Although the title "nursing professional development (NPD) practitioner" applies to many of you, my guess is that the setting in which you are employed, the requirements of your institution, and your own resourcefulness have contributed to slightly different approaches to your role implementation. However, one area of commonality is the responsibility to "support nursing research, evidence-based practice, and quality improvement through professional nurse development" (Harper & Maloney, 2016; Swihart & Johnstone, 2022). In the last issue, I wrote broadly for the need to use the literature as a jumping-off point whenever a practice or clinical question arose. In this column, I would like to speak more specifically of evidence-based practice (EBP); define what is meant by EBP; address the levels of evidence; and provide an example of when knowing how to unearth, evaluate, and synthesize the evidence may come in handy.
I'll begin by defining what is meant by EBP. For our purposes, EBP is the integration of the best available evidence with the healthcare educator's expertise and the client's needs while considering the practice environment (Straus et al., 2011). EBP is the translation of knowledge into practice (Dickerson, 2017, p. 64). There has been some controversy about the need for nursing to adopt the term "EBP" because nursing has always based practice on research, that the contribution of qualitative research is undervalued, as are the theoretical and unique ways of knowing underlying nursing practice when the term "EBP," adopted from medicine, is used. That is a rabbit hole I'd like to stay out of, except to say that I've found communication is smoother when the same language is spoken.
Another of my biases is that there is evidence and there is EVIDENCE. For example, if there is a murder, a suspect's conviction should require more than the testimony of one witness. However, if a crowd of people all agreed that the suspect was the perpetrator or, better yet, the DNA evidence collected at the murder site matches that of the suspect and they have no identical twin-well then, case closed! The point I'm getting at is that when evaluating the research evidence to ensure the best professional practice, there are research designs that might be considered to have one witness, that is, studies without a comparator group, insufficiently powered studies, methodologically weak studies, and/or theoretically incongruent and poorly controlled studies.
Although a well-designed, theoretically and methodologically strong randomized clinical trial (RCT) might be considered DNA evidence, few nursing researchers have the resources to perform RCTs. Even given the resources, quite often ethical considerations override any consideration of an RCT. So this is where multiple witnesses become important. If a systematic review with meta-analysis included only nonrandomized trials but demonstrated a large effect size for an intervention, I would feel comfortable incorporating that result into my practice. However, remember that even an RCT may have an identical twin.
There are several different rating scales for evaluating the quality of research. One accepted mechanism is the GRADE (Grading of Recommendation, Assessment, Development, and Evaluation) scale (Brozek et al., 2009). This method resulted from an international effort to standardize how studies are rated. It uses ratings from high to very low based on the estimate of the effect of the intervention/study/therapy. Another method proposed by Evans (2003) also uses a scale to evaluate studies and awards ratings from excellent to poor based on their effectiveness, acceptability, and feasibility. There is a checklist for evaluating the quality of systematic reviews known as PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis). Clinical guideline quality may be evaluated using the AGREE II (Appraisal of Guidelines for Research and Evaluation II) criteria (Brouwers et al., 2010). There are others, and the choice of scale is not as important as the consistency in its application.
As an educator, an NPD practitioner has an important role ensuring patients receive nursing care based on the best available evidence. To achieve that end, the NPD professional organization included EBP competencies in its core curriculum for both the clinical nurse as well as the advanced practice nurse (Dickerson, 2017, p. 279), whereas the World Health Organization also identified EBP as a core competency for nursing educators (Morin, 2012). Based on a recent consensus statement, 68 core competencies, identified through a systematic review and Delphi study, were recommended for inclusion in any EBP educator's curriculum (Albarqouni et al., 2018). For NPDs, incorporating and implementing these curriculum requirements may butt up against other exigencies of time and institutional needs. However, EBP principles are foundational to ensure safe, quality, informed, and timely professional development.
To illustrate, let's assume your healthcare system is considering requiring all new nursing residents be oriented entirely online and in the simulation laboratory. In your gut, you feel this is not a good idea-that working with a preceptor in the clinical area should be part of the curriculum. However, administration may require some substantive proof to dissuade them from their most excellent idea. As mentioned in the previous column, first identify your key words and then use the references cited in other well-done studies to find other current, peer-reviewed research that has investigated the best and safest way to orient new employees.
Don't dismiss nonnursing research, especially of other professions like psychology, education, and even the airline industry, if appropriate. Findings from these studies could be extrapolated to make a case for why your orientees should not be expected to jump into patient care without the benefit of hands-on supervised experience. Especially important in making your case to health system administrators is to demonstrate the added cost incurred through errors associated with unprepared staff and the associated prolonged patient stays and nursing turnover, which occur when staff feel ill-prepared; more importantly, emphasize the human cost to patients, families, and staff morale. Remember that the bibliography from a recent, strong study may provide other articles and additional key words to consider and save you some valuable time.
Organize the studies you have found, perhaps by design or intervention, and select the strongest studies and use them to make the case against the institution of nonpreceptor orientation. Obviously, time is of the essence so conducting a systematic review is unfeasible ditto a meta-analysis, but check the Cochrane data base (http://cochranelibrary.com) for a systematic review on physician training and patient outcomes that could be extrapolated to nursing. Use all the ammunition available to lob at the no-clinical orientation.
However, what if the research demonstrated that laboratory-only nurse residency training is better for learning and/or patient outcomes, yet the staff, for a variety of important reasons, is vehemently opposed; they would prefer to work with colleagues who have demonstrated hands-on competence. Does EBP require the new method be adopted? My hope is that you answered "no" to my question. Implemented correctly, EBP incorporates the research with the desires of the educator, clinician, and learner. Compromise may be an option when all parties understand the reasons for or against a particular decision. EBP, ideally, then should be part research, part educator's and clinician's expert opinion, and part administrators' preferences. Don't forget the most important consideration: maximizing patient outcomes. The weighting of each component may change, but the ingredients should all be there.
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