Chapter 5: Evidence-Based Practice

To provide patient care of the highest quality, nurses utilize an evidence-based practice approach because evidence-based practice is
a. A guide for nurses in making clinical decisions.
b. Based on the latest textbook information.
c. Easily attained at the bedside.
d. Always right for all situations.
Evidence-based practice (EBP) is a guide for nurses to structure how to make accurate, timely, and appropriate clinical decisions. A textbook relies on the scientific literature, which is often outdated by the time the book is published and is not the most reliable source for EBP.
Unfortunately, most of the best information in evidence never reaches the bedside. EBP is not to be blindly applied without using good judgment and critical thinking skills. It is not appropriate for all settings
In caring for patients, it is important for the nurse to realize that evidence-based practice is
a. The only valid source of knowledge that should be used.
b. Secondary to traditional or standard care knowledge.
c. Dependent on patient values and expectations.
d. Not shown to provide better patient outcomes
Even when the best evidence available is used, application and outcomes will differ based on patient values, preferences, concerns, and/or expectations. Nurses often care for patients on the basis of tradition or convenience, or the standard, “It has always been done this way.”
Although these sources have value, it is important to learn to rely more on research evidence than on non-research evidence. Patients who receive care based on the most recent and best evidence experience 28% better outcomes
The first step in evidence-based practice is to ask a clinical question. In doing so, the nurse needs to realize that in researching interventions, the question
a. Is more important than its format.
b. Will lead you to hundreds of articles that must be read.
c. May be easier if in PICO format.
d. May be more useful the more general it is
The PICO format allows the nurse to ask questions that are intervention focused. Inappropriately formed questions will likely lead to irrelevant sources of information. It is not
beneficial to read hundreds of articles. It is more beneficial to read the best four to six articles that specifically address the question. The more focused the question asked, the easier it will become to search for evidence in the scientific literature
In collecting the best evidence, the gold standard for research is
a. The randomized controlled trial (RCT).
b. The peer-reviewed article.
c. Qualitative research.
d. The opinion of expert committees
Individual RCTs are the gold standard for research. A peer-reviewed article means that a panel of experts has reviewed the article; this is not a research method. Qualitative research is valuable in identifying information about how patients cope with or manage various health
problems and their perceptions of illness. It does not usually have the robustness of an RCT. Expert opinion is on the bottom of the hierarchical pyramid of evidence
The nurse is writing a research article on a patient care topic. The nurse realizes that the section that will get the reader to read the article because of the value of the topic for the reader is the
a. Abstract.
b. Introduction.
c. Literature review or background.
d. Results
The introduction contains information about its purpose and the importance of the topic to the audience who reads the article. The abstract is a brief summary of the article. The literature review or background offers a detailed background of the level of science or clinical information that is available about the topic of the article. The results section is the summary section of the article.
The nurse is caring for a patient with chronic low back pain. In providing care for this patient, the nurse wonders whether the guidelines utilized for this type of pain are adequate. The nurse wants to determine the best evidence-based practice regarding these guidelines. What is the best database for the nurse to access?
c. PsycINFO
The Agency for Healthcare Research and Quality (AHRQ) includes clinical guidelines and evidence summaries. MEDLINE includes studies in medicine, nursing, dentistry, psychiatry, veterinary medicine, and allied health. EMBASE includes biomedical and pharmaceutical studies. PsycINFO deals with psychology and related health care disciplines.
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The nurse is developing a PICO question related to whether her patient’s blood pressure is more accurate while measuring with the patient’s legs crossed versus with the patient’s feet flat on the floor. With P being the population of interest, I the intervention of interest, C the comparison of interest, and O the outcome, the nurse determines that this is
a. A true PICO question, because the outcome always comes before the intervention.
b. A true PICO question regardless of placement of elements.
c. Not a true PICO question, because the comparison comes after the intervention.
d. Not a true PICO question, because the outcome comes after the population
Note that a well-designed PICO question does not have to follow the sequence of P, I, C, and O. The aim is to ask a question that contains as many of the PICO elements as possible.
In reviewing literature for an evidence-based practice study, the nurse realizes that the most
reliable level of evidence is the
a. Systematic review and meta-analysis.
b. Randomized control trial (RCT).
c. Case control study.
d. Control trial without randomization.
In a systematic review or meta-analysis, an independent researcher reviews all of the RCTs conducted on the same clinical question and reports whether the evidence is conclusive, or if further study is needed. A single RCT is not as conclusive as a review of several RCTs on the
same question. Control trials without randomization may involve bias in how the study is conducted. Case control studies also have room for bias.
Qualitative nursing research is valuable in that it
a. Excludes all bias.
b. Uses randomization in structure.
c. Determines associations between variables and conditions.
d. Studies phenomena that are difficult to quantify.
Qualitative nursing research is the study of phenomena that are difficult to quantify or categorize, such as patients’ perceptions of illness. No study can totally exclude bias. However, randomization, such as that used in randomized control studies, helps. Qualitative
nursing research does not usually randomize its subjects. Control studies determine whether there is an association between one or more predictor variables and the condition.
The nurse has used her PICO question to develop an evidence-based change in protocol for a certain nursing procedure. However, to make these changes throughout the entire institution would require more support staff than is available at this time. What is the nurse’s best option?
a. Drop the idea of making the change at this time.
b. Insist that management hire the needed staff to facilitate the change.
c. Seek employment in another institution that may have the staff needed.
d. Conduct a pilot study to develop evidence to support the change.
When evidence is not strong enough to apply in practice, or if resources are limited, the next option is to conduct a pilot study to investigate the PICO question. Dropping the idea would be counterproductive; insisting that management hire staff could be seen as a mandate and
could produce negative results. Seeking employment at another institution most likely would not be the answer because most institutions operate under similar established guidelines
The hospital policy states that when starting an intravenous (IV) catheter, the nurse must first
prepare the potential IV site with alcohol and dress it using a gauze dressing. The nurse has
done a literature review and believes that evidence-based practice dictates the use of a transparent dressing to prevent catheter dislodgment. What should the nurse do?
a. Begin to use transparent dressing instead of gauze dressings.
b. Bring findings to the policy and procedure committee.
c. Use transparent dressings on half of her IV starts and gauze on the other.
d. Continue following hospital policy without saying anything
As a result of her finding, the nurse should meet with the policy and procedure committee to recommend routine use of transparent dressings. However, until the policy is changed, or the nurse receives approval to conduct a pilot study, the nurse is obligated to follow hospital procedure. If the nurse has information that can lead to better patient care, he or she has an obligation (moral and professional) to bring it to the attention of policy makers
The nurse is trying to identify common general themes relative to the effectiveness of cardiac
rehabilitation for patients who have had heart attacks and have gone through cardiac rehabilitation programs. The nurse conducts interviews and focus groups. What type of research is the nurse conducting?
a. Evaluation research
b. Experimental research
c. Qualitative research
d. Nonexperimental research
Qualitative research involves using inductive reasoning to develop generalizations or theories from specific observations or interviews. Evaluation and experimental research are forms of quantitative research. Nonexperimental descriptive studies describe, explain, or predict phenomena such as factors that lead to an adolescent’s decision to smoke cigarettes
In conducting a research study, the researcher must guarantee that any information the subject
provides will not be reported in any manner that identifies the subject and will not be accessible to people outside the research team. This concept is known as
a. Anonymity.
b. Confidentiality.
c. Informed consent.
d. The research process.
Confidentiality guarantees that any information the subject provides will not be reported in any manner that identifies the subject and will not be accessible to people outside the research team. Anonymity occurs when even the researcher cannot link the subject to the data. Informed consent means that research subjects (1) are given full and complete information about the purpose of the study, procedures, data collection, potential harm and benefits, and alternative methods of treatment; (2) are capable of fully understanding the research; (3) have the power to voluntarily consent or decline participation; and (4) understand how confidentiality or anonymity is maintained. The research process is a broader concept that provides an orderly series of steps that allow the researcher to move from asking a question to finding the answer.
The researcher is preparing to publish his study findings. In doing so, the researcher is aware of many ways that the study could have been done better, but that he did not have the ability to do. The researcher discloses these limitations in the manuscript, but they are most likely detected during which phase of the research process?
a. Problem identification
b. Study design
c. Formulation of recommendations
d. Analysis of data
During analysis of data, the researcher interprets the demographics of the study population, as well as results, including limitations. Problem identification involves identifying the area of interest and study variables, reviewing the literature, formulating the theoretical framework, and devising research questions. Study design involves selection of research methods. Formulation of recommendations involves determining the implications of the study for nursing.
When evaluating quality improvement (QI) programs in relation to evidence-based practice
(EBP), it is easy to note that
a. Both are designed to improve performance.
b. When implementing EBP projects, it is important to review QI data.
c. EBP is not at all related to QI.
d. Evaluation of processes is the realm of performance improvement (PI), not QI.
Evidence-based practice and quality improvement go hand in hand. When implementing an EBP project, it is important to review available QI data. Reliable QI data improve the
relevance and scope of an EBP project. Performance improvement (PI) analyzes performance. QI analyzes processes.
The hospital’s quality improvement committee has identified a problem on one of the units. In
using the PDSA method to help determine ways to deal with the issue, the committee decides to do a literature review. This is an example of quality improvement
a. Combined with evidence-based practice.
b. With inability to make the right decision.
c. With delay in the action needed.
d. With no designated method for dealing with issues
Quality improvement combined with evidence-based practice is the foundation for excellent patient care and outcomes. Once a committee defines a problem, it applies a formal model for exploring and resolving quality concerns. One part of the PDSA cycle is the “Do” section,
which requires the selection of an intervention on the basis of data reviewed. Therefore the committee is taking the right action and is not unduly delaying action; data must be obtained that are needed to make the right decision as part of the PDSA method, which is in place.
The quality improvement committee has been alerted to an increased number of falls in the
hospital. Most of these falls have occurred at night and have involved patients who were trying to crawl over bedrails. A literature review brought out that most falls occur because patients are trying to go to the bathroom. The committee created a practice change that bedrails should be left in the down position, and hourly nursing rounds should be conducted. What is the committee’s next step?
a. Evaluate the changes in 1 month.
b. Wait a month before implementing the changes.
c. Implement the changes as a pilot study.
d. Communicate to staff the results of this inquiry
Quality improvement combined with evidence-based practice is the foundation for excellent patient care and outcomes. Once a QI committee makes a practice change, it is important to communicate the results to staff. Practice changes will not likely last when QI committees fail to report findings and results of interventions. Once communicated, changes should be put in place as the committee deems reasonable (i.e., either fully or as a pilot study) and as soon as practical; this should be followed by re-evaluation.
The hospital quality improvement committee has noted that the incidence of needlestick injuries on a particular unit has increased. When faced with issues, the committee applies the PDSA model, a formal model for exploring and resolving quality concerns. Because the committee is multidisciplinary in nature, and few members are nurses, it is imperative that the committee first
a. Plan.
b. Do.
c. Study.
d. Act.
“Plan” is the first step of the process; it involves a review of available data to understand existing practice conditions or problems to identify the need for change. “Do” involves
selecting an intervention on the basis of the data reviewed and implementing the change. “Study” means to evaluate the results of the change. “Act” involves incorporating the change if it is successful.
The quality improvement committee is examining an increase in medication errors on a particular unit. In conducting its analysis, what should be the committee’s primary focus?
a. Nurses who administer the medications
b. Pharmacy that prepares the medications
c. Secretaries who enter the orders
d. None of the above
A well-organized QI program focuses on systems that significantly contribute to outcomes, not on individuals. Therefore, the entire process needs to be evaluated to determine effectiveness
The nurse is preparing to conduct research that will allow precise measurement of a phenomenon. Which of the following methods will provide the nurse with the right kind of data? (Select all that apply.)
a. Experimental research
b. Surveys
c. Evaluation research
d. Phenomenology
e. Grounded theory
ANS: A, B, C
Experimental research, surveys, and evaluation research are all forms of quantitative research. Phenomenology and grounded theory are forms of qualitative research
Before conducting any study with human subjects, the researcher must obtain approval from the agency’s human subjects committee or institutional review board (IRB). The IRB ensures
that the researcher (Select all that apply.)
a. Obtains informed consent.
b. Minimizes risk to subjects.
c. Ensures confidentiality.
d. Identifies risks and benefits of participation.
e. Ensures that subjects complete the study.
ANS: A, B, C, D
Researchers must protect the confidentiality of those who participate in the study, obtain informed consent, minimize risk to subjects, identify risks and benefits of participation, ensure that participation in the study is voluntary, and allow subjects to withdraw from studies at any time.
The nurse is doing a literature review related to a potential problem that has been identified on the nursing unit. The nurse realizes that nursing research is important in that it is designed to (Select all that apply.)
a. Enhance the nurse’s chance at promotion.
b. Identify new knowledge.
c. Improve professional practice.
d. Enhance effective use of resources.
e. Lead to decreases in budget expenditures
ANS: B, C, D
Nursing research is a way to identify new knowledge, improve professional education and practice, and use resources effectively. Effective use of resources does not always result in lower budget expenditures, but rather more effective use of resources. A promotion is not a direct result of research.

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