Nursing Professional Development Evidence-Based Practice

Issues of Concern

PICOT Question

The foundation of EBP is developing a PICOT question, which identifies the terms to search for the best evidence to answer a burning clinical question.[3] This framework breaks down the question into keywords. P stands for patient/population; I refers to Intervention; C stands for comparison/control; O stands for the outcome; and T refers to the time frame. When looking at the population, it is important to consider the relevant patients, including age, sex, geographic location, or specific characteristics that would be important to the question.

The intervention examines the management strategy, diagnostic test, or exposure of interest. There may not always be a comparison in the PICOT analysis. If there is, this would be a control or alternative management strategy compared to the intervention. Outcomes should be measurable, as the best evidence comes from rigorous studies with statistically significant findings. The time factor looks at what period should be considered. PICOT questions can evaluate various clinical domains, such as intervention, diagnosis, etiology, prevention, prognosis/prediction, quality of life, or therapy. Writing a good PICOT question for an effective search and making robust, evidence-based recommendations to improve care and outcomes is critical.

The Evidence

While there are multiple ways to evaluate and rank evidence in the literature, 1 of the most widely used in nursing in the United States uses 7 levels. These 7 accepted levels of evidence are assigned to studies based on the methodological quality of the design, validity, and application to patient care. In addition, these levels provide the “grade” or strength of the recommendation.

• Level I – Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs) or evidence-based clinical practice guidelines based on a systematic review of RCTs or 3 or more RCTs of decent quality with comparable results.
• Level II - Evidence obtained from at least 1 well-designed RCT
• Level III – Evidence obtained from well-designed controlled trials without randomization
• Level IV - Evidence from well-designed case-control or cohort studies       
• Level V -Evidence from a systematic review of descriptive and qualitative studies (meta-syntheses)
• Level VI – Evidence from a single or descriptive or qualitative study              
• Level VII -Evidence from the opinion of authorities or reports of expert committees.

Roe-Prior discussed the strength of evidence by comparing it to a murder trial. A suspect’s conviction should require more than the testimony of 1 witness. If a crowd of people all agree that the suspect was the perpetrator or there was DNA evidence, that evidence is much stronger. Studies without a comparative group, methodologically weak, or poorly controlled studies could be likened to 1 witness. Roe Prior encouraged individuals to look at non-nursing research findings since research centered on other disciplines, like psychology or education, could be appropriate.

Other frameworks for identifying levels of evidence include The Oxford Centre for Evidence-Based Medicine Levels of Evidence and Burns framework.[4] The Oxford Centre describes 5 levels with various subparts as listed here:

• 1a           Systematic review of RCTs
• 1b           Individual RCT
• 2a           Systematic review of cohort studies
• 2b           Individual cohort study
• 2c           Outcomes research
• 3a           Systematic review of case-control studies
• 3b           Individual case-control study
• 4             Case series
• 5             Expert opinion

Burns uses 3 levels to differentiate the strength of the evidence presented:

• I             At least 1 RCT with proper randomization
• II.1         Well-designed cohort or case-control study
• II.2         Time series comparisons or dramatic results from uncontrolled studies
• III           Expert opinions

Roe Prior outlined guidelines for the literature review.[5] Use keywords from the PICOT question to perform simple, then more complex searches in reliable databases, preferably limited to the past 5 years, although landmark studies can be included. Limit the review to peer-reviewed and research articles and use caution when including only full-text articles, as some key papers may be missed. Check the validity of any online sources and use original research where possible. Remember that textbooks are often obsolete by publication date, and books are considered secondary sources.

The Cochran Library comprises multiple databases with systematic reviews on healthcare topics. Using the Preferred Reporting Items for Systemic Reviews and Meta-Analysis (PRISMA) Guidelines to evaluate a systemic review or meta-analysis can help the individual ensure the findings are valid and reliable. Findings from the literature review are put into an evidence-based table. There are various formats for these tables, but they all include information about the source, design, sample, summary of findings, and level of evidence for each article.

EBP Models

The most frequently used EBP models are the Iowa Model, the Advancing Research and Clinical Practice through Close Collaboration (ARCC) Model, the Star Model of Knowledge Transformation, and the John Hopkins Nursing Evidence-based Practice (JHNEBP) Model. The IOWA Model focuses on implementing evidence-based practice changes, and the ARCC model on advancing EBP in systems by using EBP mentors and control and cognitive behavioral therapies. The Star Model provides a framework for approaching EBP, and the John Hopkins Model is a problem-based approach to clinical decision-making accompanied by tools to guide its use.

The Iowa model was revised and updated in 2017 by the Iowa Model Collaborative.[6] Changes in the healthcare environment, such as a focus on implementation science and emphasis on patient engagement, prompted a reevaluation, revision, and validation of the model. This model differs from other frameworks by linking practice changes within the system. Model changes included an expansion of piloting, implementation, patient engagement, and sustaining change. Support for the ARCC Model was outlined in an article by Melnyk and colleagues in a study exploring how an evidence-based culture and mentorship predicted EBP implementation, nurse job satisfaction, and intent to stay.[7] This model involves assessing organizational culture and readiness for EBP using EBP mentors who work with clinicians to facilitate the implementation of evidence-based practice.

Lee and Park completed a concept analysis of feelings of entrapment during the COVID-19 pandemic using the ACE Star Model. The ACE Star model is used to understand the cycle, nature, and characteristics of knowledge used in various aspects of EBP. The model consists of five steps: discovery research, evidence summary, translation to guidelines, practice integration, and process and outcome evaluation. The JHNEBP Model is a problem-solving approach to clinical decision-making with user-friendly tools for individual or group use. It is explicitly designed to meet the needs of the practicing nurse and uses a 3-step process called PET: practice question, evidence, and translation. In a study conducted by Speroni and colleagues on using EBP models across the United States, this was the second most frequently used model by the 127 nurse leaders who responded to the questionnaire.[8]

EBP Competence and Implementation

NPD practitioners are instrumental in implementing EBP. Harper and colleagues conducted a national study to examine NPD practitioners’ beliefs and competencies, frequency of implementing EBP, and perceptions of organizational culture and readiness for EBP.[9] The Association for Nursing Professional Development (ANPD) collaborated with the Center for Transdisciplinary Evidence-Based Practice at The Ohio State University to explore the NPD practitioners’ beliefs and experiences with EBP, as well as to explore relationships among NPD practitioner characteristics and healthcare organizational outcomes such as nursing sensitive quality indicator scores and core measures. A total of 253 NPD practitioners from 43 states and the District of Columbia participated in this study. Findings indicated that NPD practitioners need to develop personal competence in EBP, become involved in shared governance, collaborate with others to facilitate the implementation of EBP and become comfortable with using quality metrics to demonstrate the effectiveness of NPD activities.

The Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare of the Ohio State University developed an Evidence-Based Practice Certificate approved by the Accreditation Board for Specialty Nursing Certification in 2018. There are 24 EBP competencies: 13 for practicing registered nurses and an additional 11 competencies for practicing advanced practice nurses and EBP experts. These competencies are outlined in an article by Melnyk et al.[10] Although these competencies were initially written for nurses, they apply to other interprofessional team members who have received advanced EBP education. In addition to demonstrating completion of the EBP coursework, applicants must demonstrate current EBP knowledge through content review and successful testing and submit a portfolio to review that shows an EBP practice change project before receiving a certificate.

In 2020, ANPD worked with the Helene Fuld Health Trust National Institute for Evidence-Based Practice in Nursing and Healthcare to develop a Nursing Professional Development EBP Academy curriculum.[11] The program consists of live webinars, 26 asynchronous modules, and the completion of an EBP change initiative/project. This Academy curriculum aligns with the educational requirements of the EBP Certificate. There are numerous resources available for NPD practitioners on evidence-based practice. There is a peer-reviewed journal published by Sigma Theta Tau International, Worldviews on Evidence-based Nursing, which includes original research with recommendations applicable to use as best practices to improve patient care. ANPD has a year-long evidence-based fellowship consisting of theory and completing an evidence-based project. The Nursing Professional Development Evidence-Based Practice Academy is a 12-month mentored program to guide the NPD practitioner through creating PICOT questions, gathering and critically appraising literature, and EBP implementation, evaluation, dissemination, and sustainment. Participation in the EBP Academy enhances the evidence-based competencies of NPD practitioners to enable them to fulfill their role as champions of scientific inquiry and mentor other healthcare professionals in implementing EBP practices.

EBP in Action

One organization evaluated evidence-based practice in clinical practice after nurses attended a formal evidence-based practice course.[12] Nurses who attended the organization’s EBP course were invited to participate in focus groups to provide additional qualitative data. Data from 2 focus groups highlighted the impact of the EBP course, areas for further development, and potential barriers to the use of EBP. The nurses indicated that the course changed their thinking and enhanced patient care. They stated there was a need for mentoring and that time was a significant barrier to EBP. That information was used by organizational leadership to help identify areas needing consideration for educational offerings and support mechanisms.

Another large academic medical center evaluated the implementation of an EBP program.[13]  They noted that although their approach to educating professional staff on EBP provided initial benefits, maintaining the gains over 1 year was difficult. The “train-the-trainer” model the team envisioned was unrealistic, as the participants did not feel well-versed enough to teach others. They concluded that future efforts require attention to participant feedback and the implementation of measures to decrease the barriers to implementing EBP.

Numerous examples exist in the literature of individuals/organizations using evidence-based principles to develop programs in various settings. McGarity and colleagues examined frontline nurse leaders who were oriented only to on-the-job training, questioning whether their level of competence was improved with a professional development program.[14] This project used a pre-and post-survey design to evaluate a leadership development curriculum. The intervention was an evidence-based leadership curriculum that consisted of twelve 4-hour classes. The fact that all 38 frontline nurse leaders who participated in this project improved their competencies reinforced the need for formal professional development. The outcome of this training program showed that all 38 frontline nurse leaders who attended it were more confident in their skills and improved their competence in leading effective teams, reinforcing the need for education.

Ydrogo and colleagues discussed a multifaceted approach to strengthening nurses’ EBP capabilities in a comprehensive cancer center.[15] They created a program to promote a spirit of inquiry, strengthen EBP facilitators, overcome barriers to EBP, and expand nurses’ knowledge of EBP. The program consisted of a blended interactive seminar with leader-directed discussion on promoting a spirit of inquiry, a 7-week course on retrieving, reading, analyzing, and evaluating research papers, and a monthly challenge emailed to staff, posted to the hospital intranet, and included in a weekly nursing newsletter. Both leadership and staff gained increased confidence and a foundation to initiate 2 research projects and 1 EBP project shortly after completing the course.

Integrating EBP into an emergency department nurse residency program was the subject of an article by Asselta.[16] In addition to extensive training in the core competencies of emergency nursing, this 6-month program included exemplars in EBP and its positive impact on patient care or emergency room workflow. One of the requirements for this program was for the nurses to participate in developing an EBP project specific to emergency nursing practice. An example of a project comparing intravenous push medications versus intravenous piggyback medications was shared. This project demonstrated the advantages of the intervenous push route of administration, which yielded significant cost savings for the organization.

Pediatric nurses were the focus of a project described by Cline et al.[17] They evaluated nurses’ perceptions of barriers, facilitators, confidence, and attitudes toward research and evidence-based practice. A total of 369 nurses completed the survey during the baseline data collection period, 288 nurses completed the 6-month survey, and 284 nurses completed the 12-month survey. The results indicated that implementation of a curriculum focused on research and EBP might be most successful when implemented with the availability of mentors in a research-supported environment, with grant funding support for novice researchers, and with an ample amount of time allotted to complete a research study.

Many nurses work in long-term care. Higuchi and colleagues described a study that examined the impact of EBP practice change in 10 long-term care (LTC) settings in Canada.[18] Introducing and sustaining practice changes that enhance the quality of care is a significant challenge in LTC facilities. A full-day workshop that included identifying success stories, describing current practice challenges, building a case for change, seizing the moment, and identifying an action plan was presented at each site. Participants completed a questionnaire at the end of the workshop, and all participants were invited to participate in semi-structured interviews 5 months after the program. The benefits identified in the follow-up interviews were initiating the change process and enhancing team collaboration. This study demonstrated that an interactive workshop had important positive effects on LTC staff.

Clinical nurse educators were the focus of a study by Dagg and colleagues.[19] Centralization of a new clinical nurse educator (CNE) role created role confusion and poor role outcomes. An evidence-based quality improvement project was completed to integrate the ANPD practice model and transition to the practice fellowship program. An ANPD competency assessment survey tool was selected because it included information specific to the CNE role expectations. The nurse-sensitive indicators selected were fall rates and indwelling urinary catheter rates. Self-assessed competencies and nurse-sensitive quality outcomes of the CNEs were measured before and after the ANPD practice model was integrated into their daily practice. There were only 5 CNEs who completed both the pre-and post-assessment, but results supported that CNEs influenced patient quality outcomes and improved their self-assessed competency.

Phan and Hampton described an evidence-based project that promoted civility in the workplace by addressing bullying in new graduate nurses using simulation and cognitive rehearsal.[20] Nurse bullying has been a problem for many years, and this can threaten the safety of patients, nurses, and organizations. This study used a mixed-methods, quasi-experimental design. The NPD Scope and Standards were used to assess, plan, implement, and evaluate the project. In addition to the demographic data collected at baseline, participants completed the Clark Workplace Civility Index (CWCI) at baseline and 3 times after the intervention (immediately, 2.5 months, and 5 months). The sample included 36 new graduate nurses. The intervention consisted of 2.75 hours of didactic, polling, reflection, simulation role-play, and debriefing. The training was developed virtually on the Zoom platform, and breakout rooms facilitated small group discussions and role-playing. Although there was no statistically significant increase in civility scores, the qualitative data indicated the participants could apply knowledge and skills from the intervention to improve communication, peer relationships, teamwork, patient safety, and care.

Clinical Significance

Evidence-based practice falls under the NPD practitioner's champion for scientific inquiry role. According to the NPD scope and standards of practice, the NPD practitioner promotes a spirit of inquiry and assists with generating and disseminating new knowledge. The NPD practitioner also uses evidence to advance the specialty of NPD and guide practice. The ultimate goal is to promote the quality of care for the healthcare consumer. Competencies for scholarly inquiry include championing inquiry, generating new knowledge, and integrating the best available evidence into practice. In addition, the standards include disseminating inquiry findings, including evidence-based practice and quality improvement activities, through educational and professional development activities.

Enhancing Healthcare Team Outcomes

The healthcare consumer is the ultimate recipient of NPD practice. Therefore, NPD practitioners collaborate with the interprofessional team to ensure quality care, leading to optimal care outcomes and population health. Interprofessional partnerships are critical factors in achieving safe, effective, high-quality care.