Transforming Nursing Practice through Evidence: The Joanna

Transforming Nursing Practice through
Evidence: The Joanna Briggs Institute
Course Objectives
Describe the history of and trends in evidence-based health
care (EBHC).
1.Apply techniques for moving evidence into practice.
2.Outline the steps to systematical and critical review of
3.Evaluate the clinical audit and feedback process.
The Fundamentals of Evidence-Based Nursing
Purpose/Goal: This program is designed to educate nurses
in the fundamentals of the Joanna Briggs Institute’s (JBI’s)
evidence-based nursing (EBN) process. To be useful in
practice, evidence must first be presented in an applicable,
user- friendly format. The transfer of this evidence remains
one of the greatest challenges still facing the evidence-based
practice (EBP) movement and its success requires a multidimensional approach. Nurses are at the front line of this
change and are the key facilitators of applying research
findings into routine patient care.
Module 1
History and Origins of Evidence-Based Health Care
The art of medicine, or health care as it is often called, has been practiced
formally for centuries. However, health care practices used today have
benefited from the influence of several historical figures. Over time, these
early pioneers determined that the process of healing and the effectiveness in
practices could be greatly improved. This module discusses the evolution of
practice and how our understanding of searching for and utilizing scientific
research has changed over time.
Learner Objectives
Upon completion of this module the learner will:
1. Understand the need for evidence in health care practice.
2. Describe how the concept of evidence is not new.
3. Name several pioneers credited with first applying evidence to their
4. Explain the evolution of evidence-based health care as we know it today.
Module 2
The Evidence-Based Health Care Debate
Much of the debate that encompasses evidence-based health care (EBHC) focuses on a handful of core
issues that appear consistently in the literature questioning the merits of EBHC. Listed below are the five
main areas of criticism.
1.Evidence-based health care is like “cookbook” practice with no allowance for individual patient care or
clinical expertise.
2.Evidence-based health care isn’t new at all; nurses are already doing it.
3.There is too much weight and consideration given to randomized controlled trials (RCTs) and
systematic reviews at the expense of more common observational research and expertise.
4.Oftentimes, there is no evidence.
5.Theory is more important than evidence to guide practice.
Learner Objectives
Upon completion of this module the learner will:
1.Discuss the criticisms of evidence-based health care.
2.Explain the merits and drawbacks of evidence-based health care.
3.Describe the evolution of evidence-based health care.
Module 3
Understanding the Generation of Health Care Evidence
The basis of evidence-based practice is evidence! So the generation of
evidence is fundamental in terms of making sure the process moves forward.
Evidence for health care is generated through research, experience and the
formulation of opinion. Where evidence represents our “knowledge” or
“truth,” research represents our search for it.
Learner Objectives
Upon completion of this module the learner will:
1.Utilize the appropriate research technique to generate new “knowledge” for
health care, dependent on the question that is asked.
2. Describe what a research paradigm is.
3. Explain how most evidence for health care today is a product of research
undertaken using the positivist paradigm.
4. Demonstrate how, for some research questions, other paradigms of
knowledge generation (including interpretive and critical) are equally
Module 4
Clinical Wisdom and the Use of Evidence
The use of “clinical wisdom” or “judgment” is a clearly acknowledged aspect of
mainstream evidence-based health care (EBHC). What is not understood is
the extent to which research-derived evidence outweighs clinical wisdom in
everyday clinical decision making. Patients value a technical, scientifically
informed practitioner who is also clinically wise. Health professionals
acknowledge that using evidence without clinical wisdom (which they often
refer to as “clinical judgment,” “clinical reasoning” or “critical thinking”) falls
far short of best practice.
Learner Objectives
Upon completion of this module the learner will:
1.Define clinical wisdom and its recognition, acquisition and transmission to
the clinical setting.
2.Identify ways of supporting and evaluating clinical wisdom in practice.
3.Describe the relationship between clinical evidence and clinical wisdom
within EBHC.
Module 5
What is Evidence for Practice?
Nurses make numerous clinical decisions each and every day. In making such
decisions, the nurse draws on a wide range of knowledge. This knowledge
involves the basic sciences, assessment of the context and of the individual
patient. Also taken into consideration is a nurse's own experience and
understanding of research reports. When you combine this knowledge to
make a decision, this is referred to as evidence and an answer to the question,
“Exactly what counts as evidence?”
Learner Objectives
Upon completion of this module the learner will:
1.Understand what constitutes “evidence for practice.”
2. Explain why evidence is more than just results from controlled trials.
3. Describe how EBHC strives to discover the “best available evidence.”
4. List how the “best available evidence” may take many forms beyond
Module 6
Searching for the Evidence
To be able to incorporate evidence in practice, it is essential to be able to find
the evidence! The aptitude to search for evidence is essential for any evidencebased practitioner. The sheer volume of medical literature available is an
important obstacle. To streamline access to relevant and good quality
evidence, the systematic review was developed and has been used successfully
to inform clinical practice (More about this in Module 11). To make accessing
this information more user-friendly, summaries of the best available evidence
are available. They are easy to identify and use.
Learner Objectives
Upon completion of this module the learner will:
1. Refine a research question so that it can inform a database search.
2. Formulate search questions using PICO.
3. Perform a search using several health databases.
4. Demonstrate how to use the 6S pyramid for searching.
Module 7
Critically Appraising Quantitative Research Evidence
Critical appraisal is the careful assessment of research by reviewing its
relevance, validity, value, results and its trustworthiness in a situation.
Appraisal enables you to quickly exclude papers that are of inadequate quality
and to pull out the key points of those papers that you do want. First, you
need to understand the essential components of quantitative studies and
design in order to assess quantitative research. This module discusses that
process and takes you through it step by step. Let’s begin by exploring the
benefits of critical appraisal.
Learner Objectives
Upon completion of this module the learner will:
1. Conduct a critical appraisal of quantitative research papers using RAPid.
2. Assess the relevance of published research and its applicability.
3. Critically appraise published research and judge its validity and reliability.
Module 8
Critically Appraising Qualitative Research Evidence
To date, there is no commonly accepted statement of what should be
reported in papers of qualitative research. Critical appraisal checklists
provide researchers with the main criteria with which their reports are
evaluated. This makes them a useful tool to be considered at that
stage. Critical appraisal is “the process of systematically examining
research evidence to assess its validity, results and relevance before
using it to inform a decision” (Hill & Spittlehouse, 2003). Qualitative
research is subject to the same appraisal criteria as quantitative
research, which includes validity, reliability and generalizability.
Learner Objectives
Upon completion of this module the learner will:
1.Demonstrate how to conduct critical appraisal of qualitative research
papers using RAPid.
2.Assess the relevance of published research in practice.
3.Critically appraise published research and judge its validity.
Module 9
Summarizing Evidence
Evidence-based health care practice focuses on the need for all health professionals to
use the most up-to-date evidence or knowledge available. The evidence-based
approach acknowledges the difficulties faced by busy practitioners in keeping up with
the ever growing amount of literature and providing them with condensed information.
Perhaps what is needed in health care is not more research but proper communication
of existing evidence and the means of making sense of the vast amounts of data which
have already been accumulated (Hunter, Schmidt and Jackson, 1982).
Learner Objectives
Upon completion of this module the learner will:
1. Discuss the need for summarizing evidence through the synthesis of research.
2. Outline the steps involved in the process of meta-analysis and meta-synthesis.
3. Describe which forms of synthesis are appropriate for various sources of evidence.
Module 10
Understanding Levels of Evidence
Generally speaking, the better the evidence, the higher it is ranked. How good
the evidence is depends on the study design and the methodology used to
establish the evidence. Those study designs that minimize bias, such as a RCT,
will be ranked higher than an observational study design, such as a casecontrol study.
Levels of evidence is a method for ranking research evidence. This is also
called evidence hierarchy.
Learner Objectives
Upon completion of this module the learner will:
1.Explain why EBP recommendations are assigned a level of evidence.
2.Describe the term level of evidence.
3.Outline how a level of evidence is assigned.
4.Describe what is meant by effectiveness, feasibility, appropriateness and
Module 11
Understanding Systematic Reviews
The need for evidence to support practice is paramount. The knowledge on
which clinical nursing practice is based is changing rapidly. A great deal of
what is taught to nursing students during their graduate studies may become
rapidly irrelevant as understandings of mechanisms of disease advance and
new improved methods of treatment and management are developed. Nurses
need to keep up-to-date with research evidence. This is easier said than done!
Learner Objectives
Upon completion of this module the learner will:
1. Explain why systematic reviews are fundamental to EBHC.
2. Describe how to outline a systematic review.
3. List the differences between a systematic review and a traditional literature
4. Explain the steps used in developing a systematic review to answer a
clinical question.
Module 12
Using Evidence-Based Guidelines
Throughout history without referencing research evidence, practitioners have
developed clinical practice guidelines. However, with the advent of evidencebased practice, development of guidelines includes scientific research
evidence to support expert clinicians’ recommendations.
The Institute of Medicine defines a clinical practice guideline as a
“systematically developed statement to assist practitioner and patient
decisions about appropriate health care for specific clinical circumstances.”
(IOM, 1992). Evidence-based guidelines are a series of recommendations on
clinical care, supported by the best available evidence in the clinical literature.
Learner Objectives
Upon completion of this module the learner will:
1. Describe the purposes and principles of evidence-based guidelines.
2. List the skills necessary to use evidence-based guidelines in practice.
3. Assess the potential benefits and harms/limitations in using evidencebased guidelines.
Module 13
Using Evidence
As nurses engage in practice they make numerous clinical decisions on a daily
basis. We have learned through the previous modules the role that evidence
plays in clinical decision making. The JBI model of evidence-based health
care recognizes that evidence-based practice occurs when clinical decisionmaking considers the best available evidence in the specific context in which
care is delivered. JBI believes in incorporating both the professional judgment
of the health professional and individual client preference (Pearson et al.,
2005). Inherent in this model is evidence utilization.
Learner Objectives
Upon completion of this module the learner will:
1. Explain the importance of using evidence in practice.
2. Describe the different methods of evidence utilization.
3. Outline the barriers to the implementation of evidence in clinical practice.
4. Evaluate strategies which can be used to promote implementation of
evidence in practice.
Module 14
Clinical Audit
Once we have evidence to guide practice, it is imperative that we modify our
practice and put the evidence to use! Clinical audit is one evidence utilization
tool that is used to achieve practice change. Clinical audit is an internal
mechanism for nurses to use for quality improvement and a formal process to
help get evidence into practice (evidence utilization).
Audit is commonly used internationally to improve quality of care. It is a
process that allows nurses to examine care practices and compare the results
with clinical guidelines or best practice statements (Pearson et al., 2007). In
short, it’s an effective means to measure the extent of a change in practice and
it supports further action to improve practice.
Learner Objectives
Upon completion of this module the learner will:
1. Define what clinical audit is and what its goals are.
2. Describe the importance of evidence-based clinical audit.
Module 15
Conducting a Clinical Audit
Clinical audit is an effective evidence utilization strategy to
improve professional practice. When conducting a clinical
audit it is important to follow the strategic process in the
correct order to save time and effort.
Learner Objectives
Upon completion of this module the learner will:
1. Demonstrate the steps required to perform a clinical
2. Design a clinical audit for a specific environment.
Module 16
Consumer Influence on EBHC
Consumers of health care assume that the treatment they receive is the latest, cutting
edge treatment and the best available for their condition. In countries like the United
States and Australia, consumers assume that the millions of dollars the government
spends on scientific research and health directly benefit them. Unfortunately, this is
not always the case.
Over recent years the move towards EBHC has had a significant impact on consumers
of health care. A change has occurred in Western medicine, where instead of being a
submissive recipient of treatment, patients now play a role in the decisions of their care
by giving informed consent or deciding on their own therapy. Patients have changed
from the “passive recipient of health-care to a consumer who demands autonomy”
(Gatson & Mitchell, 2005).
Learner Objectives
Upon completion of this module the learner will:
1. Describe the important role which consumers play in health care.
2. Recognize the ways that consumers have embraced EBP.
3. Discuss the benefits of consumer involvement in EBHC.
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