The most basic level of EBP competency is the application of the four steps for clinical decision making in an individual patient. This proficiency requires more than formulation of a clinical question and identification of pertinent studies needed to determine best available evidence. The advanced practice nurse (APN) must combine knowledge of best evidence with an assessment of individual patient factors likely to affect treatment effects, such as the presence of comorbid conditions, psychosocial and cultural factors such as locus of control, preference and impact on quality of life, and cost considerations.

Example: As an APN in a urology department, I am often asked by patients and physician colleagues whether cranberry juice or supplements (including cranberry capsules) should be prescribed to prevent urinary tract infection. This persistent query led me to formulate a clinical question, “Are cranberry juice or cranberry products effective in the prevention or management of urinary tract infection?” A systematic literature review based on current best evidence available in 2002 suggested that regular consumption of cranberry juice reduces the incidence of urinary tract infections in community-dwelling women and residents of long-term facilities but does not reduce the risk in patients who undergo intermittent or indwelling catheterization (Gray, 2002). However, more recent evidence has emerged that influences the conclusions I reached at that time. Specifically, two randomized controlled trials (RCTs) published in 2011 and 2012 found that cranberry juice was no more effective than antimicrobial therapy or cranberry flavored placebo drink for preventing urinary tract infection (UTI; Barbosa-Cesnik et al., 2011; Stapleton et al., 2012). On initial consideration, this evidence appeared to support discontinuing recommendations of consumption of cranberry for women seeking to prevent recurrent UTIs. However, additional evaluation of findings from one of the studies, a study using a placebo group (Barbosa-Cesnik et al., 2011), revealed that both groups experienced a considerably lower incidence of UTIs than anticipated. In a subsequent interview with one of the investigators, the researchers acknowledged a possibility that the placebo-flavored drink might have contained some of the ingredients hypothesized to exert an antimicrobial effect in the urine (Larson, 2010). In addition, I considered the fact that consumption of cranberry juice twice daily is not associated with any known harmful side effects. I also considered the fact that cranberry juice is relatively inexpensive compared with dietary supplement cranberry capsules. As a consequence of all these factors, cranberry juice is preferred as a natural means for preventing UTIs among many women in my practice.

This example of basing individual clinical decisions on an EBP process illustrates several important points. It points out the importance of remaining abreast of emerging evidence and the real possibility that newer evidence may significantly alter our understanding of the benefits or harmful effects associated with a specific intervention. In addition, this case illustrates the role of patient preference in clinical decision making. Clinical experience strongly suggests that a significant proportion of women prefer nonpharmacologic interventions for preventing UTIs, and regular consumption of cranberry juice tends to increase overall fluid intake and provide possibly beneficial effects without associated adverse side effects. Therefore, given the absence of harm, low direct cost, and mixed evidence of a possible preventive effect, I discuss consumption of cranberry juice with women as a possibly effective intervention, free from harmful side effects. However, I also counsel women to consider engaging in behavioral interventions for the prevention of UTIs, including adequate daily fluid intake based on recent recommendations from the Institute of Medicine, daily consumption of a dietary source of the probiotic lactobacillus, and consideration of avoiding use of a diaphragm and vaginal spermicide as birth control strategies (Salvatore et al., 2011).

This case also illustrates the time-consuming and rigorous demands of basing individual clinical decisions on the EBP process. Fortunately, APNs have access to various evidence-based resources. For example, the Cochrane Database of Systematic Reviews is the world’s largest single source of systematic reviews and meta-analyses addressing multiple aspects of APN practice (Cochrane Library, 2012). The U.S. Preventive Services Task Force has also produced a large number of systematic reviews linked to various clinical topics of special interest to APN practice, with its focus on primary and secondary intervention to promote optimal health (Trinite, Cherry, & Marion, 2009).

In addition to these resources, a growing number of professional societies have generated evidence-based clinical practice guidelines that address measurable clinical questions with thorough and extensive systematic reviews of existing evidence to formulate clinical recommendations covering comparatively broad topics such as heart failure, diabetes mellitus, chronic obstructive pulmonary disease, breast cancer, end-stage renal disease, osteoporosis, and other topics of special interest to APN practice. In addition to searching the resources of the appropriate professional association’s web page, the National Clearinghouse of Practice Guidelines, operated by the Agency for Healthcare Research and Quality (AHRQ), houses a large collection of evidence-based clinical practice guidelines that can be accessed at http://www.guideline.gov.

For many APNs, the growing demand to formulate evidence-based policies and protocols needed to prevent the growing list of “never events” provides an opportunity to master the second level, interpretation and use of EBP to create policies for patient care.

Example: Fineout-Overholt and colleagues (2010a, b, c) have described the EBP process needed to answer a clinical question about whether a rapid response team affects the number of cardiac arrests and unplanned intensive care unit admissions in hospitalized adults. Based on this question, the authors described the process used to search the evidence for pertinent studies, code and extract data from these studies using a standardized protocol, and synthesize data to implement policies needed to launch a rapid response team at their facility. Based on this process, the team concluded that there is sufficient evidence to justify developing policies and committing the resources needed to form a rapid response team at their facility. In addition to providing an example of the EBP described in this chapter, this series of articles describes the processes required to implement such a program. Although a detailed discussion of this translation from research-based evidence to clinical practice is beyond the scope of this chapter, the authors identify and briefly review essential components of this step in the implementation process, including engaging stakeholders in their facility, securing administrative support, preparing a campaign to launch the rapid response team, including staff education and changes in care protocols, and measuring outcomes following implementation of the practice change.

Participation in an interdisciplinary team to evaluate and determine standards of care using EBP is the third and most advanced level of the EBP competency for APN practice. Generation of an evidence-based clinical practice guideline requires identification of a number of clinically measurable questions required for establishing and evaluating clinical practice in a broad area of patient care, along with an extensive systematic review of pertinent studies. This often encompasses major assessment strategies related to the management of a particular disorder and first-line and alternative interventions for management.

Example: An interdisciplinary group, including two APNs, urologists, urogynecologists, and a medical librarian with extensive experience in systematic literature reviews, was charged with producing an evidence-based clinical practice guideline for treating interstitial cystitis–painful bladder syndrome (IC-PBS) for the American Urological Association (AUA, 2011). This broad topic was broken into clinical questions focusing on assessment strategies and the interventions used to relieve the pain and associated lower urinary tract symptoms associated with this poorly understood syndrome. After the IC-PBS working group reached consensus on pertinent clinical questions, a systematic literature review was completed that covered studies and related articles published between January 1, 1983, and July 22, 2009. The initial electronic database searches retrieved approximately 1130 articles, from which 86 articles were identified for further review. Members of the IC-PBS working group were assigned to review articles for coding and data extraction and the APNs were charged with studies evaluating behavioral interventions, including fluid and dietary strategies for managing bladder pain and related lower urinary tract symptoms (e.g., use of dietary supplements such as calcium glycerophosphate), and pelvic floor muscle training. Because of the generally low levels of supporting evidence, the IC-PBS work group determined that meta-analysis was not feasible. Nevertheless, the group found sufficient evidence to identify and create recommendations for clinical practice for first- through sixth-line treatments (AUA, 2011). Conservative interventions were advocated as first-line treatments because of their combination of moderate benefit combined with few to no harmful side effects. Although the strength of recommendations for clinical practice generated by this interdisciplinary group varied from moderate to low, the production of this clinical practice guideline illustrates the process used to evaluate and create standards of care using the EBP process in an interdisciplinary setting.