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Nurse practitioner clinical decision-making and evidence-based practice By D eb o rah V in c e n t, P hD , RN , FA A N P; M a r ie H a s tin g s -T o ls m a , P hD , C N M , FA C N M ; S h e ila G ep h a rt, P hD , RN; P a ig e M . A lfo n ro , BA , M S

Abstract: Evidence-based practice is key to improving patient outcomes but can be challenging for busy nurse practitioners to implement. This article describes the process of critically appraising evidence for use in clinical practice and offers strategies for implementing evidence-based innovations and disseminating the findings.

lthough the concept of evidence-based practice (EBP) is not new, it has been gaining momentum in recent years. 1 Spurred by the Institute of Medi­ cine’s report, “To Err is Human,” many in healthcare began championing standards of care that stemmed from scien­ tific evidence rather than tradition and individual clinical experience. 2,3 Other factors that have driven the EBP move­ ment include wide geographical variations in practice pat­ terns, strong evidence that a lot of care is either ineffective or even harmful, rising costs, and reimbursement trends, such as “pay for performance.” 3,4 Nevertheless, wide varia­ tions in the uptake of EBP still exist.

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K e y w o rd s: c r itic a l a p p ra is a l, d is s e m in a tio n and im p le m e n ta tio n , e v id e n c e -b a s e d p ra c tic e , im p le m e n ta tio n s c ie n c e

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Nurse practitioner clinical decision-making and evidence-based practice

■ Determining barriers to care

incidence and mortality o f breast cancer. Findings strongly

It has been estimated that patients receive evidence-based

suggested that screening m am m ogram s had no effect on breast cancer deaths and held no advantage over clinical

care only 55% o f the tim e.5 If that estimate is accurate, it is crucial to determ ine w hat barriers exist for providing evidence-based care. Some barriers to the use of evidence in clinical practice have been well docum ented and include lack of: awareness, agreement or familiarity, time, access to

examination. M ammography also resulted in overdiagnosis w ith 20% o f those diagnosed by m am m ogram receiving unnecessary radiation, chemotherapy, or surgery.15

inform ation, and confidence in critically appraising the

Following publication o f this study, social m edia ex­ ploded with passionate voices to retain current m am m og­

evidence and translating it into care o f individual patients.

raphy screening despite the evidence. Financial incentives

A dditional barriers are inertia, fam iliarity w ith previous

(which encourage continued m am m ography practices) and

practices, lack o f access to library services, and lack o f a supporting organizational culture.6,7 In addition, determ in­

failure to u n d erstan d the study design an d analysis are

ing how to remove harm ful practices from care has received less attention but is equally im portant.

am ong the possible reasons for o u trig h t rejection o f the findings. The negative ramifications, including exorbitant costs, require reconsideration of science that challenges or

Originally proposed by Sackett and colleagues, EBP is a problem-solving approach to patient care that integrates the

changes long-held clinical practices. Many innovations com m only used in clinical practice

strongest research evidence, clinician expertise, and patient values/preferences.810 Searching for the strongest evidence to support best care practices can be overwhelming, and busy clinicians may not have the tim e or the confidence to so rt thro u g h and select evidence suitable for individual

have not been evaluated for effectiveness or potential harm ­ ful outcomes. Prasad and colleagues reviewed 2,044 original articles regarding medical practice and were published in the New England Journal of Medicine over the last decade.16 O f the articles reviewed, only 27% evaluated established

practices. N um erous m odels have been proposed for the im plem entation o f EBP and all share com m on core ele­ ments. These elements include asking a searchable clinical

medical practices, and 40% of those examined were found to be ineffective practices. These findings are similar to those

question, finding the evidence to answer the question, ap­ praising that evidence, and applying/evaluating the evidence for effectiveness and efficiency.9 This article specifically targets the nurse practitioner (NP) in clinical practice and offers strategies for critically appraising the evidence, factors to be considered in imple­ m enting EBP, and disseminating the findings to enhance the sustainability o f an innovation. ■ EBP

EBP has been shown to improve patient outcomes, reduce healthcare costs, and lead to greater clinician satisfaction.11,12 However, Bucknell argues that clinical decisions are often not based on explicit, robust evidence.13 Rather, many clinical decisions are undergirded by value judgments, tradition or habit, and a mixture of evidence from a variety of sources that may or may not include robust research.13 Indeed, EBP is as much about removing harmful or ineffective practices as it is about implementing strong evidence into practice. This is a crucial point, as the negative ramifications of continuing to engage in ineffective or harmful practices for patients and the healthcare system are vast.14 Science is fluid, and care practices may need to change as new evidence emerges. A case in point is a recent, wellconducted, large random ized study that followed nearly 90,000 Canadian women for 25 years to compare those who did or did not undergo m am m ography screening and the 48 The Nurse Practitioner • Vol. 40, No. 5

by Villas Boas and colleagues in a study of the 2011 Cochrane Database of Systematic Reviews.17 This study found that in 45% of systematic reviews, there was insufficient evidence to endorse the interventions in the clinical trials and nearly 1 in 10 was likely to be harm ful.17 Discarding harmful clinical practices, known as exnova­ tion (a term adopted from business) is as im portant as in ­ novation.18NPs m ust know how to access the literature and be able to critically appraise it for innovative practices that may benefit patients. Similarly, any harm ful practice should be eliminated from the N P’s arm am entarium . ■ Finding the evidence

W ith well over 50 million published papers and an annual projected growth rate of approximately 2.57%, it is difficult to keep up with current evidence.19 It is useful to consider approaches that can keep the NP up-to-date with literature in a given specialty (see Strategies for maintaining currency

in research and clinical literature). Academic librarians are an im portant resource in tailoring an individual plan for accessing up-to-date evidence, with m uch of the evidence available through electronic feed. To engage in EBP, the nature and quality o f evidence and its relevancy to the clinical question should be assessed as well as the suitability of the evidence for application in individual patients or settings. While there is a plethora of research on innovations to improve patient care, n ot all of these in n o v atio n s are suitable for use in every clinical www.tnpj.com

Nurse practitioner clinical decision-making and evidence-based practice

Strategies for maintaining currency in research and clinical literature Sources

Comments

E -m ail alerts J o u rn a l ta b le o f c o n te n ts (TOC),

E-m ail o r J o u rn a l alerts a llo w : • users to receive e -m a il n o tific a tio n w h e n ne w data are ava ila b le • n o tific a tio n fo r n e w jo u rn a l issues

P ubM ed, W eb o f Science, G o o gle A le rts

• G o o gle A le rts —m o n ito r sp e cific search te rm s and phrases on th e W eb RSS feeds J o u rn a lT O C , P ubM ed, W eb o f Science, M e d lin e , PubM ed

R eally S im p le S y n d ic a tio n (RSS) fe e ds are: • s im ila r to e -m a il alerts • can be read u sin g an RSS feed a g g re g a to r ra th e r th a n e -m a il in b o x • upd ate d c o n tin u o u s ly • used by m a n y databases, jo u rn a ls , blogs, and new s sites.

RSS feed a g g re g a to rs Feedly, FeedBurner, NetVibes

RSS feed a g g re g a to rs: • organize all RSS s u b s c rip tio n s in to one place • p ro vid e co n ve nien ce o f ce n tra lize d lo ca tio n fo r all c o n tin u o u s ly u p d ate d su b scrib e d new s sites, databases, and jo u rn a ls

S p e c ia lty Practice Briefs A m e ric a n A s s o c ia tio n o f N urse P ra c titio n e rs A A N P S m a rtB rie f

S p e cia lty b rie fs are: • e le c tro n ic n e w sle tte rs

M o b ile A p p s M en d e le y, Pulse, F lip bo a rd Feedly

M o b ile a p p lica tio n s: • sp e c ific a lly d e sig n ed fo r sm a ll m o b ile screens • s tre a m lin e n a vig a tio n on m o b ile devices • m an y are "c ro s s -p la tfo rm ," m e a n in g th e y run on a v a rie ty o f d iffe re n t p la tfo rm s

L is ts e rv s /E le c tro n ic m a ilin g lists U.S. N a tio n a l L ib ra ry o f M ed icine

• d e liv e r ta rg e te d he a lthca re new s and in fo rm a tio n fro m m edia sources a ro u n d th e c o u n try

L istse rvs are: • e -m a il lists, hosted by an o rg a n iza tio n th a t fo cu s on a sp e cific to p ic

Social M ed ia L in k e d in ,T w itte r

L in ke d in a n d T w itte r a llo w : • users to fo llo w e xperts and o rg a n iza tio n s in th e ir fie ld • jo in d iscu ssio n fo ru m s such as L in ke d in G roups

J o u rn a l C lubs

Jo u rn a l clu b s p ro vid e : • a fo ru m fo r m e m b e rs to discuss th e lite ra tu re related to th e ir area o f stu d y • fo ru m s m ay be fa ce -to -face o r v irtu a l

iPad

The iPad d e vice is: • a co n v e n ie n t to o l to co n n ect te a m s • a llo w s fo r co n fe re n cin g and v ie w in g vid e o s • fo s te rs easy access to e vidence and clin ica l g u id e lin e s

Table developed by the authors.

setting . 13 A critical appraisal of the evidence can help the clinician discern which innovations have potential for im­ proving patient outcomes in the clinician’s practice setting. Clinical questions may arise from everyday practice situations or from reading or discussing problems or is­ sues with colleagues. The literature is rife with discussions of how to develop a clinical question that can poten­ tially be answered through a critical appraisal of the lit­ erature. Perhaps the most common method is known as the PICOT question, which is a systematic way to iden­ tify various com ponents of a clinical issue. These com­ ponents include: patient population (P); intervention or issue of interest (I); comparison of innovations (C); the desired outcom es (O ); and the tim e (T) involved to achieve those outcomes . 20 www.tnpj.com

As an example, the NP may use the PICOT question method to address the issue of how best to help MexicanAmerican patients who are at risk for developing diabetes to lose weight. In this case, a PICOT question might be “In Mexican-Americans (P), how effective is a culturally tai­ lored weight loss program (I) compared to a standard weight loss program (C) in reducing weight (O) over the course of six months (T)?” There may not be a comparator in a quality improvement project, but a PICOT question can still be used. For example, a clinic wants to improve its adherence to the adult im m unization schedule recom­ mended by the CDC. In this case, a PICOT question might be “How has the in tro d u ctio n of a rem inder system impacted (I) provider (P) adherence (O) to the CDC guide­ lines for immunizations?” The development of a PICOT The Nurse Practitioner • May 2015 49

Nurse practitioner clinical decision-making and evidence-based practice

question has been well described in o th er jo u rn al articles.20'22

■

O nce an N P has developed a suitable PIC O T questio n , it is

In th e event th a t n o n e o f these resources address th e p a r­

Critically appraising the evidence

tim e to search for the best evidence.

ticular clinical question, NPs m ay need to co n d u ct their ow n

In searching fo r evidence, a g o o d place to sta rt is w ith

critical appraisals. W hen critically ap p raisin g th e literature,

reso u rces th a t have a lread y sifted th ro u g h m a n y stu d ie s

several factors m u st be assessed in deciding w hich in n o v a­

a n d in c lu d e d o n ly th o se o f h ig h q u ality . T h e re are m an y

tion is suitable for a particu lar patien t o r a particu lar setting.

p re a p p ra is e d re so u rc e s su c h as th e C o c h ra n e R eview s,

These factors include level, strength, quality o f th e evidence,

b u t even th e results fro m th ese resources m u st be assessed

su ita b ility fo r th e se ttin g a n d p a tie n t, co m p le x ity o f th e

fo r q u a lity a n d s u ita b ility (see Sources for preappraised

in n o v atio n , an d cost.

evidence ).23 To a id th e b u sy N P to d is c e rn th e stre n g th a n d q u a lity o f v a rio u s p re a p p ra ise d reso u rces, D iC enso

■

Level of evidence

a n d H ay n es have d ev e lo p e d a h ie ra rc h y .23 At th e to p is

Level o f evidence is often represented by a hierarchy th a t is

th e sy stem s layer o r c o m p u te riz e d d e c isio n m o d e ls, in

based o n th e research desig n em p lo y ed . T h e re are m an y

w h ic h an e v id e n c e -b a s e d c lin ic a l in f o r m a tio n sy ste m

d iffe re n t h ie ra rc h ie s a d d ressed in th e lite ra tu re , b u t th e

assim ilates a n d su m m a riz e s re le v a n t re se a rc h e v id en c e

M elnyk and F ineout-O verholt is the only one, to the au th o rs’

a n d lin k s it th r o u g h th e u se o f an e le c tro n ic m e d ic a l

know ledge, th a t includes b o th clinical practice guidelines

reco rd to a specific p a tie n t’s s itu a tio n .23 W hile th is is th e

an d criteria for assessing qualitative stu d ies.10,24 The highest

ideal, m an y practices d o n o t have access to c o m p u te riz e d

levels o f ev idence (th o se at th e to p o f th e h ierarch y ) are

d ecisio n m odels.

system atic reviews and m eta-analysis. Evidence from expert

In th a t case, the n e x t step in u sin g p re a p p ra ise d ev i­

o p in io n a n d /o r rep o rts from expert com m ittees are con sid ­

den ce w o u ld be to lo o k fo r su m m a rie s, su ch as ev id en c e-

ered to be th e lowest o r have th e least strength o f evidence.10

b ased clinical g u id elin es o r e v id e n c e -b a se d tex tb o o k s. If

C linicians m u st be co m p eten t in assessing all types o f p ra c ­

th e r e a re n o s u m m a rie s o f e v id e n c e fo r a p a r t ic u l a r

tice evidence b u t Level 1 evidence (system atic reviews and

clinical q u e stio n , th e n th e N P w o u ld lo o k fo r sy n o p sis o f

m eta-analysis), an d natio n al clinical p ractice guidelines are

synthesis in ev id en ce-b ased a b stra c tio n jo u rn a ls, su ch as

probably th e m ost relevant types o f evidence for th e average

th o se in th e D atabase o f A b stracts o f R eview s o f Effects

clinician.25

o r s y s te m a tic review s, su c h as th o s e fo u n d in th e C o ­

Finally, it is im p o rta n t to n o te th a t qualitative evidence

c h ra n e L ib rary o r E v id en ceU p d ates. T h e low est level o f

may be useful in providing context for quantitative evidence

th e p r e a p p r a is e d h ie r a rc h y in c lu d e s s in g le , o r ig in a l

and identifying p atien t experiences w ith treatm en ts. T here

articles p u b lish ed in jo u rn a ls. E videnceU pdates an d N u rs­

is increased evidence available from m eta-synthesis in w hich

ings- are tw o reso u rces th a t p ro v id e a sy n o p sis o f single

m ultiple qualitative studies o n the sam e topic are com bined,

stu d ies th a t have been c ritically a p p ra ise d a n d have m et

synthesized, an d critically analyzed to reveal th e best evi­

m in im u m c rite ria .23

dence.26 Such evidence is im p o rta n t to consider b u t requires

S o u rc e s fo r p re -a p p ra is e d e v id e n c e

S o u rce s C o c h ra n e R e v ie w w w w .c o c h ra n e .o rg /c o c h ra n e -re v ie w s

C o m m e n ts • S y s te m a tic r e v ie w s o f p r im a r y re s e a rc h e v id e n c e . • P ro ce ss f o r re v ie w is e x p lic it. R e g u la rly u p d a te d .

B M J C lin ic a l E v id e n c e w w w .c lin ic a le v id e n c e .c o m D y n a m e d w w w .e b s c o h o s t.c o m /d y n a m e d /d e fa u lt.p h p

• In te rn a tio n a l d a ta b a s e o f p re a p p ra is e d s y s te m a tic r e v ie w s u m m a r ie s o n w id e v a r ie ty o f c lin ic a l is s u e s . • R e v ie w p ro c e s s is e x p lic it. • R e g u la rly u p d a te d .

U p T o D a te w w w .u p to d a te .c o m

• S u m m a rie s o f p re a p p ra is e d e v id e n c e a b o u t s p e c ific c lin ic a l iss u e s . • R e v ie w c r ite r ia n o t e x p lic it. • U p d a te d d a ily .

N a tio n a l G u id e lin e C le a rin g h o u s e w w w .g u id e lin e .g o v

• F re e ly a c c e s s ib le , c o m p r e h e n s iv e p ra c tic e g u id e lin e s b a s e d o n f u ll ra n g e o f e v id e n c e . N o t r e g u la r ly u p d a te d . • S o m e g u id e lin e s n o t a c c o m p a n ie d b y le v e ls o f e v id e n c e .

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Nurse practitioner clinical decision-making and evidence-based practice

judicious evaluation, as the evidence is not the same as meta-analysis. Meta-analysis uses statistical methods to evaluate several quantitative studies, increasing the power of analysis and decisions about treatment effect. It is most often used to assess the clinical effectiveness of healthcare interventions.27 Systematic reviews and meta-analyses can generally be found in Cochrane Library, and many clinical guidelines have been developed by professional and government orga­ nizations. The National Guidelines Clearinghouse is one public source for evidence-based clinical practice guide­ lines.28 Because not all clinical practice guidelines are of high quality, NPs should critically appraise any guideline for quality before selecting it for use in their clinical practices. The AGREE Collaboration (Appraisal of Guidelines for Research and Evaluation) uses an international team of practice guideline developers and researchers to develop a tool to aid practitioners in assessing the quality of a guide­ line and to provide a rigorous framework for developing guidelines.29,30 The AGREE II instrument is comprised of 6 quality categories and 23 specific criteria for appraising guideline quality. The instrum ent can be found on the AGREE website at www.agreetrust.org.30 ■ Strength of evidence

Once the evidence at the highest level has been found, the quality of the evidence must be critically appraised. Overall strength of evidence can only be determined by synthesizing both data on the level of evidence and the quality of evidence developed in each study. A critical appraisal is the process of systematically scrutinizing and evaluating research evi­ dence to determine if it is reliable, clinically appropriate, and significant.30 Validity of results should be determined when criti­ cally appraising studies. This can be done by identifying any flaws in the study design and methods. At a minimum, the NP would want to identify the following: study design used, adequacy of sample size, the sampling plan, the reli­ ability and validity of measures including questionnaires, appropriateness of data analysis, and the applicability of the findings to clinical practice. There are many sources for critical appraisal worksheets, including text books, journal articles, and websites such as the Center for Evidence-based Medicine.10,30'32 In addition, creating an evidence table can be useful in determining the overall strength of evidence because it fa­ cilitates the comparison and synthesis of all related evi­ dence.10 First, the NP would document the level and qual­ ity of evidence from each pertinent study and then proceed to synthesize evidence across these studies (see Hypothetical evidence table). Assessing the quality of evidence can be www.tnpj.com

somewhat subjective. However, the Grading of Recommen­ dations Assessment, Development and Evaluation (GRADE) is an international collaborative that has developed a com­ mon, practical approach to grade the quality of evidence.30,33 The GRADE group has developed downloadable software and tutorials for those interested in assessing the quality of evidence. These are available at www.gradeworkinggroup. org/toolbox/index.htm. Even high-quality evidence may not be suitable for use in every clinical setting. The NP must also critically appraise for cost and complexity. Some innovations may be too costly or too complex to be suitable for use in most clinical settings. For example, the Diabetes Prevention Program (DPP) clearly demonstrated that intensive lifestyle modifi­ cation delays or prevents the progression of pre-diabetes to diabetes, but it required costly resources and was not easily replicable in clinical settings.34Recently several studies have translated the DPP into lower cost, less resource-intensive innovations that can be replicated in community or clinical settings.34,35 ■ Implementation of EBP

The problem in healthcare is not only “what is the evidence?” but extends to the problem of inconsistent or inappropriate application of the evidence in real world practice.36The goal to deliver high-quality care that fits patient preferences may require adaptation of evidence-based innovations to suit the real world clinical settings in which they are applied. Evaluation of the implementation of an evidence-based innovation may be useful in assessing the degree to which the innovation was adapted, effect on patient outcomes, degree of adoption or uptake by clinicians, cost to the or­ ganization, and fit with organizational values and resourc­ es. An innovation that is highly acceptable to clinicians and the organization is easy to implement, requires few resourc­ es, and fits within the organization’s budget is more likely to be implemented and sustained than is a complex, time­ intensive, and costly innovation.37 To facilitate EBP on an organizational level may require system redesign, protected time to design, implement, and evaluate, as well as incentives for participants to continue this important work.38Administrative support is particularly im­ portant for evidence-based innovations that rely on consistent delivery by a variety of clinicians.38 The use of local change champions has been shown to enhance enthusiasm for the evidence-based innovations from clinicians and NPs are ide­ ally suited for this role and to promote the implementation of EBP.38 Finally, celebrating success when an evidence-based innovation has been effectively implemented, particularly when it resulted in positive change in patient outcomes, is a strong approach to nurture a culture of inquiry. The Nurse Practitioner • May 2015

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Nurse practitioner clinical decision-making and evidence-based practice

Hypothetical evidence table Research Question: W hat is the best approach to w ith dra w in g patients from antidepressants to avoid adverse reactions? S tu d y ty p e

S tu d y purpose

Population

Intervention

Outcome

Limitations

Adults, 18-65

3 different approaches to SSRI w ithdraw al: • abrupt w ithdraw al • tapering SSRI dose • tapering SSRI dose; initiating use o f a weak SSRI

Nature and severity of sym ptom s significantly less w ith planned reduction at 50% rate

Absence of co m o rb id i­ ties

Adults, 21-40

50 mg vitam in B6 daily, scheduled reduction of SSRI (fluoxetine, sertraline)

50% reduction in adverse reactions when taking 50 mg daily o f vitam in B6 (p = 0.5)

Variable length of tim e on medication; variable dosing

Men, 22-35

3 groups: 1) half dosing fo r tw o weeks until off, 2) half dosing for 3 days until off, 3) self-determ ination of rate of w ithdraw al

Severity of sym ptom s, relapse rates both few er when patient determ ined rate of w ithdraw al

Self-report o f com or­ bidities and dose reduction

Adults, 18-70

Not applicable

W ithdraw al debilitating w ith little provider support. Need for supportive interventions.

Limited to adults

Women, reproductive age

Not interventional; descriptive

Providers rarely m entioned w ithdraw al issues and provided little support when confronted.

Variable medication, dosing, and wom en only

D ep ression T re a tm e n t C o h o rt, 2013, Level 1

Meta-analysis, 7 studies (N = 620)

Effectiveness o f 2 different w ithdraw al techniques

Jones e t al, 2 00 9 , Level 2

RCT, 2 different approaches to w ith dra w in g from SSRIs (N = 132)

Compare use of vitam in B6 daily and gradual dose reduction

M u n k le e t a l., 2 0 0 6 , Level 3

Prospective clinical trial to differentiate 3 approaches to fluoxetine withdrawal (N = 83)

Compare 3 approaches to fluoxetine w ithdraw al

M y b e rg and S u lliv a n , 2011, Level 5

Meta-synthesis o f 6 qualitative studies (N = 73)

Patient experience o f SSRI w ithdraw al

N o lte and W a ts o n , 2010, Level 6

Q ualitative focus group (N = 11)

Describe process o f w ithdraw ing from SSRIs

LOE: level of evidence: Level 1 evidence-Systematic review and meta-analysis of randomized controlled trials (RCTs) or evidence-based guidelines based on systematic reviews or meta-analysis, Level 2-0ne or more RCT, Level 3-Controlled trial with no randomization. Level 4-Case-control or cohort study, Level 5-Systematic review of descriptive and qualitative studies. Level 6-Single descriptive study, Level 7-Expert opinion. Source for LOE: Melnyk BM, Fineout-Overholt E. Evidence-Based Practice in N ursing & Healthcare. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011. LEGEND: SSRIs= Selective Serotonin Reuptake Inhibitors, Note: Table of hypothetical data reflects strong evidence to support withdrawal of SSRIs utilizing controlled dose de-escalation. Patients need to be aware of potential withdrawal difficulties when starting SSRIs and need support during the withdrawal process. Self-determination of the rate of withdrawal meets with better patient outcome and long-term success for withdrawal with fewer complaints about adverse reactions.

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A number of different approaches to reliable implemen­ tation of evidence for practice have been proposed and the theoretical foundation for implementation is strong with 47 models identified in the literature.39,40Among the dozens of implementation science frameworks available, the Trans­ lating Research into Practice (TRIP) framework is one of the most commonly used. TRIP can be used to design imple­ mentation studies that test the degree of provider adoption of an innovation by providers and organizations. Adoption of the innovation as proposed in TRIP is influenced by: characteristics of the innovation, communication, users, and the social system. Factors that influence adoption of the innovation include users’ beliefs that the innovation is su­ perior to usual care; compatibility with existing values; limited complexity; trialability (the degree to which an innovation can be tested on a small scale); and observ­ ability.41 Institutionalizing a new innovation is challenging, but several factors may enhance successful implementation and sustainability of the innovation. In addition to those previously mentioned, a multifaceted and interdisciplinary com munication process that includes: educational out­ reach, including opinion leaders, and change champions from the earliest stages of project design can prove essential for successfully sustaining an evidence-based innovation in a clinical setting.42 ■

Disseminating evidence into practice

Dissemination and implementation research (also referred to as knowledge translation and/or knowledge utilization) identifies factors and strategies that lead to adoption, main­ tenance, and sustainability of science-based innovations and is most urgently needed.41 This process promotes highquality care, adaptable innovations, and the inclusion of sustainability and evaluation measures. To achieve these goals, essential elements must be integrated and include multidisciplinary team care, health information technology, and stakeholder engagement.43,44 Equally im portant is the dissemination of inform a­ tion about effective innovations to a larger audience. NPs who have successfully implemented evidence into prac­ tice must share their experiences and results with others to facilitate the widespread use of the evidence in an organization or clinical practice setting. This can be ac­ complished by identifying other clinicians in the organi­ zation who could benefit from learning about the results of the evidence-based innovation and who might wish to apply it to their own practices. Another dissemination strategy is to partner with other professionals who are opinion leaders or influential clinicians to share informa­ tion about a successful im plem entation of an evidencebased innovation.45 www.tnpj.com

Heavy clinical workloads and an explosion of knowledge preclude reading all relevant information from scholarly publications; it is too inefficient. Clinicians would need to read approximately 17 articles each day to keep up with the available literature in a given area of practice, and with nearly 40% of nurses reporting insufficient time to read research, this is unlikely.46,47 In addition, research suggests that moving evidence into practice is most likely to occur when the information is interactive and applied; reading alone is probably insufficient to create change in clinician behavior.48 By partnering with opinion leaders to share findings about successful implementation of an evidencebased innovation, the NP can facilitate the adoption of this practice in the organizational setting. Creation of sustained change based on best evidence requires consideration of new models of care. Project ECHO is a model of education and care delivery that has received positive review. This model takes advantage of basic com­ munication technology with activities such as weekly vir­ tual grand rounds. Teams meet and together review and manage patients, sharing cumulative knowledge of the lit­ erature and best practices.49 This type of learning network pools expertise with teams joining together to solve prob­ lems and creating best practices. NPs must participate in such networks and could serve as leaders in forming a learn­ ing network. Finally, a crucial and central consideration in the imple­ mentation of evidence in clinical practice is involvement of patients as key stakeholders. Evidence about the comparative effectiveness of varied treatment options is needed for pa­ tients to make informed healthcare decisions. Successful translation of the evidence into practice requires patient engagement that is sustained and continuous.50,51 NPs need to solicit input from patients that will make the translation of evidence more useful. ■

Moving forward

Care that is not evidence-based is likely both unethical and incompetent. For NPs who are on the front lines in the provision of primary care services, innovations with dem­ onstrated effectiveness, that are cost-effective, and that con­ sider patient perspectives hold hope for improved patient outcomes. Better use of existing knowledge by NPs can contribute to the improvement and transform ation of healthcare. The overriding goal of EBP is quality improve­ ment that ensures best practices are implemented.44 CD REFERENCES 1. Walshe K, Rundall TG. Evidence-based management: from theory to practice in health care. Milbank Q. 2001;79(3):429-457. 2. National Research Council. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press; 2000.

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The authors have disclosed that they have no financial relationships related to this article. D O I-10.1097/01 .NPR.0000463783.42721.ef

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