COLUMNS

JOURNEY TO EVIDENCE-INFORMED NURSING PRACTICE

Understanding the process as an iterative loop

by Maureen Dobbins

Maureen Dobbins

It has been my pleasure in the past month to engage in meaningful dialogue with nurses both in Canada and the United States about evidence-informed practice. While the settings for these conversations varied—a national evidence-based nursing conference, a nursing research day in a large acute-care hospital and a seminar for a nursing research interest group—I was delighted to observe significant similarities among nurses in relation to their general enthusiasm for evidence-informed practice, as well as their eagerness to learn more about the process and to share lessons they have learned along the way. And so it is with a renewed sense of motivation and inspiration—fueled by the energy of frontline nurses—that my journey of exploring and promoting evidence-informed nursing practice continues.

In the first column of this series, I suggested the process of achieving evidence-informed practice is complex, that we are just beginning to identify components of the process and develop research programs to explore those components and how they interrelate.

In this column, I will describe what I believe to be the process of evidence-informed practice. I think it is important that our efforts in this field are organized according to an overarching process to provide a starting point for proving or disproving hypotheses. For this installment, I have chosen to discuss this process from a frontline nursing perspective—knowing, however, that the role an organization plays in evidence-informed practice is of utmost importance. I will leave discussions concerning the organizational role to future columns.

Evidence-informed decision making involves incorporation of the best available evidence from a systematically collected, appraised and analyzed body of evidence (Brownson, Gurney, & Land, 1999). However, what constitutes evidence has been debated across multiple paradigms in recent years. Evidence has been defined by some as being quantitative in nature (Sackett, Rosenberg, Muir Gray, Haynes, & Richardson, 1996; Sackett, Richardson, Rosenberg, & Haynes, 1997; Scott-Findlay & Pollock, 2004), although many other forms of evidence exist, including qualitative research findings (Jack, 2006), epidemiologic data, program evaluations, clinical experience, client preferences, local context, anecdotal evidence (derived from storytelling) and multiple ways of knowing, including indigenous knowledge (Banta, 2003; Rycroft-Malone, Seers, Titchen, Harvey, Kitson, & McCormack, 2004; Scott-Findlay & Pollock, 2004; Jack, 2006).

Evidence-informed decision making is a process characterized by clearly articulating a research question, accessing relevant research evidence, appraising its methodological quality and choosing evidence of the highest quality. The process also entails extracting, interpreting, translating, and incorporating this evidence, in light of the local context and resources, into practice, program and policy decisions (Lomas, Culyer, McCutcheon, McAuley, & Law, 2005). Each step of the process requires unique skills and knowledge (Dobbins, DeCorby, Robeson, Ciliska, Thomas, Hanna et al., 2007; Lapelle, Luckmann, Simpson, & Marin, 2006).

The process is also iterative. Once evidence has been interpreted, translated and incorporated into decision making, the need for additional evidence on a different or related topic triggers the whole process again. The process includes opportunity to provide feedback to researchers about whether or not the evidence in fact answers practice questions and what additional research is needed. This information, in turn, is added to the body of evidence for future access, appraisal and interpretation.

Now that a process has been described, it is easier to identify a feasible and appropriate starting point. One strategy for promoting evidence-informed decision making among frontline nurses might begin with understanding nurses’ perceptions of what constitutes evidence, and then enhancing capacity in each step of the process. The starting point should be informed by and compatible with the vision, mission and goals of individual frontline nurses.
 
Recent travels to speak at nursing events have inspired my usually dormant creative-writing aspirations. As a teenager, I actually dreamed of writing fictional novels! So I leave you with the following musings of what evidence-informed nursing practice is:

Evidence-informed nursing—an evolving frontier
These are the voyages of nurses in pursuit of optimal care.
Our mission: To seek out, interpret and incorporate
   evidence into practice.
Our goal: To provide the highest quality care for
   patients everywhere.

— Maureen Dobbins, RN, PhD, associate professor at McMaster University School of Nursing in Hamilton, Ontario, Canada, is a founder and primary investigator for www.health-evidence.ca, a free, searchable online registry of public health review evidence that saves researchers time and effort in locating, screening and assessing the quality of evidence for improved decision making. Dobbins holds cross appointments with the School of Rehabilitation Sciences and the City of Hamilton Public Health Services.

References:

Banta, H.D. (2003). Considerations in defining evidence for public health: The European Advisory Committee on Health Research. World Health Organization Regional Office for Europe. International Journal of Technology Assessment in Health Care, 19, 559-572.

Brownson, R.C., Gurney, J.G., & Land, G.H. (1999). Evidence-based decision making in public health. Journal of Public Health Management and Practice, 5, 86-97.

Dobbins, M., DeCorby, K., Robeson, P., Ciliska, D., Thomas, H., Hanna, S. et al. (2007). The power of tailored messaging: Preliminary results from Canada's first trial of knowledge brokering. In The 5th Canadian Cochrane Symposium: Knowledge for Health.

Jack, S.M. (2006). Utility of qualitative research findings in evidence-based public health practice. Public Health Nursing, 23, 277-283.

Lapelle, N., Luckmann, R., Simpson, E.H., & Marin, E. (2006). Identifying strategies to improve access to credible and relevant information for public health professionals: A qualitative study. BMC Public Health, 6.

Lomas, J., Culyer, T., McCutcheon, C., McAuley, L., & Law, S. (2005). Conceptualizing and combining evidence for health system guidance: Final report. Canadian Health Services Research Foundation.

Rycroft-Malone, J., Seers, K., Titchen, A., Harvey, G., Kitson, A., & McCormack, B. (2004). What counts as evidence in evidence-based practice? Journal of Advanced Nursing, 47, 81-90.

Sackett, D.L., Richardson, W.S., Rosenberg, W., & Haynes, R.B. (1997). Evidence-based medicine: How to practice and teach EBM. New York: Churchill Livingston.

Sackett, D.L., Rosenberg, W.M.C., Muir Gray, J.A., Haynes, R.B., & Richardson, W.S. (1996). Evidence based medicine: What it is and what it isn't. BMJ, 312, 71.

Scott-Findlay, S. & Pollock, C. (2004). Evidence, research, knowledge: A call for conceptual clarity. Worldviews on Evidence-Based Nursing, 1, 92-97.