Strategies for Promoting Evidence-Based Nursing Practice

Criticism of Evidence-Based Practice in Nursing

Criticisms of the EBP movement have been both practical and conceptual. This section focuses on some of the constructive criticisms of EBP that need to be considered as nursing moves toward this method of practice. One of the criticisms is that nursing lacks the research evidence for implementing an EBP. EBP requires synthesizing research evidence from randomized controlled trials (RCTs), and these types of studies are limited in nursing. However, the number of RCTs conducted to test nursing interventions has greatly increased in the 2000s. Also, some of the systematic reviews and meta-analyses conducted in nursing indicate there is inadequate research evidence to support using certain nursing interventions in practice (Pearson et al., 2007). Bolton, Donaldson, Rutledge, Bennett, and Brown (2007, p. 123S) conducted a review of “systematic/integrative reviews and meta-analyses on nursing interventions and patient outcomes in acute care settings.” Their literature search covered 1999 to 2005 and identified 4000 systematic/integrative reviews and 500 meta-analyses covering seven topics selected by the authors: developmental care of neonates and infants, symptom management, elder care, caregivers, pressure ulcer prevention/ treatment, incontinence, and staffing. The authors found limited association between nursing interventions/ processes and patient outcomes in acute care settings. Their findings included the following:

Extensive evidence has been generated through nursing research, but there is a need for additional studies focused on determining the effectiveness of nursing interventions on patient outcomes (Bolton et al., 2007; Craig & Smyth, 2007; Pearson et al., 2007). Identifying the areas where research evidence is lacking is an important first step in developing the evidence needed for practice. Well-designed experimental and quasi-experimental studies are needed to test selected nursing interventions and to use that understanding to generate sound evidence for practice. Nurses also need to be more active in conducting quality syntheses (systematic review, meta-analyses, and integrative reviews) of research evidence in selected areas (Pearson et al., 2007). The next section of this chapter provides guidelines for different types of research synthesis.

Another concern is that the research evidence is generated based on population data and then is applied in practice to individual patients. Sometimes it is difficult to transfer research knowledge to individual patients who respond in unique ways (Biswas et al., 2007). More work is needed to promote the use of evidence-based guidelines with individual patients. Patients who have poor outcomes when managed according to an evidence-based guideline need to be reported and, if possible, their circumstances should be published as a case study.

Best research evidence is generated mainly from quantitative, outcomes, and intervention research methodologies (Craig & Smyth, 2007; Sackett et al., 2000) with limited focus on the contributions of qualitative research and theories. Nurse researchers need to ensure that their studies are linked to theory with an explicit study framework and that theory is used to interpret the findings (Schmelzer, 2007). Qualitative research also makes a contribution to the research evidence in selected areas. Currently, qualitative researchers have developed metasummary and metasynthesis processes to synthesize the findings from qualitative studies (Sandelowski & Barroso, 2007; Whittemore, 2005). The contribution that qualitative research will make to EBP is still evolving.

Another criticism of the EBP movement is that the development of evidence-based guidelines has led to a “cookbook” approach to health care. Health professionals are expected to follow these guidelines in their practice as developed (Pearson et al., 2007). However, the definition of EBP describes it as the conscientious integration of best research evidence with clinical expertise and patient values and needs. Thus, the clinician has a major role in determining how the best research evidence will be implemented when caring for an individual patient. For example, a nurse practitioner uses the national evidence-based guidelines for the treatment of patients with hypertension (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [JNC 7]) but also makes clinical decisions based on the individual patients’ needs and values. If the patient has a dry, persistent, irritating cough when taking angiotensin converting enzyme (ACE) inhibitor medications, this type of medication will not be used to manage the patient’s high blood pressure if at all possible. If a patient refuses a treatment based on cultural or religious reasons, these reasons will be taken into consideration in developing the patient’s treatment plan. Evidence-based guidelines provide the gold standard for managing a particular health condition, but the health care provider and patient individualize the treatment plan (Sackett et al., 2000).

Another criticism is that some health care agencies and administrators do not provide the resources necessary for nurses to implement EBP. Their lack of support might include the following: (1) not providing access to research journals and other sources of synthesized research findings and evidence-based guidelines, (2) limited time to make research-based changes in practice, (3) limited authority to change patient care based on research findings, (4) no funds to support research-based changes for practice, and (5) no rewards for providing evidence-based care to patients and families (McCaughan, Thompson, Cullum, Sheldon, & Thompson, 2002; Parahoo, 2000; Pettengill, Gillies, & Clark, 1994; Retsas, 2000). Some nurses lack the knowledge to implement EBP and need support from expert nurse researchers and clinicians. Clinical agencies could ensure that these resources are provided to practicing nurses to expand their understanding and use of research evidence in practice. The success of EBP is determined by all involved including health care agencies, administrators, nurses, physicians, and other health care professionals. We must all take an active role in ensuring that the health care provided patients and families is based on the best research available.

Benefits of Evidence-Based Practice in Nursing

The benefits of EBP are improved outcomes for patients, providers, and health care agencies. The best research evidence has been synthesized in many areas by teams of expert researchers and clinicians and then used to develop strong evidence-based guidelines for practice. These guidelines indicate the best treatment plan or gold standard for patient care in a selected area to promote quality health outcomes. Health care providers have easy access to numerous evidence-based guidelines to assist them in making their best clinical decisions. These evidence-based guidelines are communicated by presentations and publications and can be easily accessed online. They help students, novice nurses, and advanced practice nurses (APNs) to provide the best possible care (Kania-Lachance, Best, McDonah, & Ghosh, 2006). Expert APNs access evidence-based guidelines to ensure their patient care is based on the most recent research evidence available. They also use them to manage patients with uncommon conditions. EBP ensures that nurses and other health care professionals are making clinical decisions based on research evidence and not on tradition or trial and error.

Health care agencies are highly supportive of EBP because it promotes quality, cost-effective care for patients and families and meets accreditation requirements. The Joint Commission revised their accreditation criteria in 2002 to emphasize patient care quality achieved through EBP. Approximately 25% of the chief nursing officers (CNOs) identified the movement toward evidence-based nursing practice as their number one priority (Nursing Executive Center, 2005).

Many CNOs and health care agencies are trying either to obtain or to maintain magnet status that documents the excellence of nursing care in an agency. The health care agencies that currently have magnet status can be viewed online at the American Nurses Credentialing Center (ANCC) website at www.nursecredentialing.org/magnet/index.html (ANCC, 2007). The Magnet Status Program, provided through ANCC, recognizes evidence-based practice as a way to improve the quality of patient care and revitalize the nursing environment. Select criteria for magnet status, which require health care agencies to promote the conduct of research and the use of research evidence in practice, are presented next.

In working toward an EBP, nurses are encouraged to embrace the benefits of EBP, to use the evidence-based guidelines available, and to support or participate in the research needed to determine the effectiveness of certain nursing interventions.

Guidelines for Implementing and Evaluating a Systematic Review

A systematic review is a structured, comprehensive synthesis of quantitative studies in a particular health care area to determine the best research evidence available for expert clinicians to use to promote an EBP. Systematic reviews are conducted to synthesis research evidence from numerous, high-quality quantitative studies with similar methodologies, such as RCT (Craig & Smyth, 2007). Systematic reviews are often conducted by a team or panel of experts whose goal is to provide the best research knowledge for evidence-based guidelines. The following steps may help you to conduct a systematic review of research evidence:

These guidelines were adapted from Craig and Smyth’s (2007, p. 188) Evidence-Based Practice Manual for Nurses. They also provided the following steps for critically appraising the quality of a systematic review:

The critique of an evidence-based guideline should also include an assessment of how current the guideline is. This leads to the question, how quickly do systematic reviews become out of date? Shojania et al. (2007) conducted a survival analysis on 100 quantitative systematic reviews published from 1995 to 2005 “to estimate the average time to changes in evidence that are sufficiently important to warrant updating systematic reviews” (Shojania et al., 2007, p. 224). They found the average time before a systematic review should be updated was 5.5 years. However, 23% of the reviews signaled a need for updating within 2 years, and 15% needed updating within 1 year. Shojania et al. (2007) stressed that high-quality systematic reviews that were directly relevant to clinical practice require frequent updating to stay current.

The Cochran Collaboration and library include extensive collections of systematic reviews and meta-analyses (www.cochrane.org/); however, a subscription is required to access these reviews. Many University libraries and some health care agency libraries provide access to the Cochran Collaboration and library holdings. A journal titled Medical Care Research & Review includes a variety of research syntheses. The Bolton et al. (2007) review introduced earlier identified 4000 systematic/integrative reviews. There are numerous nursing and medical sources of systematic reviews, but it is important for you to know the steps of the systematic review process and be able to critically appraise the quality of the reviews. Only quality, current, systematic reviews provide the best research evidence to support protocols, algorithms, or policies for nursing practice. Chobanian et al. (2003) conducted an excellent systematic review to determine the best research evidence available for assessing, diagnosing, and managing hypertension. This systematic review, which included several meta-analyses and integrative reviews, was used to develop the JNC 7 evidence-based guideline for hypertension. The 2003 systematic review was an update of the review conducted in 1997 that provided the JNC 6 guidelines for the management of hypertension. The JNC 7 evidence-based guideline is presented later in this chapter.

Conducting Meta-Analysis to Synthesize Research Evidence

Meta-analysis statistically pools the results from previous studies into a single quantitative analysis, which then provides the highest level of evidence for an intervention’s efficacy (Conn & Rantz, 2003; LaValley, 1997). This approach allows the application of scientific criteria to factors such as sample size, level of significance, and variables examined. Meta-analysis can generate the following: (1) an extremely large, diverse sample that is more representative of the target population than the samples of the individual studies; (2) the determination of the overall significance or probability of pooled data from quality, confirmed studies; and (3) the average effect size determined from several quality studies, which indicates the efficacy of a treatment or intervention or the strength of relationships among the variables (Conn & Rantz, 2003; Craig & Smyth, 2007).

Meta-analyses make it possible for researchers to be objective rather than subjective when evaluating research findings for practice. The strongest evidence for using an intervention in practice is generated from a meta-analysis of multiple, controlled studies. However, the conduct of a meta-analysis depends on the quality, clarity, and completeness of information presented in studies. Beck (1999) provided a list of information that needs to be included in a research report if a meta-analysis is to be conducted (Table 27-1). Craig and Smyth (2007) provided guidelines for conducting a meta-analysis, which includes the following steps:

Mahon, Yarcheski, Yarcheski, Cannella, and Hanks (2006) conducted a meta-analysis to determine the predictors for loneliness during adolescence. They clearly stated their study objective, which was “to identify predictors for loneliness in adolescents through a comprehensive review of the literature and to use quantitative meta-analysis to determine the magnitude of the relationships between each predictor and loneliness” (Mahon et al., 2006, p. 308). The investigators reviewed 242 studies that were published or unpublished between 1980 and 2004. Of the studies reviewed, 95 met the inclusion criteria, and the researchers isolated 11 predictors of loneliness. Mahon et al. (2006) identified the following results and conclusions:

This meta-analysis has a clearly stated objective or focus and includes a detailed description of the process used to search the literature. Mahon et al. (2006) also recognized five specific criteria that they used for including studies in the meta-analysis. The results identified the magnitude of the relationships among the variables, and the conclusions indicated the current status of the research evidence.

Conducting Integrative Reviews of Research

An integrative review of research includes the identification, analysis, and synthesis of research findings from independent quantitative and sometimes qualitative studies to determine the current knowledge (what is known and not known) in a particular area. An integrative review of research should be held to the same standards of clarity, rigor, and replication as primary research. Thus, an integrative review needs to include the following steps:

In the past, most integrative reviews of research have included quantitative studies, but some major contributions can be made to the body of knowledge in a selected area by examining qualitative studies. Dixon-Woods et al. (2001) identified the following contributions to integrative reviews by qualitative studies:

It is essential that the integrative reviews of research be published. The Annual Review of Nursing Research, books, research journals, and clinical journals provide excellent sources for the publication of integrative reviews. The publication of the integrative review needs to include (1) the purpose and scope of the review, (2) a description of the literature search, (3) a discussion of the adequacy of the number of studies included in the review, (4) criteria used to evaluate the scientific quality of the studies, and (5) a clear presentation of the findings from the review (Gates, 2002; Stetler et al., 1998).

Gage, Everett, and Bullock (2006) conducted an integrative review of the qualitative research on parenting. They summarized their integrative review process in the following abstract.

Conducting Metasummary and Metasynthesis of Qualitative Research

Qualitative research synthesis is the process and product of systematically reviewing and formally integrating the findings from qualitative studies (Sandelowski & Barroso, 2007). Qualitative research synthesis includes two categories: qualitative metasummary and qualitative metasynthesis. Recently two noted qualitative researchers, Sandelowski and Barroso (2007), published the Handbook for Synthesizing Qualitative Research to facilitate the synthesis of qualitative studies. They identified the following guidelines for conducting qualitative research synthesis:

Sandelowski and Barroso (2007) provided a detailed description of these steps and explained how to implement them.

Stetler Model of Research Utilization to Facilitate Evidence-Based Practice

An initial model for research utilization in nursing was developed by Stetler and Marram in 1976 and expanded and refined by Stetler in 1994 and 2001 to promote EBP for nursing. The Stetler (2001) model (Figure 27-1) provides a comprehensive framework to enhance the use of research evidence by nurses to facilitate an EBP. The research evidence can be used at the institutional or individual level. At the institutional level, study findings are synthesized and the knowledge generated is used to develop or refine policy, procedures, protocols, or other formal programs implemented in the institution. Individual nurses, such as practitioners, educators, and policy makers, summarize research and use the knowledge to influence educational programs, make practice decisions, and have an impact on political decision making. Stetler’s model is included in this text to encourage individual nurses and health care institutions to use research evidence to encourage the development of EBP. The following sections briefly describe the five phases of the Stetler model: (1) preparation, (2) validation, (3) comparative evaluation/decision making, (4) translation/application, and (5) evaluation.

Iowa Model of Evidence-Based Practice

Nurses have been actively involved in conducting research, synthesizing research evidence, and developing evidence-based guidelines for practice. Thus, nurses have a strong commitment to EBP and can benefit from the direction provided by the Iowa model to expand their research-based practice. The Iowa Model of Evidence-Based Practice provides direction for the development of EBP in a clinical agency. Titler and colleagues initially developed this EBP model in 1994 and revised it in 2001. In a health care agency, there are triggers that initiate the need for change, and the focus should always be to make changes based on best evidence. These triggers can be problem focused and evolve from risk management data, process improvement data, benchmarking data, financial data, and clinical problems. The triggers can also be knowledge focused, such as new research findings, changes in national agencies or organizational standards and guidelines, an expanded philosophy of care, or questions from the institutional standards committee. The triggers are evaluated and prioritized based on the needs of the clinical agency. If a trigger is considered an agency priority, a group is formed to search for the best evidence to manage the clinical concern (Titler et al., 2001).

In some situations, the research evidence is inadequate to make changes in practice, and additional studies are needed to strengthen the knowledge base. Sometimes the research evidence can be combined with other sources of knowledge (theories, scientific principles, expert opinion, and case reports) to provide fairly strong evidence for developing research-based protocols for practice (Figure 27-2). The strongest evidence is generated from meta-analyses of several controlled clinical trials and systematic reviews that usually include meta-analyses, integrative reviews, and individual studies. Thus, systematic reviews provide the best research evidence for developing evidence-based guidelines. The research-based protocols or evidence-based guidelines would be pilot-tested on a particular unit and then evaluated to determine the impact on patient care. If the outcomes are favorable from the pilot test, the change would be made in practice and monitored over time to determine its impact on the agency environment, staff, costs, and the patient and family (Titler et al., 2001). If an agency strongly supports the use of the Iowa model, implements patient care based on the best research evidence, and monitors changes in practice to ensure quality care, the agency is promoting EBP.

Application of the Iowa Model of Evidence-Based Practice

Preparing to use research evidence in practice raises some important questions. Which research findings are ready for use in clinical practice? What are the most effective strategies for implementing research-based protocols or evidence-based guidelines in a clinical agency? What are the outcomes from using the research evidence in practice? Do the risk management data, process improvement data, benchmarking data, or financial data support making the change in practice based on the research evidence? Is the research-based change proposed an agency priority?

We suggest that effective strategies for using research evidence in practice will require a multifaceted approach that takes into consideration the evidence available, attitudes of the practicing nurses, the organization’s philosophy, and national organizational standards and guidelines. In this section, the steps of the Iowa model (Titler et al., 2001) guide the use of a research-based intervention in a hospital to facilitate EBP. Research knowledge about the effects of heparin flush versus saline flush for irrigating peripheral intravenous (PIV) catheters is evaluated for use in nursing practice. This knowledge is used to develop a research-based protocol for making a change in practice, and outcome measures are identified for determining the effectiveness of this change in practice. Nurses making the switch from heparin flush to saline flush using a research-based protocol are providing evidence-based care (Craig & Smyth, 2007; Pearson et al., 2007; Sackett et al., 2000).

Development of Evidence-Based Guidelines

Once a significant health topic or condition has been selected, guidelines are developed to promote effective management of this health condition. Since the 1980s, the Agency for Healthcare Research and Quality (AHRQ) has had a major role in identifying health topics and developing evidence-based guidelines for these topics (www.ahrq.gov). In the late 1980s and early 1990s, a panel or team of experts was often charged with developing the AHRQ’s guidelines. The AHRQ solicited the members of the panel, who usually included nationally recognized researchers in the topic area; expert clinicians, such as physicians, nurses, pharmacists, and social workers; health care administrators; policy developers; economists; government representatives; and consumers. The group designated the scope of the guidelines and conducted extensive reviews of the literature including relevant meta-analyses, integrative reviews of research, individual studies, and theories.

The best research evidence available was synthesized to develop recommendations for practice. Most of the evidence-based guidelines included meta-analyses, integrative reviews, and multiple individual studies. The guidelines were examined for their usefulness in clinical practice, their impact on health policy, and their cost-effectiveness (Stone et al., 2002). Often consultants, other researchers, and additional expert clinicians are asked to review the guidelines and provide input. Based on the experts’ critique, the AHRQ revised and packaged the guidelines for distribution to health care professionals. Some of the first guidelines focuses on the following health care problems: (1) acute pain management in infants, children, and adolescents; (2) prediction and prevention of pressure ulcers in adults; (3) urinary incontinence in adults; (4) management of functional impairments with cataracts, (5) detection, diagnosis, and treatment of depression; (6) screening, diagnosis, management, and counseling about sickle cell disease; (7) management of cancer pain; (8) diagnosis and treatment of heart failure; (9) low back problems; and (10) otitis media diagnosis and management in children.

Currently, standardized guideline development ranges from a structured process like the one just discussed to a less structured process in which a guideline might be developed by a health care organization, health care plan, or professional organization. The AHRQ initiated the National Guideline Clearinghouse (NGC) in 1998 to store the evidence-based practice guidelines. Initially the NGC had 200 guidelines, but now the collection has expanded to more than 1500 clinical practice guidelines from numerous professional organizations, health care agencies, health care plans, and other groups in the United States and other countries. The NGC is a publicly available database of evidence-based clinical practice guidelines and related documents. It provides Internet users with free online access to guidelines at www.guideline.gov. The NGC is updated weekly with new content that the AHRQ produces in partnership with the American Medical Association (AMA) and the American Association of Health Plans (AAHP) (now the American’s Health Insurance Plans). The key components of the NGC and its user-friendly resources can be found on the AHRQ website at www.guideline.gov/about/about.aspx. Some of the critical information on the NGC is provided here so you will know what is available and how to access the NGC resources:

Other features include the following:

Criteria for submitting clinical practice guidelines and the application process are provided online. Listed here are the criteria that an evidence-based guideline must meet to be submitted to the NGC:

The NGC provides varied audiences with an easy-to-use mechanism for obtaining objective, detailed information on clinical practice guidelines. In addition, the NGC provides a list of the guidelines that are in the process of being developed (www.guideline.gov/browse/workqueue.aspx). The audiences that use the NGC are identified as follows:

In addition to the evidence-based guidelines, the AHRQ has developed many tools to assess the quality of care that is provided by the evidence-based guidelines. You can search the AHRQ website (www.qualitytools.ahrq.gov) for an appropriate tool to measure a variable in a research project or to evaluate care in a clinical agency (AHRQ, 2007b).

There are also a variety of professional organizations, health care agencies, universities, and other groups that provide evidence-based guidelines for practice. Some of these websites are identified as follows:

Implementing the JNC 7 Evidence-Based Guideline in Practice

Evidence-based guidelines have become the standards for providing care to patients in the United States and other nations. A few nurses have participated in committees that have developed these evidence-based guidelines, and many advanced practice nurses (nurse practitioners, clinical nurse specialists, nurse midwives, and nurse anesthetists) are using these guidelines in their practices. An evidence-based guideline for the assessment, diagnosis, and management of high blood pressure is provided as an example. This guideline was developed from the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) and was published in the Journal of the American Medical Association (Chobanian et al., 2003). The National Heart, Lung, and Blood Institute within the National Institutes of Health (NIH) of Department of Health and Human Services (DHHS) developed educational materials to communicate the specifics of this guideline to promote its use by health care providers. This guideline is presented in Figure 27-4 and provides clinicians with direction for the following: (1) classification of blood pressure as normal, prehypertension, hypertension stage 1, and hypertension stage 2; (2) conduct of a diagnostic workup of hypertension; (3) assessment of the major cardiovascular disease risk factors; (4) assessment of the identification of causes of hypertension; and (5) treatment of hypertension. An algorithm provides direction for the selection of the most appropriate treatment method(s) for each patient diagnosed with hypertension (U.S. DHHS, NIH, National Heart, Lung, and Blood Institute, 2003).

Advanced practice nurses and registered nurses need to assess the usefulness and quality of each evidence-based guideline before they implement it in their practice. Figure 27-5 presents the Grove Model for Implementing Evidence-Based Guidelines in Practice. In this model, nurses identify a practice problem, search for the best research evidence to manage the problem in their practice, and note that an evidence-based guideline has been developed. The quality and usefulness of the guideline must be assessed by the health care provider before it is used in practice, and that involves examining the following: (1) the authors of the guideline, (2) the significance of the health care problem, (3) the strength of the research evidence, (4) the link to national standards, and (5) the cost-effectiveness of using the guideline in practice. The quality of the JNC 7 guideline is examined as an example using the four criteria identified in the Grove model (see Figure 27-5). The authors of the JNC 7 guideline were expert researchers, clinicians (medical doctors), policy developers, health care administrators, and the National High Blood Pressure Education Program Coordinating Committee. These individuals and committee have the expertise to develop an evidence-based guideline for hypertension.

Hypertension is a significant health care problem because it affects

The research evidence for the development of the JNC 7 guideline was extremely strong. The JNC 7 report included 81 references; 9 (11%) of the references were meta-analyses and 35 (43%) were randomized controlled trials (experimental studies). Thus, 44 (54%) sources are considered extremely strong research evidence. The other references were strong and included retrospective analyses or case-controlled studies, prospective or cohort studies, cross-sectioned surveys or prevalence studies, and clinical intervention studies (nonrandom) (Chobanian et al., 2003). The JNC 7 provides the national standard for the assessment, diagnosis, and treatment of hypertension. The recommendations from the JNC 7 are supported by DHHS and disseminated through NIH publication no. 03–5231. Use of the JNC 7 guideline in practice is cost-effective because the clinical trials have shown that “antihypertensive therapy has been associated with 35% to 40% mean reductions in stroke incidence; 20% to 25% in myocardial infarction [MI]; and more than 50% in HF [heart failure]” (Chobanian et al., 2003, p. 2562).

The next step is for advanced practice nurses and physicians to use the JNC 7 guideline in their practice (see Figure 27-5). Health care providers can assess the adequacy of the guideline for their practice and modify the hypertension treatments based on the individual health needs and values of their patients. The outcomes for the patient, provider, and health care agency need to be examined. The outcomes would be recorded in the patients’ charts and possibly in a database and would include the following: (1) blood pressure readings for patients; (2) incidence of diagnosis of hypertension based on the JNC 7 guidelines; (3) appropriateness of the treatments implemented to manage hypertension; and (4) the incidence of stroke, MI, and HF over 5, 10, 15, and 20 years. The health care agency outcomes include the access to care by patients with hypertension, patient satisfaction with care, and the cost related to diagnosis and treatment of hypertension and the complications of stroke, MI, and HF. This EBP guideline will be refined in the future based on clinical outcomes, outcome studies, and new controlled clinical trials. The use of this evidence-based guideline and additional guidelines promote an EBP for advanced practice nurses and physicians (see Figure 27-5).

Evidence-Based Practice Centers

In 1997, the AHRQ launched its initiative to promote evidence-based practice by establishing 12 evidence-based practice centers (EPCs) in the United States and Canada.

Under the EPC Program, the AHRQ awards 5-year contracts to institutions to serve as EPCs. The EPCs review all relevant scientific literature on clinical, behavioral, organizational, and financial topics to produce evidence reports and technology assessments. These reports are used to inform and develop coverage decisions, quality measures, educational materials, and tools, guidelines, and research agendas. The EPCs also conduct research on methodology of systematic reviews. The AHRQ developed the following criteria as the basis for selecting a topic to be managed by an EPC:

The AHRQ website (www.ahrq.gov/clinic/epc) provides the names of the EPCs and the focus of each center. This site also provides a link to the evidence-based reports produced by these centers. These EPCs have had an important role in the development of evidence-based guidelines since the 1990s and will continue to make significant contributions to EBP in the future. They are also involved in the development of measurement tools to examine the outcomes from EBP. We hope that the content in this chapter increases your understanding of EBP, the synthesis of best research evidence, and the sources for evidence-based practice guidelines. We encourage you to take an active role in moving nursing toward an EBP that improve outcomes for patients, health care professionals, and health care agencies.

• Evidence-based practice (EBP) is the conscientious integration of best research evidence with clinical expertise and patient values and needs in the delivery of quality, cost-effective health care. Best research evidence is produced by the conduct and synthesis of numerous, high-quality studies in a health-related area.

• The criticisms and benefits for EBP were described. The benefits of EBP are that the standards for hospital accreditation by the Joint Commission support EBP as does the Magnet Hospital Program managed by the American Nurses’ Credentialing Center.

• Guidelines are provided for conducting the research syntheses processes of systematic review, meta-analysis, integrative review, metasummary, and metasynthesis. These synthesis processes are used to determine the best research evidence in a selected area and the quality of the research evidence available for practice.

• Two models have been developed to promote EBP in nursing: the Stetler Model of Research Utilization to Facilitate EBP (Stetler, 2001) and the Iowa Model of Evidence-Based Practice to Promote Quality of Care (Titler et al., 2001).

• The phases of the revised Stetler model are (1) preparation, (2) validation, (3) comparative evaluation/decision making, (4) translation/application, and (5) evaluation.

• The Iowa model provides guidelines for implementing patient care based on the best research evidence and monitoring changes in practice to ensure quality care. The Iowa model is used to direct the implementation of an EBP protocol for using saline flush versus heparinized saline flush to irrigate intravenous catheters in adults.

• The process for developing evidence-based guidelines was described, and an example of the guideline for assessment, diagnosis, and treatment of hypertension was provided.

• The Grove Model for Implementing Evidence-Based Guidelines in Practice is provided to assist nurses in determining the quality of evidence-based guidelines and the steps for using these guidelines in practice.

• An excellent source for evidence-based guidelines is the National Guideline Clearinghouse that was initiated by the Agency for Healthcare Research and Quality (AHRQ) in 1998.

• Evidence-based practice centers (EPCs), created by the AHRQ in 1997, have had an important role in the conduct of research, development of systematic reviews, and formulation of evidence-based guidelines in selected practice areas.

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