Nursing and Allied Health Professions

Spring 2021 Nursing Administration (NURS 729)

Indiana University of Pennsylvania

Dr. Nashat Zuraikat

01/21/2021

Evidence Based Practice: From the Steps to its Implementation

Evidence-based practice (EBP) is the use of current best evidence along with clinical expertise

and patients’ values to make informed clinical decisions. Evidence-based practice has been in

existence for almost three decades and its’ knowledge has helped clinicians in making informed

decisions about healthcare delivery. The advent of COVID-19 pandemic has created a paradigm

shift in EBP towards a resource-based EBP strategy implantation due to availability of personal

protective equipment. In this paper, we highlight EBP steps, implementation during COVID-19

and further recommendation on EBP for healthcare providers.

Introduction

The concept of evidence-based practice (EBP) has been widely accepted into healthcare

delivery and medical education since its inception in the early 1990s. However, research has

been directed towards the development of an evidence base that informs and improves healthcare

delivery as well as patient outcomes (Cassidy, Flynn, & Shuman, 2021). It was originally

introduced by Gordon Guyatt and his team in 1991, ever since then EBP has been directed

towards focusing on best available and current evidence in clinical decision making.

The application of EBP into healthcare delivery has been documented as a method

directed towards the improvement of the quality of patient care hence, healthcare organizations

and facilities require healthcare professionals to be trained in the implementation of EBP into

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their practice (Ramukumba & El Amouri, 2020). The goal of EBP in healthcare is to improve

quality of care to patients which in-turn improve patients' outcomes (Koota, Kääriäinen, Kyngäs,

Lääperi, & Melender, 2021). However, studies conducted by Melnyk, Fineout‐Overholt,

Gallagher‐Ford, & Kaplan (2012) and Saunders, Gallagher‐Ford, & Vehviläinen‐Julkunen

(2019) revealed that healthcare professionals fail to consistently use EBP in their day-to-day

clinical decision making which hinders healthcare facilities from achieving high-quality,

evidence-based healthcare delivery.

It is essential for healthcare facilities to implement EBP into healthcare practice for

improvement in outcomes for patients, clinicians, and health systems (Straus, Tetroe, & Graham,

2009; Cassidy, Flynn, & Shuman, 2021). Institute of Medicine (2009) and Cassidy, Flynn, &

Shuman (2021) revealed that EBP consists of research findings from clinical trials and the study

of its effectiveness which provides evidence that can be summarized and packaged for use in

healthcare delivery. Over the last two decades, EBP has been made available to clinicians and

healthcare organizations in the form of various resources such as evidence-based clinical practice

guidelines and recommendations, evidence-summary reports, systematic reviews and EBP

educational programs (e.g., webinars, seminars and workshops). The availability of these

resources for use by clinicians along with their expertise with consideration of patients' values

has been employed to pilot the delivery of healthcare (Titler, 2014; Cassidy, Flynn, & Shuman

2021).

Several studies also defined EBP as the meticulous and well-judged use of current best

evidence available combined with clinician's expertise and patient values as a guide in making

informed clinical decisions (Cook, 1998; Sackett, Straus, Richardson, Rosenberg & Haynes,

2000; Jennings & Loan, 2001; Titler, 2006; Titler, 2008). Over the years, there has been

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recommendations and resources directed towards implementing EBP. Despite these resources,

we still continue to see a gap in implementation of EBP, which spans between the best available

evidence and clinical practice judgement across the world (Jylhä, Oikarainen, Perälä, &

Holopainen, 2017; Leach & Tucker, 2018; Mackey & Bassendowski, 2017; Cassidy, Flynn, &

Shuman 2021).

The Agency for Healthcare Research and Quality (AHRQ) released a 2014 National

Healthcare Quality and Disparities Report which confirms that evidence-based care is delivered

appropriately 70% of the time and an improvement of 4% have been made after 2005. The gap

between the availability of EBP recommendations and the use of EBP in healthcare delivery is

also however affected in the nursing profession (Cassidy, Flynn, & Shuman 2021; Van

Achterberg, Schoonhoven, & Grol, 2008). Several factors responsible for evidence-based

practice gap are highlighted such as lack of time, leadership, workload, social influences,

policies and philosophies stating, “this is the way we have always done it here” (Cassidy, Flynn,

& Shuman 2021; Kajermo et al., 2010; Melnyk et al., 2012; Shayan, Kiwanuka, & Nakaye,

2019; Warren et al., 2016). This research paper is directed towards highlighting the steps

involved in evidence-based practice and its implementation process in healthcare delivery.

Steps Involved in Evidence-Based Practice

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 Evidence-based practice (EBP) is further defined as the “conscientious and judicious use

of current best evidence” along with the expertise of the clinician and respect to patient's

decision and values in other to make informed clinical decisions (Cook, 1998; Sackett, Straus,

Richardson, Rosenberg & Haynes, 2000; Jennings & Loan, 2001; Titler, 2006; Titler, 2008). In

the hierarchy of evidence, systematic reviews and randomized controlled trials represent the best

form of evidence towards implementing EBP in to making informed clinical decisions. Evidence

can also be derived from other scientific methods such as qualitative research, case reports,

scientific principles and clinical expert opinion (Titler, 2008).

There are five steps involved in the EBP process. The first step involves asking the

clinical question. The clinical question is asked in the PICO format (i.e., P = patient population, I

= intervention or area of interest, C = comparison intervention or comparison group, and O =

outcome). Sackett, Straus, Richardson, Rosenberg & Haynes, (2000) stated that the first step in

the EBP process is the most important and challenging step. In other to start an EBP process, a

searchable and answerable question must be formulated and the success of the EBP process

depends on this first step. The second step is the process of searching for best evidence. The

question formulated in the first step leads to the search for best evidence and which appropriate

database to search. Systematic reviews of randomized controlled trials represent the highest level

of evidence to get answers to specific questions on efficacy of an intervention or treatment

technique (Fineout-Overholt, Melnyk, & Schultz, 2005).

The third step involves the process of critically appraising the evidence found during

literature search. The purpose of the third step in EBP process is to determine the value of

research contributions to clinical practice. The fourth step in EBP process depends on whether

there is valid, applicable and reliable evidence to implement into clinical practice. In this phase

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the clinician decides based on his expertise and patient preferences to make clinical decision

about best healthcare delivery to the patient. The final step in EBP involves the evaluation of the

clinical outcome in the healthcare provider's facility. This step is very important towards

generating outcome data for the interventions or procedures carried out in the facility (Fineout-

Overholt, Melnyk, & Schultz, 2005).

Implementation of Evidence-Based Strategies during the COVID-19 pandemic

The use of evidence-based practice expresses a standard of care, especially in evidence-

based nursing. However, there are many obstacles, some of which include difficulty in finding

research evidence, or a lack of time in searching for evidence. In the COVID-19 pandemic,

evidence-based nursing faced a challenge, as it not only focused on providing the best possible

care for patients but also on protecting ourselves from the virus (Mays, 2020).

Some principles help us understand the evidence-based practice and it has been defined

as “integrating individual clinical expertise with the best available external evidence from

systematic research” (Mays, 2020). Evidence-Based Practice is to clearly define the problem,

obtain relevant research evidence, evaluate the quality of the research, and select the

interventions that reflect the best and most relevant quality of evidence. Evidence-based nursing

takes this further “from this by adding more consideration to the values and availability of

sufficient evidence” (Mays, 2020).

Although there is an enormous amount of information about COVID-19, there are not a

large number of high-quality research studies, but there are many observational studies that have

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helped guide us, yet science is still trying to determine the basic things such as the possibility of

spread through the air. The COVID-19 pandemic has affected the United States and the global

health care system on stocks of personal protective equipment, and this has led to the legalization

and change of best preventive practices against infection (World Health Organization, 2020). In

doing so, the lack of resources forced nurses to make resource-based decisions rather than

evidence, as there will likely be an amendment to the EBP model that adds a resource-based

practice perspective to include the actual availability of resources and inform the decision-

making process of nurses and other service providers (Mays, 2020).

The COVID-19 pandemic has created major challenges for nurses and the health care

system. The nursing community has had little evidence about the new virus and a short time to

deploy resources. The lack of health care resources and the absence of standard protocols have

exacerbated the situation when trying to assess evidence during a pandemic. The lack of tangible

resources is a concept that paves the way for healthcare reform and reassessment of strategic

stocks of personal protective equipment in health systems (Yingling, 2021).

Evidence-based clinical decision-making may shift to resources when there are no

available or affordable health care resources, limiting the efficiency of the health care provider.

Standards may change during health emergencies to respond due to an imbalance between

requests for care and resource allocation. This happens quite often at times when the health

system is not in a stifling crisis. During the COVID-19 pandemic, resource-based practices were

clear and practice guidelines were based on the availability of equipment, not evidence

(Yingling, 2021).

The modified EBP model can set guidelines to address resource unavailability and

provide frameworks to guide clinical nursing practice in times of material scarcity, whether in

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natural settings or severe global health crises. Research may help an understanding of the role

that resource availability plays in the observed gap between best research and clinical practice

because the impact of resources on EBP implementation and the subsequent impact of a

resource-based approach influence patient outcomes. We do not yet know the individual and

cumulative effect of resource-based decisions on patient outcomes and the risks they may pose to

health care providers (Yingling, 2021).

Future Research Recommendations on EBP in Medical Education and Healthcare Delivery

In the United States, there is existence of multiple barriers that have slowed down the

advancement of EBP in healthcare facilities. Melnyk et al (2004), Melnyk et al (2005) and

Fineout-Overholt, Melnyk, & Schultz (2005) highlighted this major barriers which include (1)

false beliefs about EBP (i.e. EBP process is too time consuming); (2) lack of administrative

support; (3) lack of detailed EBP curriculum in professional medical education programs; (4)

lack of continuing education programs fostered towards implementation of EBP into practice; (5)

insufficient number of EBP mentors in healthcare facilities; (6) negative attitudes towards EBP

and research.

Medical education programs should teach students on proper steps to EBP process with

emphasis on how to access, critically appraise and use research towards their clinical practice.

Healthcare facilities must promote the culture of the organization towards the use and

implementation of EBP in healthcare delivery. These can be achieved in various ways which

include (1) EBP mentors within the organization; (2) creation of EBP journal clubs; (3) rewards

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for most successful team involved in EBP implementation; (4) EBP education programs

conducted for healthcare workers; (5) EBP must be infused in the core mission and value of the

organization (Fineout-Overholt, Melnyk, & Schultz, 2005).

Conclusion:

The impact of EBP on the COVID-19 pandemic played an important role, but the

pandemic showed us the inclusiveness of EBP in all respects that affects the outputs provided to

the patient and its impact on the health care provider that ultimately affects the outcome of health

care. There should be more flexibility in changing the EBP with consistency with modern

science so that there is no conflict between the legislation, the protocols, and the evidence.

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