Research studies show thatevidence-based practice(EBP) leads to higher qual- ity care, improved patient out- comes, reduced costs, and greater nurse satisfaction than traditional approaches to care.

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Research studies show thatevidence-based practice(EBP) leads to higher qual- ity care, improved patient out- comes, reduced costs, and greater nurse satisfaction than traditional approaches to care.1-5 Despite these favorable findings, many nurses remain inconsistent in their implementation of evidence-based care. Moreover, some nurses, whose education predates the in- clusion of EBP in the nursing cur- riculum, still lack the computer and Internet search skills neces- sary to implement these practices. As a result, misconceptions about EBP—that it’s too difficult or too time-consuming—continue to flourish.

In the first article in this series (“Igniting a Spirit of Inquiry: An Essential Foundation for Evidence- Based Practice,” November 2009), we described EBP as a problem- solving approach to the delivery of health care that integrates the best evidence from well-designed studies and patient care data, and combines it with patient

preferences and values and nurse expertise. We also addressed the contribution of EBP to improved care and patient outcomes, de- scribed barriers to EBP as well as factors facilitating its implementa- tion, and discussed strategies for igniting a spirit of inquiry in clin- ical practice, which is the founda- tion of EBP, referred to as Step Zero. (Editor’s note: although EBP has seven steps, they are numbered zero to six.) In this article, we offer a brief overview of the multistep EBP process. Future articles will elaborate on each of the EBP steps, using the context provided by the

Case Scenario for EBP: Rapid Response Teams.

Step Zero: Cultivate a spirit of inquiry. If you’ve been following this series, you may have already started asking the kinds of ques- tions that lay the groundwork for EBP, for example: in patients with head injuries, how does supine positioning compared with elevating the head of the bed 30 degrees affect intracranial pressure? Or, in patients with supraventricular tachycardia, how does administering the β-blocker metoprolol (Lopressor, Toprol-XL) compared with ad- ministering no medicine affect

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

The Seven Steps of Evidence-Based Practice Following this progressive, sequential approach will lead to improved health care and patient outcomes.

This is the second article in a new series from the Arizona State University College of Nursing and Health Innova- tion’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 clini- cian expertise and patient preferences and values. When delivered in a context of caring and in a supportive organi- zational culture, the highest quality of care and best patient outcomes can be achieved.

The purpose of this 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’ve scheduled “Ask the Authors” calls every few months to pro- vide a direct line to the experts to help you resolve questions. See details below.

ajn@wolterskluwer.com AJN � January 2010 � Vol. 110, No. 1 51

Ask the Authors on January 22!

On January 22 at 3:30 PM EST, join the “Ask the Authors”call. It’s your chance to get personal consultation from the experts! And it’s limited to the first 50 callers, so dial-in early! U.S. and Canada, dial 1-800-947-5134 (International, dial 001-574-941-6964). When prompted, enter code 121028#.

Go to www.ajnonline.com and click on “Podcasts” and then on “Conversations” to listen to our interview with the authors.

 

www.ajnonline.com

 

the frequency of tachycardic episodes? Without this spirit of inquiry, the next steps in the EBP process are not likely to happen.

Step 1: Ask clinical questions in PICOT format. Inquiries in this format take into account patient population of interest (P), inter- vention or area of interest (I), comparison intervention or group (C), outcome (O), and time (T).

The PICOT format provides an efficient framework for searching electronic databases, one designed to retrieve only those articles rel- evant to the clinical question. Using the case scenario on rapid response teams as an example, the way to frame a question about whether use of such teams would result in positive outcomes would be: “In acute care hospitals (patient population), how does having a rapid response team (intervention) compared with not having a response team (compar- ison) affect the number of car- diac arrests (outcome) during a three-month period (time)?”

Step 2: Search for the best evidence. The search for evidence to inform clinical practice is tre- mendously streamlined when questions are asked in PICOT format. If the nurse in the rapid response scenario had simply typed “What is the impact of having a rapid response team?” into the search field of the data- base, the result would have been hundreds of abstracts, most of them irrelevant. Using the PICOT format helps to identify key words or phrases that, when entered successively and then combined,

validity centers on whether the research methods are rigorous enough to render findings as close to the truth as possible. For example, did the re- searchers randomly assign subjects to treatment or con- trol groups and ensure that they shared key characteristics prior to treatment? Were valid and reliable instruments used to measure key outcomes?

• What are the results and are they important? For interven- tion studies, this question of study reliability addresses whether the intervention worked, its impact on out- comes, and the likelihood of obtaining similar results in the clinicians’ own practice set- tings. For qualitative studies, this includes assessing whether the research approach fits the purpose of the study, along with evaluating other aspects of the research such as wheth- er the results can be confirmed.

• Will the results help me care for my patients? This question of study applicability covers clinical considerations such as whether subjects in the study are similar to one’s own pa- tients, whether benefits out- weigh risks, feasibility and cost-effectiveness, and patient values and preferences. After appraising each study, the

next step is to synthesize the stud- ies to determine if they come to similar conclusions, thus support- ing an EBP decision or change.

Step 4: Integrate the evidence with clinical expertise and pa- tient preferences and values. Research evidence alone is not sufficient to justify a change in practice. Clinical expertise, based on patient assessments, laborato- ry data, and data from outcomes management programs, as well as patients’ preferences and val- ues are important components of

expedite the location of rele- vant articles in massive research databases such as MEDLINE or CINAHL. For the PICOT ques- tion on rapid response teams, the first key phrase to be entered into the database would be acute care hospitals, a common subject that will most likely result in thou- sands of citations and abstracts. The second term to be searched

would be rapid response team, followed by cardiac arrests and the remaining terms in the PICOT question. The last step of the search is to combine the results of the searches for each of the terms. This method nar- rows the results to articles perti- nent to the clinical question, often resulting in fewer than 20. It also helps to set limits on the final search, such as “human subjects” or “English,” to eliminate animal studies or articles in foreign lan- guages.

Step 3: Critically appraise the evidence. Once articles are selected for review, they must be rapidly appraised to determine which are most relevant, valid, reliable, and applicable to the clin- ical question. These studies are the “keeper studies.” One reason cli- nicians worry that they don’t have time to implement EBP is that many have been taught a labori- ous critiquing process, including the use of numerous questions de- signed to reveal every element of a study. Rapid critical appraisal uses three important questions to evaluate a study’s worth.6-8

• Are the results of the study valid? This question of study

Research evidence alone is not sufficient to

justify a change in practice.

52 AJN � January 2010 � Vol. 110, No. 1 ajnonline.com

 

 

which patients are most likely to benefit. When results differ from those reported in the research literature, monitoring can help determine why.

Step 6: Disseminate EBP re- sults. Clinicians can achieve won- derful outcomes for their patients through EBP, but they often fail to share their experiences with colleagues and their own or other health care organizations. This leads to needless duplication of effort, and perpetuates clinical approaches that are not evidence based. Among ways to dissemi- nate successful initiatives are EBP rounds in your institution, pres- entations at local, regional, and national conferences, and reports in peer-reviewed journals, profes- sional newsletters, and publica- tions for general audiences.

When health care organiza- tions adopt EBP as the standard for clinical decision making, the steps outlined in this article nat- urally fall into place. The next article in our series will feature a staff nurse on a medical–surgical unit who approached her hospi- tal’s EBP mentor to learn how to formulate a clinical question about rapid response teams in PICOT format. �

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.Grimshaw J, et al. Toward evidence- based quality improvement. Evidence (and its limitations) of the effective- ness of guideline dissemination and implementation strategies 1966-1998. J Gen Intern Med 2006;21 Suppl 2:S14-S20.

2.McGinty J, Anderson G. Predictors of physician compliance with American Heart Association guidelines for acute myocardial infarction. Crit Care Nurs Q 2008;31(2):161-72.

3. Shortell SM, et al. Improving patient care by linking evidence-based medi- cine and evidence-based management. JAMA 2007;298(6):673-6.

4. Strout TD. Curiosity and reflective thinking: renewal of the spirit. Indi- anapolis, IN: Sigma Theta Tau Inter- national; 2005.

5.Williams DO. Treatment delayed is treatment denied. Circulation 2004; 109(15):1806-8.

6.Giacomini MK, Cook DJ. Users’ guides to the medical literature: XXIII. Qualitative research in health care A. Are the results of the study valid? Evidence-Based Medicine Working Group. JAMA 2000;284(3):357-62.

7.Giacomini MK, Cook DJ. Users’ guides to the medical literature: XXIII. Qualitative research in health care B. What are the results and how do they help me care for my patients? Evidence- Based Medicine Working Group. JAMA 2000;284(4):478-82.

8. Stevens KR. Critically appraising quantitative evidence. In: Melnyk BM, Fineout-Overholt E, editors. Evidence- based practice in nursing and health- care: a guide to best practice. Philadelphia: Lippincott Williams and Wilkins; 2005.

9.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.

EBP. There is no magic formula for how to weigh each of these elements; implementation of EBP is highly influenced by institution- al and clinical variables. For ex- ample, say there’s a strong body of evidence showing reduced in- cidence of depression in burn pa- tients if they receive eight sessions of cognitive-behavioral therapy prior to hospital discharge. You want your patients to have this therapy and so do they. But budg- et constraints at your hospital prevent hiring a therapist to offer the treatment. This resource deficit hinders implementation of EBP.

Step 5: Evaluate the out- comes of the practice decisions or changes based on evidence. After implementing EBP, it’s im- portant to monitor and evaluate any changes in outcomes so that positive effects can be supported and negative ones remedied. Just because an intervention was ef- fective in a rigorously controlled trial doesn’t mean it will work exactly the same way in the clin- ical setting. Monitoring the effect of an EBP change on health care quality and outcomes can help clinicians spot flaws in implemen- tation and identify more precisely

Case Scenario for EBP: Rapid Response Teams

You’re a staff nurse on a busy medical–surgical unit. Over the pastthree 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 Medi- cine on the use of rapid response teams to decrease rates of in-hospital cardiac arrests and unplanned ICU admissions. The study found a sig- nificant decrease in both outcomes after implementation of a rapid re- sponse team led by physician assistants with specialized skills.9 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 have come to her with these findings and encourages you to search for more evidence to support this practice and for research on whether rapid response teams are valid and reliable.

ajn@wolterskluwer.com AJN � January 2010 � Vol. 110, No. 1 53

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In this part of the Evaluation Project, you construct an evaluation plan by aggregating all of your work on the project thus far into one cohesive document.

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Part 6: Evaluation Plan

 

In this part of the Evaluation Project, you construct an evaluation plan by aggregating all of your work on the project thus far into one cohesive document. The document should contain your PICO question, literature review (with summary table), evaluation methodology, and evaluation tool.

 

To prepare:

 

  • Consider the issues or concerns you might have when developing an evaluation plan. Reflect on the ethical issues you and your colleagues identified in the Week 9 Discussion.
  • Reflect on potential limitations and opportunities (Note: This topic will be addressed in the Week 10 Discussion).

To complete Part 6 of the Evaluation Project:

By Day 7 of Week 10

In no more than 10 pages, aggregate all of your work on the Evaluation Project so far into a single document. This document should contain:

1)       Your PICO question (See Attached PDF File)

2)       An explanation of the goals of your evaluation plan

3)       Literature review (with summary table as an appendix) (See Attached PDF File)

4)       Evaluation methodology (including research design) (See Attached PDF File)

5)       Evaluation tool (See Attached PDF File)

6)       A description of any ethical issues or concerns you may have with implementing your plan and how you could handle them if they arose (see the assignment on “Evaluations and Ethics”)

7)       A summary of the criteria you will use to define the success of your plan and how you will disseminate findings

8)       An outline of limitations to the scope of the plan and opportunities resulting from your evaluation plan (Note: based on week 10 discussion post on Identification of Opportunities and Limitations)

 

 

Required Readings

 

Friedman, C. P., & Wyatt, J. C. (2010). Evaluation methods in biomedical informatics (2nd ed.). New York, NY: Springer Science+Business Media, Inc.

  • Chapter 12, “Proposing and Communicating the Results of Evaluation Studies: Ethical, Legal, and Regulatory Issues” (pp. 338–361)

This chapter covers both how to write a proposal to conduct an evaluation and how to present the findings. It highlights the importance of conforming to legal, regulatory, and ethical standards in the evaluation and write-up.

 

Berner, E. S. (2008). Ethical and legal issues in the use of health information technology to improve patient safety. HEC Forum, 20(3), 243–258.

Retrieved from the Walden Library databases.

In this article, the author outlines key ethical and legal issues that need to be considered when using health information technology. These include issues with the establishment of a standard of care, increased availability of patient information, accuracy of information, the effectiveness of user training, and the fulfillment of informed consent obligations.

 

Goldstein, M. M. (2010). Health information technology and the idea of informed consent. Journal of Law, Medicine & Ethics, 38(1), 27–35.

Retrieved from the Walden Library databases.

This article details the reasons behind the policy of informed consent and the challenges posed to providing privacy by electronic health records and the ease of gaining access to confidential patient information.

 

Goodman, K. W. (2010). Ethics, information technology, and public health: New challenges for the clinician-patient relationship. Journal of Law, Medicine & Ethics, 38(1), 58–63.

Retrieved from the Walden Library databases.

The focus of this article is the challenge facing health care personnel in balancing the privacy of patients and the need to perform research on public health issues. The author discusses whether there is a moral obligation for patients and clinicians to be willing to share information for the “greater good.”

 

Goodman, K. W., Berner, E. S., Dente, M. A., Kaplan, B., Koppel, R., Rucker, D., et al. (2011). Challenges in ethics, safety, best practices, and oversight regarding HIT vendors, their customers, and patients: A report of an AMIA special task force. Journal of the American Medical Informatics Association, 18(1), 77–81.

Retrieved from the Walden Library databases.

This article highlights recommendations by an AMIA special task force that analyzed ethical and safety issues dealing with the increased use of HIT systems. The recommendations covered such areas as the need for HIT regulation, the ability to provide ethics training to vendors, and organizational commitment to placing patient safety as the highest priority.

 

Nykänen, P., Brender, J., Talmon, J., de Keizer, N., Rigby, M., Beuscart-Zephir, M. C., & Ammenwerth. E. (2011). Guideline for good evaluation practice in health informatics (GEP-HI). International Journal of Medical Informatics, 80(12), 815–827.

Retrieved from the Walden Library databases.

In this article, the authors highlight their efforts to develop a good practice guideline to plan and perform evaluation studies in health informatics. The authors put forth a list of sixty issues to function as a guideline for good evaluation practices.

 

Rothstein, M. A. (2011). Currents in contemporary bioethics: Physicians’ duty to inform patients of new medical discoveries: The effect of health information technology. Journal of Law, Medicine & Ethics, 39(4), 690–693.

Retrieved from the Walden Library databases.

The authors of this article analyze the duty of physicians to inform patients of relevant medical developments following their episode of care. Additionally, the authors make recommendations for promoting recognition of physicians’ duty to notify patients of new medical discoveries applicable to their health.

 

Rothstein, M. A. (2010). The Hippocratic bargain and health information technology. Journal of Law, Medicine & Ethics, 38(1), 7–13.

Retrieved from the Walden Library databases.

This article highlights the sensitive nature of much of the information contained in Electronic Health Records and its current availability to a wide range of individuals. The author calls for the development of policy to protect the privacy of patients. He suggests allowing the segmentation of patient information so that the majority of sensitive information is difficult to access.

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Case Study of Behavioral Disorders

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Case Study of Behavioral Disorders

In this assignment, you will analyze a fictional scenario and identify the possible disorders involved. All the information needed for this assignment can be found in the textbook. Review the following vignettes:

Behavioral Disorder—Male Vignette

Joe, a thirteen-year-old Asian-American boy, is enrolled in ninth grade at a public high school located in the inner city of a large metropolitan area. Since kindergarten, his teachers have reported increasing levels of concern about his behavior. In elementary school, he was described by his teachers as immature and argumentative with authority figures. In middle school, his behavior escalated to include verbal and physical aggression toward classmates.

Recent reports indicate that he disrupts the classroom often by arguing with his teacher, talking excessively and loudly, and disobeying classroom rules. During breaks or when outside the classroom, Joe associates with a group of boys who tend to get into trouble. He tends to become angry often and easily and has gotten into many fights. Some of his classmates have reported that Joe has threatened them. He does not seem to feel guilty when he gets into trouble. He rarely finishes his schoolwork and is getting poor grades. Beginning this year, Joe’s teacher has reported that he seems easily distracted.

Testing completed by the school psychologist indicates that Joe is intelligent and creative. Results do not support the presence of a learning disability or a developmental disability. The school psychologist indicates that Joe lacks sufficient motivation or desire to complete his work thoroughly or carefully. Joe’s parents report that he refuses to follow rules at home, is often angry, and tends to blame his siblings when he gets into trouble.

Behavioral Disorder—Female Vignette

Maria is an eight-year-old daughter of Mexican-American parents who recently immigrated to the United States. They speak some English, and Maria is fluent in both English and Spanish. She is enrolled in third grade at the local public elementary school. Since second grade, her parents have reported concerns about her difficulty in paying attention or maintaining her concentration. They indicate that she has significant difficulty in completing her homework because she daydreams and is easily distracted by sounds and activities in the home. Maria has the same problem in the classroom, so she often has to bring unfinished classroom work home to complete. Maria gets frustrated at school and during homework time, often stating that she “can’t do” the work and referring to herself as “dumb” or “not smart enough.”

Maria’s frustration with her schoolwork has led to some irritability lately, as well as some desire to avoid school. She tends to have more of a temper at home recently and expresses hopelessness at times. She is most content playing soccer or video games. She tends to concentrate very well during those activities.

Standardized testing completed by all children in the third grade indicates that Maria is of average intelligence. Screening by the school psychologist indicated that she most likely does not have a learning disability.

Select one of the above vignettes and analyze it in the following manner:

  • Identify and describe two possible behavioral disorders one might consider as DSM diagnoses. Make sure you support those choices with specific symptoms observed in the vignettes.
  • Compare and contrast the two diagnoses and select one that you consider as the most appropriate DSM diagnosis. Explain why one is more likely than the other.
  • After reviewing recent research studies, readings in your textbook, and other academic sources, provide a thorough description of the following:
    • The symptoms required for a diagnosis of that disorder
    • At least two possible causes of that disorder, incorporating at least one developmental factor and at least one multicultural factor that may be involved in the cause(s) of the disorder
    • At least three of the most effective treatments available for that disorder
    • At least one controversy, cultural bias, or ethical issue related to treatments available for that disorder
    • At least one controversy, cultural bias, or ethical issue related to the practice of diagnosis or “labeling” children, in general

Write an 8–10-page paper in Word format. Add an APA style title page and references page and cite your sources according to current APA standards. Cite information from at least two academic sources to support your ideas. These may include your textbook, and/or peer-reviewed research articles from the AUO library.

Make sure you write in a clear, concise, and organized manner; demonstrate ethical scholarship in accurate representation and attribution of sources, and display accurate spelling, grammar, and punctuation.

 

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1,250-1,500-word essay

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Details:

While servant leadership is often associated with Christianity and the Bible, one could argue it is compatible with most religions and philosophies and that it transcends cultures. This assignment presents you with an opportunity to explore other cultures, philosophies, and religions and asks you to think critically about how servant leadership practices are apparent in other religious and cultural values.

Select one cultural context and one religious viewpoint (other than Christianity, its denominations, or something already discussed in the textbook) and examine how the principles of servant leadership are evident in that culture and religion. In a 1,250-1,500-word essay, identify similarities and differences between servant leadership’s philosophies and the values evident in the selected cultural context and religious viewpoint. Be sure to provide specific examples of practices and/or values in your discussion.

You are required to locate two articles that examine servant leadership from a different cultural perspective and two articles that examine servant leadership from a different religious perspective. Be sure to select academic articles from reputable sources that are 10-20 pages in length. Include information from the articles in your discussion.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

Refer to the rubric attached titled, “Topic 3: Servant Leadership in Diverse Contexts,” prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center. 

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