Evidence-based practice (EBP) has become a standard for the delivery of safe, quality care and the achievement of optimal patient outcomes. Patients, families, payers, and regulatory agencies expect that care delivery will be based on the most current and best available evidence. Numerous models and frameworks exist to guide practitioners in delivering EBP. Nurse and health care staff participation in intensive EBP immersion programs is growing rapidly, and undergraduate and graduate nursing programs are embedding EBP in their curricula.
Despite this important progress, bringing evidence to routine clinical care remains an elusive, challenging, and often underresourced goal.1 To address this well-recognized gap, research and quality improvement (QI) efforts have focused on implementation and translation models and strategies that can promote the successful uptake and sustainability of EBP. This article introduces a new series focused on the implementation step of EBP. Using the research literature on implementation science, models, and strategies, we will present case studies that are designed to inform readers and practitioners about how to minimize barriers and leverage facilitators (such as unit champions or mentors) to achieve success in implementing and sustaining EBP changes.
This new series builds on the previous EBP series published in AJN from 2009 to 2011. That series describes the seven steps of EBP, giving nurses the knowledge and skills needed to implement EBP at their institutions. It also contains some of the most popular and downloaded AJN articles, reflecting a sense of urgency among nurses, other health care practitioners, and organizations to use the best evidence to provide safe and high-quality care.
EBP: STEP BY STEP
The seven steps of EBP are well established in nursing and other disciplines and present a standardized approach to EBP. As described in the previous AJN series, they are:
- Step Zero: Cultivate a spirit of inquiry and an EBP culture
- Step 1: Ask clinical questions in PICO-T (population, intervention, comparison, outcome, and, if appropriate, time) format
- Step 2: Search for the best evidence
- Step 3: Critically appraise the evidence and recommend a practice change
- Step 4: Integrate the evidence with clinical expertise and patient/family preferences and values
- Step 5: Evaluate the outcomes of the practice decisions or changes based on the evidence
- Step 6: Disseminate the results of the EBP change
The widespread endorsement of these EBP steps, along with numerous models and resources, has led to the establishment of EBP competencies for health care providers.2, 3 These competencies reflect a minimum set of attributes, such as knowledge, skills, attitudes, abilities, and judgment, that enable a clinician to meet practice standards. Examples of EBP competencies include understanding how to formulate a clinical question in PICO-T format, critically appraising the evidence, and incorporating patient preferences into the implementation of a practice change.
IMPLEMENTATION—THE MOST CHALLENGING STEP
Great progress has been made in recent years in standardizing EBP. However, Step 4, the implementation step, in which evidence is integrated with clinician expertise and patient/family preferences and values, remains perhaps the most challenging. The reasons for this are multifactorial and interrelated: the involvement of numerous and diverse stakeholders, resource intensity (such as pulling staff away from patient care to lead the practice change, or the necessity of certain equipment and supplies for the practice change), a fast-paced and constantly changing hospital environment, evolving regulatory and payer demands, resistance to change, and lack of time and effort dedicated to “hard-wiring” evidence-based change over time (making the change sustainable and embedded in the system and culture).
Implementation of EBP is thus a complex and resource-intensive step, and the time and effort needed are often underestimated and underresourced. Recognition of the research-to-practice gap was described in 2000 by Balas and colleagues, who published a landmark paper in which they noted it takes an average of 17 years to translate a scientific discovery (such as an evidence-based recommendation) into real-world clinical practice and settings.4 Since this gap was made transparent, an entire scientific field—implementation or translation science—has emerged, providing models, insight, and strategies to inform and expedite the uptake of EBPs.5 Nilsen published a summary of implementation models and theoretical approaches, categorizing them as follows: models that direct or guide the process of research into practice, frameworks for understanding and/or exploring influences on implementation, classic theories largely related to change processes, specific implementation models, and evaluation approaches.6 In this EBP series, we'll use the concepts and features of several of these models, suggesting a simplified approach to implementation to guide nurses and other health care practitioners.
SUCCESSFUL STRATEGIES
We will guide readers to think of implementation of an initiative as occurring in phases of change, using select strategies best aligned with each phase. Strategies will address organizational culture, leadership structure and support, EBP resources, patient populations and settings, technical and data needs, educational needs, reminders and reinforcement, mentors and champions, QI tools, and data trending, among other topics. Early phases of change might address potential obstacles such as staff support for the status quo, beliefs that the current practice is working fine, and a general lack of recognition or openness to exploring a practice change. Later phases of change might reflect a readiness for a practice change, widespread rollout, and efforts to institute sustainable change over time.
For each phase of the implementation step, we will introduce strategies to keep the initiative moving toward a successful practice change. These strategies will be based on the work of several researchers, including Grol and Grimshaw,7 Grimshaw and colleagues,8 Powell and colleagues,9 and Cullen and colleagues.10, 11 The two papers coauthored by Jeremy Grimshaw propose that EBP changes need to be supported by an assessment of the barriers and facilitators to applying the evidence in a specific context or setting; the best evidence should then be used to select the implementation strategies.7, 8 These strategies include, among others, the use of educational materials, reminders, computerized decision support, performance feedback, opinion leaders, multiprofessional collaboration, and mass media campaigns.7
The paper by Powell and colleagues is based on a compilation of 73 implementation strategies identified by an expert panel.9 The panel believed these strategies to be useful building blocks for the multifaceted, multilevel strategies used in the implementation of EBP changes in mental health service settings (transferrable to other specialties) and for comparative effectiveness research.
Finally, to guide our discussion of implementation strategies, we'll turn to the work of Cullen and Adams, who recommend strategies aligned with the phases of implementation and target two distinct groups: clinicians, organizational leaders, and key stakeholders, and the organizational system of support.10 They also highlight the importance of change agent roles, such as those of change champions, EBP mentors, and opinion leaders.10 This work led to the production and publication of a useful resource guide—Evidence-Based Practice in Action: Comprehensive Strategies, Tools, and Tips from the University of Iowa Hospitals and Clinics—which includes 63 implementation strategies, each presented with a definition, benefits, procedure, case example, and supporting references.11
SUSTAINABLE CHANGE
Implementation is a major step in the EBP process, but because its challenges are often underappreciated, implementation efforts are often underresourced. It's therefore not surprising that the translation of evidence into practice is often a slow process that may never fully occur or cannot be sustained. In this series, we will focus on the development of competency among nurses, nursing leaders, and other health care providers in implementing EBP. We will use published models and strategies to help readers better understand how to successfully tackle the implementation of EBP. Moreover, we'll illustrate how others have applied these implementation strategies—with various outcomes, whether successful, partially successful, or stalled and delayed—by inviting EBP experts to tell their stories. These examples will be presented along with our commentary, in which we'll detail the principles and strategies used, highlighting those that can best lead to sustainable change.
REFERENCES
1. Li SA, et al. Organizational contextual features that influence the implementation of evidence-based practices across healthcare settings: a systematic integrative review Syst Rev 2018 7 1 72
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2. Albarqouni L, et al. Core competencies in evidence-based practice for health professionals: consensus statement based on a systematic review and Delphi survey JAMA Netw Open 2018 1 2 e180281
- Cited Here
3. Melnyk BM, et al. The first U.S. study on nurses’ evidence-based practice competencies indicates major deficits that threaten healthcare quality, safety, and patient outcomes Worldviews Evid Based Nurs 2018 15 1 16 25
- Cited Here
4. Balas EA, Boren SA Managing clinical knowledge for health care improvement Yearb Med Inform 2000 1 65 70
- Cited Here
5. Dearing JW, Kee KF Brownson RC Historical roots of dissemination and implementation in science Dissemination and implementation research in health: translating science to practice 2012 New York, NY Oxford University Press 55 71
- Cited Here
6. Nilsen P Making sense of implementation theories, models and frameworks Implement Sci 2015 10 53
- Cited Here
7. Grol R, Grimshaw J From best evidence to best practice: effective implementation of change in patients’ care Lancet 2003 362 9391 1225 30
- Cited Here
8. Grimshaw JM, et al. Knowledge translation of research findings Implement Sci 2012 7 50
- Cited Here
9. Powell BJ, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project Implement Sci 2015 10 21
- Cited Here
10. Cullen L, Adams SL Planning for implementation of evidence-based practice J Nurs Adm 2012 42 4 222 30
- Cited Here
11. Cullen L, et al. Evidence-based practice in action: comprehensive strategies, tools, and tips from the University of Iowa Hospitals and Clinics. Indianapolis, IN: Sigma Theta Tau International; 2018.
- Cited Here
Supplemental Digital Content
FAQs
What are some strategies to implement EBP? ›
Implementation strategies for promoting EBP fall into seven general categories: leadership, coaching, communication, rein- forcements, recognition, measurement, and reporting. Different strategies may be appropriate at each stage of change.
Where can I find EBP nursing articles? ›The best place to start your search or Evidence-Based Practice articles for Nursing is in the CINAHL Complete database. CINAHL stands for Cumulative Index to Nursing and Allied Health Literature and is the premier database for finding Nursing literature.
What are the 6 steps in implementing EBP into clinical practice? ›- Ask a question. ...
- Look for evidence. ...
- Analyze the evidence. ...
- Integrate your finding. ...
- Evaluate the outcome. ...
- Share the information.
To effectively apply the EBP process, in addition to the basic skills required to undertake nursing work, a nurse must have the ability to: (1) identify knowledge gaps, (2) formulate relevant questions, (3) conduct an efficient literature search, (4) apply rules of evidence to determine the validity of studies, (5) ...
What is one of the biggest barriers to implementation of EBP? ›[15] conducted a study on 356 primary care nurses and identified the main barriers to EBP, namely organizational issues regarding cost, changes in work, time limitations, patient compliance, and lack of motivation to use EBP.
When implementing EBP what is first step of the process? ›Steps in the Process
Start with the patient; determine a clinical problem or question that arises from the care of the patient. Construct a well-built clinical question derived from the case. Select the appropriate resource(s) and conduct a search.
When we apply EBP to management decisions, the four main sources of evidence used are scientific literature, organizational data, stakeholders' concerns, and professional expertise.
What are the 3 sources of EBP? ›Sources for Evidence-Based Practice (EBP)
These sources include, peer-reviewed journal articles, randomized clinical trials, and clinical trials.
Major evidence based practice databases
Cochrane Library. Key source of information in evidence-based medicine (EBM). JBI EBP Database (Ovid)
Step 2: Search for and collect the most relevant best evidence. Stillwell, S. B., Fineout-Overholt, E., Melnyk, B. M., & Williamson, K. M. (2010). Evidence-based practice, step by step: searching for the evidence.
What are the 5 A's of EBP? ›
What does EBP mean in practice? Evidence-based practice is a process that involves five distinct steps which we call the five 'A's: Ask, Access, Appraise, Apply, Audit.
What are the 3 components of evidenced based practice explain each component? ›Evidence-based practice includes the integration of best available evidence, clinical expertise, and patient values and circumstances related to patient and client management, practice management, and health policy decision making. All three elements are equally important.
What is the best explanation for the way evidence-based practice EBP in nursing? ›videnced-based practice (EBP) is applying or translating research findings in our daily patient care practices and clinical decision-making. EBP also involves integrating the best available evidence with clinical knowledge and expertise, while considering patients' unique needs and personal preferences.
How does evidence-based practice influence and improve nursing care? ›It combines nurses' expertise with current research to develop evidence-based procedures. EBP can empower nurses and other clinicians by helping establish effective treatment and patient care practices. Rather than providing one-size-fits-all care, nurses can create a care plan that works for each patient.
What are evidence-based prevention strategies? ›Evidence-based prevention strategy (HPIO, 2013). Programs, policies or other strategies that have been evaluated and demonstrated to be effective in preventing health problems based upon the best-available research evidence, rather than upon personal belief or anecdotal evidence.
What challenges could be faced in clinical practice when implementing EBP? ›However, unreliable evidence, lack of knowledge and skill, time mismanagement, lack of motivation, the decision to adopt and implement an innovation made by higher up in the hierarchy than the innovation's target users and lack of commitment are the challenges of implementation of evidence-based practice.
Which factors would you consider when implementing EBP in a nursing unit? ›More specifically, research has shown that factors limiting the extent of EBP include lack of knowledge and skills, insufficient time to find research reports, difficulty in understanding research reports, lack of resources, limited support, lack of financial, material and human resources and inadequate training in ...
What is the second step in implementation of evidence-based practice? ›The second step in implementation of evidence-based practice includes systematic review.
What is step 4 in the EBP process? ›The final step of the EBP process requires you to make a clinical decision.
What is the second step in evidence-based practice? ›Evidence-Based Practice. Step 1: Frame Your Clinical Question. Step 2: Gather Evidence. Step 3: Assess the Evidence. Step 4: Make Your Clinical Decision.
What are the top three most important aspects of evidence-based practice? ›
Evidence-based practice is a process that draws information from current scientific evidence to build care delivery strategies. It is ultimately a holistic process that integrates three key elements: scientific research, a health care professional's own expertise, and the perspective and preferences of the patient.
What is an example of evidence-based practice in nursing? ›Key examples of evidence-based practice in nursing include: Giving oxygen to patients with COPD: Drawing on evidence to understand how to properly give oxygen to patients with chronic obstructive pulmonary disease (COPD).
What are the 4 elements of evidence? ›The CERR framework helps students synthesize science investigations, data analysis, and scientific concepts by having them focus on four elements: Claim, Evidence, Reasoning, and Rebuttal.
What are EBP principles? ›A fundamental principle of evidence-based practice is that the quality of our decisions is likely to improve the more we make use of trustworthy evidence – in other words, the best available evidence.
What are the 2 types of nursing research? ›Nursing Resources : Types of Research within Qualitative and Quantitative.
What is the name of the two databases recommended for use in nursing research? ›Our recommendations for conducting nursing research is to use always use the PubMed and CINAHL databases. Each of these databases incorporates its own subject headings, such as MeSH for PubMed, and uses a different syntax for keyword searching.
What are 2 sources that are available to obtain healthcare statistics? ›The main sources of health statistics are surveys, administrative and medical records, claims data, vital records, surveillance, disease registries, and peer-reviewed literature. We'll take a look into these sources, and the pros and cons of using each to create health statistics.
What is step 4 of the key steps for the practice of EBM? ›Step 4: Applying the evidence
This approach allows a “therapeutic alliance” to be formed with the patient and the parents and is consistent with the fundamental principle of EBM: the integration of good evidence with clinical expertise and patient values.
Improvement Goal: All chronic illness patients will have a Self-Management (SM) Action Plan informed by and including all the 5 A's elements (Assess, Advise, Agree, Assist, Arrange). The 5 A's Behavior Change Model is intended for use with the Improving Chronic Illness Care Chronic Care Model (CCM).
What are the 8 EBP principles for effective intervention? ›- Eight Evidence-Based Principles for Effective Interventions.
- 1) Assess Actuarial Risk/Needs.
- 2) Enhance Intrinsic Motivation.
- 3) Target Interventions.
- a) Risk Principle.
- b) Criminogenic Need Principle.
- c) Responsivity Principle.
- e) Treatment Principle.
What are the 5 A's nursing? ›
Successful intervention begins with identifying users and appropriate interventions based upon the patient's willingness to quit. The five major steps to intervention are the "5 A's": Ask, Advise, Assess, Assist, and Arrange.
What are the 4 general components of a nursing assessment? ›...
The four medical assessments regularly performed on patients are:
- Initial assessment. ...
- Focused assessment. ...
- Time-lapsed assessment. ...
- Emergency assessment.
Strong clinical reasoning and decision-making skills and research competency are essential components needed to understand and implement EBP in nursing.
How does using EBP improve patient outcomes? ›Better patient outcomes
Improved healing and shorter recovery times are other improvements in patient outcomes because of EBP. Nursing practices have changed, including previous practices like performing daily dressing changes and putting new moms on bed rest after delivering their baby.
How Does EBP Improve Patient Care? EBP improves patient care because nurses use the most current scientific information to care for and treat individuals or communities. In addition, EBP uses data that matches a patient's condition so nurses can pinpoint the ideal care strategies, thus increasing the rate of recovery.
How does using evidence-based practice improve patient outcomes? ›The intended effect of EBP is to standardize healthcare practices to science and best evidence and to reduce illogical variation in care, which is known to produce unpredictable health outcomes. Development of evidence-based practice is fueled by the increasing public and professional demand for accountability in ...
What is the impact of evidence-based practice in nursing field? ›Evidence-based practice in nursing can help patients receive better care and a more accurate diagnosis. This approach uses risk assessment to find the best treatment plans and offers patients and medical staff many benefits.
Why is it important to use evidence-based practice in nursing? ›Why is Evidence-Based Practice Important? EBP is important because it aims to provide the most effective care that is available, with the aim of improving patient outcomes. Patients expect to receive the most effective care based on the best available evidence.
What is the goal of evidence-based practice in nursing? ›EBP is a process used to review, analyze, and translate the latest scientific evidence. The goal is to quickly incorporate the best available research, along with clinical experience and patient preference, into clinical practice, so nurses can make informed patient-care decisions (Dang et al., 2022).
What are the four 4 levels of preventive strategies? ›These preventive stages are primordial prevention, primary prevention, secondary prevention, and tertiary prevention.
Which strategies promote evidence-based practice? ›
Implementation strategies for promoting EBP fall into seven general categories: leadership, coaching, communication, rein- forcements, recognition, measurement, and reporting. Different strategies may be appropriate at each stage of change.
What are the six prevention strategies? ›strategies are 1) Information Dissemination, 2) Education, 3) Alternative, 4) Problem Identification and Referral, 5) Community-Based Process, and 6) Environmental.
Where can I find free nursing articles? ›- Advanced Emergency Nursing Journal. ...
- Advances in Neonatal Care. ...
- American Journal of Nursing (AJN) ...
- Birth: Issues in Perinatal Care. ...
- Clinical Journal of Oncology Nursing. ...
- Clinical Nurse Specialist: The Journal for Advanced Nursing Practice. ...
- Critical Care Nurse. ...
- Evidence Based Nursing.
Evidence-based journal articles will include a review of current research related to the article's subject matter. If an article includes a literature review or a discussion of current research as a foundation for the resulting information presented in the article, it likely qualifies as evidence-based.
What nursing journals do you read to find out about nursing research? ›- American Nurse Today. ...
- Applied Nursing Research. ...
- Clinical Simulation in Nursing. ...
- International Journal of Nursing. ...
- Journal of Advanced Nursing. ...
- Lippincott Nursing. ...
- Medscape Nurses Journal. ...
- Minority Nurse Magazine.
Key examples of evidence-based practice in nursing include: Giving oxygen to patients with COPD: Drawing on evidence to understand how to properly give oxygen to patients with chronic obstructive pulmonary disease (COPD).
What are the most reliable evidence-based sources? ›Peer-reviewed journals are the best source of research evidence. They're where health researchers publish results of research studies testing the effectiveness of drugs, interventions, and practices.
What is the best evidence-based research? ›Best evidence includes empirical evidence from randomized controlled trials; evidence from other scientific methods such as descriptive and qualitative research; as well as use of information from case reports, scientific principles, and expert opinion.
How can I get full articles for free? ›- Sci-Hub. Sci-Hub is a website link with over 64.5 million academic papers and articles available for direct download. ...
- Z-Library. ...
- Library Genesis. ...
- Unpaywall. ...
- GetTheResearch.org. ...
- Directory of Open Access Journals (DOAJ) ...
- Researcher. ...
- Science Open.
Nursing School Books:
In most cases, you can probably expect to pay about $300-700 for books each semester. You can cut these costs by really looking for deals online, and then also reselling them after the semester is over. You can learn more by reading about how to save money on nursing school textbooks.
What is best available evidence in EBP? ›
Systematic Reviews and Meta Analyses
Well done systematic reviews, with or without an included meta-analysis, are generally considered to provide the best evidence for all question types as they are based on the findings of multiple studies that were identified in comprehensive, systematic literature searches.
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”.
How do you evaluate EBP? ›- Ask a clinical question.
- Obtain the best research literature.
- Critically appraise the evidence.
- Integrate the evidence with clinical expertise, patient preferences.
- Evaluate the outcomes of the decision.
| Title | SJR | |
|---|---|---|
| 1 | Journal of the American Medical Directors Association | 2.023 Q1 |
| 2 | Clinical and Translational Immunology | 1.771 Q1 |
| 3 | Journal of Pain and Symptom Management | 1.527 Q1 |
| 4 | International Journal of Nursing Studies | 1.470 Q1 |
The sources for research problems included in this text are (1) clinical practice, (2) researcher and peer interactions, (3) literature review, (4) theories, and (5) research priorities identified by funding agencies and specialty groups.
What is the impact factor of the American Journal of Nursing? ›