Do you ever wonder whynurses engage in practicesthat aren’t supported by evidence, while not implementing practices substantiated by a lot of evidence? In the past, nurses changed hospitalized patients’ IV dressings daily, even though no solid evidence supported this prac- tice.

Do you ever wonder whynurses engage in practicesthat aren’t supported by evidence, while not implementing practices substantiated by a lot of evidence? In the past, nurses changed hospitalized patients’ IV dressings daily, even though no solid evidence supported this prac- tice. When clinical trials finally explored how often to change IV dressings, results indicated that daily changes led to higher rates of phlebitis than did less frequent changes.1 In many hospital EDs across the country, children with asthma are treated with albuterol delivered with a nebulizer, even though substantial evidence shows that when albuterol is delivered with a metered-dose inhaler plus a spacer, children spend less time in the ED and have fewer adverse effects.2 Nurses even disrupt patients’ sleep, which is important for restorative healing, to docu- ment blood pressure and pulse rate because it’s hospital policy to

take vital signs every two or four hours, even though no evidence supports that doing so improves the identification of potential complications. In fact, clinicians often follow outdated policies and procedures without questioning their current relevance or accu- racy, or the evidence for them.

When a spirit of inquiry—an ongoing curiosity about the best evidence to guide clinical decision making—and a culture that sup- ports it are lacking, clinicians are unlikely to embrace evidence-based practice (EBP). Every day, nurses

across the care continuum perform a multitude of interventions (for example, administering medica- tion, positioning, suctioning) that should stimulate questions about the evidence supporting their use. When a nurse possesses a spirit of inquiry within a sup- portive EBP culture, she or he

can routinely ask questions about clinical practice while care is being delivered. For example, in patients with endotracheal tubes, how does use of saline with suctioning compared with suctioning without saline affect oxygen saturation?

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By Bernadette Mazurek Melnyk, PhD, RN, CPNP/PMHNP, FNAP, FAAN, Ellen Fineout-Overholt, PhD, RN,

FNAP, FAAN, Susan B. Stillwell, DNP, RN, CNE, and Kathleen M.

Williamson, PhD, RN

Igniting a Spirit of Inquiry: An Essential Foundation for Evidence-Based Practice

How nurses can build the knowledge and skills they need to implement EBP.

Every day, nurses perform interventions (for

example, administering medication, positioning,

suctioning) that should stimulate questions

about the evidence supporting their use.

This is the first article in a new series from the Arizona State University College of Nursing and Health Innovation’s Center for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. When delivered in a context of caring and in a supportive organiza- tional culture, the highest quality of care and best patient outcomes can be achieved.

The purpose of this new series is to give nurses the knowledge and skills they need to implement EBP consistently, one step at a time. Articles will appear every two months to allow you time to incorporate information as you work toward implementing EBP at your institution. Also, we’ll schedule “Ask the Authors” call-ins every few months to provide a direct line to the experts to help you resolve questions. Details about how to participate in the calls will be published with January’s Evidence-Based Practice: Step by Step.

 

 

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In patients with head injury, how does elevating the head of the bed compared with keeping a patient in a supine position affect intracra- nial pressure? In postoperative surgical patients, how does the use of music compared with no use of music affect the frequency of pain medication administration?

The Institute of Medicine has set a goal that by 2020, 90% of all health care decisions in the United States will be evidence based,3 but the majority of nurses are still not consistently imple- menting EBP in their clinical set- tings.4 To foster outcomes-driven health care in which decisions are based on evidence, providers and health care systems need a

To accelerate the use of EBP by nurses and other health care providers, some insurers have instituted pay-for-performance programs that offer clinicians incentives to follow evidence- based guidelines. And Medicare no longer reimburses hospitals for treating preventable hospital- acquired injuries or infections (such as falls, pressure ulcers, or ventilator-associated pneumonia). Although these measures should improve the overall quality of care in our hospitals, it’s well known that extrinsic motivators are typically not more successful in facilitating a change in behavior than intrinsic motivators. There- fore, for EBP to accelerate and

comprehensive approach to ensure that their results are measured.5

Without EBP, patients don’t receive the highest quality of care, health outcomes are seriously jeopar- dized, and health care costs soar.6

Findings from recent studies also indicate that when nurses and other health care providers engage in EBP, they experience greater autonomy in their practices and a higher level of job satisfaction.7 At a time when this country is facing the most serious nursing shortage in its history, empowering nurses to routinely engage in EBP may lead to less turnover and lower vacancy rates, in addition to im- proving the quality of health care and patient outcomes.

Figure 1. The EBP Paradigm: the merging of science and art. EBP within a context of caring and an EBP culture results in the highest quality of health care and patient outcomes. © Melnyk and Fineout-Overholt, 2003.

EBP Organizational Culture

Research evidence and evidence-based

theories

High-quality patient

outcomes

Clinical decision making

Patient preferences and values

Clinical expertise (for example, evidence from patient assessment

as well as use of health care resources)

Context of Caring

 

 

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with amoxicillin. However, if the child dislikes the taste and it’s likely that the medication won’t be taken, patient preference should outweigh the best practice guide- line and an alternative antibiotic should be prescribed.

Although EBP may be re- ferred to as evidence-based medi- cine, evidence-based nursing, or evidence-based physical therapy within various disciplines, we advocate referring to all of these as evidence-based practice, in order to stimulate transdiscipli- nary evidence-based care and avoid the specialized terminology that can isolate the various health professions.

When nurses implement EBP within a context of caring and a supportive organizational cul- ture, the highest quality of care is delivered and the best patient, provider, and system outcomes are achieved (see Figure 1).10 Despite outcomes being substantially

better when patients receive evidence-based care, nurses and other health care providers often cite barriers that prevent its deliv- ery, including10, 11

• inadequate EBP knowledge and skills.

• a lack of EBP mentors to work with providers at the point of care.

• inadequate resources and support from higher admin- istration.

• insufficient time, especially when there are demanding patient caseloads and staffing shortages. Conversely, a number of factors

facilitate the implementation of EBP, including8, 12, 13

• EBP knowledge and skills. • belief in the value of EBP and the ability to implement it.

• a culture that supports EBP and provides the necessary tools to sustain evidence-based care (for example, access to computer databases at the point of care and time to search for evidence).

• EBP mentors (advanced prac- tice clinicians with expertise in EBP and organizational and individual behavior-change strategies) who work directly with clinicians at the point of care in implementing EBP. Once nurses gain EBP knowl-

edge and skills, they realize it’s not only feasible within the con- text of their practice setting, but that it reignites their passion for

thrive in the U.S. health care sys- tem, nurses must have • a never-ending spirit of inquiry and consistently question cur- rent clinical practices.

• strong beliefs in the value of EBP.

• knowledge of and skills in EBP along with the confidence to use it.

• a commitment to deliver the highest quality evidence-based care to patients and their fam- ilies.

In addition, health care institu- tions must sustain a culture that embraces EBP, including providing clinicians the support and tools they need to engage in evidence- based care.

EBP is a problem-solving ap- proach to the delivery of health care that integrates the best evi- dence from well-designed studies and patient care data, and com- bines it with patient preferences and values and nurse expertise.8, 9

However, there’s no magic for- mula for what percentage of a clinical decision should be based on evidence or patient preferences or nurse expertise. The weight given to each of these three EBP components varies according to the clinical situation. For exam- ple, evidence-based guidelines might indicate that a young child with an ear infection receive amox- icillin and clavulanate (Augmentin) if the infection hasn’t resolved

Questions that Spark a Spirit of Inquiry • Who can I seek out to assist me in enhancing my evidence-based practice (EBP) knowledge and skills and serve as my EBP mentor?

• Which of my practices are currently evidence based and which don’t have any evidence to support them?

• When is the best time to question my current clinical practices and with whom? • Where can I find the best evidence to answer my clinical questions? • Why am I doing what I do with my patients? • How can I become more skilled in EBP and mentor others to implement evidence-based care?

Strategies for Building a Spirit of Inquiry

Write “WHY?” on a poster and place it in the staff lounge orrestroom to inspire questions from nurses about why they’re engaging in certain practices with their patients. Gather the responses in an answer box. After one month, take the responses and arrange them according to common themes. Address the themes in a staff meeting.

Review and answer the Questions that Spark a Spirit of Inquiry. Create a poster with these questions and post them where your colleagues will see them. Think about these clinical questions when caring for your patients.

 

 

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We’ll use this case in each column to focus on successive steps of the EBP process. In the meantime, we encourage you to answer the

Questions that Spark a Spirit of Inquiry and implement two Strategies for Building a Spirit of Inquiry in order to start your own EBP journey and begin build- ing a spirit of inquiry with your colleagues at work. �

Bernadette Mazurek Melnyk is dean and distinguished foundation professor of nursing at Arizona State University in Phoenix, where Ellen Fineout-Overholt is clinical professor and director of the Center for the Advancement of Evidence- Based Practice, Susan B. Stillwell is clinical associate professor and program coordi- nator of the Nurse Educator Evidence- Based Practice Mentorship Program, and Kathleen M. Williamson is associate direc- tor of the Center for the Advancement of Evidence-Based Practice. Contact author: Bernadette Mazurek Melnyk, bernadette.melnyk@asu.edu.

REFERENCES 1.Gantz NM, et al. Effects of dressing

type and change interval on intra- venous therapy complication rates. Diagn Microbiol Infect Dis 1984;2(4): 325-32.

2.Cates CJ, et al. Holding chambers (spacers) versus nebulisers for beta- agonist treatment of acute asthma. Cochrane Database Syst Rev 2006(2): CD000052.

3.Olsen L, et al. The learning health- care system: workshop summary. Washington, DC: National Academies Press; 2007. http://www.nap.edu/ catalog.php?record_id=11903.

4.Pravikoff DS, et al. Evidence-based practice readiness study supported by academy nursing informatics expert panel. Nurs Outlook 2005;53(1): 49-50.

5.Piper K. Results-driven health care: the five steps to higher quality, lower costs. Washington, DC: Health Results Group LLC; 2008.

6.Health Research Institute, Pricewater- houseCoopers. What works: healing the healthcare staffing shortage. Dal- las: PricewaterhouseCoopers; 2007. http://www.pwc.com/us/en/healthcare/ publications/what-works-healing- the-healthcare-staffing-shortage. jhtml.

7.Maljanian R, et al. Evidence-based nursing practice, Part 2: building skills through research roundtables. J Nurs Adm 2002;32(2):85-90.

8.Melnyk BM, et al. The evidence-based practice beliefs and implementation scales: psychometric properties of two new instruments. Worldviews Evid Based Nurs 2008;5(4):208-16.

9. Sackett DL, et al. Evidence-based medicine: how to practice and teach EBM. 2nd ed. Edinburgh; New York: Churchill Livingstone; 2000.

10.Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing and healthcare: a guide to best practice. Philadelphia: Lippincott Williams and Wilkins; 2005.

11.Melnyk BM. Strategies for overcoming barriers in implementing evidence- based practice. Pediatr Nurs 2002; 28(2):159-61.

12.French B. Contextual factors influenc- ing research use in nursing. Worldviews Evid Based Nurs 2005;2(4):172-83.

13.Melnyk BM. The evidence-based practice mentor: a promising strategy for implementing and sustaining EBP in healthcare systems. Worldviews Evid Based Nurs 2007;4(3):123-5.

14.Dacey MJ, et al. The effect of a rapid response team on major clinical out- come measures in a community hos- pital. Crit Care Med 2007;35(9): 2076-82.

their roles and assists them in delivering a higher quality of care with improved patient outcomes. We use the term Step Zero to refer

to the continual cultivation of a spirit of inquiry as an essential foundation for EBP, and we rec- ommend the routine use of a standard set of questions in prac- tice (see Questions that Spark a Spirit of Inquiry) and the use of the strategies in Strategies for Building a Spirit of Inquiry.

Remember, EBP starts with a spirit of inquiry (Step Zero). As you embark on this wonderful journey to promote the highest quality of care and the best out- comes for your patients, reflect upon Step Zero, the EBP para- digm, and how you practice care. The Case Scenario for EBP: Rapid Response Teams will provide a context for learning EBP through- out the next several columns.

Case Scenario for EBP: Rapid Response Teams

You’re a staff nurse on a busy medical–surgical unit. Overthe past three months, you’ve noticed that the patients on your unit seem to have a higher acuity level than usual, with at least three cardiac arrests per month, and of those patients who arrested, four died. Today you saw a report about a recently published study in Critical Care Medicine on the use of rapid response teams to decrease rates of in-hospital car- diac arrests and unplanned ICU admissions. The study found a significant decrease in both outcomes after implementation of a rapid response team led by physician assistants with spe- cialized skills.14 You’re so impressed with these findings that you bring the report to your nurse manager, believing that a rapid response team would be a great idea for your hospital. The nurse manager is excited that you’ve come to her with these findings and encourages you to search for more evi- dence to support this practice and for research on whether rapid response teams are valid and reliable.

Step Zero refers to the continual cultivation

of a spirit of inquiry.