Nurses are living in the age of evidence-based practice (EBP). Although the origin of EBP has roots in medicine, today EBP is nursing's appel a l'action (call to action). The highly influential Institute of Medicine's (IOM; 2011b) Future of Nursing report noted that competencies needed for nursing practice have expanded, especially in the domain of “research and evidence based practice” (p. 8). The report's recommendation that nurses transform health care by leading interprofessional teams to improve delivery systems, achieve improved patient-desired outcomes, and affect quality health care requires the use of EBP to enhance clinical decision making.
EBP is the integration of best research evidence with clinical expertise and patient values to facilitate clinical decision making (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). The origin of EBP can be traced back to 1971 when Archie Cochrane admonished the medical profession for not examining the research evidence to inform their practice. Cochrane (1972) went even further and suggested individuals should pay for health care only when it is based on scientific evidence. Cochrane (1989) and others in the EBP movement, such as the Canadian Evidence-Based Medicine Working Group (1992), believed that conducting a rigorous and systematic review of research across disciplines with emphasis on the “randomized controlled trial as the clinical ideal or paradigm” was a means for generating reliable and valid evidence needed for informing practice decisions (Oxman & Guyatt, 1993, p. 126). Jennings and Loan (2001) reported that much of the momentum that sustained the EBP movement was due to the establishment of the Cochrane Collaboration in 1993. The Cochrane Collaboration's core focus is making systematic reviews available that rate studies according to the level of quality as a means to create practice guidelines. It is important to note EBP “is not restricted to randomized trials and meta-analyses, rather it involves tracking down the best external evidence with which to answer our clinical questions” (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996, p. 72).
The EBP movement accelerated in response to two critical IOM reports: To Err is Human: Building a Safer Health System (IOM, 2000) and Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001). A key recommendation of both reports was for all disciplines to use EBP to bridge the chasm “between the health care we have and the care we could have” (IOM, 2001, p. 1) or, stated in another way, the chasm between what is known to be effective health care and what is actually practiced. In addition, Stevens (2013) noted that increasing public and professional demand for accountability in safety and quality improvement in health care also fueled the development of EBP.
In nursing education, EBP has achieved widespread acceptance by being embraced and integrated in nursing curriculums. The Baccalaureate Education for Professional Nursing Practice (American Association of Colleges of Nursing [AACN], 2008) provides a foundation for EBP, asserting “professional nursing practice is grounded in the translation of current evidence into one's practice” (p. 15). Upon graduation, bachelor of science in nursing (BSN) students are expected to “integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care” (AACN, 2008, p. 16). The Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006) identified eight core essential and specialty-focused competencies as basic underpinnings to be integrated into the doctor of nursing practice (DNP) curriculum, and the Essential 3 core statement “clinical scholarship and analytic methods for evidence based practice” (p. 11) means DNP graduates need to be able to use analytical methods to appraise existing literature and other evidence relevant to practice; apply and develop practice guidelines to improve practice and the practice environment; use information technology design evidence-based interventions; and disseminate findings from EBP to improve health care outcomes (AACN, 2006; Tymkow, 2017). The DNP degree has rapidly become the recommended and desired education preparation for all advanced practice nurses. A multitude of resources on how to teach EBP at all levels of nursing education are available (Moch, Cronje, & Branson, 2010). Most nursing research textbooks are either entirely based in an EBP pedagogy or devote significant content on the development, appraisal, and application of research in practice.
Integrating Evidence with Practice
The call to fully implement EBP into practice has been more challenging. Although nurses have positive attitudes toward EBP and the desire to obtain more knowledge and skills, there are significant barriers to implementing EBP, such as lack of time, unsupportive organizational cultures, and resistance to change by those who have not been educated within the EBP pedagogy. Melnyk, Fineout-Overholt, Gallagher-Ford, and Kaplan (2012) noted that if nurse leaders want to encourage EBP use among their staff, they need to realize a 1- or 2-day workshop is not likely to lead to sustainable change. To truly implement EBP, nurse leaders need to place enough EBP mentors at the bedside who can work side by side with clinicians to help them learn these skills and implement EBP consistently.
Initially, to facilitate EBP there was an emphasis on the creation of evidence-based guidelines, clinical pathways, evidence-based protocols, and best practices statements. EBP guidelines are systematically developed statements to assist health care providers in making decisions about appropriate heath care for specific health/illness conditions or circumstances. The EBP guideline includes recommendations intended to optimize patient care informed by systematic reviews or critical appraisal of the research evidence supporting assessment and treatment recommendations.
To facilitate the use of EBP guidelines in health service environments, a plethora of theories, models, and frameworks emerged, including well-established models such as the Iowa Model of Evidence-Based Practice (Titler et al., 1994; Titler et al., 2001); Stetler Model (Stetler, 2010); Agency for Healthcare Research & Quality (AHRQ) model (Nieva et al., 2005); Ottawa Model of Research Use (Logan & Graham, 2010); Promoting Action on Research Implementation in Health Services (PARIHS) model (Rycroft-Malone, 2010); and the Advancing Research and Clinical Practice through Close Collaboration (ARCC) model for system-wide implementation and sustainability of EBP (Melnyk & Fineout-Overholt, 2010). Models such as Fawcett and Garity's (2009) Conceptual-Theoretical-Empirical system offer a way to integrate discipline-specific knowledge derived from extant nursing conceptual frameworks and theories with EBP guidelines (Butcher, 2011).
Translational science is increasingly becoming an established area of investigation that examines the methods, interventions, and variables that influence adoption by individuals and organizations of EBP to improve clinical and operational decision making in health care (Titler & Everett, 2001). Translational science methods include testing the effect of interventions on promoting and sustaining adoption of EBP, such as describing facilitators and barriers to knowledge uptake and use, organizational predictors of adherence to EBP guidelines, attitudes toward EBP, and defining the structure of the scientific field (Titler, 2008).
Consistent use of evidence-based processes of care is essential to achieving core measure and patient safety goals and standards (i.e., the Joint Commission on Accreditation of Healthcare (JCAHO) established a set of accountability core measure sets specifying quality of care and patient safety on conditions such as stroke, heart failure, and venous thromboembolism. Since 2011, the JCAHO began a program to recognize those facilities that were identified as hospital top-performers in adhering to EBP that enhance patient outcomes. In 2014, 1,224 hospitals or 36.9% of all accredited hospitals were recognized “for their exemplary performance in providing evidence-based interventions in the right way and at the right time” (The Joint Commission, 2014, p. 4). Furthermore, the American Nurses Credentialing Center (ANCC) Magnet Recognition Program® (access http://www.nursecredentialing.org/Magnet) requires hospitals to have EBP embedded in the culture of the organization. According to this coveted nursing award program, hospitals must demonstrate that nurses evaluate and use published research in all aspects of clinical and operational processes. The ANCC also expects nurses to conduct research projects, and that knowledge from these projects will be shared with nurses within and outside the organization.
A means to enhance the actual use of EBP guidelines in health care settings and at the point of care is to make the guidelines electronic so health care professionals can access them on wireless devices. A 2009 stimulus bill appropriated $19 billion to promote the adoption and use of health information technology, particularly for the transition to electronic health care records (Foley & Lardner LLP, 2009). Computer-aided clinical decision support based on the translation of EBP guidelines into an interactive, electronic health care record can facilitate a more personalized and timely form of EBP guided care (IOM, 2011a).
To promote patient safety and quality of health care outcomes, clinical decision making must be grounded in the best available evidence for practice. Nurses and other health care providers can access EBP guidelines, reports, and protocols that have been developed and disseminated by government programs, such as the AHRQ's National Guideline Clearinghouse (access http://www.guideline.gov/index.aspx), which serves as a public resource for evidence-based clinical practice guidelines, or private entities, such as the Cochrane Collaboration. On the National Guideline Clearinghouse website, abstracts with links to full-text guidelines can be accessed, where available, or print copies can be ordered. Since 1995, the Cochrane Library (access http://www.cochranelibrary.com) has published more than 5,000 systematic reviews and 2,000 protocols designed to inform decision making.
The main purpose of developing and implementing EBP guidelines for gerontological nursing is to help nurses practice with greater knowledge and skill and improve the quality of care of older adults (Nadzam & Abraham, 2003). One resource for gerontological nursing EBP guidelines is the textbook Evidence-Based Geriatric Nursing Protocols for Best Practice (Boltz, Capezuti, Fulmer, & Zwicker, 2012), which has more emphasis on acute care of older adults, developed in collaboration with the New York University (NYU) College of Nursing. Abbreviated versions of the protocols can be accessed on the Hartford Institute for Geriatric Nursing at NYU website (access https://hign.org). Another major resource for nursing EBP guidelines that focus on specific concerns and common problems experienced by older adults in long-term care settings are those developed and published by The University of Iowa College of Nursing Csomay Center for Gerontological Excellence (CCGE) (access http://www.iowanursingguidelines.com).
The focus of the current article is to describe the process of developing the EBP guidelines published by CCGE. Manuscripts based on the complete guidelines have been published in this section of the Journal of Geronotological Nursing (JGN) since November 2007.
Gerontological EBP Guidelines at the University of Iowa College of Nursing
Since 1994, The University of Iowa College of Nursing, in conjunction with its clinical partner, University of Iowa Hospitals and Clinics Department of Nursing Services and Patient Care, has been at the forefront of making evidence-based gerontological nursing practice a reality (Goode & Piedalue, 1999; Goode & Titler, 1996; Titler et al., 2006). In the early 1990s, the Iowa Model of Evidence-Based Practice (Titler et al., 1994; Titler & Everett, 2001) was developed by a group of clinicians who were members of a research committee at the University of Iowa Hospital and Clinics (Steelman, 2016). The ongoing commitment and advancement of EBP in nursing is evident by the University of Iowa Hospital and Clinics Department of Evidence-Based Practice and Quality hosting the National Evidence-Based Practice Conference in April for the past 22 years.
Thanks to the visionary leadership of Toni Tripp-Reimer, in 1994, The University of Iowa College of Nursing established the Gerontological Nursing Intervention Research Center (GNIRC), which was supported by a 5-year National Institute of Nursing Research grant (P30 NR03979). One of the GNIRC cores was the Research Development and Dissemination Core (RDDC) led by Marita Titler, PhD, RN, FAAN. The RDDC engaged in a variety of research utilization activities; however, its primary focus was the development and dissemination of research-based gerontological practice protocols (Titler & Mentes, 1999). The GNIRC P30 was renewed twice for an additional 5 years of funding for each renewal, for a total of 15 years of funding. In addition, in 2001, The University of Iowa College of Nursing became one of the original five John A. Hartford Centers of Geriatric Nursing Excellence. In 2009, the EBP development program was moved from the GNIRC to the Hartford Center. On January 1, 2016, after 15 years of continuous funding from the John A. Hartford Foundation, the University of Iowa College of Nursing Hartford Center of Geriatric Nursing Excellence was renamed the Csomay Center for Gerontological Excellence (CCGE) after receiving a generous gift from the Csomay family.
The mission statement for the CCGE includes the belief that “nurses who are prepared in the best evidence-based gerontological practices make a critical difference in the quality of life of older persons” (The University of Iowa College of Nursing, n.d., para. 1). To this end, the CCGE at the University of Iowa develops and maintains EBP guidelines as a means to promote best practices among nurses and others who provide day-to-day care to older adults. Best practice is a generic or general phrase for a process of infusing nursing practice with research-based knowledge. The CCGE and EBP development program have flourished under past Center Directors Meridean Mass, RN, PhD, FAAN; Kathleen Buckwalter, RN, PhD, FAAN; Janet Specht, RN, PhD, FAAN; and current Director Kristine Williams, RN, PhD, FAAN. Deborah P. Schoenfelder, RN, PhD, assumed leadership of the EBP guideline program once it was transferred to the Hartford Center in 2009. As of April 2014, the EBP program has been led by Howard K. Butcher, RN, PhD.
Since the publication of the first EBP guideline in 1995, 35 different guidelines have been published; these are revised on a rotating basis. The guidelines have earned a reputation nationally and internationally for their excellence, with more than 5,000 being disseminated to nurses and health care facilities around the nation since 2008. Since 2007, every 4 months JGN has published an article that is based on one of the recently revised guidelines.
The CCGE EBP guidelines are distinguished from other EBP guidelines by: (a) being nursing care specific; (b) focusing primarily on topics that are significant issues, patient conditions, or treatments experienced by older adults in long-term care settings; (c) including an in-depth overview of the topic; (d) including systematic literature search and appraisal of the research evidence supporting assessment and treatment recommendations; (e) rating the level of evidence for assessment and treatment recommendations; (f) including a list of major standardized nursing interventions and nursing outcomes related to the topic; (g) including tools to evaluate the implementation of the guideline; (h) including standardized assessment and evaluation tools in the appendices; (i) including a Quick Reference Guide for rapid point-of-care use; and (j) being downloadable in an electronic and navigable PDF format for Android and OS devices, as well as desktop and portable computers (access http://www.iowanursingguidelines.com). Table 1 lists the current EBP guidelines that have been developed at The University of Iowa College of Nursing.
University of Iowa College of Nursing Csomay Center for Gerontological Excellence Evidence-Based Practice Guidelines
EBP Guideline Development Process
The development of an EBP guideline begins by identifying relevant and significant topics critical to promoting the safety, health, and well-being of older adults. Areas of relevance for EBP development arise when a research–practice gap exists concerning a condition, disease, treatment, or aspect of care of older adults that will result in improved outcomes when care is guided by research-based best practices. Often the CCGE is approached by nurse experts at the University of Iowa or other universities who identify a topic they wish to develop as an EBP guideline. Alternatively, the CCGE identifies topics and recruits expert nurse clinicians and researchers to develop the guideline. Guidelines are revised every 5 years to assure the content is up to date and current. When a guideline is due for revision, the previous authors are approached first to see if they are interested in revising and updating the guideline. In most instances, the original authors agree to revise the guideline, and if they are unable to, new experts in the content area are recruited. In addition, to facilitate timely completion of the guidelines, in collaboration with the authors, a timeline is developed that identifies all stages and due dates for developing a new EBP guideline or for one requiring revision. Once the topic has been narrowly defined and a projected date of completion agreed upon, the authors sign a contract with the CCGE. A detailed manual is provided to all authors with specific step-by-step instructions about how to write the EBP guideline. The manual includes the Appraisal of Guidelines for Research & Evaluation (AGREE II) instrument (AGREE Next Steps Consortium, 2009) to assist authors in the development and evaluation of the guideline. Table 2 outlines the components of an EBP guideline.
Components of a University of Iowa College of Nursing Csomay Center for Gerontological Excellence Evidence-Based Practice (EBP) Guideline
The high quality of the EBP guideline begins with completing a comprehensive review of the published research literature. Locating the research evidence begins with identifying key search terms related to the topic and using the search terms in databases, such as CINAHL, MEDLINE, PubMed, PsycINFO, EMBASE, and the Cochrane Library, to identify randomized controlled trials, systematic reviews, meta-analyses, case-controlled studies, and qualitative descriptive studies that support the assessment, treatment, and desired outcomes for the guideline topic.
For each assessment and treatment recommendation, core references are identified and reviewed by critically reading and evaluating the validity and strength of the results. National Guideline Clearinghouse Rating Schemes (access http://www.guideline.gov/content.aspx?id=37694) are used for making judgments about the level (i.e., quality) of research evidence and strength of the recommendations. The schema have seven grade levels that range from A1, which is evidence from well-designed meta-analyses or well done systematic reviews with results that consistently support a specific action (assessment, intervention, treatment), to D, which is evidence from expert opinion, multiple case reports, or national consensus reports.
When the completed guideline is returned to the CCGE, the content of the guideline is reviewed by the Series Editor, Dr. Butcher, and then sent to two expert reviewers. When the reviews are returned to the CCGE, the critiques are reviewed by the Series Editor, and both the guideline and reviews are sent to the authors for revision. Once the revisions are completed, the guideline is sent back to the CCGE for review and final approval. The guideline is then formatted, placed in PDF format, and uploaded to an e-Commerce website (access http://www.iowanursingguidelines.com) where it can be purchased and downloaded on personal computers and portable devices (i.e., OS and Android phones and tablets).
In an article published in JGN, Titler and Mentes (1999) invited readers interested in developing new EBP guidelines to contact the GNIRC's EBP guideline development program. This invitation is being extended again. Suggestions regarding new topic areas that need to be developed into an EBP guideline or any feedback concerning the published guidelines or the articles published in this section of JGN are welcome and would be appreciated (contact Howard K. Butcher, RN, PhD, at
Nurses and health care professionals want to provide the best possible care. EBP is the integration of best research evidence with clinical expertise and patient values to facilitate clinical decision making. EBP guidelines embody the integration of scientific research evidence and combine research evidence with clinical experience for the achievement of optimal patient outcomes and quality of life.
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University of Iowa College of Nursing Csomay Center for Gerontological Excellence Evidence-Based Practice Guidelines
|Acute Pain Management in the Older Adult|
|Assessing Heart Failure in Long-Term Care Facilities|
|Bathing Persons with Dementia|
|Changing the Practice of Physical Restraint Use in Acute Care|
|Detection and Assessment of Late Life Anxiety|
|Detection of Depression in Older Adults with Dementia|
|Detection of Depression in the Cognitively Intact Older Adult|
|Elder Abuse Prevention|
|Elderly Suicide: Secondary Prevention|
|Exercise Promotion: Walking in Elders|
|Fall Prevention for Older Adults|
|Family Involvement in Care for Persons with Dementia|
|Family Preparedness and End of Life Support Before the Death of a Nursing Home Resident|
|Guidelines for Writing Evidence-Based Practice Guidelines|
|Identification, Referral, and Support of Elders with Genetic Conditions|
|Improving Medication Management for Older Adult Clients|
|Management of Constipation|
|Management of Relocation|
|Non-Pharmacologic Management of Agitated Behaviors in Persons with Dementia|
|Nursing Management of Hearing Impairment in Nursing Facility Residents|
|Oral Hygiene Care for Functionally Dependent and Cognitively Impaired Older Adults|
|Persistent Pain Management in the Older Adult|
|Prevention of Deep Vein Thrombosis|
|Prevention of Pressure Ulcers|
|Progressive Resistance Training|
|Promoting Spirituality in the Older Adult|
|Prompted Voiding for Persons with Urinary Incontinence|
|Providing Spiritual Care to the Terminally Ill Older Adult|
|Quality Improvement in Nursing Homes|
|Treatment of Pressure Ulcers|
|Wheelchair Biking for the Treatment of Depression|
Components of a University of Iowa College of Nursing Csomay Center for Gerontological Excellence Evidence-Based Practice (EBP) Guideline
|Table of contents||List of all sections included in the guideline.|
|Grading scheme||The complete grading scale used to critically evaluate research literature cited to support recommendations in the guideline.|
|Introduction||The introduction provides an overview of the topic. The length of the introduction may vary from one or two paragraphs to one or two pages depending on the topic.|
|Purpose||The overall purpose of the guideline should be described, including expected benefits of using the guideline. Both the target population that will be served by this guideline and the intended users of this guideline should be identified.|
|Definition of key terms||Operational definitions of major terms or concepts in the guideline. It is important that the reader know the meaning of the concepts.|
|Individuals/patients at risk for [topic]||A brief statement or listing of patient populations that are most likely to benefit from the guideline recommendations for assessment and treatment. This section can also include case definitions, symptomatology, age, developmental levels, disease type or condition, and any other factors that place individuals at risk for the specific topic addressed in the guideline.|
|Assessment criteria||A comprehensive listing of patients and environmental assessment criteria supported and rated using grade according to the level of research evidence.|
|Assessment tools and forms||A list and description of key assessment tools available to assess patients with [topic]. The tools are included in the Appendix. Many of the forms can be scored in the electronic format. Any forms that can assist in the documentation of the assessment are also described and included in the Appendix.|
|Description of the practice||This section is a step-by-step guide of the treatments and interventions that address the topic and how to implement them into practice. The treatment recommendations are referenced with the most current grade level of research-based evidence.|
|Nursing intervention classification (NIC)||The labels and definitions of major NIC interventions that address the topic are listed. NIC (Bulechek, Butcher, Dochterman, & Wagner, 2013) is a comprehensive, standardized classification of interventions that nurses perform. The NIC includes the interventions that nurses perform on behalf of patients, both independent and collaborative interventions, both direct and indirect care. An intervention is any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes. A complete sample including all nursing activities of the most relevant NIC is included in the Appendix.|
|Nursing outcomes classification (NOC)||The labels and definitions of the major NOC that address the topic are listed. NOC (Moorhead, Johnson, Maas, & Swanson, 2013) is a standardized classification of patient/client outcomes developed to evaluate the effects of nursing interventions. An outcome is a measurable individual, family, or community state, behavior, or perception that is measured along a continuum and is responsive to nursing interventions. A complete sample including all indicators of the most relevant NOC is included in the Appendix.|
|Evaluation of process||This section includes tools to assess the effectiveness of the implementation of the guideline into practice. A 10-question Knowledge Assessment Test (with a key to the correct answers), Process Monitor, and Outcomes Monitor are included in the Appendix. The Process Evaluation Monitor uses a Likert scale to evaluate the perceived understanding of each nurse in implementing the guideline. The Outcomes Monitor is a chart listing major outcome criteria related to the topic that can be used to indicate whether patient outcomes were met.|
|References||A bibliography of all citations used to develop the EBP guideline.|
|Appendices||Appendices typically include: (a) description of search methods and processes used to collect/select the evidence; (b) standardized assessment tools; (c) sample NIC intervention, including all nursing activities; (d) sample NOC outcome, including all indicator scales; (e) Knowledge Assessment Test; (f) Process Evaluation Monitor; (g) Outcomes Monitor; and (h) Quick Reference Guide.|
|Contact resources||Author contact information; acknowledgement of expert reviewers; Csomay Center for Gerontological Excellence contact information.|