Introduction to Evidence-Based Practice

EBP is a broad concept referring to the incorporation of current, valid, and relevant external evidence during the decision-making process. In the health sciences, such evidence is most commonly found in current high-quality research studies that can be applied to the specific patient, group, or population being considered.

In the early 1900s, it was thought that flowers should never be placed in a hospital room because they would consume much-needed oxygen and rob it from the patient. In fact, during a recent orientation at a hospital on the evening shift, the nurse preceptor explained to the orienting nurse that every evening at 9 pm, all flowers and plants are removed from the patient rooms and stored until the following day. The nurse preceptor explained that “this is the way we have always done it here.” This act was based on fallacies and inaccurate science. In fact, this error in thinking traces back to 1923 in print form and spread by word of mouth from there. In a study published in International Archives of Occupation and Environmental Health (1977), the authors reported that plants altered oxygen and CO₂ levels by about 1.5% – a very negligible amount (Gale et al., 1977). When you consider that a human being, such as the person in the bed in the hospital room, uses up about 2.5 cubic feet (71 liters) of oxygen in an hour, while a pound of foliage sucks up about 0.026 gallons (0.1 liters) in that same time period, it would make far more sense to ban oxygen-sucking visitors than to ban flowers! Additionally, Park and Mattson (2009) studying therapeutic influences of plants in hospital rooms, reported that, “Patients in hospital rooms with plants and flowers had significantly shorter hospitalizations, fewer intakes of analgesics, lower ratings of pain, anxiety, and fatigue, and more positive feelings and higher satisfaction about their rooms when compared with patients in the control group” (p. 975). It seems that patients benefit from having flowers in their rooms.

Before we can really understand some of the alternative sources of “what we do”, let’s look at the timeline of conducting a research study and how long it may take to get the results of that study into practice. There is a standard refrain of “17 years to move evidence into practice” and indeed there is a long gap that prevents amazing research from being embedded (if ever) into clinical practice (Institute of Medicine [IOM], 2001).

Timeline of Evidence into Clinical Practice

Moving research into practice is a delicate balance of incorporating new findings quickly enough to maximally benefit patients, but not so quickly that we expose patients to unnecessary harm (Munro & Savel, 2016). New evidence progresses through a series of steps before it is incorporated into clinical practice:

• Testable idea must be formulated and refined.
• Research team must be assembled.
• Preliminary data gathered.
• Permissions must be obtained.
• Regulatory requirements must be met.
• Support must be obtained, including personnel, supplies, and funding.
• Subjects must be enrolled.
• Interventions must be delivered.
• Data must be collected.
• Analyses performed.
• Dissemination (sharing) of data through presentations and publications.
• Then, and maybe then, practitioners and/or facilities investigate embedding this into practice.
• Assessment must be completed to see if these changes are working/not working.
• And so on.

We now see that there can be a very long process to embed latest/most current, best evidence into practice. In the meantime, this lack of embedding best evidence in clinical practice may be harming the efforts to improve clinical outcomes. If clinicians are just doing “what we’ve always done”, and we are not using the best evidence that is out there, this creates an issue.

Principles of the Triad of EBP

• Patient preferences or values
  • This means, if the patient’s own situation renders the intervention not appropriate for them or if their own social or cultural values do not align with the intervention, then the process stops there.
• Clinician expertise
  • Decision making also includes the individual clinician’s expertise, which includes academic knowledge, experiences with patient care, and interdisciplinary sharing of new knowledge (Polit & Beck, 2021). Even very strong evidence is seldom appropriate for all patients, so clinician expertise is important.
• Best available current clinical evidence
  • The basis of EBP is to de-emphasize utilizing tradition, opinions, and anecdotal evidence.
  • Therefore, the best evidence is essential to EBP. We will explore how to determine which evidence is “best” in a bit. But, for now, just know that whatever evidence, whether we determine it to be “best” or not, is never enough by itself for the foundation of a clinical decision-making process.
  • Finally, a big concept of this is knowing that one research study (even if it is the best study ever) does not equal EBP. This means we must consider multiple pieces of evidence to consider synthesizing the results.

References

Gale, R., Redner-Carmi, R. & Gale, J. (1977). Impact of the respiration of ornamental flowers on the composition of the atmosphere in hospital wards. International Archives of Occupational & Environmental Health, 40, 255–259. https://doi.org/10.1007/BF00381413

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academies Press. https://pubmed.ncbi.nlm.nih.gov/25057539/

Munro, C. L., & Savel, R. H. (2016). Narrowing the 17-year research to practice gap. American Journal of Critical Care: An Official Publication, American Association of Critical-Care Nurses, 25(3), 194–196. https://doi.org/10.4037/ajcc2016449

Park, S., & Mattson, R. H. (2009). Therapeutic influences of plants in hospital rooms on surgical recovery. HortScience , 44(1), 102-105. https://doi.org/10.21273/HORTSCI.44.1.102

Polit, D. & Beck, C. (2021). Lippincott CoursePoint Enhanced for Polit’s Essentials of Nursing Research (10th ed.). Wolters Kluwer Health.