Evidence Based Practice In Nursing

INTRODUCTIONResearch studies are conducting all over the world, throughout the year . Research is conducted to improve the existing practices. If the study findings are implemented to practice only , the study is effective. Evidences getting from the study which are utilized into practice makes the profession more fruitful, bright and effective. Most nurse researchers want their findings to contribute to nursing practice and there is growing interest among nurses in basing their practice on solid research evidence RESEARCH UTILIZATION IN NURSING The terms research utilization and evidence based practice are used synonymously.Although there is overlap between these two concepts they are in fact distinct. Research Utilization is: â€Å"A process of using findings from conducting research to guide practice† (Titler, Mentes, Rake, Abbott, and Baumler, 1999). â€Å"The process by which scientifically produced knowledge is transferred to practice† (Brown, 1999) DIFFERENCES: N urses should not confuse EBP [Evidence Based Practice] with research utilization. While research utilization overlaps with some of the same philosophic threadworks of EBP, EBP goes beyond just the rigorous scientific research steps.Research Utilization refers to the review and critique of scientific research, and then the application of the findings to clinical practice. Evidence-Based Practice (EBP) represents a broader concept. When clinicians use the EBP approach, they go beyond the expertise of clinicians and researchers, and consider the patient's preferences and values to guide patient care. THE RESEARCH UTILIZATION CONTINUM The start point of research utilization is the emergence of new knowledge and new ideas. Research is conducted and over time knowledge on new topic accumulates.In turn knowledge works its way to use to varying degrees and different rates. Theorists who have studied the phenomenon of knowledge development and diffusion of ideas typically recognize a continu um in terms of the specificity of the use to which research findings are put At one end of the continuum are discrete , clearly identifiable attempts to base specific actions on research findings. . This type of utilization has been referred to as instrumental utilization. Research findings can be used in a more diffuse manner. In a way that promote cumulative awareness, understanding or enlightment.Caplan and Rich [1975] refer to this as the end of the utilization continuum as conceptual utilization. Conceptual utilization then refers to situations in which users are influvanced in their thinking about an issue based on their knowledge of studies but do not put this knowledge to any specific , documentable use. The middle ground of this continuum involves the partial impact of research findings on nursing activities. This middle ground is the result of a slow evolutionary process that does not reflect a conscious decision to use an innovative procedure but rather reflects what Weis s termed knowledge creep and decision accretion.‘ knowledge creep’ refers to an evolving percolation of research ideas and findings. ‘Decision accretion’ refers to the manner in which momentum for a decision builds over time based on accumulated information gained through informal discussions , readings , meetings and so on. Increasingly now a days nurses are making conscious decisions to use research in their clinical practice and the EBP movement has contributed to this change. Estrabooks [1999] studied research utilization and found evidence to support three distinct types of research utilization.Indirect research utilization: involving changes in nurses’ thinking and therefore analogous to conceptual utilization. Direct research utilization: involving the direct use of findings in giving patient care and therefore analogous to instrumental utilization. Persuasive utilization: involving the utilization of of findings to persuade [typically those i n decision making positions] to make changes in policies or practices relevant to nursing care.These varying ways of thinking about research utilization clearly suggest that both quantitative and qualitative research can play key roles in guiding and improving nursing practice The research utilization process; Rogers’ diffusion of innovation theory Rogers’ theory is one of the most accepted theories that has developed models of how knowledge gets disseminated and used. It has influvanced several research utilization projects in the nursing community. Rogers postulate that knowledge diffusion is an evolutionary process by which an innovation is communicated over time to members of a social system.The key elements in this process, all of which influence the rate and extent of innovation, adoption include the following, 1. The innovation is a new idea, practice or procedure that if adopted will result in changes the nature of innovation strongly affects the decision about adoption. 2. Communication channels are the media through which information about the innovation is transmitted and can include both mass media or individual face to face communication. Communication is most effective when there are shared believes , values and expectations on the part of the sender and receiver of information.3.  Time is component of theory in that the process of knowledge diffusion occurs over time. There are varying amounts of time that elapse between the creation of knowledge and its dissemination and between knowledge awareness and the decision to use or reject the innovation 4. The social system is the set of interrelated units that solve the problems and seek to accomplish a common goal. Diffusion occurs within the social system that vary in their norms and receptivity to innovations Rogers Characterized the innovation adoption process as having five stages knowledge, persuasion, decision, implementation and confirmation.During the knowledge stage individu als or groups become aware of the innovation and during the persuasion stage they form appositive attitude towards it. In the decision stage , a choice is made about whether to adopt or reject the innovation. The innovation is actually put into use during the implementation stage. Finally the effectiveness of the innovation is evaluated during the confirmation stage, and decisions get made about continuation or discontinuation of the innovation. Recent research on utilization has challenged the linear nature of the process Evidence-based practice.During the 1980s, the term â€Å"evidence-based medicine† emerged to describe the approach that uses scientific evidence to determine the best practice. Later, the term shifted to become â€Å"evidence-based practice† as clinicians other than physicians recognized the importance of scientific evidence in clinical decision-making. Various definitions of evidence-based practice (EBP) have emerged in the literature, but the most commonly used definition is, â€Å"the conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients† (Sackett, Rosenberg, Gray, Hayes, & Richardson, 1996).Subsequently, experts began to talk about evidence-based healthcare as a process by which research evidence is used in making decisions about a specific population or group of patients. Evidence-based practice and evidence-based healthcare assume that evidence is used in the context of a particular patient’s preferences and desires, the clinical situation, and the expertise of the clinician. They also expect that healthcare professionals can read, critique, and synthesize research findings and interpret existing evidence-based clinical practice guidelines.Definitions of research utilization, quality improvement, and nursing research Evidence-based practice is not research utilization, quality improvement, or nursing research, although it may be rela ted to each of these processes. For example, quality improvement projects may be evidence-based, and the findings may contribute to other EBP or research initiatives. Also, an evidence-based practice project can lead to a research study or quality improvement initiative. What is research utilization? For decades, nurses have used available research to guide nursing practice and their efforts to improve patient outcomes.This process involved critical analysis and evaluation of research findings and then determining how they fit into clinical practice. Incorporating pertinent research findings into clinical practice (and evaluating the changes’ effectiveness), helps close the gap between research and practice. More recently, research utilization efforts in nursing have been replaced by evidence-based practice, What is quality or performance improvement? Quality, clinical, or performance improvement focuses on systems, processes, and functional, clinical, satisfaction, and cost outcomes.Typically, quality improvement efforts are not designed to develop nursing practice standards or nursing science, but they may contribute to understanding best practices or the processes of care in which nurses are actively involved. A commonly accepted view is that quality improvement activities in healthcare are not intended to generate scientific knowledge but rather to serve as management tools to improve the processes and outcomes within a specific healthcare organization or setting.More recently, experts have focused on improving care by examining and working within clinical Microsystems or the specific places where patients, families, and care teams meet (Nelson, et al. , 2002). To improve and maintain quality, safety, and efficiency, clinical teams must blend analysis, change, and measurement into their efforts to redesign care within these clinical Microsystems. Quality improvement initiatives generally address clinical problems or issues, examine clinical processe s, and use specific indicators to help evaluate clinical performance.Data are collected and analyzed to help understand both the process and the related outcomes. The findings help contribute to efforts to achieve and maintain continuous improvement through ongoing monitoring and improvement activities. Quality improvement projects vs. research projects Many have asked whether quality improvement projects are the same as research projects—they are not. In clinical practice, these efforts may seem similar in that, for example, both may seek answers to clinical problems and use similar data collection and analysis methods.However, factors that may differ include participant or subject recruitment, the study’s methods, and how the results are used. For example, in most quality improvement activities, the participants generally are the patients within a specific clinical micro system. In research efforts, the investigator recruits human subjects using approaches that will ensure a representative sample of the population. In many improvement activities, the intervention may change as it is evaluated, whereas in a research study the treatment or intervention remains the same.Furthermore, in most quality improvement initiatives, the healthcare team is trying to solve a problem in a particular setting instead of trying to generalize the results of the study to other settings and populations. Although it might be helpful to learn about the activities and experience of other improvement teams, their findings may not apply to or be appropriate in other settings or patient populations. The intent of research, however, is to develop new knowledge that can be generalized to other similar populations and clinical settings.Despite the differences between research and quality improvement projects, however, one must consider the protection of human subjects in both. To ensure that you adequately protect the rights of patients or subjects, always ask an Institution al Review Board (IRB) to review the research proposal or quality improvement project before implementing the study and beginning data collection. Also note that, whether the effort is research or quality improvement, one goal may be to disseminate the results of the project in a published paper or oral report.For any dissemination project, address adequate human subject protection and adherence with the Health Information Portability and Accountability Act of 1996 (HIPAA) guidelines before beginning the improvement project or research study. Individuals involved in either quality improvement or research projects should seek advice from their organization’s IRB, privacy officer, and risk management department to ensure that data are managed in a manner consistent with any pertinent federal or state regulations and organizational policies and procedures..Multidisciplinary effort Within clinical settings, many such opportunities exist for both nursing and multidisciplinary impro vement efforts. Improvement activities for nursing can be as simple as reducing time in giving verbal report or improving compliance with documentation requirements. Multidisciplinary collaborative efforts may address complex health issues, such as the care of acute myocardial infarction patients or individuals with community-acquired pneumonia.These initiatives are becoming more important in acute care hospitals as the national focus on public reporting increases. Such efforts help consumers compare the quality of care that various hospitals provide. The Centers for Medicare & Medicaid Services (CMS); various organizations that represent hospitals, doctors, and employers; accrediting organizations; other federal agencies; and the public have combined efforts to develop Hospital Compare and, thus, have made key clinical outcome measures available to the public.In this way, the public can monitor performance indicators to related common medical conditions and certain evidence-based i nterventions that are consistent with achieving the best patient outcomes. Collaboration within multidisciplinary teams creates opportunities to address clinical problems and issues using various perspectives and expertise. Nurses play key roles in such efforts and often benefit from the synergy that can be realized by working with others interested in or concerned about the problem.The group can work together while measuring their progress against pre-determined objectives What is nursing research? Nursing research involves systematic inquiry specifically designed to develop, refine, and extend nursing knowledge. As part of a clinical and professional discipline, nurses have a unique body of knowledge that addresses nursing practice, administration, and education. Nurse researchers examine problems of specific concern to nurses and the patients, families, and communities they serve. Nursing research methods may be quantitative, qualitative, or mixed (i.e. , triangulated):†¢ In quantitative studies, researchers use objective, quantifiable data (such as blood pressure or pulse rate) or use a survey instrument to measure knowledge, attitudes, beliefs, or experiences †¢ Qualitative researchers use methods such as interviews or narrative analyses to help understand a particular phenomenon †¢ Triangulated approaches use both quantitative and qualitative methods Regardless of the method they use, researchers must adhere to certain approaches to ensure both the quality and the accuracy of the data and related analyses.The intent of each approach is to answer questions and develop knowledge using the scientific method. Examples of nursing research projects Examples of nursing research projects include the following: †¢ Randomized clinical trial examining best practice for orthopedic-pin site care †¢ Efficacy of examination gloves for simple dressing changes †¢ Reliability of methods used to determine nasogastric tube placement †¢ The effects of relaxation and guided imagery on preoperative anxiety †¢ Quality of life in patients with chronic pain†¢ The relationship of a preoperative teaching program for joint replacement surgery and patient outcomes The scientific method involves collecting observable, measurable, and verifiable data in a prescribed manner so as to describe, explain, or predict outcomes. For example, one might collect data to describe the effects of massage on blood pressure, explain decreased needs for sedation, or predict lower levels of anxiety. Research methods demand that the collected data remain objective and not be influenced by the researcher’s hypotheses, beliefs, or values.In the massage example, the researcher could easily bias the results by administering the massages or collecting the data. Using certain approaches to subject recruitment, performing faulty data collection, and not controlling for other confounding variables also can bias research findings. Therefor e, when developing a study proposal, the researcher must develop a plan that minimizes these risks and supports the development of reliable information and results. EVIDENCE BASED PRACTICE EBP begins with search for information about how best to solve the specific problems.Findings from rigorous research are considered the best possible source of information but EBP also draws on other sources. A basic feature of EBP is that it deemphasizes decision making based on custom, opinion of the authority, or ritual. Rather the emphasis is on identifying the best available research evidence and integrating it with clinical expertise, patient input and existing resources. EBP movement has both supporters and critics. Supporters say that EBP offers a solution to sustaining high health care quality or in our cost constrained environment.Their position is that a rational approach is needed for providing best possible care to most people, with most cost effective use of resources. Critics worry that the advantages of EBP are exaggerated and that individual clinical judgments and patient inputs are being devalued. TYPE OF EVIDENCE AND EVIDENCE HIERARCHIES Positions about what constitutes useful evidence have loosened, but there have been efforts to develop evidence hierarchies that rank studies according to the strength of evidence they provide.The most accepted hierarchy is given below 1. Meta analysis of controlled studies 2. Individual experimental studies 3. Quasi experimental studies [eg; time series, non equalant control group] or matched case control studies 4. Non experimental studies [eg; co relational studies , descriptive and qualitative studies] 5. Programme evaluations, research utilization studies, quality improvement projects, case reports 6. Opinions of respected authorities and expert committeesThe nine alternative sources include Bench marking data, Cost effectiveness analysis, Pathophysiologic data, Retrospective or concurrent chart review, Quality improv ement and risk data, international, national , and local standards, institutional data collected for infection control purposes, patient preferences and clinical expertise EBP implications for nurses Nurses serve instrumental roles in ensuring and providing evidence-based practice. They must continually ask the questions, â€Å"What is the evidence for this intervention? † or â€Å"How do we provide best practice?† and â€Å"Are these the highest achievable outcomes for the patient, family, and nurse? †Nurses are also well positioned to work with other members of the healthcare team to identify clinical problems and use existing evidence to improve practice. Numerous opportunities exist for nurses to question current nursing practices and use evidence to make care more effective. Nurses throughout the country also have been involved in multidisciplinary efforts to reduce the number and severity of falls and pressure ulcers/injuries. Such projects can help save m oney and improve care processes and outcomes.By implementing existing evidence-based guidelines related to falls and pressure ulcers/injuries, care has improved, and the number and severity of negative outcomes have decreased. Importance of evidence-based practice Evidence-based practice helps nurses provide high-quality patient care based on research and knowledge rather than because â€Å"this is the way we have always done it,† or based on traditions, myths, hunches, advice of colleagues, or outdated textbooks. Why is EBP important to nursing practice? †¢ It results in better patient outcomes †¢ It contributes to the science of nursing †¢ It keeps practice current and relevant†¢ It increases confidence in decision-making †¢ Policies and procedures are current and include the latest research †¢ Integration of EBP into nursing practice is essential for high-quality patient care often, nurses feel that they are using â€Å"evidence† to gui de practice, but their sources of evidence are not research-based In a study conducted by Thompson, et al. , (2003), nurses reported that the most helpful knowledge source was experience or advice from colleagues or patients. Of concern were reports that up-to-date electronic resources that included evidence-based materials were not useful to nurses in clinical practice.This barrier contributes to significant gaps in clinicians applying research findings to practice and dissemination of innovations. The failure to use evidence results in care that is of lower quality, less effective, and more expensive (Berwick, 2003). Evidence-based practice can be easier for nurses to use if they refer to already-developed evidence based or clinical practice guidelines. Numerous expert groups have already undertaken systematic efforts to develop guidelines to help both healthcare providers and patients make informed decisions about care interventions.Guideline developers use a systematic approach to critique the existing research, rate the strength of the evidence, and establish practice guidelines. The overall goal of these types of efforts focuses on guiding practice and minimizing the variability in care MODELS FOR EVIDENCE BASED NURSING PRACTICE During the 1980,s and 1990’s a number of different models of research utilization were developed. These models offered guidelines for designing and implementing a utilization project in a practice setting. The most prominent of these models were the Stetler model and The Iowa model.These two models were updated to incorporate the EBP process rather than research utilistion alone. THE STETLER MODEL The Stetler model of research utilization was designed with the assumption that research utilization could be undertaken not only by organizations , but by individual clinicians and managers. It was a model designed to promote and facilitate critical thinking about the application of research findings in practice. The updated and refined model is based on many of the same assumptions and strategies as the original but provides an enhanced approach to the overall application of research in the service setting.The current model involves five sequential phases 1. Preparation ;- in this phase the nurse defines the underlying process, purpose and outcome of the project ; search, sort, and select sources of research evidence; consider the external factors that can influence potential application and internal factors that can diminish the objectivity and affirm the priority of the perceived problem. 2. Validation ;- This phase involves a utilization focused critique of each source of evidence focusing in particular on whether it is sufficiently sound for potential application in practice.The process stops at this point if the evidence sources are rejected. 3. Comprehensive evaluation and decision making ;- this phase involves the synthesis of findings and the application of four criteria that , taken together are used to determine the desirability and feasibility of applying findings from validated sources to nursing practice. These criteria include Fit for setting:- Similarity of characteristics of samples to your client population. Similarity of study’s environment to the one which you work FeasibilityPotential risk for implementation to patients, staff and organization Readiness for change among those who would be involved in a change in practice Resources requirements and availability Current practice Congruency of the study with theoretical basis for current practice behaviour Substantiating evidence Availability of confirming evidences from other studies Availability of confirming evidences from Meta analysis or integrative review The end result of comprehensive evaluation is to make a decision about using the study findings. If the decision is a rejection, no further steps are necessary4.  Translation/ Application;- this phase involves activities to Confirm how the findings w ill be used formally or informally Spell out the operational details of application and implement them. It involves the development of a guideline, detailed procedure, or plan of action, possibly including plans for formal organizational charge. 5. Evaluation:- in this final phase the application is evaluated. Informal use of the innovation versus formal use would lead to different evaluative strategies.Although the Stetler Model originally was designed as a tool for individual practitioners, it has also been the basis for  formal research utilization and EBP projects by group nurses. THE IOWA MODEL Efforts to use research evidence to improve nursing practice are often addressed by groups of nurses interested in the same practice issue. Formal EBP projects typically have followed systematic procedures using one of several models that have been followed systematic procedures using one of the several models that have been developed, such as The Iowa Model of the research in practice . The model was renamed as Iowa Model of Evidence Based Practice to Promote Quality Care.The current version of the Iowa Model acknowledges that a formal EBP project begins with a trigger- an impetus to explore possible changes to practice. The start point can be either a knowledge focused trigger that that emerges from awareness of innovative research findings and thus follows a more traditional research utilization path, or a problem focused trigger that has its roots in a clinical or organizational problem and thus follows a path that more closely resembles ad EBP path. The model outlines a series of activities with three critical decision points. 1.Deciding whether the problem is a sufficient priority for the organization exploring the possible changes; if yes a team is formed to proceed with the project ; if no a new trigger will be sought. 2. Deciding whether there is a sufficient research base ; if yes , the innovation is piloted in the practice setting; if no , the team woul d either search for other sources of evidence or conduct its own research. 3. Deciding whether the change is appropriate for adoption in practice ; if yes a change would be instituted and monitored; if no the team would continue to evaluate quality of care and search for new knowledge.The 5 steps of EBN 1. SELECT A TOPIC OR PROBLEM The first step is to select a topic. Ideas come from different sources but are categorized in two areas: Problem-focused triggers and Knowledge focused triggers. When selecting a topic, nurses should formulate questions that are likely to gain support from people within the organization. An interdisciplinary medical team should work together to come up with an agreement about the topic selection. The priority of the topic should be considered as well as the severity of the problem.Nurses should consider whether the topic would apply to many or few clinical areas. Also, the availability of solid evidence should be considered because providing proof of the research will increase staffs' willingness to implement into nursing practice. Problem & Knowledge Focused Triggers Problem focused triggers are identified by health care staff through quality improvement, risk surveillance, benchmarking data, financial data, or recurrent clinical problems. Problem focused triggers could be clinical problems, or risk management issues.Knowledge focused triggers are created when health care staff read research, listen to research conferences or encounter EBP guidelines published by federal agencies or organizations. Knowledge based triggers could be new research findings that further enhance nursing, or new practice guidelines. It is important that individuals work closely together to reach the optimum outcome for the chosen topic. Some things that would ensure collaboration are working in groups to review performance improvement data, brainstorming about ideas, and achieving consensus about the final selection.With both types of triggers, it is impo rtant to ensure that there is a general consensus about the importance of the problem and the need for improving practice. The method of selecting a topic does not appear to have any bearing on the success of an EBP project. What is important however is that the nursing staff who will implement an innovation are involved in topic selection and that key stake holders are â€Å"on board. † 2 . FORM A TEAM TO ASSEMBLE AND EVALUATE EVIDENCE Some might become overwhelmed when they first learn about EBP and apply it for reasons other than improvement of patient care.Forming a team increases the chance of EBP being adopted. A team becomes paramount in implementation, and evaluation of the EBP. It is important to have representatives of the team from authority members of the organization and also grassroots members. It is also important to consider interdisciplinary involvement to decrease rejection, and for all to have an understanding of the project. All these individuals have a gr eat impact on the possibility of successful implementation.Other factors to put into consideration include power figures in the organization that may directly or indirectly sabotage the efforts if they are not consulted, and fully included in EBP implementation. The EBP team should have explanations that clearly define the types of patients, setting, outcomes, interventions and exposures. This should be in simplified language that is comprehensible to a lay person. The role of the practitioners is remarkable in any meaningful gains, they are therefore inevitable and their role becomes pivotal.The approach they adopt and their ability to educate the co-workers, answer their questions, and clarify any misconceptions greatly improves the outcomes. In doing a literature reviews background for a new study, a central goal is to discover where the gaps are and how best to advance knowledge. For EBP projects which typically have as end products, prescriptive practice protocols or guidelines , literature reviews are typically much more formalized. The emphasis is on amassing comprehensive information on the topic, weighing pieces of evidence and integrating information to draw conclusions about the state of knowledge.Commentators have noted that integrative reviews have become the cornerstone of EBP. If an integrative view already exists it is wise to make sure that it is as up-to-date as possible and that new findings published after the review are taken into account. Moreover, even a published integrative review needs to be critiqued and the validity of its conclusions assessed 3. ASSESSING THE IMPLEMENTATION POTENTIAL One of the most challenging issues in using EBP in the clinical setting is learning how to adequately frame a clinical question so that an appropriate literature review can be performed.When forming a clinical question the following should be included: the disorder or disease of the patient, the intervention or finding being reviewed, possibly a compari son intervention, and the outcome An acronym used to remember this is called the â€Å"PICO† model: P = who is the Patient Population? I = what is the potential Intervention or area of Interest? C = is there a Comparison intervention or Control group? O = what is the desired Outcome? Once the topic is selected, the research relevant to the topic must be reviewed, in addition to other relevant literature.It is important that clinical studies, (including meta-analyses, metasyntheses and meta-aggregation) and well-known and reliable existing EBP guidelines are accessed in the literature retrieval process. With the internet at one’s fingertips, a plethora of research is just a few clicks away. However, just because you found it in a respectable journal does not signify high quality research. When reviewing any article for evidence retrieval read it very closely. Articles can appear to be precise and factual on the surface but with further and much closer examination, flaws can be found.The article can be loaded with opinionated and/or biased statements that would clearly taint the findings, thus lowering the creditability and quality of the article. Use of rating systems to determine the quality of the research is crucial to the development of EBP. There are several rating systems available online. Time management is crucial to information retrieval. Nurses making their way through the vast amount of research available may find it helpful to read research articles or critical reviews instead of clinical journals.To maintain high standards for EBP implementation, education in research review is necessary to distinguish good research from poorly conducted research. Equally important is that the materials being reviewed, consider if they are current. To assess the implementation potential of an innovation in a particular setting several issues should be considered particularly the transferability of the innovation, the feasibility of implementing it, an d it’s cost benefit ratio Transferability :- The main issue with regard to transferability is that whether it makes good sense to implement an innovation in the new practice setting.If there is some aspect of the practice setting that is fundamentally incongruent with the innovation in terms of its philosophy, types of client served, personal, financial or administrative structure, then it might make little sense to try to adapt the innovation Feasibility :- Assessing the feasibility concerns address various practical concerns about the availability of staff resources, the organizational climate, the need for and availability of external resources and assistance and the potential for clinical evaluation.An important issue here is that whether the nurse will have control over the innovation. When the nurse do not have full control over the new procedure, it is important to recognize the interdependent nature of the project and to proceed as early as possible to establish the n ecessary co operative arrangements. Cost benefit ratio:- It is an important aspect of EBP project innovation. The cost benefit assessment should encompass likely cost and benefits to various groups including clients, staff and the overall organization.Clearly the most important factor is the client. A cost benefit assessment should consider the opposite side of the coin as well that is the cost and benefits of not instituting an innovation. Documentation of the implementation potential is an innovation is highly recommended. Committing ideas to writing is useful because it can resolve ambiguities, serve as a problem solving tool if there are barriers to implementation , and be used to persuade others of the value of the project. 4.APPLY THE EVIDENCE/IMPLEMENTING AND EVALUATING THE INNOVATION After determining the internal and external validity of the study, a decision is arrived at whether the information gathered does apply to your initial question. It’s important to address questions related to diagnosis, therapy, harm, and prognosis. The information gathered should be interpreted according to many criteria and should always be shared with other nurses and/or fellow researcher. Building on the Iowa model, this phase of project likely would involve the following activities Developing an evaluation planCollecting baseline data pertaining to those outcomes, to develop a counterfactual against which the outcomes of the innovation would be assessed. Developing a written EBP guideline based on the synthesis of evidence, preferably a guideline that is clear and user friendly, and that uses such devises as flow charts and decision trees. Training relevant staff in the use of the new guideline and if necessary marketing the innovation to users so that it is given in a fair test.Trying the guideline out on one or more unit or with a sample of clients Evaluating the pilot project in terms of both processes and outcomes. 5. DISSEMINATION OF THE RESULTS OF THE PRO JECT It is the final optional step but it is the one which is highly advisable. It is done so that the results of the project can be disseminated to other participating staff members. How to Critique a Research Article The critiquing process is the building block and foundation for the multiple steps that are to follow in the successful implementation of EBP.This is so because you must first ensure that the material and research that you are trying to convince others to accept is reliable and accurate. By taking the time to thoroughly critique a study you can point out both the strengths and weaknesses of the findings and weigh them accordingly. Successful completion of this vital step will help â€Å"weed out† the material lacking the needed proof of effectiveness, therefore minimizing useless, or even harmful, implementation of new practices in the healthcare field.Once the literature is located, it is helpful to classify the articles as either conceptual (theory and clinic al articles) or data-based (systematic research reviews). Before reading and critiquing the research, it is useful to read theoretical and clinical articles to have a broad view of the nature of the topic and related concepts, and to then review existing EBP guidelines Critiquing criteria are the standards, evaluation guides, or questions used to judge (critique) an article.In analyzing a research report, the reader must evaluate each step of the research process and ask questions about whether each step of the process meets the criteria. Remember when you are doing a critique, you are pointing out strengths, as well as the weaknesses. To critique an article you must have some knowledge on the subject matter. There is no replacement for reading the article many times. The reader must search the article for contradictions, illogical statements, and faulty reasoning.It is important to evaluate every section of the research article. Each section has different criteria to meet, in order to be considered a well-written addition to the article. What are the barriers to implementing evidence-based practice? The barriers that prevent nurses from using research in everyday practice have been cited in numerous studies, and some common findings have emerged Nurses often report the following: †¢ Lack of value for research in practice †¢ Difficulty in changing practice†¢ Lack of administrative support †¢ Lack of knowledgeable mentors †¢ Insufficient time to conduct research †¢ Lack of education about the research process †¢ Lack of awareness about research or evidence-based practice †¢ Research reports/articles not readily available †¢ Difficulty accessing research reports and articles †¢ No time on the job to read research †¢ Complexity of research reports†¢ Lack of knowledge about EBP and critique of articles †¢ Feeling overwhelmed by the processDespite these barriers, nurses are engaging in EBP and making a difference in patient outcomes. Furthermore, barriers can be overcome through organizational efforts focused on integrating research in practice and using strategies such as journal clubs, nursing grand rounds, and having research articles available for review The use of evidence based practice depends a great deal on the nursing student's proficiency at understanding and critiquing the research articles and the associated literature that will be presented to them in the clinical setting.According to, Blythe Royal, author of Promoting Research Utilization in nursing: The Role of the Individual, Organization, and Environment, a large amount of the preparation requirements of nursing students consists of creating care plans for patients, covering in depth processes of pathophysiology, and retaining the complex information of pharmacology. These are indeed very important for the future of patient care, but their knowledge must consist of more when they begin to practice.Evidence base d nursing in an attempt to facilitate the management of the growing literature and technology accessible to healthcare providers that can potentially improve patient care and their outcomes. Nancy Dickenson-Hazard states, â€Å"Nurses have the capacity to serve as caregivers and change agents in creating and implementing community and population-focused health systems. † There is also a need to overcome the barriers to encourage the use of research by new graduates in an attempt to ensure familiarity with the process.This will help nurses to feel more confident and be more willing to engage in evidence based nursing. A survey that was established by the Honour Society of Nursing and completed by registered nurses proved that 69% have only a low to moderate knowledge of EBP and half of those that responded did not feel sure of the steps in the process. Many responded, â€Å"Lack of time during their shift is the primary challenge to researching and applying EBP. † There is always and will always be a desire to improve the care of our patients.The ever increasing cost of healthcare and the need for more accuracy in the field proves a cycle in need of evidence based healthcare. The necessity to overcome the current issues is to gain knowledge from a variety of literature not just the basics. There is a definite need for nurses, and all practitioners, to have an open mind when dealing with the modern inventions of the future because these could potentially improve the health of patients. There are many barriers to promoting evidence based practice.The first of which would be the practitioner's ability to critically appraise research. This includes having a considerable amount of research evaluation skills, access to journals, and clinic/hospital support to spend time on EBN. Time, workload pressures, and competing priorities can impede research and development. The causes of these barriers include nurse's and other professional practitioners lack of knowledge of research methods, lack of support from professional colleagues and organizations, and lack of confidence and authority in the research arena.Another barrier is that the practice environment can be resistant to changing tried and true conventional methods of practice. This can be caused because of reluctance to believe results of research study over safe, traditional practices, cost of adopting new practices, or gaining momentum to rewrite existing protocols It is important to show nurses who may be resistant to changes in nursing practice the benefits that nurses, their patients, and their institutions can reap from the implementation of evidence-based nursing practice, which is to provide better nursing care.Values, resources and evidence are the three factors that influence decision-making with regard to health care. All registered nurses and health care professionals should be taught to read and critically interpret research and know where to find articles which rela te to their field of care. In addition, nurses need to be more aware of how to assess the information and determine its applicability to their practice. Another barrier to implementing EBN into practice is lack of continuing education programs.Practices do not have the means to provide workshops to teach new skills due to lack of funding, staff, and time; therefore, the research may be tossed dismissed. If this occurs, valuable treatments may never be utilized in patient care. Not only will the patients suffer but the staff will not have the opportunity to learn a new skill. Also, the practitioners may not be willing to implement change regardless of the benefits to patient care. Another barrier to introducing newly learned methods for improving treatments or patients' health is the fear of â€Å"stepping on one's toes†.New nurses might feel it is not their place to suggest or even tell a superior nurse that newer, more efficient methods and/or practices are available. The pe rceived threat to clinical freedom offered by evidence-based practice is neither logical nor surprising. Resistance to change and to authority is part of human nature. When we make decisions based upon good quality information we are inconsistent and biased. Human nature offers many challenges to evidence-based practice. Can we do a better job of promoting evidence-based practice?And even if we find and use the evidence, will we make consistent unbiased decisions? Even if clinicians do act consistently it is possible that their decisions are consistently biased. People put different values on gains and losses. CONCLUSION Nursing is truly an art and a science. EBP not only provides elements of each aspect, but also contributes to the profession’s overall development. As a result EBP improves everyday practice in by providing empirical data to guide the nursing interventions. Use of research in EBP provides opportunity for research utilisation by all in the field of profession.