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Problem Identification: The First Step in Evidence‐Based Practice

Stannard, Daphne PhD, RN, CNS, NPD-BC, FCCM

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There are many definitions of evidence‐based practice (EBP), including the oft‐cited Sackett et al definition that states, “Evidence‐based medicine is the integration of best research evidence with clinical expertise and patient values.”1 (p1) As I have reasoned elsewhere,2 this definition is more aligned with the discipline of medicine and associated provider‐related activities, such as ordering diagnostic tests and therapeutic remedies based on a differential diagnosis. This classic definition does not represent the broad and varied experiences of the professional nurse. As such, I offer the following more nursing‐centered and practical definition: EBP for nursing is a way of entering the situation with curiosity and engagement that follows the nursing process by responding to the issue or problem using the best available evidence. This definition is general enough to include perioperative nurses who work in a variety of roles and in a variety of settings, ranging from surgical suites to academia, but it is also specific enough to name the practice that provides an evidence‐informed response to an emerging issue or problem.The  AORN Journal Quality Improvement Showcase  follows the five steps of EBP, namely: 1) identifying the problem, 2) accessing the best evidence, 3) critically appraising the evidence, 4) applying the change to practice, and 5) evaluating the change in practice.1 As described elsewhere, the five steps of EBP also align with the steps of the nursing process.2 This editorial focuses on the first step—problem identification (or  assessment  in the nursing process)—because this initial phase in EBP is crucial. How does a nurse identify problems and what constitutes a problem?As many of you can attest, a nurse does not often look for problems; rather, problems or issues find the nurse! Consider your daily practice and reflect on the number of times that there are interruptions or disturbances to what otherwise might be a smoothly running shift. These interruptions or disturbances can present in a variety of forms depending on your practice and role. A malfunctioning piece of equipment or device is a common occurrence that can cause breakdown in care, escalate communication, and alter well‐established processes. A patient, family member, or colleague can ask a seemingly innocent question that might challenge the current workflow and established policies or require staffing changes. As a final example, perhaps an audit or a report was just issued that indicates an area for improvement on your team or unit.Framing all interruptions as problems seems deficit‐laden, yet any interruption in a smooth workflow is typically felt as a problem by the nurse. Any change to the status quo can cause a range of emotions, including a flash of insight, a burst of irritation, or a quiet disappointment leading to reflection, or it can lead to a public resolution to ensure that the interruption will not occur again. These emotional ripples are often the impetus for identifying the problem. A nurse might ask, “Why is this happening? How can this be prevented? How can I improve this situation?” Thus, although a problem is often felt negatively, searching for a solution can be perceived positively, as the identified issue becomes the driver for change.After a problem is identified, one needs to determine if all five steps of EBP will be implicated. Returning to the examples of interruptions presented earlier, depending on the device, type of failure, and scope of the failure, all five steps of EBP may not be necessary. When a device fails, the nurse may simply and successfully troubleshoot the device and resume practice. By rebooting the piece of equipment, the OR nurse initiates the five steps of EBP, but is able to solve the problem after the first step (ie, identifying the problem). This nurse entered the situation with curiosity (“Why is this alarm going off?”) and engagement (“How can I restore the device to a nonalarming state?”), but by resetting the device through deft troubleshooting skills, the nurse did not need to proceed with the other four steps of EBP.Consider the second interruption: A colleague approaches the OR charge nurse with what appears to be a complicated question that is readily answered by reviewing the facility policy. In this example, both the first and second steps of EBP are implicated: identifying the problem and accessing the literature. In this case, a thorough search of the literature was not required. The OR charge nurse could answer the question simply by using internal resources and documents, but that action still constitutes accessing the literature. Depending on the question or identified problem, a deeper search of the literature may be required using additional digital databases, such as CINAHL (Cumulative Index to Nursing and Allied Health Literature) and PubMed.Finally, consider the last interruption: an audit that shows improvement is needed in a particular OR. In this situation, the first step has already been identified, but to solve the problem, new approaches may be necessary. A review and evaluation of the literature shows some promising interventions that might improve practice in this facility, but the interventions must be tested. Problems and solutions are contextual, because every unit and facility differs in terms of structures, processes, and outcomes, as Donabedian described in his seminal work.3 For that reason, potential solutions in the form of interventions must be implemented and evaluated as part of a quality improvement or research project to ensure that the implemented solution solves the problem or improves the practice.In this issue of the  QI Showcase , problems that arose in practice led to the first step of EBP for the authors, and they explore the following questions.

· How does one reduce unnecessary traffic in an OR?

· What impact would an intraoperative power failure have on the health care team and patient management?

· How can site‐level data be used to monitor and reduce surgical site infections?

· How can facial and eye exposures be reduced?

· What is the effectiveness of implementing resistive warmers in a particular patient population?

· How does one roll out a new supply count and sharp containment policy?

· How can one leverage technology to improve efficiency?

CONCLUSION

Entering any situation with curiosity and engagement that follows the nursing process is EBP for nursing. Identifying the problem is the first of the five steps of EBP and may be the only step required in a particular situation. More often than not, however, thorny clinical issues and problems require greater attention and typically implicate more steps in the EBP process. One can search for problems, but if a clinician is curious and engaged, the problems become evident and are begging to be solved: May the evidence be with you!

We are currently seeking author submissions for the next Quality Improvement Showcase that will be published in 2021. For more information and to view the Author Guidelines, visit  www.aornj[ZEROWIDTHSPACE]ournal.org/quali[ZEROWIDTHSPACE]tyimp[ZEROWIDTHSPACE]rovement. If you have any questions, please send an e‐mail to  [email protected].

References

· 1. Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Edinburgh, UK: Churchill Livingstone; 2000. [Context Link]

· 2. Stannard D. A practical definition of evidence-based practice for nursing. J Perianesth Nurs. 2019;[ZERO WIDTH SPACE]34(5):1080–1084. [Context Link]

· 3. Donabedian A. The quality of care. How can it be assessed? JAMA. 1988;260(12):1743–1748. [Context Link]