Nurses use a variety of sources of information in making nursing care decisions for their older patients. Unfortunately, these sources of information rarely include scientific research findings (Estabrooks, 1998). Nurses have advocated for research-based practice for years (Mion, 1998). This goal has been difficult to achieve. The evidencebased practice movement is consistent with the discipline's goal of providing research-based care to patients (Ti tier & Mentes, 1999). This article briefly describes the history of evidence-based practice (EBP) and an overview of the typical activities associated with EBP. In this article, the meaning of evidence in EBP is examined, and clinical expertise and the nursing perspective in relationship to EBP is discussed.
Figure 1. Evidence- based practice in nursing.
HISTORY OF EVIDENCE-BASED PRACTICE
Evidence-based practice has a long history beginning in the 17th century with the scientific revolution. During that time, Syndenham proposed interventions with observable merit should replace practices based entirely on deduction (Estabrooks, 1998). Two hundred years later, a novel by Eliot described the difficulties in attempting to introduce evidence-based medicine (Egan, Dubouloz, Zweck, & Vallerand, 1998). Cochrane's (1972) influential book propelled forward the issue of evidence. The Cochrane Collaboration, formed in the early 1990s, is a well-known international proponent of EBP. The Cochrane Collaboration is focused on preparing, maintaining, and promoting the accessibility of systematic reviews of the effects of health care interventions. Cochrane Review Group participants employ a series of methods to assemble, appraise, and synthesize data relevant to specific practice questions. The influence of EBP is of sufficient importance for gerontological nurses to understand the concepts and apply them in practice.
DESCRIPTION OF EVIDENCEBASED NURSING PRACTICE
Evidence-based practice is the careful, deliberate, and judicious use of the best available evidence for making decisions about patient care (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). Evidence from clinical expertise, patient preferenees, and research are incorporated into decisions (Figure 1). Health care providers integrate the best external evidence from scientific research with clinical expertise when they perform EBP (Mulhall, 1998; Sackett et al., 1996). The main distinguishing characteristic of EBP compared to traditional nursing practice is the use of available scientific evidence in care decisions.
Figure 2. Stages of activities in evidence-based practice.
Traditional models of care among health care disciplines holds certain assumptions - the most important being that clinical experience is emphasized (Friedland, Shlipak, Subak, Bent, & Mendelson, 1998; Sackett et al., 1996). The traditional paradigm also assumes nursing education, combined with common sense, is adequate for evaluating potential new innovations in nursing care. In contrast, EBP recognizes clinical expertise as necessary but not sufficient to provide the best possible care. Evidence-based practice assumes individual nurses* clinical experiences are generally unsystematic and therefore not entirely adequate as a scientific basis of practice (Sackett et al., 1996). It asserts nurses must understand certain rules of evidence to be able to evaluate and apply scientific findings in patient care decisions (Friedland et al., 1998). While the traditional paradigm focuses on clinical expertise, EBP emphasizes evidence authority in combination with clinical acumen. Evidence-based practice contends information obtained from systematic, reproducible, and unbiased research applied in appropriate situations can increase the effectiveness of nursing care.
The process of engaging in EBP has been described by several authors Flemming, 1998; Gerrish & Clayton, 1998; Leipzig, 1998; Rosenberg & Donald, 1995). Nursing activities in EBP are depicted in Figure 2. In the first stage, the nurse defines the situation (usually patient attributes, such as elderly patients in long-term care settings). The problem definition also specifies the intervention in question (e.g., a particular type of pressure wound dressing), as well as the comparison intervention (e.g., a traditional pressure wound dressing). The problem definition also specifies the patient outcome of interest (e.g., days to healing of pressure wounds). The facets of the problem definition can focus on individual older adults to entire health care systems (Curley, 1998).
Next, the nurse seeks existing research that addresses the question. This stage usually involves computerized scientific literature searching, along with considerable attention to studies cited in the research papers obtained through the computerized search. The clear problem definition in stage one is essential for a productive search of the literature.
Next, the empirical studies are evaluated for internal validity or scientific credibility. External validity, generalizability to similar populations and clinical situations, must also be estimated. Clinicians then plan care for individual older adults or sets of patients, based on the scientific evidence, in combination with clinical expertise and older adult and family preferences. The final essential stage is evaluation of the effectiveness of care. This may lead to changes in the planned care for a particular older adult or further development of questions appropriate for returning to the EBP process.
THE EVIDENCE IN EVIDENCEBASED NURSING PRACTICE
Evidence is pivotal in EBP. Part of the evidence comes from expert clinician assessment of older adults. The new emphasis is scientific evidence. Attributes of scientific evidence that are especially important for EBP include significance, conclusiveness, and reproducibility. Scientific evidence that supports both statistical significance and clinical significance (effect size) is necessary. The degree of certainty associated with the research findings is also important. The most valuable evidence is reproducible (Brown, 1999). Reproducible evidence is verified when different investigators testing an intervention generate the same findings.
Different sources of scientific evidence are needed to address varied practice questions. For example, if a nurse needs to understand the experience of patients attempting to selfresolve alcohol abuse problems, then qualitative studies are the appropriate source of evidence. In contrast, efforts to determine the most appropriate intervention often require quantitative research. A hierarchy of research evidence is generally agreed on for the amount of confidence that may be placed in results of intervention testing (Figure 3).
Quantitative synthesis of multiple randomized trials and individual large randomized trials provide the most dependable intervention evidence. Randomized clinical triais provide the most reliable evidence regarding treatment effectiveness (DiCenso, CuHum, & Ciliska, 1998).
Synthesis of research findings is central to EBP. Syntheses of qualitative findings, such as meta-interpretations, are beginning to appear (Finfgeld, 1999). The most common form of quantitative research synthesis is meta-analysis. The research process is applied to a set of statistical results from previous studies in meta-analysis. Results from original research reports are statistically combined for the quantitative synthesis. Meta-analysis often answers the problem of contradictory or inconclusive findings between studies, questions related to which type of patients respond to which interventions, and the problem of multiple small sample studies (Mulrow, Langhoren, & Grimshaw, 1998).
Figure 3. Hierarchy of research evidence to support practice.
Interested readers are referred to published guides for reading metaanalyses for information beyond the scope of this article (Conn & Armer, 1994). It is important to keep in mind a research synthesis completed 5 years ago summarized existing knowledge at that time. New research is completed daily. The evidence must be reviewed frequently to maintain current best practices based on all currently available evidence.
THE IMPORTANCE OF CLINICAL EXPERTISE IN EVIDENCE-BASED NURSING PRACTICE FOR OLDER ADULTS
Clinical expertise is central in all patient care decisions, including EBP Figure 1). Correct assessments of the problem or diagnosis, and of the patient circumstances, are essential (Sackett et al., 1996). Patient circumstances include the array of physical health problems older adults may experience and the psychological state and social or family situation of the patient, as well as understanding of the patient's and family's preferences (Sackett et al., 1996). The nurse can select, or recommend to the older adult, from among the evidence-supported interventions, those interventions that are consistent with that patient's situation and preferences. Evidence-based practice provides additional information for expert clinicians. It does not replace their clinical expertise.
SAMPLE OPPORTUNITIES FOR NURSE INVOLVEMENT IN EVIDENCE-BASED PRACTICE FOR OLDER ADULTS
OPPORTUNITIES FOR NURSING IN EVIDENCE-BASED PRACTICE FOR OLDER ADULTS
Opportunities for nursing influence on EBP are enormous. Table 1 identifies some examples of nursing contributions at multiple levels, from bedside nurse through advanced practice nurses and managers, to larger aggregates of nurses. For example, individual nurses (including managers and advanced practice nurses) might work with other nurses to investigate the scientific evidence supporting practices which address common problems, such as strategies to manage wandering behavior among older adults in specialty Alzheimer's disease units of long-term care facilities.
Institution-wide committees often examine the scientific evidence for nursing interventions common across institutional units, such as appropriate use of pressure relieving equipment. It is extremely important for subspecialty groups to exert leadership to the discipline in recommending scientifically supported practices and advocating for public policies that support evidence-based nursing interventions. This section will address general opportunities for nursing impact on EBP.
Nurses have traditionally been attentive to both the context of care and providing holistic care to older adults. Nurses involvement in EBP will ensure social, psychological, and economic contexts continue to be important considerations in care design (Aveyard, 1997; DiCenso et al., 1998; Mitchell, 1997; Page, 1996). Nursing is uniquely prepared to ensure EBP addresses the entire patient by preventing scientific reductionism from becoming more important than overall patient needs.
Nursing involvement in the EBP movement will help confirm a broad range of interventions will be available to assist older adults and their families. A concern has been expressed that the range of acceptable interventions may be limited to those receiving scientific support, perhaps as a cost containment strategy (Estabrooks, 1998). It is equally possible the range of interventions covered by third-party payers might increase if evidence is found supporting their effectiveness. Strong data are necessary to provide documentation about necessary care (Curley, 1998).
SAMPLE INTERNET SITES FOR EVIDENCE-BASED PRACTICE INFORAAATION
To assure a broad range of interventions, nurses need to be involved in determining the important outcomes measured in research and in fostering studies documenting the effectiveness of a diverse array nursing interventions. For example, incontinence is a complex problem. Research testing varied interventions is needed to attempt to develop the collection of interventions that can be successfully matched with incontinence causes and the physical and cognitive status of older adults. Information is needed about treatments effective when different resources are available and m varied locations, such as home, hospital, or long-term care settings.
Evidence-based practice presents an opportunity for larger numbers of nurses to become prepared to conduct the research that will form the scientific evidence for practice (Estabrooks, 1998; Taylor-Piliae, 1998). It is vital for nurses to be involved in the design and interpretation of research that will affect nursing care. For example, research examining falls in long-term care facilities requires nursing participation in the design phase to ensure that important intervening variables (e.g., toileting issues) and extended temporal perspectives (studying interventions during months rather than weeks) be incorporated. The EBP movement presents yet another reason for increasing the numbers of nurses with advanced education prepared to review scientific evidence through meta-analysis. Nurses can harness the power of scientific research to advance the quality of nursing care (Mulhall, 1998).
SAMPLE PUBLISHED RESEARCH SYNTHESES (META- AN ALYSE S) IN GERONTOLOGY
PATIENT EMPOWERMENT THROUGH EVIDENCE-BASED PRACTICE
Older adult and family autonomy and participation in decision-making is a central value for most nurses. The EBP movement has the potential to increase patient autonomy. As nurses are able to confidently inform patients about which interventions are likely to produce which outcomes, patients will be better informed for making important decisions consistent with their preferences. Patients are increasingly able to access information about health care options on the Internet. As more research syntheses become available via the Internet, some patients will be increasingly able to make educated decisions. The high Internet use among the baby-boom population suggests large numbers of future older adults will access the evidence regarding their health problems. An important role for future nurses will include assisting older adults and their families to understand the evidence they access.
FINDING SUPPORT FOR YOUR EVIDENCE-BASED PRACTICE
Nurses attempting to incorporate research findings into practice face three major tasks after they have located existing research (Brown, 1999). First, the nurse must evaluate the scientific credibility of the research findings. Next, the clinical significance of the findings must be determined. Finally, the nurse must decide whether the findings are likely to apply to a particular patient population in a given setting.
Several sources of information are available to nurses to accomplish the tasks of evaluating scientific credibility and clinical significance of findings. Prepared syntheses are important resources. It is difficult for individuai nurses to synthesize existing research because complex skills are required to conduct the synthesis and it is difficult for even experienced computerized database searchers to locate existing studies (Adams, Power, Frederick, & Lefebvre, 1994).
Synthesis of existing research studies is a rapidly expanding dimension of health care research. Sample Internet sites addressing EBP are listed in Table 2, including the Cochrane Collaboration and the National Guideline Clearinghouse sites. The Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy Research), which produced the wellknown practice guidelines for incontinence and pain, as well as many others, now encourages professional organizations to provide the leadership in developing EBP guidelines (Agency for Health Care Policy Research, 1992a, 1992b).
Computerized searches may retrieve syntheses of the literature. Ovid's new Evidence Based Medicine Reviews (EBMR) provides content from The Cochrane Database of Systematic Reviews, as well as syntheses of health care research from other sources. A sample of some meta-analyses, which could provide useful information for gerontological nurses, are presented in Table 3.
The University of Iowa has been a leader in research utilization projects. These projects have focused on incorporating research findings into the development of practice protocols or guidelines (Titler & Mentes, 1999). The University of Iowa research utilization project has completed 20 research-based protocols for older adults. For example, protocols have been developed for family involvement in care for individuals with dementia, hydration management, prevention of falls, and progressive resistance training.
One protocol for acute pain management was recently published in the Journal of Gerontological Nursing (Young, Mentes, & Titler, 1999). A recent University of Iowa publication provides a guideline for the components of written research based practice standards (Titler & Mentes, 1999). The University of Iowa also has an innovative research utilization residency program for practicing nurses. This multifaceted research utilization effort addresses some of the complexities of moving research findings toward practice.
Another group working toward collecting and interpreting the scientific evidence for gerontological nursing practice is the John A. Hartford Foundation Institute for Geriatric Nursing at New York University. The Journal of Gerontological Nursing has published best practices information from the Hartford Institute, such as information about selecting an appropriate screening tool for cognitive status among older adults (Kurlowicz & Wallace, 1999). Evidence- based protocols, such as urinary incontinence and medication safety, are included in a recent Hartford Institute book (Abraham, Bottrell, Fulmer, & Mezey, 1999).
These completed syntheses of the empirical literature and evidencebased practice protocols provide valuable information for making practice decisions. The practicing nurse uses the information, along with an assessment of the older adults and knowledge of their preferences, in planning the best possible care for each individual (Figure 1). Thus clinical decision- making is enhanced through EBP.
Evidence-based practice is a tool nurses may use to provide excellent nursing care to older adults. Reviews of empirical evidence may also be very valuable as nurses move toward influencing public health care policy. For example, considerable policy debate has focused on care arrangements for older adults with functional limitations. Empirical evidence regarding the efficacy and costs of alternative care arrangements could inform this public policy discussion and ultimately influence policy toward higher quality care. Thus, nurses may use evidence not only to guide their practice, but also policies which affect the care provided to large populations of older adults (Conn & Armer, 1996).
The EBP movement is consistent with the goals and values of nursing. It enhances possibilities to document the effectiveness of nursing care and, thus, elevate the level of gerontological nursing care. Challenges and opportunities abound. Nurses are well positioned to use these opportunities to increase the quality of nursing care.
- Abraham, I., Bottrell, M.M., Fulmer, T., & Mezey, M.D. (1999). Geriatric nursing protocols for best practice. New York: Springer Publishing Company.
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- Agency for Health Care Policy and Research. (1992a). Urinary incontinence in adulti. AHCPR Pub. No. 92-0039. Rockvilìe, MD: U.S. Department of Health and Human Services.
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SAMPLE OPPORTUNITIES FOR NURSE INVOLVEMENT IN EVIDENCE-BASED PRACTICE FOR OLDER ADULTS
SAMPLE INTERNET SITES FOR EVIDENCE-BASED PRACTICE INFORAAATION
SAMPLE PUBLISHED RESEARCH SYNTHESES (META- AN ALYSE S) IN GERONTOLOGY