Overview of Evidence-Based Practice





This chapter begins with an overview of evidence-based practice (EBP) including generally accepted definitions, central tenets, barriers and facilitators, and trends over time. Additionally, an overview of the necessary underlying components of EBP are explored, these being the actual providers of EBP and the competencies required of EBP providers, specifically advanced practice registered nurses (APRNs).


Multiple definitions of EBP have been proposed and have evolved over the years. One of the most common definitions of EBP in use today was derived from an initial proposal for evidence-based medicine by Sackett et al. (2000). Over time the Sackett et al.’s definition evolved, such that many contemporary texts and publications agree on the definition of EBP to be “the integration of best research evidence with clinical expertise and patient values and circumstances” (Straus et al., 2005, p. 1). While many other excellent definitions are used in the literature, most would agree that Straus et al.’s definition is inclusive enough for universal use.

Regardless of the exact definition, or which discipline supports which nomenclature, there exists today much discussion and debate about implementation, barriers, facilitators, evaluation, and perhaps more importantly, the health outcomes for patients in an EBP environment. Positive health outcomes should logically result from knowledge generated from research and be reflective of an effective EBP environment; however, positive health outcomes in the United States lag far behind what we know about safe and effective healthcare, especially considering the high cost of U.S. healthcare. The knowledge-to-practice gap is even more apparent when health status outcomes are compared with those of other countries. Current data from the Organisation for Economic Cooperation and Development (OECD, 2019), indicate that the worldwide spending on health is about $4,000 per person (adjusted for purchasing power) on average across OECD countries (Figure 1.1), but the United States spends more than all other countries by a considerable margin, at over $10,000 per resident (Institute of Medicine [IOM], 2015b; OECD, 2019). Indeed the United States spends more than twice as much on healthcare than other developed countries, yet according to multiple indicators of health status, the United States is ranked considerably lower (OECD, 2019). Unsurprisingly, studies continue to indicate that the U.S. health system is inefficient. In 2013, the IOM estimated that upward of $750 billion of healthcare spending could be attributed to excess costs. Moreover, despite an increased knowledge base and a 4considerable monetary investment, there is no corresponding improvement in U.S. health outcomes; in fact, the United States falls measurably behind our international peers across essential measures of access, equity, and efficiency (IOM, 2015b).

FIGURE 1.1United States per capita healthcare spending is more than twice the average of other developed countries.

Source: Data from Organisation for Economic Co-operation and Development, OECD Health Statistics, 2019, November 2019.

Notes: Data are from 2018. Chart uses purchasing power parities to convert data into U.S. dollars.

Extending back two decades, this concerning trend in the knowledge-to-practice gap has been acknowledged and written about (IOM, 2000, 2001, 2003, 2010, 2015a; OECD, 2019). While strategic direction from policymakers needs to continually address quality and safety issues at the system or macro level, nurses (academic educators, advanced practitioners, and hospital administrators) have a role in ensuring competent practice, to the end of improving various health-related outcomes. While some may be discouraged by the slow pace of EBP implementation, progress has been made regarding the competence and the competencies expected of the nursing healthcare workforce. Insistence on EBP competence and competencies are strategies that nurses may consider within our collective scope of practice.

Providers from many health-related professions believe the implementation of EBP promotes safety, quality of care, and consistency, and improves patient outcomes while decreasing healthcare costs (Aste et al., 2020; Copeland et al., 2020; Jin & Yi, 2019; Lewis et al., 2019; Melnyk, 2016; Taxman, 2018). The IOM further recommended that 90% of clinical decisions be evidence-based by 2020 (IOM, 2010). Despite this recommendation, a persistent gap remains between what care providers do and what care providers should do based on the best available evidence (IOM, 2010; Melnyk et al., 2018), yet barriers to EBP implementation persist.


Regardless of profession or country of practice, much has been written over the past 20-plus years about the barriers and facilitators to implementing EBP. Data relating to EBP barriers and facilitators were found in the literature even before the first of the IOMs sentinel reports and extend through today. Primarily, lack of general EBP knowledge and skills (e.g., searching and critically appraising the literature) lead the list of barriers and overcoming these barriers is believed to be the most effective way to facilitate an EBP environment (Al‐Jamei et al., 2019; Alqahtani et al., 2020; Baig et al., 2016; Bhor et al., 2019; Bianchi et al., 2018; Garcia et al., 2019; Hallum-Montes et al., 2016; Haynes & Haines, 1998; Hong et al., 2019; Labrague et al., 2019; Newman et al., 1998; Nolan et al., 1998; Oliver & Lang, 2018; Renolen et al., 2020; Rojjanasrirat & Rice, 2017; Rossi et al., 2020; Shayan et al., 2019; Skela-Savič et al., 2017; Youssef et al., 2018). Other barriers include difficulty with time constraints, limited support from organizations (Connor et al., 2016; Melnyk et al., 2012), and perhaps the most disheartening of all, resistance from colleagues (Melnyk et al., 2012).

However, despite the barriers, when nurses specifically are surveyed about their beliefs and attitudes toward EBP, they continue to indicate that they value EBP and that critical appraisal of the literature is essential to translate current knowledge into practice to produce positive patient outcomes (Alqahtani et al., 2020; Azmoude et al., 2018; Bhor et al., 2019; Li et al., 2019; Stokke et al., 2014; van Der Goot et al., 2018).


Core practice needs were identified in 2001, indicating that healthcare should be safe, effective, patient-centered, timely, efficient, and equitable. Subsequently, in 2003, five core competencies were recommended by the IOM for the healthcare education curriculum with a focus on EBP. Today, as the latest edition of this text is prepared for publication, EBP, and the need for an effective EBP curriculum in healthcare education, still exist. Data are clear and compelling that healthcare education must produce competent practitioners to meet the needs of EBP (IOM, 2010, 2015a; Melnyk et al. 2018; QSEN Institute, 2012; Stevens, 2009). Following the implementation of the 2010 legislation of the Health Care and Education Reconciliation Act and the Affordable Care Act, nursing is at the forefront of leading this change in both education and practice. The Future of Nursing: Leading Change, Advancing Health report from the IOM (2010), and the Quality and Safety Education for Nurses (QSEN) initiative from the University of North Carolina and the American Association of Colleges of Nursing (AACN, 2012), are two examples of exciting initiatives available to advise and guide nursing on leading change in education and on EBP (IOM, 2010, 2015a; QSEN Institute, 2012).


Most might agree that the general definition of competency or competence is the ability or capability to accomplish something. Merriam-Webster defines competence as “. . . possession of sufficient knowledge or skill . . .” and competency “. . . as a specific area of competence . . .” (Merriam-Webster, 2020). More specifically, for our profession, the American Nurses 6Association (ANA, 2014, p. 64) define competency as “an expected and measurable level of nursing performance that integrates knowledge, skills, abilities, and judgment, based on established scientific knowledge and expectations for nursing practice.” Moreover, in the past two decades, multiple authors, from various disciples, have published similar definitions of competence or competencies when teaching or evaluating EBP (Claus et al., 2020; Kim et al., 2015; Jin & Yi, 2019; Lee & Seomun, 2016; Melnyk, 2016, 2017; Odhwani et al., 2019; Saunders & Vehvilainen-Julkunen, 2018; Stevens, 2005, 2009; Stiffler & Cullen, 2010; Ruzafa-Martinez et al., 2013).


While The Future of Nursing report (IOM, 2010, IOM 2015a) plotted a course to position nurses for advanced practice, the QSEN competencies provide specific knowledge, skills, and attitudes that are quite similar to, and no doubt developed from, the original five core competencies proposed by the IOM in 2003 to ensure quality in patient care. Comparisons of the core competencies recommended by the IOM in 2003 and the 2012 QSEN competency categories are displayed in Table 1.1. The graduate-level QSEN competencies for EBP are listed in Table 1.2.

Of note, The Baccalaureate Essentials for Professional Nursing Practice (AACN, 2008), The Essentials of Master’s Education in Nursing (AACN, 2011), and The Essentials of Doctoral Education for Advanced Nursing Practice (AACN, 2006, 2015) were also developed using data and recommendations from the IOM (2003) report; however, all the AACN Essentials are currently in the process of revision; therefore, this chapter will briefly discuss some of the proposed conceptual, forward-focused changes to the AACN Essentials related to competencies and their role in evidence-based nursing education (AACN, 2019).


Competency-based education, as preparation for practice, is emerging within the health professions to address training deficits (Claus et al., 2020; Englander et al., 2013; Jin & Yi, 2019; Nodine, 2016). Moreover, at the national level, consensus is growing related to competency-based education to prepare health professionals (Englander et al., 2013; Jin & Yi, 2019; Josiah Macy Jr. Foundation, 2017; Kavanagh & Szweda, 2017; Litwack & Brower, 2018; Tharp-Barrie et al., 2020; Wagner et al., 2018).

TABLE 1.1 Comparisons of the Core Competencies Proposed by the Institute of Medicine (IOM) in 2003 and the 2012 Quality and Safety Education for Nurses (QSEN) Competency Categories

IOM (2003)


• Patient-centered care

• Patient-centered care

• Interdisciplinary skills

• Teamwork and collaboration

• Quality improvement skills

• Quality improvement

• Information technology

• Informatics

• Evidence-based practice

• Evidence-based practice

• Safety

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Oct 17, 2021 | Posted by in NURSING | Comments Off on Overview of Evidence-Based Practice

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7TABLE 1.2 Graduate-Level Quality and Safety Education for Nurses (QSEN) Competencies for Evidence-Based Practice (EBP)




Demonstrate knowledge of health research methods and processes

Use health research methods and processes, alone or in partnership with scientists, to generate new knowledge for practice

Appreciate the strengths and weaknesses of scientific bases for practice

Describe evidence-based practice to include the components of research evidence, clinical expertise, and patient/family/community values

Role model clinical decision-making based on evidence, clinical expertise, and patient/family/community preferences

Value all components of evidence-based practice

Identify efficient and effective search strategies to locate reliable sources of evidence

Employ efficient and effective search strategies to answer focused clinical or health system practices

Value development of search skills for locating evidence for best practice

Identify principles that comprise the critical appraisal of research evidence

Critically appraise original research and evidence summaries related to the area of practice

Value knowing the evidence base for one’s practice specialty area

Summarize current evidence regarding major diagnostic and treatment actions within the practice specialty and healthcare delivery system

Exhibit contemporary knowledge of best evidence related to practice and healthcare systems

Value cutting-edge knowledge of the current practice

Determine evidence gaps within the practice specialty and healthcare delivery system

Promote a research agenda for evidence that is needed in the practice specialty and healthcare system

Value working in an interactive manner with the institutional review board

Identify strategies to address gaps in evidence-based guidelines