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Increased attention is being directed toward the development of methods that can provide valid and reliable information about what works best in healthcare. As a result, the careful scientific evaluation of clinical practice became a prominent focus during the second half of the 20th century. 1 Evidence-based practice encompasses implementing the best-known practices into the clinical setting using a scientific approach. It evolved from evidence-based medicine, which was developed in Canada to teach medical students. "Evidence-based medicine has been defined as the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients." 2,p. 3 The Agency for Healthcare Research and Quality (AHRQ) supports organizations in their efforts to improve the quality and efficiency of healthcare by facilitating the use of evidence-based research findings in clinical practice. 3
The nursing discipline has also embraced evidence-based practice over the past 25 years, initially through its support of "research utilization," the integration of research into nursing curricula, and the education of nurse scientists. Sigma Theta Tau International, the Honor Society of Nursing, considers evidence-based nursing "as an integration of the best evidence available, nursing expertise and the values and preferences of the individuals, families and communities who are served." 4 Clinical practice guidelines, evidence reports and clinical/critical pathways for practicing clinicians are central to evidence-based practice. 5 Rosswurm and Larrabee developed a model, derived from theoretical and research literature, that guides nurses through a systematic process for the change to evidence-based practice. The steps of the model are as follows:
1. Assess need for change in practice;
2. Link problem with interventions and outcomes;
3. Synthesize best evidence;
4. Design a change in practice;
5. Implement and evaluate the practice change;
6. Integrate and maintain the practice change. 6
Specific to palliative care, there is considerable work to be done in relation to evidence-based practice. According to Lipman, "evidence-based palliative care is more often the exception rather than the rule."2,p. 3 Evidence-based practice has the potential to improve the quality of care and enhance clinical judgment in life-limiting illness. Hospice and palliative nurses must know how to obtain, interpret, and integrate the best available research evidence with patient data and clinical observations. The employers that hospice and palliative care nurses work for also have an instrumental role to play in supporting evidence-based practice. Researchers from across healthcare disciplines must actively continue to expand the knowledge base about what constitutes quality of care for persons with life-limiting illnesses. Finally, the federal government, through the National Institutes of Health, must continue to fund research in end-of-life care.
The Hospice and Palliative Nurses Association (HPNA) supports the development and implementation of evidence-based nursing practice in hospice and palliative care.
* Hospice and palliative care nurses should actively engage in using evidence (eg, clinical practice guidelines, evidence reports and clinical/critical pathways) to guide the care they provide to persons, and their loved ones, at the end of life.
* Hospice and palliative care nurses should actively participate in the development of clinical practice guidelines as well as clinical/critical pathways.
* Nurse researchers, in collaboration with researchers from other disciplines, should actively engage in research to identify the elements, standards, and benchmarks of quality care for persons with life-limiting illnesses.
* Hospice and palliative care employers should assure that their organization has an "organizational capacity for change," 5 including the necessary infrastructure to support evidence-based practice.
* The National Institutes of Health, including but not limited to, the Agency for Healthcare Research and Quality, should continue to fund research in end-of-life care.
* Hospice and palliative care employers, as well as providers, must advocate for expanded federal funding for end-of-life care research.
* HPNA will continue to develop evidence-based educational materials that support hospice and palliative nurses to provide optimum care to persons, and their loved ones, at the end of life.
Clinical/Critical Pathways: "A clinical (critical) pathway directs the entire healthcare team in the daily care goals for select healthcare problems. It includes a nursing care plan, interventions specific for each day of hospitalization, and a documentation tool. The clinical pathway is part of a case management system that organizes and sequences the caregiving process at the patient level to better achieve quality and cost outcomes... The case types selected for clinical pathways are usually those that occur in high volume and are highly predictable."7, p. 13
Clinical Practice Guideline: "systematically developed statement designed to assist practitioner and patient make decisions about appropriate healthcare for specific clinical circumstances." 8
Evidence-Based Practice: Integration of best evidence with clinical experience and patient values. It involves obtaining research evidence and combining the evidence with clinical experiences, available resources, and patient preferences to determine the best care for the patient. 3
Research Utilization: "Broadly speaking, research utilization refers to the use of some aspect of a scientific investigation in an application unrelated to the original research. Current conceptualizations of research utilization recognize a continuum in terms of the specificity or diffuseness of the use to which knowledge is put. At one end of the continuum are discrete, clearly identifiable attempts to base some specific action on the results of research findings... However, there is a growing awareness that research can be utilized in a more diffuse manner-in a way that promotes cumulative awareness, understanding, or enlightenment... research utilization at all points along this continuum appears to be an appropriate goal for nurses." 9(p25-26)
1. Tunis SR, Stryer DB, Clancy CM. Practical clinical trials: increasing the value of clinical research for decision making in clinical and health policy. JAMA. 2003;290(12):1624-32. [Context Link]
2. Lipman AG. Evidenced-based palliative care. In: Lipman AG, Jackson KC, Tyler LS, eds. Evidenced Based Symptom Control in Palliative Care-Systematic Reviews and Validated Clinical Practice Guidelines for 15 Common Problems in Patients with Life Limiting Disease. Binghamton, NY: Haworth Press, Inc.; 2000:1-9. [Context Link]
3. Pape TM. Evidence-based nursing practice: to infinity and beyond. J Continuing Educ Nurs. 2003;34(4):154-61. [Context Link]
4. Sigma Theta Tau International. Position Statement on Evidence-Based Nursing. Available at: http://www.nursingsociety.org/research/main.html. Accessed October 31, 2003. [Context Link]
5. Cronenwett LR. Keynote address: Midwest Nursing Research Society, March 3, 2001: Research, practice and policy: issues in evidence based care. J Issues Nurs [serial online]. February 19, 2002. Available at: http://www.nursingworld.org/ojin/keynotes/speech_2.htm. Accessed October 14, 2003. [Context Link]
6. Rosswurm MA, Larrabee JH. Model for change to evidence-based practice. Image: J Nurs Scholarship. 1999;31(4):317-22. [Context Link]
7. O'Brian PG. Critical thinking in the nursing process. In: Lewis SM, Heitkemper MM, Dirkson SR, eds. Medical-Surgical Nursing. 6th ed. St. Louis, MO: Mosby; 2004:13. [Context Link]
8. Oxford Centre for Evidence-Based Medicine. Evidence-Based Medicine Glossary. Available at: http://www.cebm.net/glossary.asp. Accessed May 2, 2004. [Context Link]
9. Polit DF, Hungler BP. Nursing Research Principles and Methods. 5th ed. Philadelphia, PA: JB Lippincott; 1995:25-26. [Context Link]
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