Session: (06)

Session (6)

Step 5: Assessing the Evidence

By now, you have developed a clinical question, sought out research to answer your question, critically assessed that research and applied the findings to your patient or population. The process does not end here though. Evidence-based practice is iterative, meaning that it builds on itself, constantly being reshaped by new evidence and the clinical expertise of those who practice it.
The steps of evidence-based practice can be illustrated by a continuous evidence cycle. Once you have applied your evidence to your situation, you should evaluate how well it worked. This process often generates new clinical questions, prompting you to begin the cycle again.

To evaluate evidence for credibility, accuracy, and reliability, consider the following questions:

Who/what is the source of the evidence? It is important to determine the credentials of the person/group responsible for the evidence, and, depending on where the evidence is found, it may be (fairly) easy to do so. For example, if the evidence is published in an academic journal article, then the evidence is likely credible because of both the person/people responsible for writing the article (a scholar or scholars in the field) as well as the journal that published it (that relies on a peer review process). The author’s/authors’ credentials likely will be found in the article at the beginning or end, and the journal’s will be found on the journal website.
Is the evidence found in a primary or secondary source? A primary source is an original source, such as a literary work, historical document, photo, etc., whereas a secondary source provides content that has already been interpreted (and thus is a step or steps removed from the original). Depending on the scope of the project and the focus of the argument, primary sources may be needed more so than secondary sources and vice versa.
How does the evidence from one source compare and contrast with the evidence from another source? Particularly for academic writing, arguments are generally supported by evidence found in multiple sources. It’s important to consider how evidence may or may not represent a pattern across sources, and the implications of that for the argument being made.
How current is the evidence? Generally you will want evidence to be as up-to-date as possible, particularly in areas such as science, health/medicine, and technology that can evolve quickly. In some cases if evidence is from even just two years ago it may be outdated, whereas in other cases the evidence may have a longer “shelf life.”
Is the evidence specific to the reasons for which it is being provided, and does it ultimately support the claim? Sometimes “tangential” evidence may be all that is available at the time to back a reason or reasons, but almost always the evidence should be specific to the reasons and claim, not merely related.
Why is the evidence important to the argument? Generally when making an argument there are many choices to be made, including what evidence from the range of evidence available is the best to include. Consider whether and why the evidence that has been provided or that you are considering using is necessary to the argument.
What does the evidence perhaps suggest, but not explicitly show? In order to develop a strong argument it’s necessary to consider the possible different interpretations of the evidence, and address them as needed.
What is interesting about the evidence that will make it catch the attention of the reader and be memorable? In some cases evidence that states the obvious may be necessary, but often argument is more complex than that and, therefore, requires more engaging evidence.

Internal evidence, or the data and observations collected on an individual client, is collected both for the accountability of your session and for tracking a client’s performance. When assessing the internal evidence, you are determining whether an intervention has affected your client. You may analyze your data to address the following questions:

Is your client demonstrating a response to the intervention?
Is that response significant, especially for the client?
How much longer should you continue the intervention?
Is it time to change the therapy target, intervention approach, or service delivery model?

External evidence, found in scientific research literature, answers clinical questions such as whether an assessment measures what it intended to measure or whether a treatment approach is effective in causing change in individuals. Because the quality of external evidence is variable, this step of assessing the evidence is crucial and includes determining the reliability, importance, and applicability of the relevant scientific research to your client’s condition and needs.

Critically appraising the external evidence can help you determine if the conclusions from one or more studies can help guide your clinical decision. To assess the external evidence, you should

Combining Evidence and Evaluating Results

Step four of the EBP process integrates the best evidence found in the literature with clinical expertise and patient preferences.
There will be times when compelling evidence for specific treatments will conflict with a patient’s values or beliefs. In these instances, despite compelling evidence, the patient has the right to make the final decision.
It is the nurse’s responsibility to thoroughly assess and educate the patient on the risks and benefits, allowing ample time to fully discuss concerns, fears, and clarify understanding.
There will also be times where healthcare resources may not be available to implement treatments deemed best practice by EBP.
It is the nurse’s responsibility to find practical alternatives and potentially begin the literature review process again in search of alternative methods.
The premise of evidence-based nursing care is integrating medical evidence with nursing experience, clinical decision-making, and patient preferences. For this reason, many nurses report being more comfortable with EBP mid-career after 10 or more years of practice.
Nursing experience over time provides a solid foundation to support clinical decision-making and critical thinking.
Once the EBP has been implemented into the nurse’s practice, the next step is to evaluate the outcomes and effectiveness of the change.
Outcomes must be measured based on their impact on healthcare quality and/or patient outcomes. The results do not always reflect those found in research; this may be due to differences in the implementation of the intervention or due to discrepancies in the characteristics or demographics of the patient population.
Implementing an EBP change across an organization is a more extensive undertaking. Typically, the organization will need to start by enacting change incrementally.
Some organizations may develop an EBP implementation team to generate new tools and processes needed to integrate the practice. This team can be multidisciplinary and involve team members from all levels of management. Implementing EBP may change the daily workflow and staff routines.
Even motivated nurses can have difficulty practicing in a continuously changing environment and require support from their organization’s administration.
Piloting small changes and making adjustments based on staff feedback can ensure positive attitudes and successful adaptation to the new process.
The results should be shared with all staff involved at the end of each pilot to ensure open communication, maintain motivation, and receive feedback. Pilot testing in selective patient care areas prior to organization-wide implementation is an efficient way to identify and remedy problems.
The pilot areas can then be used as training sites for the rest of the organization when widespread use is initiated.
Once evidence-based changes have been made, clinical outcomes should be evaluated.
It is important to remember that not all variables can be controlled, patients may not mirror those included in research studies, and the outcomes may be different than expected. Outcome evaluation is important to assess how research translates into real-world use.
Outcomes should be measured before, shortly after, and then again within a reasonable length of time after implementation. Data from each of these points are important to fully evaluate the change. The EBP team should be a part of collecting and evaluating the outcomes data.

Case Scenario Outcome

In the case scenario, HAPU rates show a rapid decline after the initiation of the yearly competency and training. Six months after implementation, the HAPU rate on the medical-surgical unit decreases from 4% to 0%. A simple explanation is that the initial assessment and correct staging of pressure ulcers appropriately identify pressure ulcers in all stages on admission. Through the implementation of the EBP process, the wound nurse and task force are able to make a sustainable, substantial change in the organization and improve patient outcomes.