Always think about your practice when caring for patients. Question what does not make sense to you and what needs to be clarified. Think about a problem or area of interest that is time consuming, costly, or not logical (Stilwell et al., 2010). Use problem- and knowledge-focused triggers to think critically about clinical and operational nursing unit issues (Titler et al., 2001). A problem-focused trigger is one you face while caring for a patient or a trend you see on a nursing unit. For example, while Rick is caring for patients following abdominal surgery, he wonders, “If we changed our patients’ activity levels after surgery, would they experience fewer episodes of postoperative ileus?” Other examples of problem-focused trends include the increasing number of patient falls or incidence of urinary tract infections on a nursing unit. Such trends lead you to ask, “How can I reduce falls on my unit?” or “What is the best way to prevent urinary tract infections in postoperative patients?”

A knowledge-focused trigger is a question regarding new information available on a topic. For example, “What is the current evidence to improve pain management in patients with migraine headaches?” Important sources of this type of information are standards and practice guidelines available from national agencies such as the Agency for Healthcare Research and Quality (AHRQ), the American Pain Society (APS), or the American Association of Critical Care Nurses (AACN). Other sources of knowledge-focused triggers include recent research publications and nurse experts within an organization.

Sometimes you use data gathered from a health care setting to examine clinical trends to develop clinical questions. For example, most hospitals keep monthly records on key quality of care or performance indicators such as medication errors or infection rates. All magnet-designated hospitals maintain the National Database of Nursing Quality Improvement (NDNQI) (see Chapter 2). The database includes information on falls, pressure ulcer incidence, and nurse satisfaction. Typically quality and risk management data do not give you evidence in finding a solution to a problem, but the data inform you about the nature or severity of problems that then allow you to form practice questions.

The questions you ask eventually lead you to the evidence for an answer. When you ask a question and then go to the scientific literature, you do not want to read 100 articles to find the handful that are most helpful. You want to be able to read the best four-to-six articles that specifically address your practice question. Melnyk and Fineout-Overholt (2011) suggest using a PICOT format to state your question. The five elements of a PICOT question are summarized in Box 5-1. The more focused a question you ask, the easier it becomes to search for evidence in the scientific literature. For example, Rick develops the following PICOT question: Do patients who have had abdominal surgery (P) and who rock in a rocking chair (I) have a reduced incidence of postoperative ileus (O) during hospitalization (T) when compared with patients who receive standard nursing care following surgery (C)? Another example is: Is an adult patient’s (P) blood pressure more accurate (O) when measuring with the patient’s legs crossed (I) versus the patient’s feet flat on the floor (C)?

Inappropriately formed questions (e.g., What is the best way to reduce wandering? What is the best way to improve family’s satisfaction with patient care?) are background questions that will likely lead to many irrelevant sources of information, making it difficult to find the best evidence. Sometimes a background question is needed to identify a more specific PICOT question. The PICOT format allows you to ask questions that are intervention focused. For questions that are not intervention focused, the meaning of the letter I can be an area of interest (Melnyk and Fineout-Overholt, 2011). For example, What is the difference in retention (O) of new nursing graduates (P) who have previous experience as nurse assistants (I) versus those who do not (C)?

The questions you ask using a PICOT format help to identify knowledge gaps within a clinical situation. When you raise well–

thought-out questions, you should understand the evidence that is missing to guide clinical practice. Remember: do not be satisfied with clinical routines. Always question and use critical thinking to consider better ways to provide patient care.

When using the scientific literature for evidence, seek the assistance of a medical librarian. He or she knows the various databases that are available to you (Table 5-1). The databases contain large collections of published scientific studies, including peer-reviewed research. A peer-reviewed article is one reviewed by a panel of experts familiar with the topic or subject matter of the article before it was published. The librarian is available to help translate your PICOT question into the language or key words that will yield the best evidence search. When conducting a search, it is necessary to enter and manipulate different key words until you get the combination that gives you the key articles that you want to read about your question. When you enter a word to search into a database, be prepared for some confusion with the evidence you obtain. The vocabulary within published articles is often vague. The word you select sometimes has one meaning to one author and a very different meaning to another.

When Rick searches for evidence to answer his PICOT question, he asks for help from a medical librarian. The medical librarian helps him learn how to choose alternative words or terms that identify his PICOT question. During their search Rick identifies three research articles published since 1990 that address the effects of rocking in a rocking chair on return of bowel function following abdominal surgery (Massey, 2010; Moore et al., 1995; Thomas et al., 1990).

MEDLINE and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) are among the best-known comprehensive databases to search for scientific knowledge in health care (Melnyk and Fineout-Overholt, 2011). Among the many databases, some are available through vendors at a cost, some are free of charge, and some offer both options. As a student you have access to an institutional subscription through a vendor purchased by your school. One of the more common vendors is OVID, which offers several different databases. Databases are also available free on the Internet. The Cochrane Database of Systematic Reviews is a valuable source of high-quality evidence. It includes the full text of regularly updated systematic reviews and protocols for reviews currently under way. Collaborative review groups prepare and maintain the reviews. The protocols provide the background, objectives, and methods for reviews in progress (Melnyk and Fineout-Overholt, 2011). The National Guidelines Clearinghouse (NGC) is a database supported by the AHRQ. It contains clinical guidelines, systematically developed statements about a plan of care for a specific set of clinical circumstances involving a specific patient population. Examples of clinical guidelines on NCG include care of children and adolescents with type 1 diabetes and practice guidelines for the treatment of adults with low back pain. The NGC is invaluable when developing a plan of care for a patient (see Chapter 18).

Fig. 5-2 represents the hierarchy of available evidence. The level of rigor or amount of confidence you can have in a study’s findings decreases as you move down the pyramid. At this point in your nursing career, you cannot be an expert on all aspects of the types of studies conducted. But you can learn enough about the types of studies to help you know which ones have the best scientific evidence. At the top of the pyramid are systematic reviews or meta-analyses, which are state-of-the-art summaries from an individual researcher or panel of experts. Meta-analyses and systematic reviews are the perfect answers to PICOT questions because they rigorously summarize current evidence.

As a student new to nursing, it takes time to acquire the skills to critique evidence like an expert. When you read an article, do not put it down and walk away because of the statistics and technical language. Know the elements of an article and use a careful approach when reviewing each one. Evidence-based articles include the following elements:

After Rick critiques each article for his PICOT question, he combines the findings from the three articles he found about the use of rocking chairs to determine the state of the evidence. He uses critical thinking to consider the scientific rigor of the evidence and how well it answers his PICOT question. He also considers the evidence in light of his patients’ concerns and preferences. As a clinician Rick judges whether to use the evidence for the group of patients for whom he normally cares on the surgical unit. Patients frequently have complex medical histories and patterns of responses (Melnyk and Fineout-Overholt, 2011). Ethically it is important for Rick to consider evidence that will benefit patients and do no harm. He needs to decide if the evidence is relevant, is easily applicable in his setting of practice, and has the potential for improving patient outcomes.

Once you decide that the evidence is strong and applicable to your patients and clinical situation, incorporate it into practice. Your first step is simply to apply the research in your plan of care for a patient (see Chapter 18). Use the evidence you find as a rationale for an intervention you plan to try. For instance, you learned about an approach to bathe older adults who are confused and decide to use the technique during your next clinical assignment. You use the bathing technique with your own assigned patients, or you work with a group of other students or nurses to revise a policy and procedure or develop a new clinical protocol.

The literature Rick found reveals that rocking in a rocking chair after bowel surgery usually results in a quicker return of bowel function following surgery when compared with standard nursing care (Massey, 2010; Moore et al., 1995; Thomas et al., 1990). Rick then meets with his colleagues on the unit practice committee to recommend a protocol for patients who have abdominal surgery. The protocol outlines guidelines to have patients routinely sit in rocking chairs when they get out of bed after surgery.

Evidence is integrated in a variety of ways through teaching tools, clinical practice guidelines, policies and procedures, and new assessment or documentation tools. Depending on the amount of change needed to apply evidence in practice, it becomes necessary to involve a number of staff from a given nursing unit. It is important to consider the setting where you want to apply the evidence. Is there support from all staff? Does the practice change fit with the scope of practice in the clinical setting? Are resources (time, secretarial support, and staff) available to make a change? When evidence is not strong enough to apply in practice, your next option is to conduct a pilot study to investigate your PICOT question. A pilot study is a small-scale research study or one that includes a quality or performance improvement project.

After applying evidence in your practice, your next step is to evaluate the outcome. How does the intervention work? How effective was the clinical decision for your patient or practice setting? Sometimes your evaluation is as simple as determining if the expected outcomes you set for an intervention are met (see Chapters 18 and 20). For example, after the use of a transparent intravenous (IV) dressing, does the IV dislodge, or does the patient develop the complication of phlebitis? When using a new approach to preoperative teaching, does the patient learn what to expect after surgery?

When an EBP change occurs on a larger scale, an evaluation is more formal. For example, evidence showing factors that contribute to pressure ulcers might lead a nursing unit to adopt a new skin care protocol. To evaluate the protocol, nurses track the incidence of pressure ulcers over a course of time (e.g., 6 months to a year). In addition, they collect data to describe both patients who develop ulcers and those who do not. This comparative information is valuable in determining the effects of the protocol and whether modifications are necessary.

When evaluating an EBP change, determine if the change was effective, if modifications in the change are needed, or if the change needs to be discontinued. Events or results that you do not expect may occur. For example, a hospital that implements a new method of cleaning IV line puncture sites discovers an increased rate of IV line infections and reevaluates the new cleaning method to determine why infections have increased. If the hospital does not evaluate this change in practice, more patients will develop IV site infections. Never implement a practice change without evaluating its effect.

In Rick’s case the unit practice committee collects evaluation data after 3 months of implementing the rocking chair protocol to determine if patients experienced a lower incidence of postoperative ileus following abdominal surgery. After completing chart reviews, the committee discovers that patients who used the rocking chairs following abdominal surgery experienced fewer incidences of postoperative ileus compared with patients who did not use rockers before the protocol was implemented. The protocol patients went home 1 to 2 days sooner than the patients who did not use the rocking chairs. Patient interviews revealed that the patients were satisfied with the rocking movement and that, not only did the rocking chairs help them pass gas faster, but the patients also felt less anxious because of the rocking motion. After talking with the committee, Rick discovered that not all patients were able to use rocking chairs during this time because the unit did not have enough rocking chairs. He presented these data to his manager who approved the purchase of more rocking chairs.