Evidence-Based Patient-Centered Needs Assessment

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A Five-Step Evidence-Based Practice Primer for Perioperative RNs Christopher H. Stucky, PhD, RN, CNOR, CSSM, NEA-BC; Marla J. De Jong, PhD, RN, CCNS, FAAN; Jose A. Rodriguez, DNP, RN, CCNS, CNOR

ABSTRACT Perioperative nurses work in one of the most complex healthcare settings and must adapt to rapid advances in technology, treatments, and scientific discoveries to maintain clinical competence and provide care that reflects current evidence. Evidence-based practice (EBP) is a standard of professional nursing performance and an expec- tation of professional nursing practice. Because EBP is foundational to health care quality and safety, periop- erative nurses must understand the concepts of EBP and have the capacity to apply evidence to their clinical practice. However, some perioperative nurses struggle with EBP concepts and find it difficult to access, appraise, and apply evidence. In this article, we describe the five-step EBP process and provide valuable insights into EBP for perioperative RNs.

Key words: evidence-based practice, health care quality, health care safety, EBP.

Perioperative nurses work in one of the most com- plex health care settings and must adapt to rapid advances in technology, treatments, and scientific

discoveries to maintain clinical competence and provide clinical care that reflects current evidence.1 Evidence- based practice (EBP) is the process by which perioperative nurses plan and deliver care based on the best evidence, expert clinical knowledge, and patient preferences and values.2 Evidence-based practice is foundational to health care quality and safety, and perioperative nurses must understand the concepts of EBP and have the capacity to apply evidence to their clinical practice. The fundamen- tal premise of EBP is ensuring that health care is reliable, safe, effective, affordable, and efficient.3 As health care progresses toward a value-based system, where value is a function of quality and cost,4 consumers, policymakers, and payers are increasingly demanding EBP.5

Evidence-based practice is a standard of nursing profes- sional performance,6 and all nurses have an ethical and

legal commitment to integrate evidence into practice.7 AORN considers research to be the foundation of periop- erative nursing practice and regards EBP as fundamental to quality patient care.8 However, some perioperative nurses struggle with EBP concepts and find it difficult to access, appraise, and apply evidence.9 Therefore, the pur- pose of this article is to describe the five-step EBP process and provide valuable insights into EBP for perioperative RNs.

BACKGROUND Evidence-based practice in nursing has a rich history, beginning with Florence Nightingale in the 1800s.10 Although robust EBP frameworks are relatively contem- porary, historically, nurses applied informal frameworks to guide clinical practice through scientific discoveries. In the 1980s, when the emphasis was to close the gap between research and practice, nurses started using a process known as research utilization (ie, applying

http://doi.org/10.1002/aorn.13220 © AORN, Inc, 2020

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findings from single studies to change nursing prac- tice).11 In the 1990s, EBP supplanted research utilization, given increased awareness regarding the importance of using multiple sources of evidence to make practice decisions.11

The impetus for evidence-based approaches was the con- cern that it required years to translate scientific discover- ies to clinical practice,12 and the aim to integrate current evidence and individual clinician expertise. Sackett et al13 defined evidence-based medicine as:

the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research.13(p71)

Within nursing, science and art merge in a context of car- ing that integrates research evidence.14 This context of caring combines research evidence, clinical expertise, and patient preferences and values to inform clinical decision making and influence high-quality patient outcomes.14 In practice, nurses often employ a practical approach to EBP, using the nursing process as a guide.15 Stannard proposed a pragmatic definition of EBP for nursing: “EBP for nursing is a way of entering the situation with curios- ity and engagement that follows the nursing process by responding to the issue or problem using the best avail- able evidence.”15(p1080)

Benefits of an Evidence-Based Process The benefits of EBP extend to patients, consumers of health care, nurses, and health care organizations. Through creating and sustaining EBP environments, health care organizations, educators, and clinicians have advanced the quality and safety of health care delivery and promot- ed optimal patient outcomes.11 Evidence-based practice provides nurses and organizations confidence that they are optimizing health system performance and advanc- ing each element of the Quadruple Aim (ie, improving the patient experience of care, improving the health of popu- lations, lowering the cost of care, and improving the work experience of caregivers).16

Evidence-based practice empowers nurses by building autonomy.17 As nurses develop a command of relevant evidence through increased clinical knowledge, they become empowered to practice to the fullest extent of their capabilities.17 When nurses are empowered to make informed, evidence-based clinical decisions tai- lored to patients’ needs and values, their job satisfaction improves and they are more likely to remain in the nurs- ing profession.18

A health care organization’s financial health is related to clinician performance.5 National pay-for-performance initiatives and value-based purchasing have heavily influ- enced leaders of health care organizations to implement and standardize evidence-based practices to achieve the best financial and clinical outcomes.5 Thus, by basing their practice on evidence, nurses can impact the finan- cial health of the entire health system and improve overall patient health.

Barriers to EBP Leaders in the health care industry have recognized the importance of EBP for decades, and yet consistent implementation of EBP remains a challenge.19 Barriers to EBP implementation typically occur in two categories: individual (ie, those inherent to the nurse) and organiza- tional (ie, those related to leadership, resources, and cul- ture).11 Common individual barriers are inadequate skills, lack of knowledge, and lack of time.20 Some researchers determined that although nurses could identify clinical practice issues, they were unable to translate the issues into well-constructed clinical questions.21 This finding is consistent with previous studies, which found that nurs- es lacked the confidence and skills to evaluate research and implement EBP effectively.5,21,22 The major organiza- tional barriers to EBP are workload (ie, time pressures),

As nurses develop a command of relevant evidence through

increased clinical knowledge, they become empowered to practice to the fullest extent of their capabilities.

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insufficient resources (eg, lack of access to online jour- nals), ineffective interprofessional collaboration, lack of authority to change practice, and a workplace culture resistant to change.19

EBP Models Nurses have developed several EBP models to help demystify the translation of scientific evidence into clinical practice.23 Many health care organizations have adopted EBP models that align with their organizational goals, fit their clinical context, and guide a systematic approach to implement and sustain practice changes collaboratively.24 The predominant EBP models are the Iowa Model of Evidence-Based Practice to Promote Quality Care, the Advancing Research and Clinical Practice Through Close Collaboration Model, and the Johns Hopkins Nursing Evidence-Based Practice Model.23 Although EBP models have distinct differenc- es that hinder their application within some settings,24 they share similar steps. Next, we discuss five intuitive and pragmatic steps to EBP (Figure 1) that were first described by Sackett.2

STEPS OF EBP The best evidence available to clinicians is a fusion of research evidence, their expert clinical knowledge, and patient and family preferences. Evidence-based practice is not simply applying science to nursing care. Rather, as nurses think critically and integrate all knowledge, both clinical and scientific, they will make the best patient care decisions.25

Step 1: Identify the Problem The first step is for nurses to identify a clinical practice problem within the perioperative continuum and create a clinical question. For EBP initiatives, nurses typically structure clinical questions in the PICOT format:

• P (patient, population, or problem),

• I (intervention or issue),

• C (comparative or current treatment),

• O (outcomes), and

• T (time).14

A well-formulated clinical question is needed to produce focused and timely literature searches that will yield appro- priate evidence to answer the question.14 Sometimes, questions exclude one or more PICOT elements, specifi- cally the intervention or time component.

Step 2: Access the Best Evidence The second step of EBP is to access the best evidence. The PICOT question helps streamline the search process. The search strategy depends on factors such as the context of the question, available resources, and urgency of the search. One approach is to access published guidelines in which subject matter experts have already searched and appraised the literature, and formed, rated, and published practice recommendations. For example, perioperative nurses commonly use AORN’s Guidelines for Perioperative Practice8 to identify expeditiously broad evidence-based recommendations for perioperative patient care. These guidelines, which are published annually, contain a review of research and non-research evidence and clinical prac- tice recommendations rated according to their underlying strength and quality of evidence.8 National agencies such as the Agency for Healthcare Research and Quality and Figure 1. The five steps of evidence-based practice.

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the Centers for Disease Control and Prevention also offer clinical guidelines.26,27

Searching medical and nursing literature can seem over- whelming to some nurses.9 Nurses who are unfamiliar with searching the literature can ask an advanced practice RN, a nurse scientist, or a health science librarian within their institution to help them comprehensively search the literature.

Initially, perioperative nurses may search electron- ic databases for systematic reviews about their top- ic. Databases, such as the Cochrane Library,28 contain systematic reviews and meta-analyses that experts produced to summarize research results. Finding syn- thesized evidence can save clinicians time, especially if the review is recent. If no systematic review is avail- able or the review is outdated, perioperative nurses can search electronic databases (eg, Cumulative Index to Nursing and Allied Health Literature [CINAHL], Embase, PubMed, Google Scholar, Web of Science) for individual peer-reviewed studies using keywords from the PICOT question and considering contextual factors such as set- ting and available resources. Although nurses can search most electronic databases for free, the availability of full-text articles depends on the subscription status of an organization. Searching for literature is an iterative process, and often yields many results. Nurses should narrow the search results to relevant studies by carefully reading manuscript titles and abstracts.

In the PICOT question example offered in Sidebar 1, expe- rienced team members performed a systematic literature search using electronic databases and key words relative to surgical site infection (SSI) reduction and SSI bun- dles. Ultimately, they found a combination of systematic reviews, prospective clinical trials, non-experimental stud- ies, case reports, and clinical practice guidelines that met their criteria.

Step 3: Critically Appraise the Evidence The third step in EBP is to critically appraise the evidence from the literature review. Nurses must use the most cur- rent, the most relevant, and the highest-quality evidence to support changes in nursing practice.14 Although other sources29 provide more extensive explanations, a powerful

Sidebar 1. Example of a Perioperative PICOT Question

Perioperative leaders at a busy military medical center were concerned about increased rates of surgical site infections (SSIs) for patients having elective surgeries (P), which were occurring at levels higher than benchmarked national averages. Nursing leaders formed an interprofessional team to assess the problem and review current practic- es. Team members were concerned by the lack of standardized protocols, inconsistent patient education, and bioburden on surgical instruments. Team members recalled reading AORN Journal articles about clinical strategies to reduce SSIs,1 including infection prevention bundles that involve patient education, antibiotic protocols, surgical site preparation, postoperative incision care, and staff engagement;2 and innovative adjunctive technologies to decrease bioburden.3 This led team members to question whether implementing a comprehensive infection prevention bundle (I) in subsequent patients, as compared to previous patients (C), would decrease SSI rates (O), when analyzed over 12 months (T). The team decided to compare quarterly SSI rates to track trends and determine intervention efficacy. The team wrote the question in a PICOT format: “In _____ (P), how does _____ (I), as compared to _____ (C), predict or influence _____ (O) over _____ (T)?” For example, “In patients undergoing elective surgeries (P), how does implementing an infection prevention bundle (I), as compared to prior practices (C), predict or influence SSI rates (O) over 12 months (T)?”

REFERENCES 1. Bashaw MA, Keister KJ. Perioperative strat-

egies for surgical site infection prevention. AORN J. 2019;109(1):68-78.

2. Money L, Eyer M, Duncan K. Creating a sur- gical site infection prevention bundle for patients undergoing cesarean delivery. AORN J. 2018;108(4):372-383.

3. Rodriguez JA, Hooper G. Adenosine triphos- phate-bioluminescence technology as an adjunct tool to validate cleanliness of surgical instruments. AORN J. 2019;110(6):596-604.

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skill for nurses to develop is a practical understanding of the various categories of published research and non-re- search (Table 1).

Standardized tools help nurses critically appraise the strength and quality of scientific and other forms of evi- dence. To better address perioperative clinical questions, AORN adapted the Johns Hopkins Nursing Evidence- Based Practice Model30 to form the AORN Evidence Rating Model.31 At a glance, appraisal tools may appear intimidat- ing. However, through education and practice, nurses can develop proficiency in categorizing and appraising evidence. As with previous steps, it may be helpful for perioperative nurses to request assistance from an advanced practice RN or a librarian the first time that they appraise the evidence.

Perioperative nurses can begin the appraisal process by determining the evidence level or strength of the study

(Figure 2). The hierarchy of evidence ranges from I (stron- gest) to III for research evidence and IV to V (weakest) for non-research evidence.31 Nurses rate the evidence strength based on the study design. Level I evidence, such as randomized controlled trials and experimental studies, is the strongest, most reliable, and best evidence to answer a clinical question.32 Level V evidence, such as expert opinion and case reports, is the weakest and least reliable evidence but may be relevant if no stronger evidence is found.

Next, the perioperative nurse can use AORN’s Research Evidence Appraisal Tools31 to determine the quality of evidence: “A” for high quality, “B” for good quality, or “C” for low quality or major flaws. To obtain an “A” rating, the research should have consistent results, sufficient sample size, adequate controls, definitive conclusions, and consis- tent recommendations.29 Combined with the strength of the evidence, research that receives a final score of I–A

Table 1. Categories of Literature Used to Inform Evidence-Based Practice Decisions1

Randomized controlled trial (RCT) A type of experimental study in which investigators randomly assign participants and manipulate variables to find cause-and-effect relationships between experimental and control groups

Meta-analysis A rigorous, statistical approach for combining findings from multiple independent studies, if statis- tically appropriate, in a quantitative systematic review

Quasi-experimental research Similar to experimental research, this type of research lacks either a random assignment of partici- pants, manipulation of variables, or a control group

Non-experimental research (eg, cross-sectional and retrospective studies, case report, survey)

A type of research that differs from experimental research, in that investigators do not manipulate independent variables or randomly assign participants

Quantitative research A type of research that investigates phenomena relying on data that is observed or measured using statistical techniques

Qualitative research (eg, focus groups, interviews, observation)

A type of research that aims to provide an improved understanding of behaviors and perceptions, typically in naturalistic settings

Descriptive research A type of research that describes the characteristics of a phenomenon or population studied with- out regard for explaining cause-and-effect relationships

Systematic review A type of secondary research that is an unbiased and high-level systematic analysis of all primary evidence using precise search, selection, and appraisal methodology to answer a predefined research question

Literature review A descriptive or narrative summary of evidence on a topic

Clinical practice guideline, consensus, posi- tion statement, or white paper

A set of evidence-based recommendations by experts, and sometimes includes a multidisciplinary panel of experts, intended to optimize patient care

Case report A detailed scientific report of a single clinical observation

Expert opinion (eg, column, letter to the editor)

An opinion made by an expert that is often based on clinical expertise and observation, but may or may not be evidence-based

Reference 1. Gliner JA, Morgan GA, Leech NL. Research Methods in Applied Settings: An Integrated Approach to Design and Analysis. 3rd ed. New York, NY:

Routledge; 2017.

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(ie, strongest evidence, highest quality) is better evidence to implement as compared to research assessed as V–C (ie, weakest evidence, lowest quality).29 Because appraiser characteristics can potentially influence quality evidence appraisal, some subjectivity exists within the process.29 Thus, it is helpful for a group of nurses to reach a con- sensus regarding the score. In many organizations, small groups of nurses (eg, hospital-, department-, or unit-based EBP committees) work together to critically appraise the evidence. Continuing the perioperative SSI bundle exam- ple, interprofessional team members used the AORN Research Evidence Appraisal Tools to determine the strength and quality of the evidence. Using the best qual- ity evidence, the interprofessional team identified an evi- dence-based intervention (ie, a comprehensive SSI bundle) to implement.

Step 4: Apply the Change to Practice The fourth step is to apply the change to practice. In this step, nurses integrate scientific evidence with their expert clinical judgment while considering patients’ beliefs, preferences, and values.14 Because nursing is a science and an art, nurses rely heavily on their ability to apply evidence to their unique care environment and individual patients. Sometimes, after carefully reviewing the evidence and considering care con- cerns, no change in current practice is warranted.

Research evidence is necessary for EBP but is insufficient alone for making patient care decisions.33 The ability to con- sider patient preferences in clinical decision-making requires critical reflection and practical wisdom.34 For instance, nurs- es employ critical thinking when evidence supporting patient care decisions are conflicting or non-existent.35 The inter- vention also may conflict with patient values, cultural norms, or patient preferences. Expert clinical knowledge helps nurs- es to consider care alternatives that meet the needs of their patients or clinical settings after considering the context of all critical elements, including merging evidence with patient rights and preferences.13 The ability of nurses to individualize care is what differentiates EBP from research use, and helps to ensure a patient-centered approach.35

Applying changes to practice frequently involves making an organizational change or adopting new policies and practices. Practice changes may involve

• forming an interprofessional implementation team,

• revising standard orders,

• ordering new equipment or supplies,

• making changes to the electronic medical record,

• creating a timeline with scheduled checkpoints for the practice change,

• educating clinicians,

• developing a clinical tool,

• piloting the change with a particular surgical specialty, or

• using change champions to promote and operationalize EBP changes.14

Nurses can use templates, flowcharts, spreadsheets, or Gantt charts (ie, a chart that displays a project schedule) to maintain project progression and enhance communication

Figure 2. An example hierarchy of evidence and

quality appraisal rating. AORN Hierarchy of Evidence

Model. Adapted with permission from AORN.org.

Copyright © 2015, AORN, Inc, 2170 S. Parker Road,

Suite 400, Denver, CO 80231. All rights reserved.

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among team members. Depending on the nature of the surgical setting and proposed change, perioperative nurs- es may need to obtain institutional review board approval before changing clinical practice and collecting outcome data.

Continuing the perioperative SSI bundle example, the interprofessional team created a comprehensive plan for an evidence-based SSI prevention bundle, project time- lines, variables targeted for data collection and analysis, proposed benchmarks, and dissemination strategies. Next, EBP team leaders engaged senior medical center leaders to obtain their support for the implementation. The team invited all relevant stakeholders to solicit their feedback regarding the plan. The institutional review board determined that the work was not human subjects research and therefore was offered exempt status. Team members collected SSI data, trained clinicians through- out the medical center on SSI bundle elements, provided patient and family education preoperatively and post- operatively, and invited change champions to join the implementation team. Lastly, the interprofessional team started small by slowly introducing the change across the medical center, focusing on the implementation pro- cess, and overcoming challenges that required attention (eg, reinforcing change).

Step 5: Evaluate the Change The final step of the EBP process is to evaluate the change in practice. Evaluation is instrumental in determining the effectiveness of the practice change and helping nurses determine whether the translation of evidence into prac- tice was successful. The nurse should evaluate:

• how effectively the team followed the first four steps of the EBP process,

• the outcome of the intervention, and

• how the outcomes compared to those found in the literature.35

Perioperative nurses can compare postimplementation data to baseline data to determine the effectiveness and impact of the intervention.36 Continuous monitoring of both the EBP process and the outcome measures by the perioperative nurse helps refine the change in prac- tice to achieve similar outcomes as those identified in the

literature. However, interventions from controlled stud- ies do not always guarantee similar clinical results when implemented,37 partially because of differences in popu- lations, settings, implementation strategies, and measure- ment. When nurses identify unfavorable outcomes, it is crucial to determine the cause. Nurses must analyze the results, investigate potential errors in measurement, and address any issues that could produce undesired results. Through monitoring, nurses can support the positive effects of the practice change and implement measures to resolve negative effects.37

Extending the perioperative SSI bundle example, the interprofessional team continuously monitored the prac- tice change and reported results after three months. The rate of SSIs decreased from 4.3% (n = 107) to 1.9% (n = 47), lowering their SSI rate to below the national average. The initial results appeared promising, so team members continued monitoring for trends and variations. After 12 months, the interprofessional team determined that the SSI bundle implementation was a success, and the proj- ect potentially improved quality and safety for surgical patients.

Disseminate Results While not a formal step, nurses should disseminate their results locally and nationally through venues such as hospital or surgery center grand rounds, conferences, and publications. Although the results may lack gener- alizability, dissemination enables perioperative nurses to facilitate thoughtful discourse about lessons learned; address potential transferability of the practice change considering factors such as patient demographics, clini- cal setting, and patient and family preferences; and rec- ommend future research. Given a cyclical relationship between research and clinical practice,38 perioperative

Evaluation is instrumental in determining the effectiveness of

the practice change and helping nurses determine whether the translation of evidence into practice was successful.

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nurses are well-positioned to identify topics for research and improvement.

To conclude the perioperative SSI bundle example, the interprofessional team shared data regarding the effec- tiveness of the comprehensive SSI bundle and its impact on surgical patient outcomes with all stakeholders. Additionally, perioperative nurse team members present- ed the findings at local, regional, and national profession- al meetings, and published their work in a perioperative nursing journal.

CREATING SUPPORTIVE EBP ENVIRONMENTS To create a supportive EBP environment, hospital lead- ers must develop and embrace a spirit of inquiry and sup- portive culture that values and supports EBP and nursing innovation.5 A spirit of inquiry empowers nurses and pro- vides the ability for nurses to challenge current practices and share innovative solutions.39 A supportive organiza- tional culture allows the time and space for nurses to for- mulate ideas, seek advice, receive mentorship, and share their ideas with others.39

Executive leaders (both clinicians and administrators) hold key positions that influence EBP in their facilities. Nursing leaders can increase organizational EBP capac- ity by obtaining support and buy-in from senior leaders within the hospital system, integrating EBP in every decision-making activity, transparently sharing data sys- tem-wide, and launching initiatives to increase clinician autotomy.19,40 To overcome individual barriers, health care organizations can provide clinicians with time, edu- cation, training, and mentorship to improve and maintain their use of evidence and identify change champions to lead organizational change toward the achievement of an EBP culture.19,41

Nurses can increase EBP capacity in their hospitals by learning, cultivating, and mentoring other staff members’ EBP competence.42 Evidence-based practice competence is a valuable skill set that perioperative nurses can apply and share with others during the entire span of their career. Thus, it is important to recognize the critical indi- vidual importance of nurses in progressing toward a sup- portive environment and culture that embraces EBP.

CONCLUSION Evidence-based practice is a powerful problem-solving approach for clinical decision-making and is a standard and expectation of professional nursing practice. In this article, we described the five-step EBP process and pro- vided valuable insights into EBP for perioperative RNs. To improve health care quality and safety, perioperative nurses must develop the capability to identify clinical problems, access and appraise the best evidence, and implement and evaluate best practices. Evidence-based practice competence is a valuable skill set that periopera- tive nurses can apply across the entire span of their career and share with others.

Editor’s notes: CINAHL is a registered trademark of EBSCO Industries, Inc, Birmingham, AL. Embase is a registered trade- mark of Elsevier Limited, Oxford, UK. PubMed is a registered trademark of the US Department of Health and Human Services, Bethesda, MD. Google Scholar is a trademark of Google, LLC, Mountain View, CA. Web of Science is a regis- tered trademark of Camelot UK Bidco Limited, London, UK.

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Christopher H. Stucky, PhD, RN, CNOR, CSSM, NEA- BC, is a nurse scientist and deputy chief of research at the Center for Nursing Science and Clinical Inquiry at Womack Army Medical Center, Fort Bragg, NC. Dr Stucky has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

Marla J. De Jong, PhD, RN, CCNS, FAAN, is the dean at University of Utah College of Nursing, Salt Lake City. Dr De Jong has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

Jose A. Rodriguez, DNP, RN, CCNS, CNOR, is an assistant professor and deputy director of the Adult- Gerontology Clinical Nurse Specialist Program at the Uniformed Services University of the Health Sciences, Bethesda, MD. Dr Rodriguez has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.

Editor’s note: The views expressed are solely those of the authors and do not reflect the official policy or position of the US Army, US Air Force, the Department of Defense, or the US Government.

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