It has been suggested that the idea of delivering care based on evidence had its early foundations in the 1800s with Florence Nightingale, who aimed to provide better outcomes for patients who experienced unsanitary conditions (Mackey and Bassendowski, 2017). However, it is generally agreed that Professor Archie Cochrane, whose work inspired the Cochrane Collaboration (Smith and Rennie, 2014; Barker and Linsley, 2016), is credited for being at the forefront of the modern evidence-based practice (EBP) approach. The concept of evidence-based medicine (EBM) emerged from researchers at McMaster University, Canada, who redefined the practice of medicine to move from a culture based solely on clinical experience, to one which is more inclusive of medical evidence (International Council of Nurses, 2012). Smith and Rennie (2014) noted that the phrase EBM was coined by Gordon Guyatt in 1991, so has had a relatively short life span. Although a number of individuals contributed to the development of EBM, David Sackett is regarded as the father of EBM as in 1996 he distinguished EBM as one that combines research evidence with clinical skills, and patient values and preferences (Smith and Rennie, 2014).
From the emergence of EBM, the terminology EBP developed, which relates to all professional denominations, and then evidence-based nursing, as other professions adopted this approach (Rees, 2010; Mackey and Bassendowski, 2017). EBP evolved into the nursing profession in the 1990s and in the context of the UK, is now endorsed by the Nursing and Midwifery Council (NMC) as the professional responsibility of registered nurses to adopt this approach (NMC, 2018a). From the introduction of EBP into the nursing profession, there is now a global consensus that healthcare providers integrate research evidence into their practice so new generations of health professionals have EBP embedded in programmes of study (Al Khalaileh et al, 2016). There are multiple positive outcomes related to evidence-based care, such as improvements in healthcare quality, safety and a reduction in care costs (Beyea and Slattery, 2013; Melnyk et al, 2018; Al Qadire, 2019). Despite the great strides undertaken in the previous three decades to integrate this concept into healthcare, there is evidence to suggest there are issues in understanding EBP and an inconsistent approach to implementing evidence-based care in practice (Melnyk et al, 2010).
Exploration of definitions
Despite the range of terminologies used with regards to EBP, which includes discipline-specific evidence-based nursing and evidence-based medicine (Barker and Linsley, 2016), the aim and key elements are essentially the same. Evidence-based medicine is the:
‘Conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.’
Although this definition recognises the need to integrate best current evidence with clinical expertise, a criticism is that it does not include the perspectives of service users (Barker and Linsley, 2016) as previously outlined by Sackett and described by Smith and Rennie (2014). The definition of EBP acknowledges a three-pronged approach, which includes best current evidence, clinical expertise, and the values and preferences of patients. The International Council of Nurses (ICN) states that:
‘Evidence-based practice is a problem-solving approach to clinical decision-making that incorporates a search for the best and latest evidence, clinical expertise and assessment, and patient preferences and values, within a context of caring.’
A definition of evidence-based nursing is the:
‘Conscientious, explicit, and judicious use of theory-derived, research-based information in making decisions about care delivery to individuals or groups of patients reflective of individual needs and preferences.’
EBP is embedded in the principle that patient care should be informed by rigorous evidence (Mackey and Bassendowski, 2017); therefore, nurses need to learn how to gather evidence and how to put this knowledge into everyday practice. As not all evidence is robust or reliable, nurses must learn how to identify the best available evidence, taking into account the needs and preferences of health service users, while using their own expertise and clinical judgement to ascertain the feasibility of its use (ICN, 2012).
Outcomes related to adopting an evidence-based practice approach
The main rationale for adopting an evidence-based approach in practice is to enhance the quality of care for patients and improve outcomes (LoBiondo-Wood et al, 2019). Using an EBP approach also provides a framework that supports decision-making (Mantzoukas, 2008; ICN, 2012; Beyea and Slattery, 2013), and helps health professionals make informed judgements (Pooler, 2012). Using this approach helps nurses to be more prepared to ask relevant questions regarding changes to their practice and more equipped to evaluate their practice (ICN, 2012). An evidence-based approach also contributes to a potential reduction in care costs (Beyea and Slattery, 2013; Melnyk et al, 2018; Al Qadire, 2019).
Components of evidence-based practice
EBP is based on evidence that originates from three key components (Rees, 2010):
- Best available external evidence from published research
- Clinical expertise
- Patient values and preferences.
Each component is limited in its value until combined with the neighbouring components.
Best available external evidence
The first component of EBP is the sourcing, appraisal and implementation of best available external clinical evidence. Best evidence can originate from a range of sources such as randomised controlled trials, evidence from other scientific designations, which includes descriptive and qualitative research, and information from case reports (LoBiondo-Wood et al, 2019).
Clinical expertise
The second component relates to clinical expertise, which is the proficiency and judgement that clinicians acquire through clinical experience (Sackett et al, 1996) and has both knowledge and skill set components (McCracken and Marsh, 2008). External evidence can inform, but not replace, individual clinical experience, as it is the expertise that decides whether the external evidence can be applied to the individual patient (Sackett et al, 1996).
Patient values and preferences
The final component of EBP relates to patients' values and preferences, which are crucial in deciding on the appropriate management (Haynes and Haines, 1998) because even excellent external evidence may be inapplicable to an individual patient (Sackett et al, 1996). Incorporating patients' values and perspectives aligns to the person-centred approach to care, in which patients are active participants in their care (Siminoff, 2013).
Steps in evidence-based practice
There are a range of models which outline the steps in the EBP process. One such model involves seven steps from step 0 to step 6 (Melnyk et al, 2010):
- Step 0 relates to cultivating a spirit of inquiry, which involves health professionals adopting an inquisitive approach to practice
- Step 1 involves developing a focused question with one relevant framework available being PICO(T). This was introduced by Richardson et al (1995) and subsequently applied to other disciplines (Schlosser et al, 2007). The acronym PICO(T) identifies the population (P), intervention (I), comparator (C), outcome(s) (O) and, if appropriate, the time (T) element in a focused question
- Step 2 relates to searching for the best evidence using the key words and synonyms identified in the PICO(T) framework. Sources of evidence may include books, journals, government and policy documents, and grey literature, which is literature not formally published (Barker and Ortega, 2016)
- Step 3 involves critically appraising the evidence sourced in Step 2. Registered nurses should have the ability to evaluate the strengths and weaknesses of research evidence, to determine the merit of research for use in practice (LoBiondo-Wood et al, 2019)
- Step 4 relates to integrating the evidence sourced, along with clinical expertise and patient preferences in making the best clinical decisions
- Step 5 involves evaluating the outcome(s) of the EBP approach, to determine the impact
- Step 6 relates to disseminating the outcome(s) to enable others to learn and develop their practice (Melnyk et al, 2014).
Hierarchy of evidence
When critically appraising the evidence as part of step 3 in the EBP process, an understanding of the hierarchy of evidence is important (Table 1). This provides the rank order of sources of evidence, indicating which has the highest (level 5), and which has the lowest (level 1) with regards trust in their use for clinical decision making (Rees, 2010). Although this is useful in determining the strongest evidence, it has been argued that this hierarchy is too linear and orderly and does not exist in the reality of clinical practice (Mantzoukas, 2008). Therefore, it is crucial the reviewer continues to use their critical judgement skills to appraise the sources of evidence.
Table 1. Hierarchy in evidence-based practice
| Level 1 | Opinions of respected authorities, based on clinical evidence, descriptive studies or reports of expert committees |
| Level 2 | Qualitative studies |
| Level 3 | Trials that did not use randomisation or non-experimental studies |
| Level 4 | A well-designed randomised controlled trial |
| Level 5 | Systematic reviews (such as a Cochrane review) based on well-designed randomised controlled trials |
Current challenges to evidence-based practice
Although the national agenda for EBP is at the forefront of healthcare, there continues to be low implementation of EBP in healthcare settings (Melnyk et al, 2018). It is argued that EBP is not the standard of care practised consistently across the globe despite the published benefits (Melnyk et al, 2014). Organisational factors, including a lack of time to source, appraise, implement and evaluate evidence, are outlined by many authors as a key barrier to the EBP process (Melnyk et al, 2005; Rees, 2010; Melnyk et al, 2014; Al Khalaileh et al, 2016; Kalavani et al, 2019). Nurses have also reported barriers to EBP connected to a lack of authority to change care procedures in practice (Al Khalaileh et al, 2016) or a culture that adopts an attitude of ‘having always done it this way’ (Melnyk et al, 2014). Consequently, nurses in the clinical environment often rely on policies and protocols for guidance on best practice.
Barriers associated with practitioners relates to not having the critiquing skills to assess the quality of the evidence (Rees, 2010; Melnyk et al, 2014) or finding it challenging to interpret research findings due to the terminologies used and the statistical presentation of research results (Rees, 2010; Barker and Linsley, 2016). Despite these challenges, the findings of an integrative review demonstrated that nurses had a positive attitude and belief in the value of EBP; however, they perceived their knowledge and skills related to EBP were insufficient for employing evidenced practice and, consequently, did not use this approach (Saunders and Vehviläinen-Julkunen, 2016).
Barriers related to the evidence available includes the dearth of high-quality methodologically robust and clinically relevant research. When relevant evidence is available, research evidence is often translated into clinical practice at a slow pace (Melnyk, 2017), with a lack of effective and efficient knowledge transfer activities. At times, there is conflicting evidence as a result of contextual variations in different settings; however, new research approaches are being introduced that seek to identify the impact of contextual variations on outcomes, such as realistic evaluation (Pawson and Tilley, 1997).
A further challenge in the current context of the COVID-19 global pandemic relates to the surge of new evidence being presented and an associated urgency to collate, review, appraise and apply this information (Carley et al, 2020). It remains crucial that evidence-based solutions continue to be embedded in responses to the challenges currently confronting the healthcare system (Lake, 2020).
Recommendations to address current challenges for NMC registrants
Finding efficient and effective ways to promote the uptake of evidence-based interventions is a priority (Haines et al, 2004). Although the health workforce has a positive view of the value of EBP (LoBiondo-Wood et al, 2019), their knowledge and skills can be limited (Kalavani et al, 2019). For many frontline nurses, there is no protected time available for providing a consistent approach to sourcing and implementing the current best available external evidence. Although it is important to follow best practice guidelines to enhance patient outcomes (Mackey and Bassendowski, 2017), nurses should also engage individually in sourcing, appraising and implementing best evidence. To assist with this endeavour, research departments and practice development units within healthcare organisations are a resource to support nurses in sourcing and applying evidence in practice. There are also local clinically based initiatives to increase nurses' knowledge and capacity in evidence-based practice. One such example is the development of a hospital-based enhancement model to plan, develop and implement a research outreach, ward-based seminar programme focused on addressing common barriers to EBP and how to apply EBP in nursing (Edward and Mills, 2013).
Protected time away from direct patient care should be available for nurses working in clinical practice for these activities. Although this may seem an unrealistic recommendation in already stretched healthcare systems, viable options may include support to complete modules of study and having access and time to search online databases (Kalavani et al, 2019), or attend conferences in person or virtually. Some health and social care trusts and boards have appointed clinical educators with responsibilities that include encouraging frontline nurses to engage with clinically relevant research through initiatives such as journal clubs. However, time available away from clinical areas remains a challenge for frontline nurses.
Sourcing innovative methodologies to translate research findings into a language that is relatable to clinically based nurses is a priority, in addition to methods to effectively disseminate findings to expedite the process of implementing emerging evidence into practice. Knowledge translation refers to:
‘The process through which research knowledge is created, circulated and adopted into clinical practice.’
One knowledge transfer and exchange model is EMTReK (an Evidence-based Model for the Transfer and Exchange of Research Knowledge), which identifies six core components of knowledge transfer in the context of palliative care (Payne et al, 2019). Highlights include ensuring the message outlines the impact on user need, the message being accessible, credible and actionable, having an ability to market the research findings through diverse activities, including social media, and considering the social, economic and cultural context to promote the possibility of a fertile ground for the implementation of research findings in practice.
Pre-registration nursing programmes
Within the NMC document Future nurse: Standards of proficiency for registered nurses (NMC, 2018b) there is continual reference to evidence-based nursing to ensure the registrant will have the underpinning knowledge to base their skills and nursing care on both theoretical and clinical components. These standards outline the importance of ‘being an accountable professional’, providing clear direction to academic institutions that nursing students must have a knowledge of the methods related to evidence-based practice. The standards state that, on entry to the NMC register, each nursing student should also be able to understand the processes of research methods (NMC, 2018b). It further identifies the need for the registrant to be able to critically analyse, safely use and apply the research findings to promote and inform the nurse's practice (NMC, 2018b), contributing to an evidence-based practice approach to care delivery. A knowledge and application of research methods is, therefore, important in pre-registration programmes of study.
The ability to scrutinise evidence and subsequently apply it in practice is emphasised in the theoretical components and procedural skills of the Future nurse standards (NMC, 2018b). The Future nurse proficiencies to be assessed in the clinical setting clearly state that each nursing student on registration to the NMC can safely demonstrate evidence-based practice related to the seven identified learning platforms in the specific communication and procedural skills and these form a component of the practice assessment documents (NMC, 2018b). Evidence-based nursing skills are also assessed in the university setting through simulated practice and in academic assessments that focus on the student demonstrating their ability to source, appraise and apply evidence. Each new NMC registrant should be able to provide the rationale for undertaking a skill in practice and use evidence-based research to support their actions. This should contribute to registered nurses demonstrating an approach which applies evidence-based knowledge and skills in every clinical situation and the continued development of autonomous practitioners.
However, despite EBP being embedded in pre-registration programmes of study (Mackey and Bassendowski, 2017), with convincing evidence that an EBP approach contributes to the delivery of high quality patient care (André et al, 2016), nursing students commonly struggle to recognise the relevance of EBP (Disler et al, 2019). Recent literature has identified that nursing students have a low level of knowledge of EBP (Al Qadire, 2019) and can experience challenges in linking the relevance of EBP from learning at the academic institution to their clinical practice, with many not recognising the relevance of the theory to practice (Disler et al, 2019). These insights highlight the importance of academic institutions continuing to communicate the importance of EBP (Melnyk et al, 2018) and adopt innovative learning methods with a focus on the application of theory to clinical practice (Oh and Yang, 2019). This will enable students to increasingly recognise the relevance of an EBP approach in enhancing their practice (Disler et al, 2019) and improving patient outcomes. Embedding reflection within clinical practice should also equip the student to incorporate EBP into their everyday nursing care (Florin et al, 2012).
Conclusion
EBP is a global phenomenon that promotes best practice, clinical effectiveness and quality of care (Barker and Linsley, 2016). It is a relatively new concept in healthcare, yet there has been a movement to recognise the value of using an EBP approach and embed this approach in practice. The national agenda for EBP is at the forefront of healthcare (LoBiondo-Wood et al, 2019). However, there continues to be low implementation of EBP in some healthcare settings (Melnyk et al, 2018). The challenge is to adopt innovative approaches to supporting nurses to implement EBP both in academic institutions and in practice settings. As nurses evolve to become more autonomous in decision-making and clinical judgement skills, the role must be developed so that nurses feel supported to search, appraise, implement and evaluate evidence, and integrate this with clinical expertise, while ensuring patients are increasingly empowered to be active participants in their care. The context of the COVID-19 global pandemic places a further emphasis on the need to ensure practice is evidence-based as emerging research requires an urgent and rigorous appraisal before the implementation of findings into practice. This will contribute to the development of a profession that is becoming increasingly autonomous in decision-making and in its significant contribution to maximising favourable patient outcomes.
KEY POINTS
- Evidence-based practice (EBP) aims to promote best practice, clinical effectiveness and high-quality care
- Although EBP is a relatively new concept in healthcare, there has been a global movement and recognition of the need to adopt this approach to care
- Current challenges to the implementation of EBP in nursing include nurses having difficulty applying evidence to everyday practice and lack of time away from the clinical area to keep up to date with research
- Recommendations to address the challenges related to the low implementation of EBP in nursing include an emphasis on EBP in nurse education, including academic assessments focusing on using evidence in everyday clinical situations
CPD reflective questions
- What are the professional challenges in adopting an evidence-based practice (EBP) approach to care delivery?
- What are the organisational barriers in embedding an EBP approach to care delivery?
- Think about what two steps you could take to promote EBP in your care delivery