Evidence-based practice for the busy nurse practitioner: Part one: Relevance to clinical practice and clinical inquiry process

Transcription

1 SPECIAL ARTICLE Evidence-based practice for the busy nurse practitioner: Part one: Relevance to clinical practice and clinical inquiry process Lynda Facchiano, DNP, FNP-BC (Nurse Practitioner) & Charlene Hoffman Snyder, DNP, FNP-BC (Nurse Practitioner) Mayo Clinic Arizona, Scottsdale, Arizona Keywords Evidence-based practice; evidence-based medicine; EBP steps; practitioner. Correspondence Lynda Facchiano, DNP, FNP-BC, Mayo Clinic Arizona, E. Shea Blvd., Scottsdale, AZ Tel: ; Fax: ; Received: October 2011; accepted: April 2012 doi: /j x Abstract Purpose: Evidence-based practice (EBP) continues to gain momentum within health care. The purpose of this four-part EBP series is to provide an introductory overview of the EBP process, emphasizing EBP steps one through three, in order to assist nurse practitioners (NPs) in building EBP skills that can be integrated into clinical practice. The relevance of EBP to the NP s clinical practice, an introduction to the EBP process steps, and clinical inquiry process begin the series. Data sources: Scientific literature review, gray literature, and online evidence-based practice databases and resources. Conclusions: EBP has become increasingly important to NPs, yet there is evidence suggesting it is not being fully implemented in clinical practice. EBP is one way to keep the busy NP s knowledge up to date, enhance clinical judgment, and augment the existing provider client decision-making process. Implications for practice: The principles of EBP have become the cornerstone strategy for NPs to translate research findings into clinical practice. Practicing in an ever-changing healthcare environment, NPs have a responsibility to provide their clients with the best available evidence, while incorporating that evidence into the provider client decision-making process. In 1970, the Institute of Medicine (IOM) was created as an independent, nongovernmental, nonprofit organization to provide unbiased and authoritative advice to decision makers and the public. In 2001, the IOM called for all healthcare professionals to deliver patient-centered care as part of an interdisciplinary team that emphasizes evidence-based practice (EBP), quality improvement (QI) approaches, and informatics (Institute of Medicine [IOM], 2001). The EBP momentum was fueled when it became evident that practices rooted in tradition were often outdated, and research findings were frequently not integrated into practice (Melnyk, Fineout-Overholt, Stillwell, & Williamson, 2010). In 2008, the IOM indicated that unbiased, reliable information in health care is essential in addressing several persistent health policy changes, including: containing healthcare costs, reducing geographic variation in the use of healthcare services, improving quality, consumer-directed health care; and making health coverage decisions (IOM, 2008). EBP has grown so much over the last 15 years that it now reaches beyond health care into other industries (such as business and education). While informatics has provided the nurse practitioner (NP) access to huge stores of scientific evidence, implementation of EBP is still not the norm in the United States healthcare system (Stiffler & Cullen, 2010). EBP has continued to grow in importance in nursing education and is one of the core competences found in doctor of nursing practice (DNP) programs (Stiffler & Cullen, 2010). The principles of EBP have become the cornerstone strategy for NPs to translate research findings into clinical practice. A survey of 90 Tennessee NPs assessed NP s beliefs, attitudes, and implementation of evidence-based nursing practice (Butler, 2011). Participants reported positive beliefs and attitudes toward EBP. However, implementation of EBP by the NP was not consistent with reported positive beliefs and attitudes (Butler, 2011). The conclusion drawn Journal of the American Academy of Nurse Practitioners 24 (2012) C 2012 The Author(s) Journal compilation C 2012 American Academy of Nurse Practitioners 579

2 Evidence-based practice for the busy NP: Part one L. Facchiano & C. H. Snyder is the need for EBP continuing education programs to expand NP EBP skills remains. Building on that spirit of educational inquiry, a four-part series on the first three steps of EBP was developed to provide an introduction to NPs that were not trained in EBP, and as a review for those who were trained and may not have implemented the process into their clinical practice. Part one of this series explores the history of EBP, its importance to NPs, key steps in the EBP process, and development of a clinical guiding question. Part two will focus on search strategies, part three on the critical appraisal process, and part four uses a reproducible example to walk the reader through the EBP process steps. Background and significance EBP has been evolving for several years. The philosophical basis of evidence-based medicine dates back to the mid-19th century in Paris; but not until 1972 did the EBP movement begin to get recognition. In 1972, British physician Dr. Archie Cochrane criticized the healthcare profession for not providing systematic reviews of existing evidence, which showed that thousands of premature infant deaths could have been prevented by administering corticosteroids to women during premature labor (The Cochrane Collection, 2008). However, EBP did not gain significant momentum until the early 1990s when Dr. David Sackett recommended it be used in medicine (Melnyk et al., 2010). EBP has continued to be refined with more emphasis now placed on how the evidence can be applied to individual patients. Melnyk and Fineout- Overholt (2005) defined EBP as a problem solving approach for clinical practice that integrates the conscientious use of best evidence (internal & external) in combination with a clinician s expertise as well as patient preferences and values to make decisions about the type of care that is provided (p. 6). There are several definitions of the interchangeable terms evidence-based medicine or evidence-based practice. The most widely accepted definition is by Sackett, Rosenberg, Gray Haynes, and Richardson (1996) who defined evidence-based medicine as the conscientious, judicious, and explicit use of current best evidence in making decisions about the care of the individual patients (p. 71). The fundamental key to the process is using the best evidential findings on populations to inform decisions about individuals. Within healthcare organizations and among NPs and nursing educators, there occasionally appears to be confusion regarding research, QI, and EBP. The role of research is to create scientific knowledge that can be generalized to similar clients, populations, and clinical settings (Beyea & Slatterly, 2008; Kring, 2008; Polit & Beck, 2008). EBP does not conduct new research; rather it utilizes the clinical findings from previous research and applies it to individual patients (Malloch & Porter O Grady, 2010). Evaluation of the applied evidence to one s patient or practice is an important step in the EBP process, but it is not considered research. EBP is not a utilization of research from a single study, but an evaluation of findings from multiple studies (Malloch & Porter O Grady, 2010). QI refers to individuals or groups of individuals, working to improve systems in an attempt to improve overall outcomes (Newhouse, 2007). QI addresses an organization s experiences through the generation of descriptive data unique to that organization. Dissemination of results from a QI project is limited to lessons learned rather, than the generalizablity of a research study. Research and EBP inform QI. The use of the EBP process can often identify gaps of knowledge and areas needing additional research, which can serve to generate new research studies (Melnyk et al., 2010). While similarities exist and overlap, research, EBP, and QI are different tools with distinct roles within health care. Why is EBP important to the busy NP? To understand the importance of EBP to NPs clinical practice, a brief review of how clinical knowledge is acquired and NPs professional role development is reviewed. The NP profession began in the United States in the mid-1960s in response to a physician shortage. Historically, initial decision making of the NP was limited, relying on preapproved symptom or disease-based algorithms or the personal expertise of supervising physicians (Christian, Dower, & O Neil, 2007). The professional role of the NP has evolved into clinical independence requiring increased decision-making skills for diagnosis, testing, and treatment. While the scopes of practice, supervision, and/or collaborative requirements vary from state to state, all NPs must be able to find evidence to answer clinical inquiries and interpret data. Thus, keeping up with the latest advances has become a daunting task. The inadequacies of traditional sources of information such as textbooks, experts, didactic continuing education, or the overwhelming number of clinical journals has been well-documented (Straus, Glasizou, Richardson, & Haynes, 2011). How one acquires knowledge to make decisions is often thought to determine the quality of the clinician (IOM, 2008; Straus et al., 2011). In estimating the number of articles an NP would need to read to stay up to date, it has been suggested that a family or internal medicine physician would have to read 19 articles a day every day of the year in order to stay current on the latest advancements (Straus et al., 2011). However, because of the busy schedules of healthcare providers, only 580

3 L. Facchiano & C. H. Snyder Evidence-based practice for the busy NP: Part one 1 or 2 h a week may be available to devote to reading professional journals. The creation of information systems that allow for more efficient database searches and publication of preappraised evidence has made the finding and utilization of evidence much more accessible. Nevertheless, studies show the availability of evidence does not always change practice (Butler, 2011; Davidoff et al., 1995; Straus et al., 2011). There is danger in anchoring clinical decisions to just one s own clinical experiences. Instead, basing clinical decisions on the collective experience of a much larger population would be much more beneficial (Straus et al., 2011). A welldesigned clinical trial will yield greater information on expected treatment outcomes and adverse events than what is learned from limited anecdotal cases (Straus et al., 2011). NPs often take pride in knowing the latest cutting edge study results in press. With the existence of the Internet, web updates are readily available and supported by some NP organizations. Using this approach to inform clinical knowledge runs the risk of not knowing the origin of such results, the characteristics of the population studied, disease severity, and the spectrum of adverse events (Greenhalgh, 2010). It is not uncommon for many NPs to rely on published clinical guidelines from the numerous clinical specialty organizations to guide clinical decisions. Unfortunately, closer scrutiny shows some of these guidelines were developed by a weekend of work by good old boys (experts) sitting around a table developing clinical management guides. This has been coined as decision making by GOBST (Greenhalgh, 2010). The danger in expert opinion guidelines is that they are based on lifelong anecdotal clinical experiences rather than evidence from high-level clinical trials. Using EBP appraisal skills improves the NP s ability to determine trustworthy guidelines and the application of the guideline to clinical practice. One of the first ways that EBP impacted the healthcare profession is through the development of meta-analysis studies. Another was the application and dissemination of clinical practice guidelines that are based on evidence from rigorous systematic reviews and synthesis of published medical literature (Newhouse, 2010). Many critics of EBP fear that this practice will replace clinical experiences. As EBP has grown, its proponents have made it clear that the values and preferences of patients is an important knowledge source to the applicability of any evidence, and these must supplement each other (Guyatt, Drummond, Meade, & Cook, 2008; Melnyk et al., 2010; Straus et al., 2011). Honing evidence-based skills allows the NP to separate irrelevant and relevant studies by assessing the studies validity and relevance. When reading research articles important questions to ask are: What do the research findings mean to me, my clients, and the population of clients I care for? Can I identify a research article that is weak, poorly done, poorly analyzed, or all three? When reviewing clinical practice guidelines one must ask: Is the guideline applicable to my client(s) in the way the guidelines have been written? When working with multiprofessional colleagues one must not be afraid to challenge them. For example, if a peer recommends a drug be prescribed at a certain dose, question if that dose or drug is appropriate for the client or population being cared for. Many NPs fear that EBP focuses on statistics, something that can cause anxiety and negative reactions toward EBP. While EBP does not require the NP to be a statistician, it does require some use of mathematics to estimate items such as: risk of benefit and harm of interventions, determining effect size, and confidence intervals (Straus et al., 2011). The recent study by Butler (2011) on NP attitudes and beliefs about implementing EBP found a majority of respondents identified a lack of knowledge on how to measure clinical outcomes. Many believed it was too difficult (Butler, 2011). As with most skills, learning clinical measures that are most relevant to clinical practice (absolute risk ratio, number needed to treat/harm) is achievable and well worth the effort and practice. EBP is a strategy to keep knowledge up to date, enhance clinical judgment, and lead to cost-effective treatment modalities. The conclusion is that practice based on what was always done is no longer acceptable. Furthermore, EBP enables us to present accurate evidence to clients, while further involving clients and families in the clinical decision-making process. The EBP process If the central feature of EBP is finding the best evidence to guide a clinical decision for an individual patient, it is helpful to have a clear understanding of how trusted the information is based on study design. Study designs are rated according to level or strength of evidence. The terms levels of evidence or strength of evidence refer to systems for classifying evidence in a body of literature through a hierarchy of scientific rigor and quality. A hierarchy guideline of study designs methodologies, often described as an evidencebased pyramid, has emerged in the EBP literature. Several variations of the pyramid hierarchy, have been used with the strongest level of evidence referred to as Level I and the weaker evidence as Level VI (see Table 1; The Cochrane Collection, 2008; Melnyk & Fineout- Overholt, 2011; Newhouse, 2007; Newhouse, Dearholt, Poe, Pugh, & White, 2007; Sackett, Strauss, Richardson, 581

4 Evidence-based practice for the busy NP: Part one L. Facchiano & C. H. Snyder Table 1 Hierarchy of evidence Level Study design Design definition Level I Level II Level III Level IV Strongest level of evidence if based on SR or MA of RCTs; evidence-based CPGs based on a SR Strength comes from a well-designed RCTs Well-designed controlled trials without randomization Well-designed case controlled and cohort studies; CPGs Systematic reviews (SRs) usually focus on a clinical topic and answer a specific question. An extensive literature search is conducted, which allows the reviewer to identify studies with sound methodology. Studies are reviewed, assessed, and results summarized according to predetermined criteria of a review question. Meta-analysis (MA) thoroughly examines a number of valid studies on a topic and combines results using accepted statistical methodology to report the results, as if it were one large study. Clinical practice guidelines (CPGs) are statements containing recommendations based on evidence from systematic review and synthesis of published medical literature that help NPs make appropriate decisions about health care. Randomized Control Trial (RCT) is a planned study that introduces a treatment to study its effect on real patients. The researchers use methodologies that reduce the potential for bias (randomization and blinding) and that allow for comparison between intervention groups and control groups (no intervention). The lack of randomization weakens the strength of findings because of the possibility of not being able to predict the same outcome in another group of patients. Case control studies are retrospective studies in which patients have a specific condition and are compared to individuals who do not have the condition. Because the researcher often relies on medical records and/or patient recall for data collection, these types of studies are less reliable than RCTs and cohort studies. Even if the researcher can show a statistical relationship, it is very difficult to determine if one factor caused the other. Cohort studies involves two groups (cohort) of patients where one group will have a certain condition and/or receive a particular treatment then followed over time and compared with another group who are not affected by the condition under investigation or did not receive a treatment. Cohort examples: individuals born between 1950 and 1955; all individuals with chronic obstructive pulmonary disease; all master s-prepared NPs; or all ICU nurses employed from 2005 to Level V Single descriptive or qualitative studies Case report is a collection of information on a single patient that may include treatment of a single patient. Case series are a collection of several case reports, usually five or greater. Because case reports do not include control groups to compare outcomes, little statistical validity exists. Case controlled studies Level VI Weakest level of evidence if based on opinions of authorities or expert committees Expert opinions include clinical experiences, expertise, and judgments that may come from a variety of sources. Expert committees, such as The Agency for Healthcare Research and Quality provide outcome research and The National Clearinghouse provides CPGs. Note. CPG, clinical practice guidelines; EBP, evidence-based practice; MA, meta-analysis; RCT, randomized control trial; SR, systematic review. Data from The Cochrane Collection (2008), Melnyk and Fineout-Overholt (2011), Newhouse (2007), Newhouse et al. (2007), Sackett et al. (2000), Strauss et al. (2011). Rosenberg, & Haynes, 2000; Straus et al., 2011). Levels of evidence are important to the NP as higher levels of evidence reflect stronger evidence. Stronger evidence leads to clinical decisions being made with confidence that is more reliable and precise (trustworthy). Level I, or strongest evidence, is study designs from systematic reviews or meta-analyses of all relevant randomized control trials (RCTs). Level II is evidence obtained from a well-designed RCT that introduces a treatment in order to study effects on treated patients compared with 582

5 L. Facchiano & C. H. Snyder Evidence-based practice for the busy NP: Part one patients not receiving the treatment or intervention. Level III is evidence obtained from well-designed controlled trials without randomization. Level IV is evidence from well-designed case-controlled and cohort studies. Level V is evidence from single descriptive or qualitative studies. Level VI is evidence from the opinion of authorities and/or reports of expert committees. NPs frequently access and reference clinical practice guidelines for utilization within their clinical practices. Clinical practice guidelines are considered summarized research reviews based on a variety of strength and quality of evidence. Clinical practice guidelines therefore would be considered Level I or VI research depending on the strength of the studies cited (Melnyk & Fineout- Overholt, 2011; Newhouse et al., 2007). If the guidelines are based on systematic reviews, then the quality and strength of the resultant guideline would allow consideration as Level I evidence. If case-controlled studies are used as the basis of the guideline, a Level IV would be assigned. Guidelines based solely on expert opinion may introduce error and/or bias. It is important to remember that the highest level of study design may not always be available to answer the clinical question. In the absence of top levels of evidence, one must move down the pyramid to find the best available evidence to answer the question being considered. EBP steps The process of EBP described in the medical literature is composed of five steps (Sackett et al., 1996; Straus et al., 2011). In the nursing literature the steps are similar, but an additional step for dissemination was added (Melnyk & Fineout-Overholt, 2011): 1 Ask a clinical guiding question. 2 Search for the best evidence. 3 Critically appraise the evidence. 4 Integrate the evidence with one s clinical expertise and client preferences to make the best clinical decision. 5 Evaluate the outcome(s) of the EBP practice decision or change based on evidence of the EBP decision or change. 6 Disseminate the outcome. EBP step 1: Formulating a clinical guiding question Each day many clinical questions are raised regarding clients health concerns, new treatment or diagnostic modalities, new or alternative procedures, and preventative health issues. Before searching the literature to answer these questions, it is imperative to formulate a wellwritten clinical guiding question. A well-written, refined, clinical question has four or five components and is organized in a format known as PICO (T). There are several templates available online, in books, and journal articles to assist the reader with writing a clinical guiding question in this format (see Table 2; Melnyk & Fineout- Overholt, 2011; Straus et al., 2011). The P stands for patient, population, or problem of interest (consider age, gender, clinical setting, client symptoms); I for intervention or prognostic factor being considered; C for comparison or intervention (not all questions will have a comparison or the comparison may not be easily identified or apparent); O for outcome measured (may include improved treatment outcomes, decreased adverse event, decreasedcost,orimprovedqualityoflife);andtfortime period. Newhouse and colleagues (2007) suggest that the PICO (T) format utilizes familiar nursing critical thinking standards, clarity, precision, logic, and relevance. A poorly built question may be too broad and difficult to manage resulting in squandered search time. Thus, learning to write a well-formulated question can facilitate a more efficient literature search. This clinical question allows filters to be used in the search process, and assist with finding desired evidence in a timely fashion. In addition, the clinical guiding question can help to define inclusion and exclusion criteria and outcome(s) of interest. In other words, the more refined the clinical guiding question is, the fewer articles the NP will need to review. Terms used in the search question should be spelled out (e.g., computed tomography instead of CT), avoiding the use of jargon, and clearly defining the population (such as adults over 19 or 55), and limiting outcomes to one or two (Greenhalgh, 2010; Guyatt et al., 2008; Melnyk et al., 2010; Straus et al., 2011). Two other key components of the well-formulated question are type of question being asked and type of study design that will answer the clinical inquiry question. Type of question refers to the question being asked. For example, is the clinical inquiry question a diagnostic, prognostic, therapy, prevention, or harm type of question? Knowing the type of question being asked will help identify the study design best available to answer that question. Diagnostic questions focus on determining which test has the most power to differentiate between those with and without a specific disease or healthcare condition. Additionally, these studies will often address cost, feasibility, and availability of the diagnostic test (Melnyk & Fineout-Overholt, 2011). Study designs that may best answer a diagnostic clinical inquiry are prospective or clinical trial studies. Prognostic questions look at specific healthcare symptoms or characteristics that predict 583

6 Evidence-based practice for the busy NP: Part one L. Facchiano & C. H. Snyder Table 2 Online, book, and journal resources (some) Agency for Healthcare Research and Quality Center for Evidence-Based Medicine Centre for Evidence-Based Research Center for Evidence-based Medicine, Toronto Cochrane Library Duke University Medical Center Library Evidence-Based Medicine tool kit Mayo Nursing Evidence-Based Practice Melnyk, B. M., Fineout-Overholt, E., Stillwell, S., & Williamson K. M. (2010). Evidence-based practice: Step by step: The seven steps of evidence-based practice. Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare, a guide to best practice (2nd ed.). Office of Medical Education, Research & Development, College of Human Medicine Michigan State University Evidence-Based Medicine Course Straus, S. E., Glasizou, P., Richardson, W. S., & Haynes, R. B. (2011). Evidence-based medicine: How to practice and teach it (4th ed.). Edinburgh, London http// Article Book Book specific healthcare conditions or diseases. Cohort and case studies may best address prognostic clinical inquiries. Therapy questions focus on identifying the effect of interventions, such as medications and/or treatments, on clinically important outcomes (symptoms, function, morbidity, mortality, and cost). The study designs that may best answer these clinical inquiries include: RCTs, systematic reviews (SRs), cohort, and/or case series. Prevention questions focus on whether an intervention reduces risk of future problems. The study designs that may best answer prevention or harm clinical inquiries are: RCTs, case series, or cohort studies (Guyatt, Drummond, Meade, & Cook, 2008; Melnyk & Fineout-Overholt, 2011). Of the many study designs available, knowing which study design can answer a particular type of clinical question helps focus the literature search. The more focused the literature search, the easier it is to find the evidence being sought to answer the clinical inquiry. Learning to formulate well-built clinical questions written in PICO (T) format takes time, is considered the first step in the EBP process, and key to the critical thinking process required to translate evidence into practice (Melnyk & Fineout- Overholt, 2011; Straus, et al., 2011). Skill building The following scenarios are provided to help the reader practice writing well-formulated clinical guiding questions (PICO[T]). Additional scenarios can be found in Table 3. Searching for and appraising the evidence will be covered in parts two and three of this series. Scenario one: A 58-year-old male presents to the emergency department with sudden onset of shortness of breath and chest pain after a 12-h flight. Initial labs reveal an elevated D-dimer. What is the best test to use to detect a pulmonary embolism (PE)? The clinically guiding question could be written as follows: In adults over the age of 19 with suspected PE and elevated D-dimer (P) is a ventilation perfusion scan (I) compared to helical computed chest tomography (C) as effective in detecting an acute PE (O)? This is a diagnostic question; therefore the best study design to answer this question would be a prospective or RCT study. Scenario two: A 40-year-old obese female is hospitalized with acute pancreatitis. As an NP you wonder, does obesity predict acute pancreatitis and hospitalizations? The clinical question can be written as follows: In females over 19 and under age 50 (P) is a body mass index (BMI) < 29 (I) or BMI > 29 (C) a better predictor of acute pancreatitis (O)? This is a prognostic question, therefore the best study design would be a cohort or case series study. Scenario three: A 69 year-old male hospitalized with atrial fibrillation has had a poorly controlled international normalized ratio (INR) on warfarin. The NP wonders, would dabigatran etexilate be an alternative therapy? The clinical question could be written as follows: In adults over 65 years of age with atrial fibrillation (P) is warfarin (I) compared to dabigatran etexilate (C) more effective in reducing risk of embolic stroke (O) over 1 year (T)? This is a therapy question and the best study design to answer the question would be a RCT or a meta-analysis of several RCTs. 584

7 L. Facchiano & C. H. Snyder Evidence-based practice for the busy NP: Part one Table 3 Skill building Scenario PICO (T) Type of question Study design A 72-year-old Hispanic female, Arizona winter visitor, is being seen at a routine office visit for recent hospitalization of congestive heart failure (CHF), her third one this year. As her NP you wonder what other treatment modalities (e.g., telemedicine) may decrease readmissions, lead to better treatment compliance, and augment the existing provider client relationship. An 11-year-old sexually active girl is accompanied to her office visit by her 29-year-old mother who inquires about human papillomaviruses (HPV) infections and vaccinations for prevention of HPV infections. As her NP you are aware of two vaccines, Gardasil and Cervarix that have been FDA approved for prevention of cervical cancer and some HPV infections. You wonder which is more effective. While working in an urgent care late one night, a 2-year-old baby presents with a 3-day history of rhinorrhea, cough, sneezing, nasal congestion, and no fever. Her 19-year-old mother is requesting an antibiotic. As her NP you believe this is a viral nasopharyngitis, which does not require an antibiotic at this time and wish to discuss antibiotic use with the baby s mother. In adults hospitalized with congestive heart failure (P), does telemedicine (I) compared to standard of care (routine office visits) (C) decrease readmission to the hospital for congestive heart failure (O) over 1 year (T)? In adolescent females, age 10 17, who are sexually active (P), which vaccine, Gardasil vaccine (I) compared to Cervarix vaccine (C), is more effective in reducing and/or preventing HPV infections (O)? In children between the ages of 2 and 5 with upper respiratory infections (P), does the use of an antibiotic (I) compared to no antibiotic (C) shorten the duration of the upper respiratory infection or illness (O)? Prevention Prevention Therapy RCT, cohort, or case series study RCT, cohort, or case series study RCT or a meta-analysis of several RCTs MA, meta-analysis; PICO (T), patient/population, intervention, comparison, outcome, and time; RCT, randomized control trial; SR, systematic review. Take a few moments to reflect on the clients seen in your clinical practice the past week. Were any questions raised regarding a procedure, diagnosis, medication, or therapy? Practice your own clinically relevant scenarios and development of clinically guided questions written in PICO (T) format. Conclusion EBP continues to gain momentum within health care. As NPs practicing in a frequently changing healthcare environment, the responsibility to provide clients with the best available evidence exists, while incorporating that evidence into the provider client decision-making process. Having reviewed the history of EBP, its importance to NPs, the key steps in the EBP process, and the development of a clinical guiding question (PICO [T]), the reader has begun the clinical inquiry process. Part two of this series will focus on searching for the best evidence to answer the NP s clinical inquiries. References Beyea, S., & Slatterly, M. J. (2008). Evidence-based expert: Quality improvement vs. research: Are they the same? Staff Development Weekly: Insight on Evidence-Based Practice in Education, Retrieved from hcpro.com/nrs /Evidencebased-expert-Qualityimprovement-vs-research-Are-they-the-same.html Butler, K. D. (2011). Nurse practitioners and evidence-based nursing practice. Clinical Scholars Review, 4(1), Christian, S., Dower, C., & O Neil, E. (2007). Overview of nurse practitioner scopes of practice in the United States Discussion. The Center for the Health Professions. Retrieved from Discussion 2007.pdf Davidoff, F., Haynes, B., Sackett, D., & Smith, R. (1995). Evidence based medicine: A new journal to help doctors identify the information they need. British Medical Journal, 310, Greenhalgh, T. (2010). How to read a paper: The basics of evidence-based medicine (4th ed.). Oxford, UK: BMJ. 585

8 Evidence-based practice for the busy NP: Part one L. Facchiano & C. H. Snyder Guyatt, G., Drummond, R., Meade, M. O, & Cook, D. (2008). Users guides to the medical literature: A manual for evidence-based clinical practice (2nd ed.). New York, NY: McGraw Hill. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21 st century. Retrieved from 27/184/Chasm-8pager.pdf Institute of Medicine. (2008). Knowing what works in healthcare: A roadmap for the nation. Retrieved from What-Works-in-Health-Care-A-Roadmap-for-the-Nation.aspx Kring, D. L. (2008). Research and quality improvement: Different process, different evidence. Medsurg Nursing, 7(3), Malloch, K., & Porter O Grady, T. (2010). Introduction to evidence-based practice in nursing and health care (2nd ed.). Boston, MA: Jones and Bartlett Publishers. Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins. Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and healthcare, a guide to best practice (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Melnyk B. M., Fineout-Overholt, E., Stillwell, S., & Williamson K. M. (2010). Evidence-based practice: Step by step: The seven steps of evidence-based practice. American Journal of Nursing, 110(1), Newhouse, R. P. (2007). Diffusion, confusion among evidence-based practice, quality improvement, and research. Journal of Nursing Administration, 17(10), Newhouse, R. P. (2010). Clinical guidelines for nursing practice. Journal of Nursing Administration, 40(2), Newhouse, R. P., Dearholt, S. L, Poe, S.S., Pugh, L.C., & White, K. M. (2007). John Hopkins nursing evidence-based practice model & guidelines. Indianapolis, IN: Sigma Theta Tau International Honor Society of Nursing. Polit, D. F., & Beck, C. T. (2008). Nursing research: Generating and assessing evidence for nursing practice (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Sackett, D., Rosenberg, W., Gray, J., Haynes, R., & Richardson, W. (1996). Evidence-based medicine: What it is and what it isn t: It s about integrating individual clinical expertise and the best external evidence. British Medical Journal, 3(12), Sackett, D., Strauss, S. E, Richardson, W. S., Rosenberg, W., & Haynes, R. B. (2000). Evidence-based medicine: How to practice and teach EBM. New York, NY: Churchill Livingston. Stiffler, D., & Cullen, D. (2010). Evidence-based practice for nurse practitioner students: A teaching competency-based teaching framework. Journal of Professional Nursing, 26(5), Straus, S. E., Glasizou, P., Richardson, W. S., & Haynes, R. B. (2011). Evidence-based medicine: How to practice and teach it (4th ed.). Edinburgh, London: Churchill Livingstone Elsevier. The Cochrane Collection. (2008). The name behind the Cochrane Collaboration. The Cochrane Collaboration. Retrieved from http// 586