A critical component of any change project is an evaluation of the stakeholders and determination of an effective communication plan to support successful implementation of the evidence-supported chan

To meet the needs of the modern healthcare system, the Institute of Medicine (IOM), now the National Academy of Medicine, published a set of five core competencies required of each health professional. \ This is not an exhaustive list but represents those competencies com - mon among a variety of health professionals and those most impor - tant to advancing healthcare. These competencies included providing patient-centered care, working in interdisciplinary teams, applying quality improvement, utilizing informatics, and employing evidence- based practice (IOM, 2003). As a core competency, evidence-based practice (EBP) represents a significant skill for nurses and other healthcare providers who have considerable influence on healthcare decisions and improving the quality and safety of care. EBP allows clinicians and interprofessional teams to keep up with the rapidly changing environment.

The world is experiencing an information and technology explo - sion, and healthcare is no exception. Unfortunately, in healthcare, the growth of knowledge outpaces the application to practice. The 1 Evidence-Based Practice: Context, Concerns, and Challenges Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021.

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4 process of incorporating new knowledge into clinical practice is often c\ onsider - ably delayed. Curry (2018) reports that it may take up to 15 years to \ approve new drugs. The average time for the uptake of research into actual pract\ ice is 17 years (Hanney et al., 2015). New knowledge has grown exponentially. Early in the 20th century, many healthcare professionals had but a few, hard-to-access journals available to them. Today, MEDLINE indexes 5,600 journals (National Library of Medicine, 2020), with more than 26 million references. The Cumulative I\ ndex to Nursing and Allied Health Literature (CINAHL) indexes more than 5,500 \ jour - nals and includes more than 3.4 million records (EBSCO Publishing, 2020\ ). Ac - cessibility of information on the web also has increased consumer expect\ ation of participating in treatment decisions. Patients with chronic health probl\ ems have accumulated considerable expertise in self-management, increasing the pr\ essure for providers to be up to date with the best evidence for care.

Despite this knowledge explosion, healthcare clinicians can experience a\ decline in knowledge of best care practices that relates to the amount of informati\ on avail - able and the limited time to digest it when no longer in a school or tra\ ining envi - ronment. Estabrooks (1998) reported that knowledge of best care practi\ ces nega - tively correlated with year of graduation—that is, knowledge of best \ care practices declined as the number of years since graduation increased. EBP is one o\ f the best strategies to enable healthcare providers to stay abreast of new practic\ es and tech - nology amid this continuing information explosion.

The objectives for this chapter are to: ■ Define EBP ■ Describe the evolution of EBP in healthcare ■ Discuss EBP in relation to outcomes and accountability ■ Highlight the healthcare clinician’s role in EBP Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021.

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Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professi\ onals, Fourth Edition 5 EBP: Definition EBP is a problem-solving approach to clinical decision-making within a h\ ealthcare organization. EBP integrates the best available scientific evidence wi\ th the best available experiential (patient and practitioner) evidence. EBP uses a\ deliberate approach to consider internal and external influences on practice and \ to encourage critical thinking in the judicious application of such evidence to the c\ are of individual patients, a patient population, or a system (Dang & Dearholt\ , 2018).

The challenge for healthcare providers is to use such evidence to implem\ ent the best interventions to improve patient outcomes. The Johns Hopkins Evidence-Based Practice Model (JHEBP) for Nursing and Healthcare Profe\ ssionals provides a structured and systematic way for clinicians to effectively u\ se current research and nonresearch evidence to determine best practices an\ d provide safe, high-quality care.

EBP supports and informs clinical, administrative, and educational decis\ ion- making. Combining research, organizational experience (including qualit\ y improvement and financial data), clinical expertise, expert opinion, \ and patient preferences ensures clinical decisions based on all available evidence. \ EBP enhances efficacy (the ability to reach a desired result); efficie\ ncy (the achievement of a desired result with minimum expense, time, and effort); and effect\ iveness (the ability to produce a desired result). Additionally, EBP weighs risk, benefit, and cost against a backdrop of patient preferences. This evidence-based \ decision- making encourages healthcare providers to question practice and determin\ e which interventions are ready to be implemented in clinical practice. EBP can \ lead to: ■ Optimal outcomes ■ Reductions in unnecessary variations in care ■ Standardization of care ■ Equivalent care at lower cost or in less time ■ Improved patient satisfaction ■ Increased clinician satisfaction and autonomy ■ Higher health-related quality of life Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021.

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1 Evidence-Based Practice: Context, Concerns, and Challenges 6 The History EBP in healthcare is not conceptually new. From a nursing perspective, Florence Nightingale pioneered the concept of using research evidence to dictate \ care (Nightingale, 1858). In the 1920s, Mary McMillan worked to bring a sci\ entific basis to the practice of physical therapy and to standardize the practic\ e (American Physical Therapy Association, 2020). As with any applied sci\ ence, the terms associated with evidence-based practice changed as the science evo\ lved.

As early as 1972, Archibald L. Cochrane, a British medical researcher, criticized the health profession for administering treatments not supported by evid\ ence (Cochrane, 1972). By the 1980s, the term evidence-based medicine was b\ eing used at McMaster University Medical School in Canada. Positive reception\ given to systematic reviews of care during pregnancy and childbirth prom\ pted the British National Health Service in 1992 to approve funding for “a\ Cochrane Centre” to facilitate the preparation of systematic reviews of random\ ized controlled trials of healthcare, eventually leading to the establishment\ of the Cochrane Collaboration in 1993 (Cochrane Collaboration, 2016). Cochran\ e continues to provide systematic reviews about the effectiveness of healt\ hcare and sound scientific evidence for providing effective treatment regimes. I\ n 1996, Alan Pearson founded the Joanna Briggs Research Institute (now JBI) to link\ research with practice, thus impacting global health outcomes and providing evide\ nce to inform clinical decision-making (JBI, 2020).

The use of tradition and ritual was and still is the basis for care by m\ any clini - cians. To use research in clinical practice, many disciplines sought scientifi\ c back - ing for common practices. For example, the Conduct and Utilization of Re\ search in Nursing Project (CURN) (Horsley et al., 1978) aimed to develop an\ d test a model for bringing research knowledge into clinical practice. Through th\ e initial work, ten areas were identified as having adequate evidence to use in \ practice, and the authors published guidelines and nursing protocols for each area\ (Hors - ley et al., 1983): ■ Structured preoperative teaching ■ Reduction of diarrhea in tube-fed patients Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021.

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Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professi\ onals, Fourth Edition 7 ■ Preoperative sensory preparation to promote recovery ■ Prevention of decubitus ulcers ■ Intravenous cannula change ■ Closed urinary drainage systems ■ Distress reduction through sensory preparation ■ Mutual goal-setting in patient care ■ Clean intermittent catheterization ■ Deliberate nursing interventions to reduce pain This is just one example of many to highlight the beginning of using res\ earch in practice. However, EBP incorporates more than research findings. Clinician experience, patient preference, and internal organizational data are all\ used as evidence to inform decisions and improve patient outcomes. Building on t\ hese early efforts, EBP has evolved to include increasingly sophisticated ana\ lytical techniques; improved presentation and dissemination of information; adva\ nced tools for searching and tracking literature; growing knowledge of how to\ implement findings while effectively considering patient preferences, \ costs, and policy issues; and a better understanding of how to measure effect and u\ se feedback to promote ongoing improvement. The Push for EBP EBP has experienced tremendous growth in the past few decades. For examp\ le, the first detailed description of EBP and nursing in primary care was \ published in 1996; less than 10 years later, an entire journal dedicated to EBP, Worldviews on Evidence-Based Nursing, was published. This growth can be attributed to two main factors. First, as mentioned previously, knowledge development is outpacing our ability to put findings into practice, driving the ne\ ed for a systematic way of evaluating evidence. Second, the development of EBP ha\ s been further driven by a desire to improve outcomes, pressure from consumers \ for more accountability, and regulatory requirements by accreditation bodies.

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1 Evidence-Based Practice: Context, Concerns, and Challenges 8 EBP and Outcomes Healthcare providers, by nature, have always been interested in the outc\ omes and results of patient care. Traditionally, such results have been characterized in terms of morbidity and mortality. Recently, however, the focus has broadened to include clinical outcomes (e.g., hospital-acquired infection, falls,\ pressure ulcers), functional outcomes (e.g., performance of daily activities),\ quality-of-life outcomes (e.g., physical and mental health), and economic outcomes (e\ .g., direct, indirect, and intangible costs). EBP is an explicit process by which cl\ inicians conduct critical evidence reviews and examine the link between healthcar\ e practices and outcomes to inform decisions and improve the quality of ca\ re and patient safety. EBP and Accountability Nowhere is accountability a more sensitive topic than in healthcare. Kno\ wing that patient outcomes are linked to evidence-based interventions is crit\ ical for promoting quality patient care. Professional and regulatory organization\ s and third-party payers mandate the use of evidence-based practices. Addition\ ally, patients and families expect care to be based in best evidence. Public e\ xpectations that healthcare investments lead to high-quality results most likely wil\ l not diminish soon. In today’s environment, quality and cost concerns drive healthcare. Consumers expect professionals to deliver the best evidence-\ based care with the least amount of risk.

Despite these mandates, much of the available data suggests that consume\ rs are not consistently receiving appropriate care (IOM, 2001). Nurses an\ d other healthcare professionals operate within an age of accountability (Leone\ nko & Drach-Zahavy, 2016); this accountability has become a focal point for healthcare (Pronovost, 2010). It is within this environment that nurses, physicia\ ns, public health scientists, and others explore what works and what does not. It i\ s within this context that nurses and other healthcare providers continue the jou\ rney to bridge research and practice.

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Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professi\ onals, Fourth Edition 9 Governments and society challenge healthcare providers to base their pra\ ctices on current, validated interventions. In 2012, the National Center for Ad\ vanc - ing Translational Sciences at the National Institutes of Health was establish\ ed to accelerate the translation of scientific discoveries into practice \ (Austin, 2016).

Nursing has responded to the groundswell of information by educating nur\ ses at every level to be competent practitioners of EBP and to close the gap\ between research and practice (Melnyk et al., 2017).

EBP provides a systematic approach to decision-making that leads to best\ prac - tices and demonstrates clinician accountability for the care they provid\ e. When the strongest available evidence is considered, the odds of doing the ri\ ght thing at the right time for the right patient are improved. Given the complexity \ of linking research and clinical practice, EBP provides the most useful framework t\ o trans - late evidence into practice. The Healthcare Clinician’s Role in EBP EBP encompasses multiple sources of knowledge, clinical expertise, and p\ atient preference. Because of their unique positions and expertise, nurses and \ other healthcare providers often play a pivotal role in generating questions a\ bout patient care and safety. This, along with the fact that practice questions and concerns often cross disciplines, makes it critical to enlist an interpr\ ofessional team and to include patient and family input as part of the process. Thu\ s, clinicians need to develop the necessary knowledge and skills to not onl\ y participate in the EBP process but also serve as leaders of interdiscipl\ inary teams seeking best practices to improve patient care. These leaders also play \ a vital role in modeling and promoting a culture that supports the use of collaborati\ ve EBP within the organization and in ensuring that the necessary resources (e\ .g., time, education, equipment, mentors, and library support) are in place to fac\ ilitate and sustain the process. The JHEBP model is an effective and efficient\ process for conducting EBP. The model has been used in many institutions and has been embraced by frontline nurses, pharmacists, occupational therapists, and \ many other disciplines. The tools developed as part of the model enable the t\ eam to use a step-by-step process for successfully completing an EBP project.

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1 Evidence-Based Practice: Context, Concerns, and Challenges 10 Summary This chapter defines EBP and discusses the evolution that led to the c\ ritical need for practice based on evidence to guide decision-making. EBP creates a c\ ulture of critical thinking and ongoing learning and is the foundation for an envi\ ronment in which evidence supports clinical and operational decisions, and decis\ ions related to improvements in learning. EBP supports rational decision-maki\ ng, reducing inappropriate variation in practice and making it easier for cl\ inicians to do their job. EBP is an explicit process that facilitates meeting the\ needs of patients and delivering care that is effective, efficient, equitable, \ patient-centered, safe, and timely (IOM, 2001). References American Physical Therapy Association. (2020). 100 milestones of physical therapy . https:// centennial.apta.org/home/timeline/ Austin, C. P. (2016). 2016 director’s messages . National Center for Advancing Translational Sciences. https://ncats.nih.gov/director/message2016 Cochrane, A. L. (1972). Effectiveness and efficiency: Random reflections on health services.\ Nuffield Provincial Hospitals Trust. Cochrane Collaboration. (2016). About Cochrane. http://www.cochrane.org/about-us Curry, S. H. (2018). Translational science: Past, present, and future. BioTechniques, 44(2S). https:// doi.org/10.2144/000112749 Dang, D., & Dearholt, S. (2012). Johns Hopkins Nursing evidence-based practice: Model and guidelines (2nd ed.). Sigma Theta Tau International. EBSCO Publishing. (2020). CINAHL Plus Full Text. https://www.ebsco.com/products/research- databases/cinahl-plus-full-text Estabrooks, C. A. (1998). Will evidence-based nursing practice make practice perfect? Canadian Journal of Nursing Research , 30 (1), 15–36. Hanney, S. R., Castle-Clarke, S., Grant, J., Guthrie, S., Henshall, C., Mestre\ -Ferrandiz, J., Pistollato, M., Pollitt, A., Sussex, J., & Wooding, S. (2015). How long does biomedical research take? Studying the time taken between biomedical and health research and\ its translation into products, policy, and practice. Health Research Policy and Systems , 13 (1). https://doi. org/10.1186/1478-4505-13-1 Horsley, J., Crane, J., & Bingle, J. (1978). Research utilization as an organ\ izational process. Journal of Nursing Administration , 8(7), 4–6. https://doi.org/10.1097/00005110-197807000-00001 Horsley, J. A., Crane, J., Crabtree, M. K., & Wood, D. J. (1983). Using research to improve nursing practice. Grune & Stratton.

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Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professi\ onals, Fourth Edition 11 Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. The National Academies Press. Institute of Medicine. (2003). Health professions education: A bridge to quality. The National Academies Press. JBI. (2020). Our history. https://joannabriggs.org/our-history Leonenko, M., & Drach-Zahavy, A. (2016). “You are either out on the court, or sitting on the bench”: Understanding accountability from the perspectives of nurses \ and nursing managers.

Journal of Advanced Nursing , 72 (11), 2718–2727. https://doi.org/10.1111/jan.13047 Melnyk, B. M., Gallagher-Ford, L., Long, L. E., & Fineout-Overholt, E. (2017). Implementing the evidence-based practice (EBP) competencies in healthcare . Sigma Theta Tau International. National Library of Medicine. (2020). MEDLINE: Overview. https://www.nlm.nih.gov/bsd/medline. html Nightingale, F. (1858). Notes on matters affecting the health, efficiency, and hospital administration of the British Army . Harrison & Sons. https://wellcomelibrary.org/item/ b20387118#?c=0&m=0&s=0&cv=88&z=-1.2809%2C-0.0462%2C3.5618%2C1.8022 Pronovost, P. J. (2010). Learning accountability for patient outcomes. JAMA , 304 (2), 204–205. https://doi.org/10.1001/jama.2010.979 Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021.

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1 Evidence-Based Practice: Context, Concerns, and Challenges Dang, Deborah, et al. Johns Hopkins Evidence-Based Practice for Nurses and Healthcare Professionals, Fourth Edition, Sigma Theta Tau International, 2021.

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