of EBPs at unit develop
• Maintain and facilitate and measurement
develop own implementation regional levels tools, disseminate
expert in • Develop, evidence into
knowledge own specialized disseminate practice
area and monitor • Evaluate EBP
• Disseminate clinical and
EBP practices conduct
knowledge in • Maintain and intervention
own develop own and effectiveness
specialized area expert research
• Maintain and knowledge • Support
develop own development
expert by different types
knowledge of
experts
• Maintain and
develop own
expert
knowledge
Focus of action Patient/client Patient/client Staff/organization Staff/organization

*Clinical nurse specialists include advanced nurse practitioners (such as nurse practitioners).

Table 6: Source: Nursing Research Foundation (93), modified from Ministry of Social Affairs
and Health. (Jylhä,V., Oikarainen,A., Perälä,M-L., & Holopainen,A., 2017).
 29

2.4 Main Types of Barriers to EBP

Types of barrier Examples

Organization • Insufficient support from management
• Lack of support structures and limited
resources and tools
• Lack of organizational culture to support EBP
• Outdated organizational policies
• Hierarchical structures
• Lack of multi-professional collaboration
• Outdated and unquestioned routines
• Resource shortages
Leaders and management • EBP not defined as an aim of the organization
• Insufficient commitment to EBP
• Insufficient support for staff
• Insufficient authority
Professionals • Inadequate knowledge and skills in EBP
• Unfamiliarity with guidelines
• Negative attitudes
• Preconceptions concerning EBP
• Lack of time
• Disagreement with guidelines
Evidence • High-quality studies not available
• Massive amount of information
• Unclear clinical-practice guidelines
• Guidelines not updated or incomplete
Table 7: Sources: Melnyk et al.; Alanen et al.; Solomons et al.; Dalheim et al.; Brämberg et al.
(Jylhä,V., Oikarainen,A., Perälä,M-L., & Holopainen,A., 2017).
 30

Chapter 3

Clinical Practice and Effectiveness of Clinical Decision Making with EBP

3.1 Best available Research Evidence with Clinical Practice

Providing research training opportunities to point of care clinicians is a promising strategy for
healthcare organizations seeking to promote EBP, empower clinicians, and showcase excellence
in clinical research. ( Black,A.T.,Balneaves,L.G.,& Qian,H., 2015).

Research confirms that patient outcomes improve when nurses practice in an evidence-based
manner. Described as “a problem-solving approach to clinical care that incorporates the
conscientious use of current best practice from well-designed studies, a clinician’s expertise, and
patient values and preferences,” evidence-based practice (EBP) has been shown to
increase patient safety, improve clinical outcomes, reduce healthcare costs, and decrease
variation in patient outcomes. The importance of EBP is substantiated; however, barriers to
widespread use of current research evidence in nursing remain, including the fluency and
knowledge level of clinical nurses. ( Black,A.T.,Balneaves,L.G.,& Qian,H., 2015).

Nurses have identified individual and organizational barriers to research utilization. Individual
barriers include lack of knowledge about the research process and how to critique research
studies, lack of awareness of research, colleagues not supportive of practice change, and nurses
feeling a lack of authority to change practice. Organizational barriers identified include
insufficient time to implement new ideas, lack of access to research, and lack of awareness of
available educational tools related to research. ( Black,A.T.,Balneaves,L.G.,& Qian,H., 2015).

Research demonstrates that the most important factor related to nurses’ EBP is support from their
employing organizations to use and conduct research. Other facilitators include the presence in
the clinical setting of advanced practice nurses, research mentors, and educators knowledgeable
about research nursing research internships and designated nurse-researchers. In their
BARRIERS scale studies, Funk and colleagues recommended strategies for reducing barriers to
EBP, including employment of research role models, establishment of collegial relationships
with academics, and participation in research interest groups. Similar strategies have been more
 31

recently highlighted in the context of the Magnet Recognition Program. (

Black,A.T.,Balneaves,L.G.,& Qian,H., 2015).

There is, however, a notable lack of rigorous intervention studies focused on identifying
organizational barriers to improve nurses’ engagement in EBP.To address this gap, leaders at a
tertiary healthcare organization implemented a point-of-care research training program, led by
the organization’s nursing research facilitator, targeting nurses and other clinicians to reduce
EBP barriers and to promote engagement in research. ( Black,A.T.,Balneaves,L.G.,& Qian,H.,
2015).

3.2 Clinical Expertise with Clinical Practice

Clinical nursing expertise is central to quality patient care. Research on factors that contribute to
expertise has focused largely on individual nurse characteristics to the exclusion of contextual
factors. ( McHugh,M.D, & Lak,E.T., 2010).

Clinical nursing expertise is fundamental to quality of care. Research on the foundations of

expertise has focused on individual characteristics particularly a nurse's years of experience and
level of education. Debate continues about the respective contributions of experience and
education to expertise. A notable gap in this debate that we examine is the influence of hospital
contextual factors on an individual nurse's expertise. These contextual factors include the
educational and experience levels of a nurse's coworkers as well as the nursing practice
environment. ( McHugh,M.D, & Lak,E.T., 2010)

Can define clinical expertise as a hybrid of practical and theoretical knowledge, based on Benner
(1984). Clinically expert nurses are distinguished from their colleagues by their often intuitive
ability to efficiently make critical clinical decisions while grasping the whole nature of a
situation. Expertise influences nurses' clinical judgment and quality of care and develops when a
nurse tests and refines both theoretical and practical knowledge in actual clinical situations. (
McHugh,M.D, & Lak,E.T., 2010).

Benner (1984) also detailed the acquisition of nursing expertise and proposed five possible
expertise levels: novice, advanced beginner, competent, proficient, and expert. Nurses at the
novice stage are still in nursing school. Nurses at the advanced beginner stage use learned
 32

procedures and rules to determine what actions are required for the immediate situation.
Competent nurses are task-oriented and deliberately structure their work in terms of plans for
goal achievement. Competent nurses can respond to many clinical situations but lack the ability
to recognize situations in terms of an overall picture. Proficient nurses perceive situations as a
whole and have more ability to recognize and respond to changing circumstances. Expert nurses
recognize unexpected clinical responses and can alert others to potential problems before they
occur. Experts have an intuitive grasp of whole situations and are able to accurately diagnose and
respond without wasteful consideration of ineffective possibilities. Because of their superior
performance, expert nurses are often consulted by other nurses and relied upon to be preceptors.
Although most nurses will progress to the competent level of expertise, many will not become
experts. (Thompson,C.J., 2017).

Experience and expertise

Experience and expertise are related but different concepts. We define experience, also based
on Benner (1984), as both time in practice and self-reflection that allows preconceived notions
and expectations to be confirmed, refined, or disconfirmed in real circumstances. Merely
encountering patient conditions and situations is not experience; rather, experience involves
nurses reflecting on encountered circumstances to refine their moment-to-moment decision
making at an unconscious, intuitive level, (Benner, 1984; Benner & Tanner, 1987; Simmons,
Lanuza, Fonteyn, Hicks, & Holm, 2003).

Experience is a necessary but not sufficient condition for expertise and not all experienced nurses
are experts (Christensen & Hewitt-Taylor, 2006; Ericsson, Whyte, & Ward, 2007). For
example, Benner (1984) noted that a number of years on the job in the same or similar situations
may create competence; however, the passage of time and occurrence of events and interactions
does not automatically confer expert status. As Benner stated, there is a discontinuity or leap
between expertise at the competent level and expertise at the proficient and expert levels. One
potential explanation for this discontinuity (Bobay, 2004) is that years of experience may provide
fluidity and flexibility but not the complex reflexive thinking that has been hypothesized to be an
important component of clinical nursing expertise. (Thompson,C.J., 2017).
 33

Few quantitative studies have been able to capture both the temporal and transactional nature of
experience and these studies have been limited to measuring experience in terms of years in
practice. Young, Lehrer, and White (1991) found that nurses with more experience reported
performing more complex functions than those with less experience. In a recent study of five
hospitals, Bobay, Gentile, and Hagle (2009) found that years of experience were associated with
expertise. However, Kovner and Schore (1998) did not find such a relationship. (Thompson,C.J.,
2017).

The majority of the research on how experience contributes to expertise is at the individual nurse
level; however, experience has also been assessed as a contextual variable. This latter work has
primarily focused on the influence of aggregate experience on patient and nurse outcomes. For
example, Aiken, Clarke, Cheung, Sloane, and Silber (2003) assessed the influence of the
mean years of experience among nurses on surgical patient mortality in 168 hospitals. They
found that the mean experience level was not a significant predictor of mortality. In a study that
used the patient care unit as the level of analysis, researchers found that a higher proportion of
nurses with ≥ 5 years of experience were associated with fewer medication errors and lower
patient fall rates (Blegen, Vaughn, & Goode, 2001). Similarly, Clarke, Rockett, Sloane, and
Aiken (2002)examined the effect of the mean nurse experience level at the hospital level on
nurse needlestick injuries; they concluded that a low mean experience level was associated with
more near-miss needlestick incidents. In another study of nursing outcomes, Kanai-Pak, Aiken,
Sloane, and Poghosyan (2008) found that the odds of high burnout, job dissatisfaction and poor-
to-fair quality of care were twice as high in hospitals with 50% inexperienced nurses (nurses
with less than 4 years’ experience) versus those with 20% inexperienced nurses. (Thompson,C.J.,
2017).

Education and expertise

Education influences expertise by providing a theoretical and practical knowledge base that can
be tested and refined in actual situations (Dreyfus & Dreyfus, 1996). Didactic learning alone
cannot generate clinical expertise, and one distinguishing aspect of nursing education is a focus
on clinical learning. Benner (2004) suggested that hands-on learning is at the heart of good
clinical judgment. Mentored clinical learning situations in both classrooms and practice sites
offer critical opportunities for nurses to apply and integrate theoretical knowledge with actual
 34

events (Field, 2004). A sound educational foundation expedites the acquisition of skills through
experience (Benner, 1984). Without background knowledge, nurses risk using poor judgment
and lack the tools necessary to learn from experience. ( McHugh,M.D, & Lak,E.T., 2010).

Theory and principles enable nurses to ask the right questions to hone in on patient problems to
provide safe care and make good clinical decisions. Bonner's (2003) research on nephrology
nurses showed expert and non-expert nurses differed based on types of learning opportunities
(both formal and informal) rather than years of experience. In a literature review on the
relationship between nursing education and practice, Kovner and Schore (1998) reported mixed
findings regarding whether and in what ways Bachelor of Science in nursing (BSN) prepared
nurses' skills and abilities differ from those of associate degree and diploma-prepared nurses. (
McHugh,M.D, & Lak,E.T., 2010).

The collective education level of staff may impart a unique contribution to the development of
expertise in the clinical setting. Few researchers have focused directly on the aggregate
educational composition of the staff with whom a nurse practices as a factor affecting individual
clinical nursing expertise. There are, however, examples where researchers have examined the
relationship of contextual variables including education at the hospital level, to outcomes. For
example, Aiken et al. (2003) found that the proportion of BSN-prepared nurses in a hospital was
associated with lower surgical patient mortality and failure to rescue. In the same study, mean
years of experience in a hospital was not associated with outcomes and did not alter the
relationship between education and outcomes. Aiken et al. (2003) hypothesized that the effect of
education was due, in part, to better critical thinking and clinical judgment skills associated with
BSN preparation. Estabrooks, Midodzi, Cummings, Ricker, and Giovannetti (2005) also found
that the proportion of BSN-prepared nurses in a hospital was associated with lower patient
mortality. In a report on two studies, Blegen et al. (2001) found no association between the
nursing unit's proportion of BSN-prepared nurses and patient falls and mixed-results for the
association with medication errors. ( McHugh,M.D, & Lak,E.T., 2010).

Nurse practice environment and expertise

Many expert nurses leave hospital practice due to negative working conditions (Orsolini-Hain &
Malone, 2007). The nurse practice environment may offer a modifiable avenue through which
 35

nurse managers and administrators can cultivate nursing expertise and attract and retain nurse
experts. Benner (1984) noted that the most skilled clinical nursing performance can be attained
in a supportive environment where clinical learning with colleagues from all levels of expertise
takes place. Organizations that facilitate a professional nursing practice environment foster
clinical autonomy, support the continued education and advancement of nurses, increase the
opportunity for shared experience and knowledge with physician colleagues, and provide support
for professional decision making and action. (Lake & Friese, 2006). In one study of the nurse
practice environment and expertise, researchers surveyed 103 nurses in two military hospitals
(Foley, Kee, Minick, Harvey, & Jennings, 2002). The investigators measured the practice
environment with the Revised Nursing Work Index (NWI-R; Aiken & Patrician, 2000).
Expertise was measured by the Manifestation of Early Recognition instrument, a 16-item scale
based on the concepts of clinical expertise (Minick, 2003). The results indicated significant,
positive although modest correlations between nursing expertise and two of the three reported
NWI-R subscales: control over practice and collaborative relationships between nurses and
physicians. ( McHugh,M.D, & Lak,E.T., 2010).

Overall, the relationship between contextual factors and expertise is limited. It will hypothesize
that contextual factors would affect expertise over and above individual factors. ( McHugh,M.D,
& Lak,E.T., 2010).

3.3 Patient Preferences with Clinical Practice

To be an evidence-based practitioner one must find the best evidence available, include
one’s clinical expertise as an additional source of evidence, and then incorporate patient
preferences and values into a recommendation for care. (Thompson,C.J., 2017).

What Are Patient Preferences?

This construct is made up of several concepts including the patient’s preferences about inclusion
in their own healthcare decisions; patient’s religious or spiritual values; social and cultural values
(including family involvement in care decisions); values around quality of life; personal
priorities; and beliefs about health and personal responsibility.
 36

Guyatt, Jaeschke, Wilson, Montori, and Richardson (2015) defined patient values and
preferences as: “The collection of goals, expectations, predispositions, and beliefs that
individuals have for certain decisions and their potential outcomes” (p. 12). If the goal of EBP is
to provide excellent care for individual patients, we must make sure we have the skills needed to
elicit these preferences and then to consider them in shared decision-making with the patient.
(Thompson,C.J., 2017).

As cited in Guyatt et al., 2015 ,the beneficiary of EBP is the patient. The patient is the one who
will benefit from clinicians who can interpret research findings, understand the patient’s unique
circumstances, and then work with the patient to construct a plan of care that will be in the
patient’s best interest; however the patient defines it. (Thompson,C.J., 2017).

According to Carman & Workman in 2017, newer conceptual models of patient and family
engagement are being developed to bring the patient and family into more of a partnership with
the healthcare team. One, the Conceptual Model for Patient and Family Engagement, proposes
to involve the patient and family in evaluating the research findings for the patient’s own
healthcare decisions; and then extrapolated to the whole healthcare system. (Thompson,C.J.,
2017).

How to Elicit Patient Preferences

Interpersonal skills are important to successful EBP practice. Explaining the risks and benefits of
a choice of interventions is not always easy. There seems to be a lot of uncertainty and a certain
level of discomfort for some clinicians as to how to elicit and integrate the patient’s preferences
most effectively into clinical decisions. (Thompson,C.J., 2017).

How to Elicit Patient Preferences

Interpersonal skills are important to successful EBP practice. Explaining the risks and benefits of
a choice of interventions is not always easy. There seems to be a lot of uncertainty and a certain
level of discomfort for some clinicians as to how to elicit and integrate the patient’s preferences
most effectively into clinical decisions. (Thompson,C.J., 2017)

Developing a good rapport with the patient engenders trust. Many research studies have shown
that healthcare providers do not make the same choices as patients when presented with the same
 37

set of facts. A trusting relationship between the patient and clinician can make it easier for the
patient to share their goals and expectations with the clinician and for the clinician to have an
honest discussion with the patient about their care. (Thompson,C.J., 2017)

Here is an important key to shared decision-making: you need to have a conversation with the
patient, not just offer information (Hargraves, LeBlanc, Shah, & Montori, 2016). This seems like
a “duh” moment, doesn’t it? But think about the last encounter you had with a patient were you
just asking rote questions or were you having a conversation? When’s the last time you sat down
with the patient and family to mutually develop a plan of care? I was in the hospital once for 9
days the day of discharge the nurse brought me my care plan to sign. (Thompson,C.J., 2017).

Conversations are important to shared decision-making “because evidence is intended to offer a

dispassionate presentation of what medical science knows and doesn’t know about disease and
treatment in the population in general” (Hargraves et al., 2016, p. 627, emphasis added). So it is
not enough to just offer evidence, risks, and benefits. “Just the facts, ma’am” is not a caring
intervention. (Thompson,C.J., 2017).

Having a conversation with patients and families, instead of talking to them, allows them to think
about and debate options, ask questions, and mutually determine with the clinician the best path
for the individual patient. Hargraves et al. pointed out that patient-clinician conversation is not a
“nice-to-have moment” but that it is a bona fide “instrument of care” (2016, p. 628). Patient-
clinician conversation has been shown to be an effective technique for true shared decision-
making. (Thompson,C.J., 2017).

There certainly are many challenges to involving patients in healthcare decisions. Patient literacy
levels and previous knowledge also will affect the patient’s ability to be involved in decision-
making. Gender, race, sociocultural influences, socioeconomic status, and educational levels
may impact the patient’s ability to voice their preferences or concerns. Patients go to the Internet
for information about their conditions, but many don’t have the skills required to discern the
validity of Internet sources they encounter, which may lead to false hope or unreasonable
expectations. (Thompson,C.J., 2017).

As cited by Cathy J. Thompson in 2017, clinicians and patients may have dissimilar
expectations of what information to share, the priorities of care, or of how to treat the patient’s
 38

condition (Montgomery & Fahey, 2001; Schattner & Fletcher, 2003). This incongruence can
lead to conflict and mistrust of healthcare providers and the healthcare system itself (Hawley &
Morris, 2017; Siminoff, 2013).

Furthermore, some patients want the clinician to share all relevant information , all the risks and
benefits associated with a certain intervention; while other patients, due to personal or cultural
beliefs, may not want to participate in the decision-making process at all (Hawley & Morris,
2017; Say & Thomson, 2003). However, many studies show that patients desire information,
even if the patient does not want to be involved in making healthcare decisions (Say & Thomson,
2003).

Listen to Your Patients

The patient plays an important role in the process of shared decision-making. But the patient can
only play this role well if they are well-informed that is part of your responsibility to the
patient. To apply the appraised evidence, the clinician needs to provide information in a way
that makes sense to the patient. Providing details about best evidence is usually considered the
physician’s or advanced practice nurse’s purview, but the bedside nurse may have to help the
patient interpret the information. So, it is important that all members of the healthcare team
understand how to make sure that the patient is not left out of the process. (Thompson,C.J.,
2017).

The key to this important EBP component is not to forget the patient. Clinicians need to listen to
their patients. Nurses are already tuned in to our patients, so talking with the patient and finding
out what is important to them is not a stretch for nurses. To involve the patient in
decisions, nurses need to understand their patients’ lives, their values, and what’s important to
them. Patients are “experts with a unique knowledge of their own health and their preferences for
treatments, health states, and outcomes” (Say & Thomson, 2003, p. 542). Again, that’s why
evidence alone is not enough to guide clinical practice. (Thompson,C.J., 2017).

How Much Information Does the Patient Want?

For the patient and family to be knowledgeable consumers, those with “western” world mindsets
characteristically believe that the patient should be provided with as much information about the
 39

risks and benefits of treatment, as possible. If this is your patient, make sure that the information
being provided is at an appropriate level for the patient to truly understand the care options.

However, keep in mind that not all patients want information or to be involved in making their
healthcare decisions (Hawley & Morris, 2017; Say & Thomson, 2003). We make a lot of
assumptions as educated health care providers – that do not always ring true for our
patients. Guyatt et al. (2015) pointed out that some patients believe that the responsibility for
medical decision-making rests with the healthcare provider, not the patient. The decision to be an
active participant in clinical decision-making, or not, is the patient’s. (Thompson,C.J., 2017).

Also, do not assume that you know what is best for the patient! The clinician cannot assume that
their decisions will mirror the decisions of their patients; and in fact, research bears out the
opposite (Hunink, 2003; Montgomery & Fahey, 2001; Schattner & Fletcher, 2003). Many other
authors have shown that patient and provider priorities for care often are dissimilar (Hargraves et
al., 2016; Say & Thomson, 2003).

Nurses need to know patients for their care to be truly caring. This is a hallmark of excellent
nursing practice. And if nurses are honest with patients, this is a component for which they all
could do better.

As cited by Purnell in 2014, being aware of your patient’s cultural values and expectations is
important. In some cultures, any medical information, especially bad news, may be considered a
burden to the patient; family members make the decisions as to which information will be
shared. Sharing personal information with family members of the opposite sex may be prohibited
in some cultures. (Thompson,C.J., 2017).

Nursing and Patient Preferences

As a nurse, you are expected to be a theory-guided, evidence-based practitioner. One of the

benefits of using theory is that it can guide our processes and help us predict outcomes. There are
nursing theories that you could use to help guide you to involve the patient and family in their
care (e.g., Watson, Orem, and Leininger). There are also theories specific to patient and family
engagement (For example, Carman & Workman, 2017). Find a theory that resonates with you
 40

and use it to direct your nursing process for eliciting patient preferences and engaging the patient
in care. (Thompson,C.J., 2017).

The ASK (AskShareKnow) Patient–Clinician Communication Model (Shepherd et al., 2015) is

an intervention directed at teaching consumers three questions to ask to get information they
needed to make healthcare decisions. The questions are

1. What are my options?

2. What are the possible benefits and harms of those options?

3. How likely are each of those benefits and harms to happen to me? Including ‘What will
happen if I do nothing?’ (Thompson,C.J., 2017).

Shepherd and colleagues (2015) tested this intervention using a short video clip to introduce the
questions to the patients before the patient met with the healthcare provider. This education
resulted in patients asking one or more of these questions to their provider during the course of
the consultation; patient recall of these questions weeks later was good. (Thompson,C.J., 2017).

What is your responsibility if the patient does not want to be involved in the decision-making
process?

You would want to ensure that any decisions made by the healthcare team about care
interventions would be congruent with what you know about the patient and their preferences.

Evidence-based practice is an ethical, best-practice, and patient-centered approach to health care

if the patient is not forgotten in the process. There are many articles directed at how to engage
the patient in the decision-making process. (Thompson,C.J., 2017).

Critical strategies to demonstrate your commitment to incorporating patient preferences, values,

and beliefs into your practice include:

 Making time to listen to your patients and showing interest by maintaining eye contact
and using affirmative head gestures or phrases. Be aware of nonverbal cues (yours and
the patients). Be empathetic.
 41

 Asking the patient to what extent they want to be involved in their healthcare decisions.
Who else should be involved in the process? How information is shared and processed
among the patient and family?

 Asking the patient what their goals for care are – what are their priorities? What’s
important to them? What expectations do they have?

 Recognizing that cultural values influence the decision-making process.

 Asking patients for their opinions on what is causing their symptoms or ailment. Do they
have preferences about treatment? Find out where they obtained their information (e.g.,
Internet sources) and correct inaccurate information or understandings. Redirect patients
to credible sources, if needed.

 Using validation and reflective responses to verify concerns and clarify viewpoints.

 Tailoring your communication style and interventions to the patient’s cultural

background and beliefs, as appropriate.

 Providing patients with the best research findings and other evidence and “invite them to
choose a treatment option” (Hargraves et al., 2016, p. 627).

 Explaining treatment options, risks, and benefits in a way the patient can understand.

 Providing patients with informative materials about treatment options.

 Using the “teach back” method to validate the patient’s understanding of your
explanations and materials. (Thompson,C.J., 2017).
 42

Chapter 4

Case Study

A Critical Reflection of Own Clinical Practice and Evaluation of the Effectiveness of

Clinical Decision Making Using the Elements of Evidence- based Practice: Best Available
Research Evidence; Clinical Expertise; and Patient Preferences

4.1 Best Available Research Evidence and Patient Preferences to Clinical Practice

ASSESS the Problem

I would like to describe here a clinical problem / question arises from the care of the patients
regularly in the clinical practice.

Peripheral IV catheter insertion is a common nursing procedure often required for the
administration of chemotherapy, antibiotics, blood products, fluids, and other medical therapies
in hematologic patients with cancer. Although necessary and usually brief, IV insertion often is a
source of patient anxiety and discomfort and can be extremely difficult to achieve, particularly in
individuals receiving repeated courses of chemotherapy. Unfortunately, not all IV insertions are
successful on the first attempt; multiple attempts may occur, which may cause patient distress
and anxiety and increase costs as a result of additional supplies and nursing time. Nurses
currently use various techniques, including heat, to improve the success rates of IV insertion;
however, few are based on evidence.

In an effort to improve the patient experience I look at the evidence for using dry versus moist
heat for IV catheterization.

ASKED the questions

 Choose the BEST clinical question?

 Is dry or moist heat more effective at reducing pain and anxiety?
 Does heat help improve the time to insertion of an IV catheter?
 Is dry or moist heat helpful in reducing pain and time of IV catheter insertion in patients
undergoing chemotherapy?
 43

ACQUIRED the evidence

 Choose the best PubMed search strategy to address the clinical question.
 Search: heat and chemotherapy Limited to randomized controlled trial
 Search: hyperthermia and catheterization Limited to randomized controlled trial
 Search: heat and IV catheter Limited to Human and English and last 5 years

APPRAISED the evidence

Fink RM. The impact of dry versus moist heat on peripheral IV catheter insertion in a
hematology-oncology outpatient population. Oncol Nurse Forum. 2009 Jul; 36(4):E198-
204. doi: 10.1188/09.ONF.E198-E204. PubMed PMID: 19581223.

Abstract

PURPOSE/OBJECTIVES: To determine whether dry versus moist heat application to the

upper extremity improves IV insertion rates.

DESIGN: Two-group, randomized, controlled clinical design.

SETTING: An academic cancer infusion center in the western United States. Sample: 136
hematologic outpatients with cancer or other malignancies.

METHODS:
Participants were randomly assigned to dry or moist heat with warmed towels wrapped
around each patient's arm for seven minutes prior to IV insertion. Skin and room
temperatures were monitored pre- and post-warming. Two experienced chemotherapy
infusion nurses performed the venipunctures according to protocol. Outcomes were
examined using variance analysis, with 34 patients for each combination of nurse and heat
type.

MAIN RESEARCH VARIABLES: Number of IV insertion attempts, time to achieve IV

insertion post heating, patient anxiety levels pre- and post-heating, and patient comfort.
 44

FINDINGS: Dry heat was 2.7 times more likely than moist heat to result in successful IV
insertion on the first attempt, had significantly lower insertion times, and was more
comfortable. Heat type had no effect on patient anxiety.

CONCLUSIONS: Dry heat application decreases the likelihood of multiple IV insertion

attempts and procedure time and is comfortable, safe, and economical to use in an outpatient
oncology setting.

Evaluating the medical literature is a complex undertaking. Need to find that the answers to
the questions of validity may not always be clearly stated in the article and that I may have to
use my own judgment about the importance and significance of each question.

 Randomization: Were patients randomized?

 Concealed allocation: Was group allocation concealed?
 Baseline characteristics: Were patients in the study groups similar with respect to
known prognostic variables?
 Blinding: To what extent was the study blinded?
 Follow-up: Was follow-up complete?
 Intention to Treat: Were patients analyzed in the groups to which they were first
allocated?
 Equal treatment: Aside from the experimental intervention, were the groups treated
equally?

What were the results & how can I apply them to patient care?

Results: Controlling for prewarming vein status, dry heat was 2.7 times more likely to result
in successful IV insertion. After controlling for pre-insertion anxiety, vein status, and the
participants’ number of venipunctures in the prior year, dry heat resulted in significantly
lower insertion times than moist heat. No significant difference was found between the heat
modalities or between nurses on post-insertion patient reported anxiety scores. Dry heat was
associated with significantly higher participant self-reported comfort after controlling for
preinsertion anxiety and vein status and the participants’ numbers of venipunctures in the
prior year.
 45

Questions that considered before applying the results of a study to my patient:

 Were the study patients similar to my population of interest?

 Does your patient match the study inclusion criteria? If not, are there compelling reasons
why the results should not apply to your patient?

 Were all clinically important outcomes considered?

 Are the likely treatment benefits worth the potential harm and costs?

NURSING INTERVENTION: According to the aforementioned steps, I talked with the

patient and informed the benefits of using dry heat for IV catheterization. Then integrated
that evidence with clinical expertise, patient preferences and applied it to my practice.

EVLUATION of EFFECTIVENESS: The benefits of using dry heat for IV catheterization

are increased comfort and satisfaction for patients, potentially preventing the needs for
several times insertion attempts or insertions of a central catheter, thus eliminating and
reducing costs overall. Not only that it helps to save the valuable time of nurses, but it
increases the clinical expertise also.

4.2 Change in Clinical Practice Based on Expert Opinion

When I was working in a spinal trauma unit recognized that the incidence of skin breakdown was
high. Patients in the unit were acutely ill and immobile, making them at increased risk for
pressure ulcers. Fecal incontinence adds to that risk. A new fecal containment device was
purchased, and I was charged with developing a procedure for use of the device a. His team of
caregivers and I began to explore what needed to be done to write the new procedure and
disseminate it to the ICU staff members. The vendor agreed to offer in-service education on the
product, but the guidelines for nursing care extend beyond the specific practical details of
product insertion.

I reviewed the AACN Procedure Manual for Critical Care33 and the manufacturer’s instructions
for use of the fecal containment device. The evidence found was rated as level D (expert
opinion) and level M (manufacturer’s recommendations). Procedures that are developed on the
basis of evidence gleaned from expert opinion and manufacturers’ recommendations may be the
 46

only information available for new products and practices. I recognized that publications may be
outdated and that a search of the most current literature for pertinent research was a priority. He
was obligated to do a thorough literature search to verify concurrence among sources and
findings.

I appreciated that the practices might be fluid and could change over time as clinical use of the
product led to new clinical studies and outcomes analysis. After reviewing all the available
recommendations for the use of the fecal containment device, he decided to adapt or adopt the
procedure from the AACN Procedure Manual for Critical Care. He wrote the procedure and
included references from the manufacturer’s recommendations, the AACN manual, and other
current research. He was careful to note on the procedure that the levels of evidence were D and
M. He made plans for disseminating and educating staff about the new procedure. When
exploring the literature on the subject of fecal incontinence containment, I recognized that the
use of this device would present an opportunity for clinical research that would add a higher
level of evidence to the knowledge base. He made a note to discuss this prospect with his
colleagues and the clinical nurse specialist.

4.3 Patient Preference for Clinical Practice

In most acute care facilities, bed-bound patients unable to provide self-care are bathed by nursing
personnel using a basin of warm tap water, soap and washcloths. This traditional method of
bathing can result in significant variation from caregiver to caregiver; excessively dry skin on
patients and exposure to bacteria, increasing the risk of healthcare-associated infection. So bed –
bound patients so really unsatisfied with traditional bathing methods. Such baths also take longer
and require more nursing time.

The American Association of Critical-Care Nurses (AACN) continues to advocate for daily
bathing to improve hygiene and promote patient comfort with prepackaged cleansers that do not
require rinsing. The practice alert also advocates scheduling bath times based on patient
preference and clinical needs, not on nursing convenience. The period between midnight and 6
a.m. is a common time for bed baths and other nursing care activities, but the AACN said nurses
should determine optimal bath time by individual patient preference and clinical stability, and
 47

avoid waking patients solely to bathe them. (AACN issues new protocols for bathing patients,
2013).

Evidence-based protocols related to bathing adult patient by AACN

 Provide a daily bath for bed-bound patients to improve hygiene and promote comfort.
More frequent baths may be performed upon patient request or to respond to patient
needs.
 Determine bath time based on patient preference and clinical stability instead of based on
organizational factors.
 Use disposable basins and dispose of them after one use to reduce risk of bacterial
contamination.
 Avoid use of unfiltered tap water. Alternatives include prepackaged bathing products,
sterile or distilled water or filtered water from faucets.
 Use no-rinse pH balanced cleansers, which are superior to alkaline soaps that require
wash-rinse cycles.
 Apply emollients after each non-prepackaged bath to prevent dry skin. Prepackaged
bathing products include skin emollients.
 Use prepackaged bathing products to reduce process variation.
 Bathe patients daily using a disposable cloth that is prepackaged with a 2% solution of
Chlorhexidine Gluconate (CHG). Use of CHG is associated with significant reductions in
colonization of specific bacteria and infections with multidrug-resistant organisms.

Currently, I am trying to use that method as much as possible, in to my routing nursing practice
with patients in acute and critical care environments. Patients are more satisfied, convenient and
reduced their duration of staying in the hospital with new upgrade of bathing. Even more such a
routine activity as bathing a bed-bound patient needs to be updated to all,to reduce the risk and
increase the benefit to the patient. As nurses, need to educate patients and their families about
how bathing technology has changed to improve patient’s satisfaction, care and reduce risk of
infection.
 48

Conclusion

Evidence-based nursing practice involves integration of a problem-solving approach within the

context of caring, considering best evidence from studies, patient care data, clinical experience
and expertise, and patients’ preferences and values. Health care agencies, government agencies,
and national professional organizations such as the American Association of Critical-Care
Nurses have all been supporters of evidence-based practice (EBP) as studies continue to show
improved outcomes when best evidence is used in the delivery of patient care. Despite the
awareness of the importance of practice being based on best evidence, achieving and sustaining
EBP within practice environments can be challenging, and research suggests that integration of
EBP into daily clinical practice remains inconsistent. (American Association of Critical-Care
Nurses, 2013).

EBP is essential to the delivery of high-quality care that optimizes patients’ outcomes. Studies
continue to show improved outcomes when best evidence is used in the delivery of patient care.
Despite awareness of the importance of practicing by using best evidence, achieving and
sustaining evidence-based practice within practice environments can be challenging, and
research suggests that integration of evidence-based practice into daily clinical practice remains
inconsistent. To achieve excellence in practice, critical care nurses must embrace EBP as the
norm. We cannot knowingly continue clinical practice interventions that are not supported by
current best evidence, especially if those actions are known to be unhelpful and possibly
harmful. (American Association of Critical-Care Nurses, 2013).
 49

References

American Association of Critical-Care Nurses. (2013). Retrieved from 10 August, 2018, from
www.ccnonline.org.

Beyea,S.C., & Slattery,F.M.J. (2006). Evidence-Based Practice in Nursing.

Black,A.T.,Balneaves,L.G.,& Qian,H. (2015). Promoting Evidence-Based Practice Through a

Research Training Program for Point-of-Care Clinicians. Retrieved from 15 August,
2018, from https://www.ncbi.nlm.nih.gov/pmc/articles.

Colorado Mesa University. (2016). Why Evidence-Based Practice Is Vital to Improving Patient
Care. Retrieved from 10 August, 2018, from https://degree.coloradomesa.edu/articles/why-
evidence-based-practice-is-vital-to-improving-patient-care.

Introduction to Evidence-based Practice. (2018). Retrieved from 20 August, 2018, from

https://guides.mclibrary.duke.edu.

Jylhä, V., Oikarainen, A., Perälä,M-L & Holopainen,A. (2017). Facilitating evidence-based
practice in nursing and midwifery in the WHO European Region. Retrieved from 12 August,
2018, from http://www.euro.who.int.

Matthew, J .L. (2006). Evidence-based practice: A framework for clinical. International Journal
of Nursing Practice.

McHugh,M.D, & Lak,E.T. (2010). Understanding Clinical Expertise: Nurse Education,

Experience, and the Hospital Context. Retrieved from 10 August, 2018, from
https://www.ncbi.nlm.nih.gov/pmc/articles.

Melnyk,B.M. (2016). Improving healthcare quality, patient outcomes, and costs with evidence-
based practice. Retrieved from 30 August, 2018, from
https://www.reflectionsonnursingleadership.org.

Thompson,C.J. (2017). What Does “Patient Preferences” Mean in Evidence-Based Practice?

Retrieved from 18 August, 2018, from https://nursingeducationexpert.com.