Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice 4th Edition

Book Preface

Like many of you, I have appreciated healthcare through a range of experiences and perspectives. As someone who has delivered healthcare as a combat medic, paramedic, nurse, and trauma surgeon, the value of evidencebased practice is clear to me. Knowing what questions to ask, how to carefully evaluate the responses, maximize the knowledge and use of empirical evidence, and provide the most effective clinical assessments and interventions are important assets for every healthcare professional. The quality of U.S. and global healthcare depends on clinicians being able to deliver on these and other best practices. The Institute of Medicine (now the National Academy of Medicine) calls for all healthcare professionals to be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics. Although many practitioners support the use of evidence-based practice, and there are indications that our patients are better served when we apply evidence-based practice, there are challenges to successful implementation. One barrier is knowledge. Do we share a standard understanding of evidence-based practice and how such evidence can best be used? We need more textbooks and other references that clearly define and provide a standard approach to evidence-based practice. Another significant challenge is the time between the publication of research findings and the translation of such information into practice. This challenge exists throughout public health. Determining the means of more rapidly moving from the brilliance that is our national medical research to applications that blend new science and compassionate care in our clinical systems is of interest to us all. As healthcare professionals who currently use evidence-based practice, you recognize these challenges and others. Our patients benefit because we adopt, investigate, teach, and evaluate evidence-based practice. I encourage you to continue the excellent work to bring about greater understanding and a more generalizable approach to evidence-based practice. Richard H. Carmona, MD, MPH, FACS 17th Surgeon General of the United States

OVERVIEW OF THIS BOOK The evidence is irrefutable: evidence-based practice (EBP) is key to meeting the quadruple aim in healthcare. It improves the patient experience through providing quality care, enhances patient outcomes, reduces costs, and empowers clinicians, leading to higher job satisfaction. Although there are many published interventions/treatments that have resulted in positive outcomes for patients and healthcare systems, they are not being implemented in clinical practice. In addition, qualitative evidence is not readily incorporated into care. We wrote this book to address these issues and many others as well. We recommend that learners read this book, then read it again, engage in the online resources, the appendices, the glossary . . . then read it again. It is chock-full of information that can help learners of all disciplines, roles and educational levels discover how to be the best clinicians. We hope you find that EBP pearl that is just the right information you need to take the next step in your EBP journey to deliver the best care! Purpose The purpose of Evidence-Based Practice in Nursing and Healthcare has never changed. The purpose of this edition, as with the last three, is to incorporate what we have learned across the years to provide resources and information that can facilitate clinicians’ ready translation of research findings into practice, as well as their use of practice data to improve care and document important outcomes, no matter the clinician’s healthcare role. Each edition has provided additional features and resources for readers to use in their journey to become evidence-based clinicians. Since the first book was published, there has been some progress in the adoption of EBP as the standard of care; however, there is still much work to be done for EBP to the paradigm used in daily clinical decision making by point-of-care providers. Clinicians’ commitment to excellence in healthcare through the intentional integration of research findings into practice while including patients in decisions remains a daunting endeavor that will take anywhere from years to decades. Therefore, increased efforts across the healthcare industry are required to provide a culture that fosters empowered point-of-care clinicians with the knowledge, skills, attitudes, and resources they need to deliver care that demonstrates improved healthcare system, clinician, and patient outcomes. We will always believe that anything is possible when you have a big dream and believe in your ability to accomplish that dream. It was the vision of transforming healthcare with EBP, in any setting, with one client– clinician encounter at a time and the belief that this can be the daily experience of both patients and care providers, along with our sheer persistence through many “character-building” experiences during the writing and editing of the book, that culminated in this user-friendly guide that aims to assist all healthcare professionals in the delivery of the highest quality, evidence-based care. The fourth edition of this book has been revised to assist healthcare providers with implementing and sustaining EBP in their daily practices and to foster a deeper understanding of the principles of the EBP paradigm and process. In working with healthcare systems and clinicians throughout the nation and globe and conducting research on EBP, we have learned more about successful strategies to advance and sustain evidence-based care. The new material throughout the book, including new chapter material, a unit-by-unit EBP example, new chapters, EBP competencies, and tools to advance EBP, are included so that clinicians can use them to help with daily evidence-based decision making. Worldview A solid understanding of the EBP paradigm, or worldview, is the first mastery milestone for readers of this EBP book. The next milestone is using the paradigm as the foundation for making clinical decisions with patients. This worldview frames why rigorously following the steps of the EBP process is essential, clarifies misperceptions about implementing evidence-based care, and underpins practical action strategies that lead to sustainable evidence implementation at the point of care. It is our dream that the knowledge and understanding gained from thoughtfully and intentionally engaging the contents of this book will help clinicians across the country and globe accelerate adoption of the EBP paradigm until evidence-based care is the lived experience for clinicians, patients, and health professions students across various healthcare settings and educational institutions. NEW FEATURES AND RESOURCES FOR THIS EDITION The book contains vital, usable, and relatable content for all levels of practitioners and learners, with key exemplars that bring to life the concepts within the chapters. Each unit now begins with “Making Connections: An EBP Exemplar.” This unfolding case study serves as a model or example of EBP in real-life practice. We recommend that learners read each unit exemplar before they engage in that unit’s content; the characters in the healthcare team in the exemplar use the information within the unit’s chapters to carry out the steps of EBP, leading to a real evidence-based change to improve the quality and safety of care. These characters may be fictional, but the exemplar is based on an important quality indicator (i.e., hospital falls) and an actual synthesis of published research that offers the opportunity for readers to better understand how they can use EBP in their clinical practice or educational setting to improve outcomes. Readers may wish to refer back to the exemplar as they are reading through the chapters to see how the healthcare team used the information they are learning. Furthermore, it is recommended that readers follow the team as they make evidence-based decisions across the units within the book. There are online resources as well as resources within the appendices of the book that will be used in the exemplar, offering readers the opportunity to see how the team uses these resources in evidence-based decision making. Our unit-ending feature, “Making EBP Real: A Success Story,” has been updated and continues to provide real-life examples that help readers to see the principles of EBP applied. Readers can explore a variety of ways that the steps of the EBP process were used in real EBP implementations. Clinicians who desire to stimulate or lead change to a culture of EBP in their practice sites can discover in both of these unit-level features how functional models and practical strategies to introduce a change to EBP can occur, including overcoming barriers in implementing change, evaluating outcomes of change, and moving change to sustainability through making it standard of care. To help recognize that knowledge and understanding of EBP terms and language is essential to adopting the EBP paradigm, in this edition, we added EBP Terms to Learn that features key terms at the beginning of each unit and chapter. Readers can review terms in the glossary before reading the chapters so that they can readily assimilate content. Furthermore, we have provided learning objectives at the unit and chapter level to continue to reinforce important concepts and offer the opportunity for readers to quickly identify key chapter content. When readers come across bolded terms within the chapter, they are encouraged to go to the glossary at back of the book to further explore that concept. EBP Fast Facts is an important feature at the end of each chapter that we retained for this edition, offering readers some of the most important pearls of wisdom from the chapter. These elements in our fourth edition will help learners master the terminology of EBP and identify important content for developing EBP competence. Finally, for faculty, there is new content in the chapter on teaching EBP in academic settings that can help educators to parse teaching EBP across academic learning degrees. Educators are encouraged to review the online resources that can facilitate teaching EBP in both academic and clinical settings. Further resources for all readers of the book include appendices that help learners master the process of evidence-based change, such as rapid critical appraisal checklists (be sure to check online on for Word versions of RCA checklists for readers to use), sample instruments to evaluate EBP in both educational and clinical settings, a template for asking PICOT questions, and more. Some appendices appear online only on , including an appraisal guide for qualitative evidence, an ARCC model EBP mentor role description, and examples of a health policy brief, a press release, and an approved consent form for a study. More details about the great resources available online can be found below. ORGANIZATION OF THE BOOK As in prior editions, the Table of Contents is structured to follow the steps of EBP: Chapters 1 to 3 in Unit 1 encompass steps 0, 1, and 2 of the EBP process. This unit gets learners started by building a strong foundation and has significant content updates in this new edition. Chapters 4 to 8 in Unit 2 delve deeply into step 3 of the EBP process, the four-phased critical appraisal of evidence. In this edition, Chapters 7 and 8 were moved into Unit 2 to better align the steps of the EBP process with the chapters, including the important consideration of patient concerns, choices, clinical judgment, and clinical practice guidelines in the recommendation phase of critical appraisal. In Unit 3, Chapters 9 to 12 move the reader from recommendation to implementation of sustainable practice change. To facilitate understanding how to implement evidence-based change, Chapter 11 was added to describe the context, content, and outcome of implementing EBP competencies in clinical and academic settings. Unit 4 promotes creating and sustaining a culture of EBP. In this unit, we included new content and resources in the chapters on teaching EBP in educational and healthcare settings (Chapters 16 and 17, respectively). Educators can be most successful as they make the EBP paradigm and process understandable for their learners. Unit 5 features a new Chapter 19 on health policy. In today’s political climate, nurses and healthcare professionals need to understand how to ensure sustainable change through influencing the formulation of policies governing healthcare, fully supported by the latest and best evidence. This new chapter joins Chapter 20 on disseminating evidence. In Unit 6, Chapter 21 now combines two previous chapters’ content on generating evidence through qualitative and quantitative research, greatly streamlining the material for enhanced understanding of important concepts and making the information more accessible to learners. Chapter 23 provides updated information on ethics in EBP and research generation. The glossary is one of the best resources within this book. Readers are encouraged to use it liberally to understand and master EBP language, and thereby enhance their fluency. Often, educators teach by following chapters in a textbook through their exact sequence; however, we recommend using chapters of this fourth edition that are appropriate for the level of the learner (e.g., associate degree, baccalaureate, master’s, doctoral). For example, we would recommend that associate degree students benefit from Units 1, 3, and 4. Curriculum for baccalaureate learners can integrate all units; however, we recommend primarily using Units 1 to 4, with Unit 5 as a resource for understanding more about research terminology and methods as readers learn to critical appraise evidence. Master’s and doctoral programs can incorporate all units into their curricula. Advanced practice clinicians and doctorally-prepared clinical experts will be able to lead in implementing evidence in practice, thoughtfully evaluate outcomes of practice, and move to sustainable change, whereas those learning to become researchers will understand how to best build on existing evidence to fill gaps in knowledge with valid, reliable research that is clinically meaningful.