CorrectCare

Evidence-Based Nursing Practice: The Time Is Right!

by Lorry Schoenly, PhD, RN, CCHP

Judging from the response to a recent NCCHC conference session, interest is growing for application of evidence-based nursing practice (EBNP) in correctional health care. Speaker Susan Laffan, RN, CCHP-A, considers this a perfect time to apply the evidence-based approach to nursing care. “The trend toward evidence-based practice is growing in the nursing profession,” says Laffan, a consultant based in Toms River, NJ. “Our, clinical practice should rest on solid research evidence where possible.”

In fact, the origins of the modern nursing profession in the 1800s with Florence Nightingale included seeds of EBNP. In her 1861 landmark book, Notes on Nursing, she states, “The most important practical lesson that can be given to nurses is to teach them what to observe—how to observe—what symptoms indicate improvement—which are of none—which are the evidence of neglect—and what kind of neglect.”

What Is EBNP?
Evidence-based nursing practice involves the use of the most credible and up-to-date research to guide patient care. This way of practicing stresses the use of protocols and procedures that are based on research and other objective information, rather than ritual, opinion or “the way we have always done it.” A 1992 survey of staff nurses regarding the sources of knowledge used to guide practice revealed that most relied on nursing school, workplace sources, physicians and intuition. Although enthusiastic about using research evidence as a basis for practice, nurses can be bewildered by how to do so.

EBNP brings many potential advantages, including more effective practice, greater confidence in decision-making and better patient outcomes. Sara Jo Brown, PhD, RN, author of Evidence-Based Nursing: The Research-Practice Connection, a nursing textbook, sees a bright future for nursing practice built on a strong foundation of credible evidence.

“Nursing is science and art—sort of like yin and yang that are complementary opposites within a greater whole,” Brown says. “Many nurses have strong nursing art knowledge and skills but have not incorporated the use of science into their practice. Effective practice needs both.” The correctional nursing specialty can undoubtedly help inmates achieve better health outcomes by turning more often to research evidence as a basis for practice.

Key Steps to EBNP
Practicing nurses need not conduct an actual research study to determine effective interventions. Fortunately, that is neither desirable nor advocated by EBNP specialists. Instead, EBNP focuses on using the wide array of published research to determine application to practice. Here are the key steps to the practice of evidence-based nursing.

• Identify a specific patient problem or situation that is in need of a better approach

• Systematically search for research evidence that could be used to address the issue

• Appraise the validity of the research evidence, and its relevance and applicability to your population and setting

• Integrate the research evidence with site information that might influence management of the issue

• Thoughtfully implement the evidence-based practice decision

• Evaluate the outcome of the decision

Locating and Assessing Evidence
The isolated nature of correctional nursing practice once made it difficult to find clinical research. Without easy access to a medical library or hospital resources, correctional nurses could be frustrated in attempts to locate answers to clinical challenges. In the last decade, however, the advent of the Internet, with its an increasing variety of search engines and online resources, has eliminated barriers to acquiring information. Now there are many Internet sites dedicated to serving as health care data repositories, with some specific to nursing.

Thus, the Internet is a great first stop on the road to implementing EBNP. The EBNP Web Sites table lists some of the most fruitful sites. Of course, traditional sources such as university and medical libraries are also helpful, if available.

The fastest road to EBNP is locating evidence-based clinical guidelines already developed by a reliable entity. In this case, there is no need to go back to the original studies—it has already been done for you. The next most helpful is a published systematic research review. Here, the author has studied the array of research in a particular area and synthesized the information and often the degree of confidence in the findings. The last choice would be to review individual published studies. This, of course, requires a greater understanding of research principles to determine if the findings are applicable in your setting.

Many organizations that produce evidence-based guidelines rate the strength of the evidence in support of each of the recommendations that make up the guideline. The AHRQ Levels of Evidence table shows an abbreviated version of one of these rating systems. The strongest evidence classification for a recommendation is 1A and the weakest is 4.

Where to Start
Brown suggests starting with clinical issues that aren’t currently being handled well. “Nursing issues with patient groups that are high volume, consume a significant amount of time or are not achieving good outcomes are good places to start,” she says. These issues often are identified through the continuous quality improvement program. A quality deficit generates an opportunity to pursue better patient outcomes. The standard of care, the nursing interventions, should be based on available research.

EBN Example: Pressure Ulcer Prevention
Pressure ulcer prevention is an example of a thorny correctional nursing issue that could be improved by adopting evidence-based interventions. The first step is to identify the populations that are developing pressure ulcers in your setting. Then, search the literature for research evidence relevant to your population. Look first for evidence-based clinical practice guidelines produced by respected organizations. If you cannot find one, then look for a systematic research review about the issue. Carefully consider all of the keywords that might lead to information about pressure ulcer prevention and management. Search words could include wound care, pressure ulcer, decubiti and wound healing. The Pressure Ulcer Search Results table outlines search findings from the various Web sites.

With search results in hand, decide which guidelines or study review results are most applicable to your situation. Then, working with administrative and medical leadership, determine which practices to incorporate into site policy and procedure for pressure ulcer prevention and care. Involvement of all clinical staff in the process encourages staff development and speeds adoption of new practice. Finally, patient outcomes should be tracked over time.

— About the author: Lorry Schoenly, PhD, RN, CCHP, is a clinical education manager with Correctional Medical Services and is based in Pennsylvania. She also hosts an Internet site dedicated to increasing awareness of correctional nursing practice: www.correctionalnurse.net. Follow her on Twitter: lorryschoenly.

[This article first appeared in the Spring 2009 issue of CorrectCare.]