Addressing the current challenges of adopting evidence-based

practice in nursing
Kerr , H., & Rainey, D. (2021). Addressing the current challenges of adopting evidence-based practice in
nursing. British Journal of Nursing, 30(16), 970-974. https://doi.org/10.12968/bjon.2021.30.16.970

Published in:
British Journal of Nursing

Document Version:
Peer reviewed version

Queen's University Belfast - Research Portal:

Link to publication record in Queen's University Belfast Research Portal

Publisher rights
Copyright 2021, Mark Allen Healthcare.
This work is made available online in accordance with the publisher’s policies. Please refer to any applicable terms of use of the publisher.

General rights
Copyright for the publications made accessible via the Queen's University Belfast Research Portal is retained by the author(s) and / or other
copyright owners and it is a condition of accessing these publications that users recognise and abide by the legal requirements associated
with these rights.

Take down policy

The Research Portal is Queen's institutional repository that provides access to Queen's research output. Every effort has been made to
ensure that content in the Research Portal does not infringe any person's rights, or applicable UK laws. If you discover content in the
Research Portal that you believe breaches copyright or violates any law, please contact [email protected].

Open Access
This research has been made openly available by Queen's academics and its Open Research team. We would love to hear how access to
this research benefits you. – Share your feedback with us: http://go.qub.ac.uk/oa-feedback

Download date:11. Feb. 2025

Title:
Addressing the current challenges of adopting evidence-based practice in nursing.

Author details:

Corresponding author:

Dr Helen Kerr PhD; RN

Senior Lecturer
School of Nursing and Midwifery
Medical Biology Centre
Queen’s University Belfast
Lisburn Road
Belfast
Northern Ireland
BT9 7AB
Email address: [email protected]
Telephone number: 028 9097 5810
Orchid: 0000-0003-3710-2046

Dr Debbie Rainey EdD; RN

Lecturer
School of Nursing and Midwifery
Medical Biology Centre
Queen’s University Belfast
Lisburn Road
Belfast
Northern Ireland
BT9 7AB
Email address: [email protected]
Telephone number: 028 9097 2016

1
Keywords

Evidence-based nursing

Evidence-based practice

Nursing practice

Key points 4-6 full sentences summarising main themes of paper

Evidence-based practice aims to promote best practice, clinical effectiveness and quality of
care.

Although evidence-based practice is a relatively new concept in healthcare, there has been a
global movement and recognition of the need to adopt this approach to care.

Discussion of the current challenges contributing to the implementation of evidence-based

practice in nursing.

Action focused recommendations to address the challenges related to the low

implementation of evidence-based practice in nursing.

Reflective questions

What are the professional challenges in adopting an evidence-based practice approach to

care delivery?

What are the organisational barriers in embedding an evidence-based practice approach to

care delivery?

What two steps will you take to promote evidence-based practice into your care delivery?

2
3
Aim of paper

This aim of this paper is to explore the current position of evidence-based practice (EBP) in

nursing. The paper provides an overview of the historical context and emergence of EBP with

an outline of the EBP process. There is an exploration of the current challenges facing the

nursing profession as they endeavour to adopt EBP into care delivery, along with actions to

address these challenges. There will be a discussion on how to integrate EBP into

undergraduate nursing curricula as academic institutions implement the Future nurse:

Standards of proficiency for registered nurses by the Nursing and Midwifery Council (NMC,

2018).

Background to the emergence of evidence-based practice

It has been suggested that the idea of delivering care based on evidence had its early

foundations in the 1800s with Florence Nightingale aiming to provide better outcomes for

patients who experienced unsanitary conditions (Mackey and Bassendowski,

2017). However, it is generally agreed that Professor Archie Cochrane, whose work inspired

the Cochrane Collaboration (Smith, 2014; Barker and Linsley, 2016), is credited for being at

the forefront of the modern EBP approach. The concept of evidence-based

medicine emerged from researchers at McMaster University, Canada, who redefined the

practice of medicine to move from a culture based soley on clinical experience, to one which

is more inclusive of medical evidence (International Council of Nurses, 2012). It was

1992 before the phrase evidence-based medicine was coined by Gordon Guyatt (Smith, 2014)

so has had a relatively short life span. Although a number of individuals contributed to

the development of evidence-based medicine, David Sackett is regarded as the father of

evidenced based medicine as in 1996 he distinguished evidence-based medicine as an

4
approach that combines research evidence with clinical skills, and patient values and

preferences (Smith, 2014).

From the emergence of evidence-based medicine, the terminologies EBP developed which

relates to all professional denominations, and evidence-based nursing, as other professions

adopted this approach (Mackey and Bassendowski, 2017; Rees, 2010). EBP evolved

into the nursing profession in the 1990s and in the context of the United Kingdom, is now

endorsed by the NMC and it is the professional responsibility of registered nurses to adopt

this approach (NMC, 2015). From the introduction of EBP into the nursing profession, there

is now a global consensus that healthcare providers integrate research evidence into their

practice so new generations of healthcare professionals have EBP embedded in programmes

of study (Al Khalaileh et al, 2016). There are multiple positive outcomes related to evidence-

based care such as improvements in healthcare quality, safety and reduction in care costs

(Beyea and Slattery, 2013; Melnyk et al, 2018; Al Qadire, 2019). Despite the great strides

undertaken in the previous three decades to integrate this concept into healthcare, there is

evidence to suggest there are issues in understanding EBP and an inconsistent approach to

implementing evidence-based care in practice (Melnyk et al, 2010).

Exploration of definitions

Despite the range of terminologies used with regards EBP, which includes discipline specific

evidence-based nursing and evidence-based medicine (Barker and Linsley, 2016), the aim and

key elements are essentially the same. Evidence-based medicine is the ‘conscientious,

explicit, and judicious use of current best evidence in making decisions about the care of

individual patients. The practice of evidence-based medicine means integrating individual

5
clinical expertise with the best available external clinical evidence from systematic

research’ (Sackett 1996, 71). Whilst this definition recognises the need to integrate best

current evidence with clinical expertise, a criticism is it does not include the perspectives of

service users (Barker and Linsley, 2016) as previously outlined by David Sackett in 1990

(Smith, 2014). The definition for EBP acknowledges a three-pronged approach which includes

best current evidence, clinical expertise, and the values and preferences of patients. The

International Council of Nurses (2012, 6) states that ‘evidenced-based practice is a problem-

solving approach to clinical decision-making that incorporates a search for the best and latest

evidence, clinical expertise and assessment, and patient preferences and values, within a

context of caring.’ A definition of evidence-based nursing is the ‘conscientious, explicit, and

judicious use of theory-derived, research-based information in making decisions about care

delivery to individuals or groups of patients reflective of individual needs and preferences’

(Ingersol, 2000, 152). EBP is embedded in the principle that patient care should be informed

by rigorous evidence (Mackey and Bassendowski, 2017), therefore, nurses need to learn how

to gather evidence and how to put this knowledge into everyday practice. As not all evidence

is robust or reliable, nurses must learn how to identify the best available evidence, taking into

account the needs and preferences of health service users, whilst using their own expertise

and clinical judgement as to the feasibility of its use (International Council of Nurses, 2012,

no page number).

Outcomes related to adopting an evidenced-based practice approach

The main rationale for adopting an evidence-based approach in practice is to enhance the

quality of care for patients and improve outcomes (LoBiondo-Wood et

al, 2019). Using an EBP approach also provides a framework that supports decision-making

6
(Mantzoukas, 2008; International Council of Nurses, 2012; Beyea and Slattery, 2013),

contributing to healthcare professionals making informed judgements (Pooler, 2012). Using

this approach facilitates nurses being more prepared to ask relevant questions regarding

changes to their practice and more equipped to evaluate their practice (International Council

of Nurses, 2012). An evidence-based approach also contributes to a potential reduction

in care costs (Beyea and Slattery, 2013; Melnyk et al, 2018; Al Qadire, 2019).

Components of evidence-based practice

EBP is based on evidence that originates from three key components; best available

external evidence from published research; clinical expertise; and patient values and

preferences (Rees, 2010) (Figure one). Each component is limited in its value until combined

with the neighbouring components.

Insert Figure one

Best available external evidence

The first component of EBP is the sourcing, appraisal and implementation of best available

external clinical evidence. Best evidence can originate from a range of sources such as

randomised controlled trials, evidence from other scientific designations which includes

descriptive and qualitative research, and information from case reports (LoBiondo-Wood et

al, 2019).

7
Clinical expertise

The second component relates to clinical expertise which is the proficiency and judgment that

clinicians acquire through clinical experience (Sackett et al, 1996) and has both knowledge

and skill set components (McCracken and Marsh, 2008). External evidence can inform, but

not replace individual clinical experience, as it is the expertise that decides whether the

external evidence can be applied to the individual patient (Sackett et al, 1996).

Patient values and preferences

The final component of EBP relates to patients’ values and preferences which are crucial in

deciding on the appropriate management (Haynes and Haines, 1998) as even excellent

external evidence may be inapplicable to an individual patient (Sackett et

al, 1996). Incorporating patients’ values and perspectives aligns to the person-centred

approach to care, in which patients are active participants in their care (Siminoff, 2013).

Steps in evidence-based practice

There are a range of models which outline the steps in the EBP process. One such model

involves seven steps from step zero to step six (Melnyk et al, 2010) (Figure two). Step

zero relates to cultivating a spirit of inquiry which involves healthcare professionals adopting

an inquisitive approach to practice. Step one involves developing a focused question with

one relevant framework available being PICO(T). This was introduced by Richardson et

al (1995) and subsequently applied to other disciplines (Schlosser et al, 2007). The

acronym PICO(T) identifies the population (P), intervention (I), comparator (C), outcome(s)

(O) and if appropriate, the time (T) element in a focused question. Step two relates to

searching for the best evidence using the key words and synonyms, identified in the PICO(T)

8
framework. Sources of evidence may include books, journals, government and policy

documents, and grey literature, which is literature not formally published (Barker and Ortega,

2016). Step three involves critically appraising the evidence sourced in Step

two. Registered nurses should have an ability to evaluate the strengths and weaknesses of

research evidence, to determine the merit of research for use in practice (LoBiondo-Wood et

al, 2019). Step four relates to integrating the evidence sourced, along with clinical expertise

and patient preferences in making the best clinical decisions. Step five involves evaluating

the outcome(s) of the EBP approach, to determine the impact. The sixth and final step

relates to disseminating the outcome(s) to enable others to learn and develop their practice

(Melnyk et al, 2014).

Insert Figure two

Hierarchy of evidence

When critically appraising the evidence as part of step three in the EBP process, an

understanding of the hierarchy of evidence is important (Figure three). This provides the

rank order of sources of evidence indicating which has the highest, and which has the lowest

with regards trust in their use for clinical decision making (Rees, 2010). Although this is useful

in determining the strongest evidence, it has been argued this hierarchy is too linear and

orderly and does not exist in the reality of clinical practice (Mantzoukas, 2008). Therefore, it

is crucial the reviewer continues to use their critical judgement skills to appraise the sources

of evidence.

Insert Figure three

9
Current challenges to evidence-based practice

Although the national agenda for EBP is at the forefront of healthcare, there continues to be

low implementation of EBP in healthcare settings (Melnyk et al, 2018). It is argued EBP is not

the standard of care practiced consistently across the globe despite the published benefits

(Melnyk et al, 2014). Organisational factors include a lack of time to source, appraise,

implement and evaluate evidence is outlined by many authors as a key barrier to the EBP

process (Melnyk et al, 2005; Rees, 2010; Melnyk et al, 2014; Al Khalaileh et

al, 2016; Kalavani et al, 2019). Nurses have also reported barriers to EBP connected to a lack

of authority to change care procedures in practice (Al Khalaileh et al, 2016) or a culture which

adopts an orientation of ‘having always done it this way’ (Melnyk et al, 2014). Consequently,

nurses in the clinical environment often rely on policies and protocols for guidance on best

practice.

Barriers associated with practitioners relates to not have the critiquing skills to assess the

quality of the evidence (Rees, 2010; Melnyk et al, 2014) or finding it challenging interpreting

research findings due to the terminologies used and the statistical presentation of research

results (Barker and Linsley, 2006; Rees, 2010). Despite these challenges, findings of an

integrative review demonstrated that nurses had a positive attitude and belief in the value of

EBP, however, they perceived their knowledge and skills related to EBP was insufficient for

employing evidenced practice and, consequently, did not use this approach (Saunders and

Vehvilainen-Julkunen, 2016).

Barriers related to the evidence available includes the dearth of high quality methodological

robust and clinically relevant research. When relevant evidence is available, there is often

10
a slow pace at which research findings are translated into clinical practice (Melnyk, 2017) with

a lack of effective and efficient knowledge transfer activities. At times, there is conflicting

evidence as a result of contextual variations in different settings, however, new research

approaches are being introduced which seek to identify the impact of contextual

variations on outcomes, such as realistic evaluation (Pawson and Tilley, 1997).

A further challenge in the current context of the COVID-19 global pandemic relates to the

surge of new evidence being presented and an associated urgency to collate, review, appraise

and apply this information (Carley et al, 2020). It remains crucial that evidence-based

solutions continue to be embedded in responses to the current challenges currently

confronting the healthcare system (Lake 2000).

Recommendations to address current challenges for NMC registrants

It is a priority to find efficient and effective ways to promote the uptake of evidence-based

interventions (Haines et al, 2004). Although the health workforce has a positive view of the

value of EBP (LoBiondo-Wood et al, 2019), their knowledge and skills can be limited

(Kalavani et al, 2019). For many frontline nurses, there is no protected time available in

providing a consistent approach to sourcing and implementing current best

available external evidence. Whilst it is important to follow best practice guidelines to

enhance patient outcomes (Mackey and Bassendowski, 2017) nurses should also engage

individually in sourcing, appraising and implementing best evidence. To assist with this

endeavour, research departments and practice development units within organisations are a

resource to support nurses in sourcing and applying evidence in practice. There are also local

clinically based initiatives to increase nurses’ knowledge and capacity in evidence-based

11
practice. One such example is the development of a hospital-based enhancement model to

plan, develop and implement a research outreach, ward-based seminar programme focused

on addressing common barriers to EBP and how to apply EBP in nursing (Edward and Mills,

2013). Protected time away from direct patient care should be available for nurses working

in clinical practice for these activities. Whilst this may seem an unrealistic

recommendation in already stretched healthcare systems, viable options may

include support to complete modules of study and having access and time to search

online databases (Kalavani et al, 2019), or attend in person or virtual conferences. There are

also appointments of clinical educators in some Health and Social Care Trusts with

responsibilities which include engaging frontline nurses to engage with clinically relevant

research through initiatives such as journal clubs, however, time available away from clinical

areas remains a challenge for frontline nurses.

Sourcing innovative methodologies to translate research findings into a language that is

relatable to clinically based nurses is a priority, in addition to methods to effectively

disseminate findings to expedite the process of implementing emerging evidence into

practice. Knowledge translation refers to the ‘process through which research knowledge is

created, circulated and adopted into clinical practice’ with well documented enablers of

knowledge translation (Curtis et al, 2016, 862). One such knowledge transfer and exchange

model is EMTReK, identifying six core components of knowledge transfer in the context of

palliative care (Payne et al, 2019). Highlights include ensuring the message outlines the

impact on user need, the message being accessible, credible and actionable, having an ability

to market the research findings through diverse activities including social media, and

12
considering the social, economic and cultural context to promote the possibility of a fertile

ground in contemplating the implementation of research findings in practice.

Pre-registration nursing programmes

Within the Future nurse: Standards of proficiency for registered nurses (NMC, 2018) there is

continual referral to evidence-based nursing to ensure the registrant will have the

underpinning knowledge to base their skills and nursing care on both theoretical and clinical

components. These Standards outline the importance of ‘being an accountable professional’,

providing clear direction to academic institutions that nursing students have a knowledge of

the methods related to evidence-based practice. The Future nurse: Standards of proficiency

for registered nurses (NMC, 2018) state that on entry to the NMC register each nursing

student should also be able to understand the process of research methods. It further

identifies the need for the registrant to be able to critically analyse, safely use and apply the

research findings to promote and inform the nurses practice (NMC, 2018) contributing to an

evidence-based practice approach to care delivery. A knowledge and application of research

methods is, therefore, important in pre-registration programmes of study.

The ability to scrutinise evidence and subsequently apply in practice is emphasized in the

theoretical components and procedural skills of the Future nurse: Standards of proficiency

for registered nurses (NMC, 2018). The proficiencies to be assessed in the clinical setting

clearly state that each nursing student on registration to NMC can safely demonstrate

evidence-based practice related to the seven identified learning platforms in the specific

communication and procedural skills and these form a component of the practice assessment

documents (NMC, 2018). Evidence-based nursing skills are also assessed in the university

13
setting through simulated practice and in academic assessments which focus on the student

demonstrating their ability to source, appraise and apply the evidence. Each new NMC

registrant should be able to provide the rationale for undertaking a skill in practice and use

evidence-based research to support their actions. This should contribute to registered nurses

demonstrating an approach which applies evidence-based knowledge and skills in every

clinical situation and the continued development of autonomous practitioners.

However, despite EBP being embedded in pre-registration programmes of study (Mackey and

Bassendowsk (2017) with convincing evidence that an EBP approach contributes to the

delivery of high quality patient care (Andre et al, 2016), nursing students commonly struggle

to recognise the relevance of EBP (Disler et al, 2019). Recent literature has identified nursing

students have a low level of knowledge of EBP (Al Qadire, 2019) and can experience

challenges in linking the relevance of EBP from learning at the academic institution to their

clinical practice with many not recognising the relevance of the theory to practice (Disler et

al, 2019). These insights highlight the importance of academic institutions continuing to

communicate the importance of EBP (Melnyk et al, 2018) and adopt innovative learning

methods with a focus on the application of theory to clinical practice (Oh and Yang, 2019).

This will enable students to increasingly recognise the relevance of an EBP approach in

enhancing their practice (Disler et al, 2019) and improving patient outcomes. Embedding

reflection within clinical practice should also equip the student to incorporate EBP into their

everyday nursing care (Florin et al, 2012).

14
Conclusion

EBP is a global phenomenon which promotes best practice, clinical effectiveness and quality

of care (Barker and Linsley, 2016). It is a relatively new concept in healthcare, yet there has

been a movement to recognise the value of using an EBP approach and embed this approach

in practice. The national agenda for EBP is at the forefront of healthcare (LoBiondo-Wood et

al, 2019), however, there continues to be low implementation of EBP in some healthcare

settings (Melnyk et al, 2018). The challenge is to adopt innovative

approaches to supporting nurses to implement EBP both in the academic institution and in

practice settings. As nurses evolve to become more autonomous in decision-

making and clinical judgment skills, the role must be developed to support nurses to search,

appraise, implement and evaluate evidence, and integrate this with clinical expertise, whilst

ensuring patients are increasingly empowered to be active participants in their care. The

context of the COVID-19 global pandemic adds a further emphasises on the need to ensure

practice is evidence-based as emerging research requires an urgent and rigorous appraisal

prior to the implementation of findings into practice. This will contribute to the development

of a profession which is becoming increasingly autonomous in decision-making and in their

significant contribution to maximising favourable patient outcomes.

15
 References

Al Khalaileh M, Al Qadire M, Musa AS, Al-Khawaldeh OA, Al Qudah H, Alhabahbeh, A.

2016. Closing the gap between research evidence and clinical practice: Jordanian nurses'

perceived barriers to research utilisation. J Education and Practice 7(8):52–57.

Al Qadire, M. 2019. Undergraduate student nurses’ knowledge of evidence-based practice: A

short online survey. Nurse Educ Today 72:1-5.

Andre B, Aune AG, Brænd JA. 2016. Embedding evidence-based practice among nursing

undergraduates: Results from a pilot study. Nurse Educ in Practice 18: 30e35.

Barker J, Linsley P. 2016. ‘Introduction: What is Evidenced-based Practice?’ In: Barker, J.,

Linsley, P. and Kane, R, editors. Evidence-Based Practice for Nurses and Healthcare

Professionals. London: Sage Publications, p.3-14.

Barker J, Ortega M. 2016. ‘Finding the evidence.’ in Barker, J., Linsley, P. and Kane, R,

editors. Evidence-Based Practice for Nurses and Healthcare Professionals. London: Sage

Publications, p.60-77.

Beyea SC, Slattery MJ. 2013. Historical Perspectives on Evidence-Based Nursing. Nurs Science

Quarterly 26(2):152-155.

Carley S, Horner D, Body R, Mackway-Jones K. 2020 Evidence-based medicine and COVID-19:

what to believe and when to change. Emerg Medicine 37:572-575.

16
Curtis K, Fry M, Shaban RZ, Considine J. 2016. Translating research findings to clinical nursing

practice. J Clinical Nurs 26:862-872.

Disler RT, White H, Franklin N, Armaric E, Jackson D. 2019. Reframing evidence-based practice

curricula to facilitate engagement in nursing students. Nurse Educ in Practice 41: 102650.

Edward K, and Mills C. (2013). Hospital Nursing Research Enhancement Model. The J

Continuing Education in Nurs 44(10):447-453.

Florin J, Ehrenberg A, Wallin L, Gustavsson P. 2012. Educational support for research

utilization and capability beliefs regarding evidence-based practice skills: a national survey of

senior nursing students. J Adv Nurs 68(4): 888e897.

Haines A, Kuruvilla S, Borcher M. 2004. Bridging the implementation gap between knowledge

and action for health. Bulletin to the World Health Organisation-Policy and

Practice 82(10):724-733.

Haynes B, Haines A. 1998. Barriers and brides to evidence-based clinical practice. Br Med J

317:273-276.

Ingersoll, GL. 2000. Evidence-Based Nursing: What It Is and What It Isn’t. Nurs Outlook

48(4):151-152.

17
International Council of Nurses. 2012. Closing the gap from evidence to practice

[internet]. Available

from https://www.nursingworld.org/~4aff6a/globalassets/practiceandpolicy/innovation--

evidence/ind-kit-2012-for-nnas.pdf (accessed 15 February 2021)

Kalavani K, Mohebbifar R, Fafieie S. 2019. Evidenced based practice among healthcare

providers: a cross sectional study. International J of Health Care Quality Assurance 32(5):867-

878.

Lake ET. 2020. How effective response to COVID-19 relies on nursing research. Respiratory

Nurs Health 43:213-214.

LoBiondo-Wood G, Haber J, Titler MG. 2019. Evidence-based Practice for Nursing and

Healthcare Quality Improvement. Missouri: Elsevier.

Mackey A, Bassendowski S. 2017. The History of Evidenced-Based Practice in Nursing

Education and Practice. J of Professional Nurs 33(1):51-55.

Mantzoukas S. 2008. A review of evidence-based practice, nursing research and reflection:

levelling the hierarchy. J of Clinical Nurs 17:214-223.

McCracken SG, Marsh JC. 2008. Practitioner Expertise in Evidence-Based Practice Decision

Making. Res in Social Work Practice 18(4):301-310.

18
Melnyk BM. 2017. The Difference Between What is Known and What is Done is Lethal:

Evidence-Based Practice is a Key Solution Urgently Needed. Worldviews on Evid-Based Nurs

14(1):3-4.

Melnyk BM, Fineout-Overholt E, Stetler C, Allen J. 2005. Outcomes and Implementation

Strategies form the First U.S. Evidenced Based Practice Leadership Summit. Worldviews on

Evid-Based Nurs 113-121.

Melnyk BM, Fineout-Overholt E, Stillwell SB. Williamson KM. 2010. The Steven Steps of

Evidence-Based Practice. American J of Nurs 110(1):51-53.

Melnyk MB, Gallagher-Ford L, Long EL, Fineout-Overholt E. 2014. The Establishment of

Evidence-Based Practice Competencies for Practicing Registered Nurses and Advanced

Practice Nurses in Read-World Clinical Settings: Proficiencies to Improve Healthcare Quality,

Reliability, Patient Outcomes, and Costs. Worldviews on Evid-Based Nurs 11(1):5-15.

Melnyk BM, Gallahger,-Ford L, Zellefrow C, Tucker S, Van Dromme L, Koshy Thomas B.

2018. Outcomes from the First Helene Fuld Health Trust National Institute for Evidence-Based

Practice in Nursing and Healthcare Invitational Expert Forum. Worldviews on Evid-Based

Nurs 15(1):5-15.

Nursing and Midwifery Council 2015. The Code: Professional standards of practice and

behaviour for nurses, midwives and nursing associates. London: Nursing and Midwifery

Council.

19
Nursing and Midwifery Council 2018. Future nurse: Standards of proficiency for registered

nurses. London: Nursing and Midwifery Council.

Oh EG, Yang YL. 2019 Evidence-based nursing education for undergraduate students: A

preliminary experimental study. Nurse Educ in Practice 38: 45–51.

Pawson R, Tilley N. (1997) Realistic Evaluation. London: Sage Publications.

Payne C, Brown MJ, Guerin S, Kernohan G. 2019. EMTReK: An Evidence-based Model for the

Transfer & Exchange of Research Knowledge-Five Case Studies in Palliative Care. Open Nurs

5:1-8.

Pooler, A. 2012. An Introduction to Evidence-based Practice in Nursing and

Healthcare. England: Pearson Education Limited.

Rees, C. 2010. ‘Understanding evidence and its utilization in nursing practice’, In: Holland, K.

and Rees, C, editors. Nursing: Evid-based Practice Skills. New York: Oxford University Press,

18-38.

Richardson SW, Wilson MC, Nishikawa J, Hayward RSA. 1995. The well-built clinical question:

a key to evidence-based decisions. American Coll of Physicians J Club 123:A12.

20
Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. 1996. Evidence-based

medicine: What It Is, and It Isn’t. Br Med J 312:71-72.

Saunders H, Vehvilainen-Julkunen K. 2016. The state of readiness for evidence-based practice

among nurses: An integrative review. International J of Nurs Stud 56:128-140.

Schlosser RW, Koul R, Costello J. 2007. Asking well-built questions for evidence-based practice

in augmentative and alternative communication. J of Communication Disorders 40:225-238.

Siminoff, LA. 2013. Incorporating patient and family preferences into evidence-based

medicine. Med Informatics and Decision Making 13(Suppl 3):2-7.

Smith, R. 2014. Evidence-based medicine-an oral history. Br Med J 348:1-3.

21