Achieving Evidence-Based Nursing Practice in Ambulatory Care

AAACN Viewpoint, Nov/Dec 2004 by Greenberg, Elizabeth, Pyle, Becky

Evidence-based practice (EBP) has recently become a prominent feature in nursing literature as well as a major force in shaping nursing practice (DeBourgh, 2001; Estabrooks, 1999; Swan, McGinley, & Lang, 2002). Ambulatory care nurses are being challenged to explore how they can champion positive change in the workplace. The concept of EBP has been identified as an essential method for bringing about this change. Ideally, EBP has the potential to improve the quality of nursing care based on the best evidence available. Identifying the most appropriate care can result in the best possible outcomes for the recipient(s). Why wouldn't EBP be enthusiastically embraced and implemented by nurses?

Unfortunately, it's not quite that simple. Important conceptual and practical issues stand in the way of widespread acceptance and support of evidence-based nursing. Barriers to the acceptance and implementation of EBP in nursing include poor understanding of EBP concepts and an inability to integrate them into nursing philosophy or practice. More practically, a lack of time, limited access to information, and a lack of organizational support are also barriers to EBP (Gerrish, 2003; Mohide & King, 2003). Discussions among 2004 AAACN conference participants suggested that for many ambulatory care nurses, misunderstanding and concerns about EBP stem from the wide range of definitions for EBP, and are perpetuated by the failure to clarify the meaning of EBP in the context of the discussions. Individual nurses and nursing organizations share responsibility for stimulating discussion, addressing EBP issues, and facilitating understanding within the context of their own practice and/or organization.

This is the first of two articles. The purpose of this article is to provide an overview of EBP and to clarify issues relevant to the nursing profession - those which should be considered in any discussion of EBP. The second article will provide clinicians with practical information and useful strategies for utilizing EBP.

What is EBP?

EBP is the use of evidence to support decision-making in health care. The concept of EBP emerged out of the evidence-based medicine (EBM) movement, which is rooted in the work of A.L. Cochrane. In the 1970s, Cochrane strongly encouraged his colleagues to use evidence from random controlled trials to determine the effectiveness and efficiency of medical interventions (The Cochrane Collaboration, 2002). Driven by the need to reduce variations in practice and to demonstrate to third-party payers that the care provided is effective, EBM has evolved over the last 20 years to include evidence-based practice in other health-related disciplines (Haynes, 2002; Youngblut & Brooten, 2001).

Evidence-based medicine has been defined as "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 evidence from systematic research" (Sackett, Rosenberg, Muir Gray, Haynes, & Richardson, 1996, p. 71). Although there is no universal definition for EBP, most of the definitions used today stem from EBM; in fact, the terms EBP and EBM are used interchangeably (Jennings & Loan, 2001; Haynes, 2002). "The aim of evidence-based practice is to reduce wide variations in individual clinicians' practices, eliminating worst practices and enhancing best practices, thereby reducing costs and improving quality" (Tanner, 1999, p. 99).

EBP Meets Nursing

EBP is a growing trend in nursing. The difficulties associated with EBP in nursing do not necessarily lie in the definition or the ambitious goals, but rather in the wide range of meanings and uses associated with the term and the failure to clarify them in the context of a nursing discussion. Furthermore, because EBP originated in medicine, the assumptions associated with it may or may not apply to other disciplines and therefore must be identified and addressed. Specifically, the assumptions equate practice decisions with medical interventions and evidence with quantitative research. Is the definition of EBP, along with these underlying assumptions, congruent with nursing practice?

Prior to adopting EBP in nursing, clinicians must determine what constitutes evidence and what an effective nursing intervention is. It is important to distinguish how these concepts of evidence and intervention differ when applied in fields other than medicine. Any discussion of the application of EBP within nursing must be accompanied by a clarification of these terms and consideration of how they fit into the nursing discipline. This article will consider the nature of evidence and intervention in nursing, and the implications of these concepts for the use of EBP in our discipline.

The Evidence Base in Nursing

The American Academy of Ambulatory Care Nursing (AAACN) has defined evidence-based practice as "a process by which nurses make clinical decisions using the best available research evidence, their clinical expertise, and patient preferences in the context of available resources" (AAACN, 2004a, p. 19). EBP underpins the AAACN practice standards for both Ambulatory Care Nursing (AAACN, 2004a) and Telehealth Nursing Practice (AAACN, 2004b). This definition provides an ideal description of evidence: research, clinical expertise, and patient preference. Because nursing advocates balanced attention to and consideration of all three aspects of evidence and the context in which care is delivered, an equilateral triangle is used in Figure 1 to illustrate this ideal.