Most chief nurse executives think evidence-based practice improves quality outcomes. Yet, its implementation in hospitals is relatively low.
As nursing leaders, graduates of Doctor of Nursing Practice (DNP) programs have an extraordinary opportunity to change lives through evidence-based practice.
This blog will explore its evolution and benefits. You will also learn how earning a DNP will prepare you to foster evidence-based practice in nursing practice, education and administration.
What Is Evidence-Based Practice?
Evidence-based practice is a method for making clinical treatment decisions. It combines provider expertise with clinical research and patient preferences.
According to the American Association of Nurse Practitioners (AANP), the process involves using the “best evidence to make the best clinical decisions to achieve the best clinical outcomes.”
From emergency rooms to primary care clinics, evidence-based practice benefits patients wherever they receive treatment.
What Is the History of Evidence-Based Practice?
According to the Journal of Professional Nurses, Florence Nightingale pioneered evidence-based practice in the 19th century.
Nightingale led a group of nurses in caring for sick and wounded soldiers during the Crimean War. The hospitals were in dire condition when they arrived on the frontlines. As a result, the death toll was enormous.
Nightingale relied on the new discipline of mathematical statistics to prove that increased cleanliness would save lives. After enacting measures such as handwashing and ventilation, Nightingale drastically improved patient outcomes.
Nightingale’s method of integrating nursing, scientific research and patient advocacy is an early model of evidence-based practice.
How Has Evidence-Based Practice Evolved?
Since Nightingale’s time, health care experts have identified strategies for delivering evidence-based practice that benefit patients and providers alike.
In 2004, Bernadette Mazurek Melnyk, PhD, and Ellen Fineout-Overholt, PhD, published “Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice.” The book introduced a now frequently cited model for implementing evidence-based practice.
The model has seven steps (numbered zero to six) that leads to improved health care and patient outcomes.
This section will explore each step so that you can see how the delivery of evidence-based practice has become formalized.
Step 0: Cultivate a Spirit of Inquiry
According to the model authors, the implementation of evidence-based practice will likely fail without a culture that supports it. That is why cultivating a spirit of inquiry is called “Step 0.”
They say health care providers need intrinsic and extrinsic motivators to adopt evidence-based practice.
- The spirit of inquiry
- A belief in the value of evidence-based practice
- The knowledge and skills to implement it
To promote the above traits, health care organizations must provide support, tools and resources. This is key to cultivating a spirit of inquiry.
Step 1: Ask a Clinical Question
Evidence-based practice starts with a question. Nurses formulate an inquiry with five components.
They are collectively known as PICOT:
- Patient population of interest
- Intervention or area of interest
- Comparison intervention or group
What does a PICOT question look like? Here is an example from an investigation published in the American Nurse Journal:
“In adult coronary care unit patients who experience runs of tachycardia with a wide QRS complex (P), will use of lead V1 (I) compared to lead II as a standard for all patients (C) result in more effective differentiation of ventricular tachycardia from supraventricular tachycardia with aberrancy (O)?”
Step 2: Search for the Best Evidence
Now, it is time to find the best evidence to answer the question.
According to the Agency for Healthcare Research and Quality (AHRQ), evidence-based practice derives from four types of research:
- Laboratory experiments
- Clinical trials
- Epidemiological research
- Outcomes research, such as case reports
Today, most of this research is accessible online. Nurses search databases for the best evidence, relying heavily on literature published in peer-reviewed scholarly journals.
Using the PICOT framework for questions ensures that searchable databases return relevant articles. Each component of the question acts as a keyword. When combined, they streamline the search results.
AHRQ points to clinical guidelines as another source of evidence. Health care organizations develop clinical guidelines based on the best available evidence or expert recommendations.
Step 3: Critically Appraise the Evidence
The third step of the model is to review the evidence.
An appraisal does not have to be time-consuming. The model suggests asking three questions to evaluate a piece of evidence quickly:
- Are the results valid? — Determine whether researchers used the appropriate methods to reduce the risk of bias.
- What are the results and why are they important? — Determine the efficacy of the intervention and the likelihood of achieving similar results in clinical practice.
- Will the results help me care for my patients? — Determine the similarity between the study subjects and the patients, benefits and risks of applying the evidence to practice, feasibility and cost-effectiveness and patient values and preferences.
Together, the answers will determine whether the evidence is relevant, valid, reliable and applicable.
Once a provider has chosen the best evidence, they should synthesize it. The goal is to decide whether the evidence conclusions are similar enough to justify an evidence-based decision about the patient care problem.
Step 4: Integrate the Evidence
Remember that evidence-based practice has three components: provider expertise, clinical research and patient preferences. In this step, the provider considers all three to decide on a treatment plan. The model authors say there is no “magic formula” for how to weigh the components.
Often an interdisciplinary team collaborates with the patient to decide on a plan of action based on the evidence.
Institutional and clinical variables also drive the decision-making. For example, a hospital’s budget constraints may prevent clinicians from offering a particular evidence-based intervention.
Step 5: Evaluate the Outcomes
What happens after a provider implements an evidence-based decision? The model calls for evaluating the outcome.
This step is crucial. The model authors say it allows the clinician to discover how the intervention impacted the population. Clinicians also use evaluation to determine whether the intervention produced the same results as the evidence. Either way, the conclusion is important.
Clinicians use the outcomes of evidence-based practice to:
- Bolster the positive effects of the intervention or help fix negative ones.
- Identify flaws in the intervention’s implementation.
- Determine which patients may experience the greatest benefits from the intervention.
- Why results of the intervention differ from those reported in the evidence.
Step 6: Disseminate the Results
The final step in the model is to share the outcome.
Disseminating the results has two goals. First, it saves other providers from duplicating efforts. It also prevents them from continuing to use interventions that are not evidence-based.
There are many ways to share results. The model authors suggest:
- Evidence-based practice rounds in the health care organization
- Presentations at conferences
- Reports in peer-reviewed journals
- Professional newsletters
- Publications for general audiences
What Are the Benefits of Evidence-Based Practice?
According to the AANP, the broad use of evidence-based practice can optimize the U.S. health care system. That is because the practice benefits patients outcomes, health care expenditure and nurses.
The following sections explore precisely how.
How Does Evidence-Based Practice Benefit Patients?
Evidence-based practice benefits patients in numerous ways. Researchers say that patients treated under evidence-based practice have 28% better outcomes than those who are not.
Let’s explore examples of how evidence-based practice leads to improved patient outcomes.
Evidence-based practice improves patient outcomes by enhancing safety.
One example comes from New York. The state’s largest health care system implemented an evidence-based AHRQ program aimed at improving communication and teamwork skills among health care providers.
The system credits the program for enhancing its culture around patient safety. It reported a 60% reduction in one type of health care-associated infection (HAI) and a 50% drop in another.
Health Care Utilization
Evidence-based practice can decrease health care utilization through quality improvement.
The Wisconsin Hospital Association implemented in over 100 hospitals an evidence-based program to improve the quality of discharge processes. The program consists of 12 actions that a hospital takes during and after a hospital stay to “ensure a smooth and effective transition at discharge.”
The program prevented 30-day readmissions for over 3,500 patients in 18 months. That is a reduction of 22%.
In California, three health care networks reduced utilization through a quality improvement initiative. One approach focused on growing evidence-based practice. The networks disseminated clinical guidelines, built clinical guidelines into providers’ electronic medical records systems and established new decision support tools and standard order sets.
As a result, the networks prevented a total of 67,000 emergency room visits over four years.
Research also shows that evidence-based practice is linked to lower mortality.
In a study of over 625,000 U.S. patients with traumatic rib fractures, reduced mortality was associated with three evidence-based practices: surgical rib fixation, plus neuraxial blockade and intensive care unit admission for patients age 65 years and over with three or more rib fractures.
A 2016 study looked at evidence-based care implementation among pre-term infants in 11 European countries. It found that the combined use of four evidence-based practices was associated with lower in-hospital mortality.
The evidence-based practices were:
- Delivery in a maternity unit with neonatal care
- Administration of antenatal corticosteroids
- Prevention of hypothermia
- Use of surfactant within two hours of birth or early nasal continuous positive airway pressure
How Does Evidence-Based Practice Benefit Health Care Expenditure?
Evidence-based practice reduces health care costs through improved quality, safety and outcomes. Improvements, such as shorter hospital stays and fewer HAIs, lower the cost of providing care.
There are many examples of evidence-based practice generating cost savings.
The Wisconsin and California initiatives mentioned above created savings of $45.6 and $345 million, respectively. In Wisconsin, that amount included $34.1 million on hospital readmissions and $10 million on HAI treatment.
In another instance, the U.S. Oncology Network achieved cost savings through an evidence-based clinical pathways program for Medicare patients. The network saved more than $3 million over three years, thanks to:
- Lower medication costs
- Fewer inpatient stays
- Decreased emergency room visits
Nationwide, AHRQ credits evidence-based safety initiatives for $19.8 billion in hospital savings between 2010 and 2014. HAIs decreased by 2.1 million, leading to a 775% increase in annual savings from 2011 to 2014.
Evidence-based practice can lower health care spending, but savings are not guaranteed. When evidence-based practice does not create savings, the Healthcare Financial Management Association says the practice can still achieve critical outcomes that help organizations fulfill their missions.
How Are DNP Graduates Prepared to Implement Evidence-Based Practice?
Despite the many benefits of evidence-based practice, there are barriers to implementation. Health care providers often point to:
- A lack of evidence-based practice knowledge and skills
- Insufficient evidence-based practice mentors who can guide delivery
- Inadequate resources and support from organizational leaders
The good news is that these barriers can be remedied. A recent study of practicing nurses in the U.S. showed positive associations between evidence-based practice competency and evidence-based practice knowledge, mentorship and organizational culture.
Health care organizations need leaders with expertise in these areas to drive the implementation of evidence-based practice. Data suggests that among nurses, DNP graduates lead the charge.
Compared with nurse practitioners (NPs) educated at the master’s level, those with a DNP have a greater self-perceived ability to practice evidence-based practice. That is because DNP graduates have more advanced education in evidence-based practice and quality improvement.
But what makes DNP graduates so confident in their ability to provide evidence-based practice?
The DNP curricula equip graduates with the highest nursing knowledge, advanced leadership skills and a strategic mindset. These competencies enable them to facilitate evidence-based practice as clinical experts, mentors and organizational leaders.
DNP graduates are clinical experts who are uniquely positioned to implement evidence-based practice. That is because DNP programs build proficiency in each of the three components:
- Clinical Knowledge: The DNP is the highest level of academic preparation for clinical nursing practice. Graduates understand how to integrate the natural and social sciences to identify patient problems, develop evidence-based interventions and evaluate the outcomes.
- Clinical Research: DNP graduates are qualified to translate, apply and evaluate new science. They also know how to produce evidence that can be used to shape quality and outcome improvements.
- Patient-Centered Care: Patient-centered care is central to nursing education programs, including at the doctoral level. DNP coursework focuses on building competencies that promote patient safety and quality outcomes.
The DNP curricula build leadership skills that enable graduates to serve as guides and mentors in the workplace. Candidates learn advanced communication skills and processes to lead quality improvement initiatives, such as evidence-based practice.
They also explore effective collaboration. As graduates, they work with colleagues at every level to develop and implement practice models and guidelines.
DNP graduates also gain a strategic mindset. As health care leaders, they foster a culture of continuous improvement and facilitate organizational changes in practice delivery.
The DNP program of study emphasizes ongoing improvement based on scientific findings. It also covers health care policy and advocacy so that graduates can shape health care delivery and outcomes at the local, regional and national levels.
DNP Graduate Roles
DNP programs prepare graduates for leadership roles in clinical practice, education and administration. Here is how DNP graduates can advance evidence-based practice in three of the top nursing positions.
Many DNP graduates who complete advanced practice nursing coursework become NPs. NPs can use their clinical knowledge to implement evidence-based practice in clinical settings as independent clinicians and team leaders.
They can also advance evidence-based practice by guiding fellow nurses in how to deliver it and promoting its value on interprofessional teams.
DNP graduates who work as nurse educators have the vital role of educating the next generation of nurses on evidence-based practice.
Nurse educators deliver evidence-based instruction and serve as student mentors and advisors. They also foster creativity and innovation. Each of these responsibilities is vital to expanding evidence-based practice.
DNP graduates also become nurse administrators. In this role, they lead, plan and coordinate nursing and health care.
Nurse administrators can utilize evidence-based practice to ensure the organization is delivering the best care to ensure quality patient outcomes. They can also drive adoption by guiding the delivery of evidence-based practice and building a culture that values it.
Prepare to Make a Positive Impact in Health Care
Earning an online DNP from Walsh University will equip you with the highest competency in nursing. As a graduate, you will be prepared to improve quality and outcomes on a larger scale.
Walsh University’s accredited programs are nationally recognized by U.S. News & World Report for their value and academic excellence. The University offers DNP programs for BSN or MSN entry:
- Doctor of Nursing Practice - Family Nurse Practitioner (BSN entry)
- Doctor of Nursing Practice - Nurse Educator (BSN entry)
- Doctor of Nursing Practice - Psychiatric Mental Health Nurse Practitioner (BSN entry)
- Doctor of Nursing Practice (MSN entry)
The curricula will help you develop leadership and advocacy skills and expertise in organizational and health systems. You will also build your critical thinking abilities. As a result, you will be ready to drive quality improvement within your organization.
The programs are designed with working nurses in mind. Many students continue working and benefit from the program’s convenience and dedicated support.
Walsh University offers:
- Assistance finding a preceptor and sites for advanced practice direct patient care clinical placements.
- Small class sizes that encourage connection with peers and an engaged faculty of experienced nurses.
- Proactive support and one-on-one coaching to help you succeed.
- A flexible online format that allows you to continue working while earning your degree.
Read more of Walsh online's top DNP blogs below: