Evidence: More Than the Literature

This issue of Critical Care Nursing Quarterly (CCNQ) focuses on projects that have been conducted to attempt to solve clinical problems using an evidence-based approach.

Evidence-based practice (EBP) is more than reading the literature and doing what has been found to be helpful by others. A true evidence-based approach to changing practice involves a complex process of (a) identifying staff/physician and patient values, (b) evaluating resources in dollars, labor, and equipment available to make the change, and (c) reviewing the evidence.

In their article on cultural and religious needs at birth and death, Davidson and colleagues went directly to the consumers to gather feedback regarding their values to identify whether changes in hospital services were needed. In Kloos and Daly's article related to family anxiety after cardiac surgery, the family members' values regarding helpfulness of a diary were explored. Gutierrez and Smith went to the nursing staff to identify what interventions they felt best helped reduce falls and to identify what obstacles prevented them from achieving fall-reduction goals.

Evaluation of the evidence takes many forms. Projects are usually identified through internal evidence that a problem exists, such as when benchmarks are not met for quality initiatives, or recurrent incidents or errors caused by process flaws. Gutierrez and Smith's article on fall reduction, Dibsie's article on pressure ulcer reduction, and Dennis-Rouse and Davidson's article on tracheostomy care are all examples of this type of EBP project. Evidence can also be gathered from community/geographic standard by conducting surveys of practices in local hospitals. The evidence behind our practices may be scant or nonexistant, such as in Dennis-Rouse's article on tracheostomy care, in which she found no research to support most of what is done to maintain the device after insertion. When the evidence in the literature is elusive, the nurse may next look for evidence in the form of community standard or expert opinion. In the tracheostomy example, no consensus was found in local community practices. Expert opinion may be found in review articles or by contacting experts in the field. Obtaining expert opinion is easier to do with the advent of the Internet; e-mailing an author is merely a click away. Dennis-Rouse e-mailed authors of review articles only to find that they also identified that a lack of substance with which to make practice standards related to tracheostomy care. Where no evidence exists and there are no statements to guide the nurse from professional organizations or regulatory bodies, decisions are made by judgment and stakeholder consensus.

After considering the evidence, values, and resources surrounding a clinical issue, the real task at hand, then, is to determine how to launch the project. Process design influences the success of any project. Nelson created an entirely new process by taking the evidence regarding family needs and, in an attempt to meet those needs, created a new position called the family care nurse specialist. Furthermore, many clinical leaders find themselves in the position of attempting to maintain standards across disciplines. McGinty and Anderson's article on compliance with evidence-based standards for patients with acute myocardial infarction focused on studying adherence patterns to be able to focus resources on physicians who had the lowest compliance rates. Gutierrez and Smith's article on fall reduction focused on obstacles to implementing practices that were known to be evidence-based crossing disciplines involving physical therapy, nursing, and medicine.

It is hoped that this issue of CCNQ provides the reader with examples of strategies used by others to determine the need for practice change, evaluate EBP, and design practice change projects. The authors have provided testimony to problems and challenges encountered while launching projects. These honest disclosures are meant to assist the reader in avoiding similar pitfalls encountered in the design or execution of an EBP project.

Judy E. Davidson, RN, DNP, CCRN, FCCM

Clinical Nurse Specialist Scripps Mercy Hospital San Diego, California