EBP PICOT question affecting ICU nurses

EBP PICOT question affecting ICU nurses

Overview of Evidence Based Practice (EBP) in Nursing

Evidence-Based Practice (EBP) forms the basis of effective care delivery in nursing. 

This makes it one of the most important assessment areas for nursing students.

Markedly, EBP entails an elaborate approach towards improvement of care delivery.

It is considered very essential in nursing practice as is seeks the application of available reliable evidence, patient’s preferences, and the judgment of the nurse in helping provide the best care possible.

For this reason, nursing students will occasionally be required to write assignments on evidence-based practice (EBP). 

Note that just like writing a care plan for nursing, or writing a nursing diagnosis, the EBP is a major area of assessment for nursing students.

It is therefore important for every nurse practitioner and nurse student to understand evidence-based practice (EBP).

Accordingly, Evidence-Based Practice (EBP) can be defined as:

“A dedicated problem-solving approach in clinical practice that applies the best available evidence derived from reliable research, clinician’s expertise, and patient’s values and preferences in patient care decision making process.” 

Generally, application of EBP in nursing entails the use of nursing literature in the patient treatment process.

The application of EBP in nursing would require you to integrate the best available clinical evidence with your nursing expertise and patient values in the treatment process.

Per se, the best available evidence is adjusted to suit the circumstances and preferences of the patient with the aim of enhancing the quality of clinical decisions.  

It is therefore an essential tool in the improvement of patient care.

In academics, it is usually important to effectively illustrate your understanding of EBP when writing either your nursing essay or nursing research paper. 

Knowledge in EBP as such comes in handy when executing your key assignments.

As explained below, EBP is essential in numerous ways. 

Benefits of Evidence-Based Practice in Nursing

There are numerous benefits of evidence-based practice in nursing.

They include:

1. Helps Improve Patient Outcomes

This is one of the key benefits of evidence-based practice in nursing. In this, the application of EBP seeks to provide effective care aimed at enhancing patient outcomes.

As illustrated by different evidence based practice nursing examples, the patient is always the center of EBP.

This obliges the nurse practitioner to put the interests of the patient into consideration in the care decision making process.

2. Helps Reduce Risks

Evidence-based practice in nursing and healthcare play an important role in helping reduce potential practice risks.

Together with practice experience, EBP forms the basis of nurse practitioner expertise. Such expertise is important in making judgments that minimize risks in nursing practice.

Further, research evidence in EBP could be synthesized to create policies, standards, guidelines, and protocols that could be used to direct health interventions to help reduce practice risks.  

3. Saves Time

Time saving is another of the key benefits of evidence-based practice in nursing. EBP plays a vital role in helping nurses and other clinicians identify activities beneficial to patients.

Different evidence based practice nursing examples indicate that this helps save time as nurses do not have to waste time on activities not essential to the care delivery process.

This is important in making care delivery more efficient.

4. Enhances Accountability

The ability to enhance accountability among nurse practitioners emphasizes the importance of evidence-based practice nursing care provision approach.  

Such accountability is realized through the spirit of inquiry among health care practitioners as promoted by EBP.

In this, EBP makes the practitioners ask questions on why they are doing certain things in a particular way and whether there is evidence to help do it more effectively.

5. Fosters Effective Use of Resources

This is another benefit of evidence-based practice in nursing and healthcare in general. EBP has been accredited for helping put health resources into the most effective use possible.

To do this, relevant evidence is used when arriving at the decisions on the health services to fund, reduce funding, or increasing funding on.

Various evidence based practice nursing examples show that this approach helps in effective prioritization of funding.

Steps in Evidence-Based Practice in Nursing 

All that said, EBP is founded on six key steps as illustrated below.

Step 1: Asking an Answerable Question

Clinical nursing practice requires the nurse to find answers to treatment questions.

This entails asking the appropriate PICO question for nursing.

In this, practice may demand answers to questions or issues such as “most effective”, “quickest”, or “best” medication for a particular disease or condition.

This practice requires you to get an evidence-based answer.

As such, the first step towards getting this answer entails asking the appropriate clinical question.

It is evident that clinical nursing questions could be complex, wide, and multi-leveled.

For instance, a nurse may face a question like, “which asthma treatment is the most effective, fastest, and has the least side effects?”

Answering such clinical questions requires a methodological approach. Markedly, the “PICO” framework is the scientifically approved approach for answering nursing questions.

This framework stands for:

P: Patient or Population

I: Intervention or Indicator

C: Comparison or Control

O: Outcome

T: Time 

• Patient or Population looks at the patient(s) characteristics, including gender, age, or condition.

• Intervention or Indicator reviews elements such as exposure, diagnostic test, or therapy you are interested in for a particular condition of population.

• Comparison or Control looks at the alternative to be contrasted with the identified intervention or indicator.

• Outcome stands for the measurable results you intend to realize.

• Time entails the duration within which the outcomes should be monitored or revealed.

Notably, there are five categories of these questions that include:

Therapy/Intervention: These are questions that address the treatment of a disability or an illness.

Diagnosis: These questions address the process of identifying and establishing the cause and nature of an injury or a disease through clinical evaluation.

Etiology: Questions under this category address the origins or causes of a disease.

Prognosis: These questions address the prediction of a disease’s course.  

Meaning: Questions in this category address how an individual experiences a phenomenon.

Sample Questions

Intervention Question

In Mexican-Americans male adults with lupus (P), how does Cortisol-corticosteroid (I) compared to azathioprine-Immunosuppressive (C) affect kidney function (O)?  

Etiology Question

Are women between 18 and 35 years (P) who have given birth (I) compared to those who have not given birth (C) at higher risk for developing cervical cancer (O) within the first 5 years of oral contraception use (T)?  

Therapy Question

In adolescents with Attention Deficit and Hyperactivity Disorder (ADHD) (P), what is the effect of Parent-Child Interaction Therapy (I) compared to Parent Management Training (C) on development of the adolescent’s relationships?

In EBP, you should aim to use systematic reviews as first choice source of information. This is because they are usually considered “Level I Evidence”. Systematic reviews are usually determined by;

1. their address of focused and clearly designed question, and

2. their use of systematic and explicit methods in identifying, selecting, and examining relevant research as well as collecting and analyzing data in the studies encompassed in the review.

However, it is clear that there lacks systematic reviews for every nursing clinical question. The nurse is therefore obligated to look for other types of studies.

Notably, the level of evidence for different category of questions vary from one study to another. This is as illustrate below.

Type of Question	Type of Study with Highest Evidence Level
Diagnosis	Cohort study with all subjects receiving both the study test as well as the gold standard reference test.
Intervention/ Therapy	Randomized controlled trial
Prognosis	Longitudinal cohort
Etiology/Risk factors	Cohort for rare/uncommon exposure with similar outcome   Randomized controlled trial

Step 2: Searching for Available Literature

After asking the PICO question for nursing, you should proceed to looking for appropriate literature.

This is the second step in EBP and entails searching available materials for respective evidence.

In this step, you should use the PICOT question components to help identify the search terms instrumental to your search strategy. This is as illustrated below.

	Search terms	Alternatives
	The elderly Cholinesterase	Geriatric, aged, old, etc. Memantine
Patient
Intervention
Comparison
Outcomes

The search should utilize the different PICOT elements. This search should involve both internal evidence (practice data in healthcare records) and external evidence (journal articles).

Notably, there are two major categories of external evidence that include 1) textbooks and journals and 2) consolidated resources.  

Journal articles could be searched through numerous journal articles websites like Google Scholar, JSTOR, and Bioline International.

On the other hand, consolidate resources (databases) may include CINAHL, MEDLINE, and PsycINFO.  

As earlier noted, the search process should involve a combination of the PICOT elements, where you should employ the Boolean operators “OR” and “AND to control the search results.

While “OR” will stretch your search by producing results for either of the terms derived from the PICOT elements, “AND” will restrict the search by producing results containing the two terms.     

Step 3: Appraising Literature for Evidence

This step requires you to evaluate the articles found through the search process to determine whether they are good for use in clinical practice, not good for use in clinical practice, or okay but containing some limitations that require discretion when applying the results in clinical practice.

As such, critical appraisal seeks to determine whether the research in the articles is accurate, reliable, and applicable.  

Usually, critical appraisals look at 3 key areas that include:

1. Whether it is worth looking at the study’s results.

2. What the results are.

3. Whether the results are relevant to the patients under treatment.

Whether it is worth looking at the study’s results

This part of the appraisal examines key areas that encompass:

1. Why the study was done.

2. What the research question was.

3. What study design type was used, and whether it was the most appropriate for entailed research question.

4. What the study characteristics are, and whether they are compatible with the entailed research question.

5. Whether the results are valid (presence of potential research biases and their impact on the results).

What the results are

This part of the appraisal looks at different issues, including:

1. Whether the outcome measures used in the study are relevant and comprehensive.

2. What the size of the “results effect” is.

3. What the precision of the “results effect” is.

Whether the results are relevant to the patients under treatment

This part of the appraisal looks at whether the study results could be generalized effectively for proper application in the current clinical practice. It looks at key issues like:

1. Whether similar definitions are applicable.

2. Whether a similar patient population is used. 

3. Whether similar protocols can be followed. 

4. Whether the health systems are similar.

Step 4: Integrating the Research Evidence into Decision Making

This step involves applying the acquired evidence in clinical settings in order to improve the quality of patient care, patient outcomes, patient care consistency, and cost containment.

It provides answers to respective PICO question for nursing.

Per se, the application of this evidence is usually a complex process that involves individual clinician, clinical teams, clinical systems, and clinical organizations.

Obviously, the application process should follow certain procedures as outlined by different models.

Some of the key application models include:

1. John Hopkins Model 

2. Stetler Model 

3. Iowa Model

Note that the John Hopkins Model is the most commonly used model.

Step 5: Evaluating the Effectiveness of the Evidence

This step entails monitoring and evaluating changes in clinical outcomes resulting from the application of the evidence.

It is important in ensuring that positive outcomes are supported and negative outcomes are remedied.

Evaluation can also be used to detect flaws in clinical implementation process and accurately determine the category of patients that stands the most benefits.   

Step 6: Dissemination of Results

This step involves sharing the EBP experiences with colleagues, other clinical field professionals, and respective organizations.

You are required to share answers to the entailed PICO question for nursing.

Dissemination is essential for improvement of clinical practice as well as avoiding duplication of efforts.

Clearly, some of the common dissemination channels include EBP rounds, conferences, professional newsletters, peer-reviewed journals, and general audience publications. 

Sources of Evidence-Based Practice in Nursing

Evidence and its sources are very important in evidence-based practice in nursing and healthcare.

Accordingly, evidence is usually divided into different levels.

These levels are:

1. LEVEL A

This is the strongest level of evidence. It is founded on the most reliable sources of evidence-based practice in nursing.

As shown in evidence based practice nursing examples, such sources should encompass:

1. Randomized control trials: These entail the classic study design in scientific studies. In such studies, selection of study subject is random.

Further, assignment of these subjects to groups is random.

Within these groups, the subjects are put under experimental conditions or interventions that are rigorously controlled.

2. Systematic review and meta-analysis of randomized control trials:  This is also another of the reliable Level A sources of evidence-based practice in nursing.  

Systematic reviews would entail critical analysis of existing evidence on a specific clinical question.

On the other hand, a meta-analysis would encompass studies using statistical approaches to put together and analyze data from randomized control trials.

3. Clinical practice guidelines: The guidelines are based on randomized control trials’ systematic reviews and therefore provided best available evidence.

2. LEVEL B

This encompasses the second most reliable sources of evidence-based practice in nursing.

Evidence based practice nursing examples of such evidence include:

1. Non-randomized well-designed control trials: These sources of evidence-based practice in nursing involve studies without random selection of research subjects in the experimental and control groups.

Such studies suffer weak internal validity and may therefore contain unintentional or intentional sample enrollment bias.

2. Case-controlled study: This source is also often used in evidence-based practice in nursing and healthcare.

It entails an observational approach where subjects with an outcome or a disease are compared with other subjects without the outcome or disease.

3. Clinical cohort study: This source involves an examination of subject groups with common characteristics or experiences in exposure and then comparing the outcomes between those exposed and the non-exposed.

Evidence based practice nursing examples in this source category may for instance look at development of child diabetes in 10 year olds among those on school food program and those not on the program.

4. Epidemiological study: These studies observe subjects over a lengthy time frame to establish the likelihood or risk of developing a particular disease.

They may include prospective studies on a population or retrospective database searches.

5. Uncontrolled study: These sources are also used in evidence-based practice in nursing and healthcare.    

They do not in any way control interventions or participant selection and may usually use convenience sampling.

6. Qualitative or quantitative study: A qualitative study would entail a descriptive approach that is word-based such as behaviors, symptoms, and group dynamics and culture.

Differently, a quantitative study would use statistical approaches to establish numerical relationships.

3. LEVEL C

 This is also among the categories of sources of evidence-based practice in nursing.

Sources under this category include:

1. Meta-synthesis: This entails a systematic review synthesizing qualitative studies’ findings through an interpretive technique aimed at adopting small study findings like case studies into clinical application.

2. Consensus viewpoint and expert opinion: Consensus viewpoint entails a study with an agreement among clinical experts in a review panel on particular practices.

Expert opinion on the other hand encompasses agreement among a review panel’s majority clinical experts.   

4. LEVEL ML

Evidence based practice nursing examples under this category include recommendations based on evidence and clinical practice guidelines.

These examples should be obtained from above one evidence level as defined by the rating system.

Evidence Based Practice Nursing Examples

As earlier observed, the importance of evidence-based practice nursing approach can be examined from the arising benefits.

These benefits can be illustrated through various evidence based practice nursing examples in care delivery.

Accordingly, evidence based practice nursing examples can be on an array of areas.

That noted, a good example of evidence based practice in nursing could be as discussed below.

Alarm Fatigue

Alarm fatigue has been cited as one of the major care area where benefits of evidence-based practice in nursing can easily be demonstrated.   

Alarm Fatigue among Nurses

It has been observed that there are numerous alarm sounds in a nurse’s care environment. The numerous alarms can make nurses become desensitized to sound.

In this, nurse care environment is characterized by alarms from infusion pumps, beds, ventilators, cardiac monitors, etc.

Nonetheless, despite the importance of such alarms, 72-99% of the alarms are not related to an emergency.

Patient deaths have however resulted from alarm fatigue, e.g. the Boston case-alarm volume had been turned off.  

Turning off the alarm was associated with alarm fatigue.

Evidence-Based Practice on Alarm Fatigue

Healthcare facilities should bring together teams to conduct a study on alarm fatigue.

Such a study could be guided by the below questions:

1. What are the different alarm types relied on by nurses and in what areas?

2. What different alarm levels exist (low, medium, or high)?

3. What are the frequencies of these alarms?

4. What process do nurses take to respond to alarms?

5. What are the obstructions to response to alarms?

The information gathered using the above questions could be used to generate protocols that ensure effective patient monitoring.

For instance, evidence-based practice in nursing and healthcare indicate that some of the strategies from such a study that could be adopted to address alarm fatigue may include:

1. Daily change of electrodes: Quality improvement projects have adduced evidence indicating that daily ECG electrodes change can help avoid unnecessary alarms.

2. Adequately prepare the skin for electrode placement: Proper skin cleaning before placement of an electrode can help reduce impedance, decrease signal noise, and improve conductivity.

Using water and soap to clean the skin and excessive hair clipping can lessen artifact and improve skin-electrode interface.

3. Alarm customization to suit patient needs: Alarms reduction can be realized by customizing alarm ranges for specific patient needs. 

Besides alarm fatigue, there are other areas where evidence-based practice in nursing and healthcare is applicable.

On this, other areas to explore for evidence based practice nursing examples may include:

1. Infection Control

2. Noninvasive Blood Pressure Measurement in Children

3. Oxygen Use in COPD Patients

4. Intravenous Catheter Size and Blood Administration

5. Catheter-associated UTIs

6. Bloodstream infections that are central line-associated

7. Ventilator-associated pneumonia

8. Early mobilization of patients who have been hospitalized

9. ICU-acquired delirium prevention

10. Prevention of venous thromboembolism  

Evidence Based Practice (EBP) in Nursing

EBP PICOT question affecting ICU nurses