Evidence Digest

Advancing Evidence-Based Practice inClinical and Academic Settings

Bernadette Mazurek Melnyk, RN, PhD, CPNP/NPP, FAAN, FNAP

The purpose of the evidence digest, a recurring col-umn in Worldviews, is to provide concise summaries of

well-designed/clinically important, recent studies and arti-cles along with implications for practice, research, admin-istration, and/or health policy. Articles highlighted in thiscolumn may include quantitative and qualitative studies,systematic and integrative reviews, as well as consensusstatements by expert panels. Along with relevant impli-cations, the level of evidence generated by the studies orreports highlighted in this column (see Table 1) is includedat the end of each summary so that readers can integratethe strength of evidence into their health care decisions.

Pravikoff D.S., Pierce S.T. & Tanner A. (2005).Evidence-based practice readiness study supported byacademy nursing informatics expert panel. Nursing Out-look, 53(1), 49–50.

Purpose. The purpose of this study was to determinenurses’ readiness to implement evidence-based practice(EBP), including (a) awareness of a need for information,(b) ability to identify needed information, (c) ability tosearch available research, and (d) ability to apply the infor-mation or evidence to practice.

Sample. The stratified random sample was composedof 1,097 registered nurses. Nine hundred eighty-seven ofthese nurses were still employed. Eighty percent were morethan 40 years of age, and 72% received their most recentdegree before 1995.

Design. A descriptive survey was conducted.Findings. Major findings indicated that (a) the most fre-

quent source of information is a colleague or peer; (b)34.5% of the sample felt that they needed information onlyseldomly or occasionally; (c) almost half were not familiarwith the term “evidence-based practice”; (d) more than halfdo not believe that their colleagues utilize research findingsin the practice environment; (e) most do not search appro-priate information resources, such as Medline or CINAHL,to gather practice information; (f) only 27% of the respon-dents had any instruction in using electronic databases; (g)

Copyright ©2005 Sigma Theta Tau International1545-102X1/05

besides time, the greatest personal barrier in using informa-tion in practice was “lack of value for research,” and (h) thegreatest organizational barrier to using information in prac-tice was “presence of other goals with a higher priority.”

Commentary With Implications for Clinical Practice,Administration, and Education. Based on this survey’sfindings, it is easy to understand why it takes an averageof 17 years to translate research findings into practice inthe form of evidence-based care (Balas & Boren 2000).Despite the fact that thousands of EBP articles have beenpublished in the nursing literature over the past decade,the majority of nurses are continuing to base their care ontradition versus evidence from well-designed studies. Ifnurses do not value research and do not believe that EBPresults in the best patient outcomes, the teaching of EBPknowledge and skills will most likely not result in a shiftto evidence-based care. The valuing of research and EBPneeds to begin in foundational courses in educationalprograms. Continuing to teach students to conduct re-search instead of to use and apply research at the bachelorand master’s levels has, in large part, led to negative atti-tudes toward research. It is time for a paradigm shift inwhich the EBP process is started early in the educationalprocess and threaded throughout all didactic and clini-cal courses so that it becomes a lifelong approach to thedelivery of care. However, advanced practice and directcare nurses must model EBP if the movement is goingto accelerate in both academic and clinical settings. Be-liefs about the value of EBP also must be strengthened,as prior research has indicated that nurses who believethat EBP improves clinical care and patient outcomesare more likely to implement evidence-based care thanthe nurses who do not believe in its value (Melnyk et al.2004). Finally, administrators need to create a culture ofEBP that includes appropriate resources (e.g., access toquality computer databases at the point of care; time todevote to the EBP process), an institutional philosophyof EBP, encouragement of their staff to engage in EBP,and the use of EBP mentors to assist nurses in deliveringevidence-based care (Melnyk et al. 2005).

Level of Evidence: VI.

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TABLE 1Rating system for the hierarchy of evidence (from Melnyk & Fineout-Overholt 2005)

� Level I: Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs), or evidence-basedclinical practice guidelines based on systematic reviews of RCTs

� Level II: Evidence obtained from at least one well-designed RCT� Level III: Evidence obtained from well-designed controlled trials without randomization� Level IV: Evidence from well-designed case-control and cohort studies� Level V: Evidence from systematic reviews of descriptive and qualitative studies� Level VI: Evidence from a single descriptive or qualitative study� Level VII: Evidence from the opinion of authorities and/or reports of expert committees

Modified from Guyatt & Rennie 2002; Harris et al. 2001.

Newhouse R., Dearholt S., Poe S., Pugh L. & White K.(2005). Evidence-based practice: A practical approach toimplementation. Journal of Nursing Administration, 35(1),35–40.

Purpose. The purpose of this paper was to describe a pi-lot test of a nursing EBP model and guidelines that were de-veloped by a team of hospital and academic nurse leaders.The model emphasizes the use of best available evidenceas the core element required for decision making.

Sample. The sample consisted of 15 Johns Hopkins Hos-pital post-anesthesia care unit nurses, who comprised var-ious levels of education and practice. They were invitedto participate in the pilot project by their nurse manager,because they were experienced nurses who were regardedas experts by their peers.

Design. Pre-experimental; one group post-test design.Intervention. The nurses were charged with identifying a

clinical question relevant to the PACU clinical setting (e.g.,Should ambulatory surgery patients void prior to dischargefrom the PACU?). The nurses attended five 1- to 2-hr EBPeducational sessions over an 8-week block of time. As apart of the sessions, the nurses received a guidebook withinstructions on how to use the EBP model and guidelines.The guidebook also included tools on how to (a) select animportant clinical topic, (b) form a team, (c) rate the evi-dence found, and (d) implement findings from the review.During the sessions, the nurses were mentored in the EBPprocess by the leadership team.

Outcomes. Participating nurses completed an evaluationat the end of each session, rating the clarity, usefulness,adequacy, and feasibility of the model as well as satisfactionwith the EBP process and outcomes.

Findings. The results of the pilot project were used tomake revisions in the model and guidelines. Once themodel was revised, additional training occurred with abroader sample of nursing leadership, including standardsof care, nursing research, and nursing quality committeemembers in a train-the-trainer model. Overall, on a 4-pointscale, with 4 representing a favorable response, the nursesreported the following: the model was clear (M = 3.65), the

content was useful (M = 3.69) and adequate (M = 3.63),and the EBP process was feasible for practicing nurses(M = 3.51). In addition, the nurses reported that they weresatisfied with the EBP process (M = 3.81) and outcomes(M = 3.77). Barriers to implementation included (a)nurses’ concerns about relevancy of the EBP process totheir clinical setting, (b) knowledge deficit and feelings ofinadequacy regarding how to search for and critique thestudies found, (c) overwhelming feelings of informationoverload as nurses uncovered the evidence to answer theirclinical questions, and (d) lack of time needed for the EBPprocess. A key element in assisting nurses in overcomingthese barriers was the use of consistent mentors to guidenurses in this process.

Commentary With Implications for Clinical Practiceand Future Research. This study provides additionalevidence to support that the role of an “EBP mentor”is essential in facilitating the process with nurses inhospital settings, as was first proposed by the ARCC(Advancing Research and Clinical practice through closeCollaboration) model (Melnyk & Fineout-Overholt2002). Knowledge alone is usually not enough to effecta change in behavior, as there also must be strong beliefsabout the value of EBP and commitment by cliniciansto use EBP along with consistent practice in the newskills to exert changes in care. Caution must be used ingeneralizing the results of this study to other settings,because of the small sample size and the nature of thedesign (i.e., pre-experiment). Pre-experiments are weakin terms of internal validity (i.e., the ability to attributechanges in outcomes to the intervention). Randomizedcontrolled trials (RCTs) are the strongest design fortesting cause-and-effect relationships. A major weaknessin the science of EBP in nursing is that the professioncurrently has conceptual models to advance EBP, butthey have not been tested in the context of RCTs.Replication of this study using an RCT is needed, withmore long-term follow-up to determine the effects of the

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intervention over time. Measurement of other outcomesin addition to those that were assessed in this pilot studyalso will be important (e.g., nurse satisfaction, intent toleave, patient outcomes, cost) in a future RCT.

Level of Evidence: VI.

Fink R., Thompson C. & Bonnes D. (2005). Overcom-ing barriers and promoting the use of research in practice.Journal of Nursing Administration, 35(3), 121–129.

Purpose. The purpose of this study was to determinethe effect of multifaceted organizational strategies on reg-istered nurses’ (RNs’) use of research findings to changepractice in an academic hospital. The specific aims wereto (a) identify nurses’ attitudes and perceptions about or-ganizational culture and research utilization, (b) identifyperceived barriers and facilitators to nurses’ use of researchin practice, and (c) determine which factors correlate withresearch utilization.

Sample. The convenience sample was composed of allRNs on the inpatient units at a large university-affiliatedMagnet hospital. At baseline, 215 of 880 surveys were re-turned (i.e., a response rate of 24%). Two hundred thirty-nine nurses completed the post-intervention survey (i.e.,a response rate of 27%). The average survey participantwas a 39-year-old staff nurse employed full time with 14years of practice experience. Sixty-seven percent of the re-spondents were bachelor’s prepared nurses and 16% heldadvanced degrees.

Theoretical Framework. Rogers’ Diffusion of Innova-tions, a behavioral theory that outlines the processesthrough which a new invention gets adopted or rejected,was used to guide the study. Five stages in the model in-clude (1) the knowledge stage, (2) the persuasion stage,(3) the decision stage, (4) the implementation stage, and(5) the confirmation stage. This study focused on the firsttwo stages of the theory.

Design. Pre-experimental; a descriptive, cross-sectionalpre- and post-survey design.

Intervention. The intervention consisted of a PracticeOutcomes Research Manual, a 125-page manual designed tostimulate staff nurses’ learning about EBP and the researchprocess, which was distributed to all nursing units. Multi-ple organizational strategies also were developed and im-plemented after assessing the pre-intervention data. Thesestrategies included (a) the integration of an EBP philosophyinto nursing job descriptions and orientation, (b) develop-ment and dissemination of research competencies as partof a clinical career ladder, (c) implementation of unit-basedjournal clubs, (d) offering of research and EBP workshops,(e) research-focused grand rounds, (f) formation of an EBPcouncil to assist colleagues in implementing and complet-

ing EBP projects, and (g) development of an EBP champi-ons group to encourage staff to participate in and engagein EBP practice change.

Outcomes. The BARRIERS to Research Utilization Scaleand the Research Factor Questionnaire, both with excellentinternal consistency reliabilities, were used to measure thenurses’ attitudes and beliefs about research utilization.

Findings: The three major barriers identified by the pre-intervention sample respondents included (a) RN author-ity to change practice, (b) RN awareness of research, and(c) time to read on the job. The perception of these bar-riers improved on the post-intervention survey, after im-plementation of the multifaceted intervention strategies.Journal club participation was one of the key strategiesthat enhanced research utilization (105 nurses reportedparticipation in a journal club). The majority of the post-intervention sample reported a low level of research ac-tivity participation (62%; n = 149), with only 5% (n =13) reporting a high level of participation. In the post-implementation period, 83% of the nurses (n = 199) whocompleted the survey reported that they understood theconcept of research utilization, 63% reported that they wereaware of organizational strategies related to research utiliza-tion over the past year (n = 150), and 65% reported thatthey had an increased awareness of research findings fromparticipating in research activities (n = 155). One hundredeighteen nurses (49%) reported the belief that their pa-tients benefited from their research involvement in termsof positive outcomes.

The four major barriers to research use reported by therespondents were (1) difficulty in changing practice, (2)lack of administrative support (i.e., from managers andsupervisors) and mentoring, (3) insufficient time, and (4)lack of education on the research utilization process. Activ-ities considered most useful by the staff were a “hands-on”approach to critiquing research findings, allowing the par-ticipants to see how findings get translated into practice,and encouraging discussion by the staff.

Commentary With Implications for Clinical Practice andFuture Research. This study provides evidence to sup-port that multifaceted interventions to advance EBP anduse of research findings into practice can improve nurses’attitudes, beliefs, and participation in research activities.However, great caution must be used in generalizingthese results to other clinical settings for the followingreasons: (a) the design used was pre-experimental, sothat it is difficult to determine whether the interventionstrategies alone caused a change in the outcomes orwhether there were confounding variables responsiblefor the change, (b) the same nurses did not complete

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the pre- and post-intervention surveys, which calls intoquestion whether the results are a true indicator ofchange in this sample, (c) the intervention was mul-tifaceted and it cannot be known exactly what compo-nents were specifically responsible for the change in out-comes, and (d) the response rate was low and, therefore,it cannot be determined whether the nurses who partic-ipated in the study were different as well as more inter-ested and motivated to implement EBP than the nurseswho did not participate in the study. Despite these lim-itations, this study reinforces how important adminis-trative support and mentoring, empowerment of nursesto change practice, and adequate resources (e.g., time,access to educational workshops, and hands-on experi-ences) are to advance evidence-based care. Randomizedcontrolled trials that test the efficacy of specific EBP in-terventions to advance evidence-based care are urgentlyneeded.

Level of Evidence: VI.

Green M. & Ruff T. (2005). Why do residents fail to an-swer their clinical questions? A qualitative study of barriersto practicing evidence-based medicine. Academic Medicine,80(2), 176–182.

Purpose. The purpose of this research was to exploreresidents’ experience in trying to answer their clinicalquestions.

Sample. The convenience sample consisted of 34 resi-dents in a university-based internal medicine program.

Design. Qualitative study.Methods. Three 90-min focus groups were conducted

by a professional facilitator and the investigators, with thepurpose of answering the key question of what barriersthe residents encountered in attempting to answer theirclinical questions. The sessions were recorded and subse-quently transcribed. A thematic analysis of the transcriptswas conducted, using the constant comparison method ofanalysis by the two investigators.

Findings. Eight themes of barriers emerged, including(a) lack of access to medical information (e.g., computerterminals at the point of care); (b) inadequate skills insearching information resources and knowing when to stopsearching (e.g., When is the answer to a clinical questioncompleted?); (c) clinical question tracking (e.g., postpon-ing the question to a later time, but not pursuing the an-swer); (d) perceived lack of time; (e) difficulty in prioritiz-ing clinical questions; (f) lack of personal initiative (e.g.,commitment to finding the answers to clinical questionsdiminished with fatigue and burnout); (g) team dynamics(e.g., an attending who was authoritative in his/her style

and suppressed residents’ desire to seek answers to theirclinical questions); and (h) an institutional culture thatdid not support clinical inquiry. To overcome the barriers,the residents stressed that it was important to have pro-tected time, specific curricula that focused on the neededknowledge, and mentoring to pursue their clinical ques-tions. They also emphasized that it was necessary to havepersonal commitment and discipline to engage in the pro-cess, because if these factors were not present, the presenceof an ideal environment and sufficient resources would notbe enough to facilitate evidence-based care.

Commentary With Implications for Clinical Practice,Education, and Research. Although this study was con-ducted with medical residents in one hospital and socaution must be exerted in generalizing findings to otherhospital settings and interdisciplinary care providers, itdoes have clinical implications for other direct healthcare providers. The findings reinforce that there are mul-tiple factors that need to be present in a health care en-vironment for EBP to occur, beyond the availability ofadequate resources. Education in EBP skills needs to in-clude not only how to form clinical questions in PICO(P = Patient population, I = Intervention or area of In-terest, C = Comparison group, O = Outcome) formatand search for the best evidence, but also how to de-termine when a search is complete. Having electronicinformation resources available at the point of care isessential along with educational workshops/sessions inthe EBP process. In addition, having a faculty who en-courages “a spirit of inquiry” is necessary in sparking asearch for answers to burning clinical questions. Futureresearch in the form of RCTs is necessary to develop andtest interventions to overcome these barriers.

Level of Evidence: VI.

Rothenberger D.A. (2004). Evidence-based practice re-quires evidence. British Journal of Surgery, 91(11), 1387–1388.

Purpose. The purpose of this thought-provoking paperis to question the quantity and quality of evidence that iscurrently available to guide clinical practice in medicine.

Content. This article emphasized that although duringthe last half of the 20th century there were 131,000 ran-domized controlled trials of medical interventions pub-lished, there is often a lack of high-level evidence toguide clinical decisions. The author emphasizes that to bean evidence-based profession, our culture must be trans-formed into an evidence-seeking profession in which every

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medical professional and health care system must assumeresponsibility for the collective need to create high-levelevidence.

Commentary With Implications for Clinical Practice, Ed-ucation, and Research. This article has strong implica-tions for nursing, as the evidence gap in our professionis even larger than in medicine. Currently, only approx-imately 20–25% of the nursing studies are interventiontrials. In addition, there are few systematic reviews ofintervention trials in nursing, which is the strongestlevel of evidence to guide clinical practice (Melnyk &Fineout-Overholt 2005). As a result, the nursing pro-fession needs to accelerate the conduct of interventionstudies so that decisions can be based on evidence versussteeped in tradition or what we believe works in clini-cal practice. Doctoral students need to be encouragedto conduct pilot intervention trials in areas where thereis sufficient descriptive work to guide the design of anexperimental study, so that they can launch an experi-mental research career. In addition, it must be remem-bered that individual nursing units and institutions cando much in the way of generating internal evidence toguide clinical practice through outcomes managementwhen external evidence is not available.

Level of Evidence: VII.

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Melnyk B.M. & Fineout-Overholt E. (2005). Evidence-based practice in nursing & healthcare. A guide to bestpractice. Philadelphia: Lippincott, Williams & Wilkins.

Melnyk B.M., Fineout-Overholt E., Feinstein N.F., Li H.,Small L., Wilcox L. & Kraus R. (2004). Nurses’ per-ceived knowledge, beliefs, skills, and needs regardingevidence-based practice: Implications for acceleratingthe paradigm shift. Worldviews on Evidence-Based Nurs-ing, 1(3), 185–193.

Melnyk B.M., Fineout-Overholt E., Stetler C. & Allan J.(2005). Outcomes and implementation strategies fromthe first U.S. evidence-based practice leadership summit.Worldviews on Evidence-Based Nursing, 2(3), 113–121.

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