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Follow the evidence to up-to-date practice
By Anna Ver Hage, MSN, RN, AG-ACNP, CCRN, CNRN
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This course is 1 contact hour
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Course must be completed by June 30, 2018
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Goals and objectives: The goal of this continuing education program is to provide nurses with information about evidence-based practice and strategies to increase evidence-based practice in their work. After studying the information presented here, you will be able to:
  1. Review the concepts of evidence-based practice and the evolution of the field
  2. Give examples of evidence-based practice in clinical nursing practice
  3. Examine ways a nurse can incorporate evidence into daily clinical practice
Nurse.com educational activities are provided by OnCourse Learning. For further information and accreditation statements, please visit Nurse.com/Accreditation. The planners and authors have declared no relevant conflicts of interest that relate to this educational activity. OnCourse Learning guarantees this educational activity is free from bias. See “How to Earn Continuing Education” to learn how to earn CE credit for this module or visit http://ce.nurse.com/instructions.aspx.
Jim, a graduate nurse, is caring for ventilated patients under the guidance of his preceptor. One day, he hears nurses around him talking about a new protocol that requires brushing patients’ teeth. Because the new protocol “suddenly appeared” and requires additional care, the nurses see it as just one more extra job to do, mandated by administration.
But Jim is curious. Having recently graduated with skills enabling him to search for the evidence, he retrieves articles on ventilated patients and learns that brushing patients’ teeth is one of the components of a “ventilator bundle,” an evidence-based group of interventions to help prevent ventilator-associated pneumonia.1 At first, Jim is hesitant to show the articles to his preceptor. Will she be receptive to learning from a graduate nurse? But Jim is fortunate: His preceptor is pleased to receive the information, and his manager gives him positive feedback, asking him to present the information at a staff meeting.

A few short years ago, evidence-based practice (EBP) was less well known, and nurses were not as prepared for or open to using data and evidence in professional practice. It’s difficult to keep up with new practice changes. Many nurses learned to function according to procedures, obtaining knowledge and technical skills from nursing instructors and textbooks.

Nurses believed these methods of learning provided the most accurate information on how to care for patients. The nursing profession has sometimes been reluctant to change practice even in light of research that challenges the traditional way of doing things.2 But times have changed dramatically. Now nurses know some of their most widely used techniques and information about nursing practices have been based on tradition, not evidence. All nurses can think of examples of changes in nursing care, such as no longer placing a postpartum patient on bed rest or transferring the care of many surgical patients to the outpatient arena.

Evidence provided the basis for these significant practice changes, and this evidence is now available to nurses with a click of a computer mouse. Many nurses, however, still choose to seek information from colleagues rather than use the computer to find the most current evidence. A 2005 descriptive exploratory study surveying more than 1,000 RNs reported that 67% used colleagues rather than evidence in practice, 58% had never used research reports, and 82% had never used library resources for updating practice.3 (Level B)

Gaining knowledge of EBP and learning strategies for implementation are critical skills for changing practice in nurses’ work, whatever the setting. Nurse clinicians also have hands-on experience that is invaluable in improving patient care outcomes while reducing cost.4
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What, when and where
EBP is the delivery of patient care by a provider who integrates clinical expertise with the best available evidence from systematic research.2,4 Started by physicians in England and Canada in the 1980s and 1990s, evidence-based medicine reviews and uses the best evidence available so healthcare decisions can be made in a cost-effective way based on valid research.

The Cochrane Collaboration, an international nonprofit organization supporting evidence-based practice, develops rigorous reviews of the medical research literature to promote evidence-based medicine decisions. Its reviews are based on criteria that include randomized clinical trials and outcomes evaluation to ensure providers find unbiased recommendations for practice. EBP is now considered an essential component of high-quality healthcare.5 In the U.S., the Agency for Healthcare Research and Quality has been a leader in generating evidence-based standards for healthcare providers, including publishing practice guidelines on outcomes, such as pressure ulcers and pain management. Its website offers extensive resources to both professionals and consumers. Over the years, the focus of EBP has expanded to include not only clinical trial research, but also data on patient preferences and values.5 These modifications are important because research-based interventions for a patient problem are not easily implemented if the patient refuses to be treated.

Nursing EBP, generated from the concepts of evidence-based medicine, continues to grow, with journals, models, and books to help nurses understand the concepts and process. Evidence-based nursing, like evidence-based medicine, emphasizes a systematic approach to examining the evidence rather than relying on tradition and anecdotal opinions. Not all evidence in nursing and patient-care practice has been systematically researched, however.

Various EBP models have been developed that incorporate nonresearch sources of evidence, such as quality data, expert consensus, and benchmark data. Benchmarking is the process of comparing outcomes with national standards, and it is an important tool to promote change and improvement in one’s own practice.5,6

There continue to be many interpretations of evidence-based nursing practice and some controversy over how this movement affects the caring, qualitative focus of nursing.7 Using evidence enhances caring in practice by providing the nurse with the tools to deliver safe, quality care. Implementing EBP is a major criterion for organizations seeking to gain Magnet status for nursing excellence.2
What about research utilization?
Experienced nurses may know about research utilization and wonder what the difference is between it and evidence-based practice. Research utilization is a more structured way of using research findings, examining outcomes in a selected area of nursing practice, reviewing the literature and changing practice based on findings. EBP uses a broader focus, including patient preferences and data on the costs of care, among other dimensions.4 While nursing now emphasizes EBP, nursing research utilization was a significant force in moving nursing research from academia into the clinical environment and encouraged nurses to use research at the bedside. Important projects were undertaken to advance research in practice, including the Conduct and Utilization of Research in Nursing project.8

The CURN project produced 10 research-based nursing care protocols, many of which provided the foundation for how we now practice. One example of this practice change was the management of urinary catheters. Accepted nursing practice had been to clamp and then disconnect the urinary catheter tubing when the patient ambulated. Research showed that interrupting the closed system this way increased the likelihood of a urinary tract infection.

This landmark CURN protocol promoted change in nursing practice across the country. Research utilization brought a clinical focus to nursing research, involved staff nurses in the process and increased clinical nursing research publications, all significant advances. As the evolution of practice-based research continues, the emphasis is now moving to multidisciplinary evidence-based practice teams, recognizing the importance of multiple disciplines working together to determine best practices in patient care.9 EBP and research utilization both require a nurse to learn to search for and analyze the evidence. Nurses can learn these skills independently, in a classroom, through continuing education, through library services, or in a degree program.

Practicing with guidance is an important way to gain confidence when searching and analyzing evidence; finding a peer or a mentor for support and help is beneficial. A local librarian, a clinical nurse specialist, or a faculty member can be a coach to guide learning.
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Evidence-based practice examples
Jim, the graduate nurse, learned to search for the evidence in his undergraduate education and quickly located the evidence about brushing teeth of vented patients. Other clinical scenarios show why critical evidence needs to be translated into practice. Translating research into practice can take up to 20 years — delays that mean patient outcomes are not improved.5

An example of the gap between evidence and practice, and a delay in moving knowledge to patient care, can be seen in the use of saline versus heparin in flushing lines. In 1993, a nursing study reported evidence that saline was as effective as heparin in flushing lines, was less expensive, and had better outcomes for patients because heparin is often contraindicated for a patient’s condition.10 This study was based on original research reported a decade earlier. Even today, some hospitals do not incorporate these findings into practice. In another example, two care variances had been detected with male catheterized patients even though nurse competencies were verified. Urology physicians were consulted to determine best practices for male catheterization procedures because evidence was limited. This evidence-based project evolved into a research project because there was so little evidence to evaluate.11

Study outcomes revealed that some nursing literature contained outdated facts about male catheterization, including incorrect information on the distance to insert the catheter (6 to 8 inches when it should be 10 to 12 inches) and the incorrect assumption that residual urine return indicates that the catheter is in the bladder. Increasingly, nursing journals include an evidence-based or research column to help nurses keep abreast of developments in their field. Some specialty organizations also sponsor grants for members to conduct research. Nurses should keep up their membership in professional organizations to gain access to these excellent evidence-based practice resources.
Starting an evidence-based work culture
Nurses cannot assume that other healthcare professionals, including physicians, know the most recent evidence because such a large volume of data is being disseminated. For example, when a group of nurses was working on two nursing EBP projects, alcohol withdrawal preprinted order sets and a sedation assessment scale for ICU patients, it was discovered that physicians often did not use the same evidence.

Nurses initiated the searches for evidence, and after months of journal clubs and the examination of other sources of evidence, including benchmarking data, the collaboration resulted in evidence-based order sets. The practice teams collected pre- and post data, demonstrating improved outcomes for patients, safer care, and increased satisfaction for staff and providers.

These nurse-led evidence-based projects now monitor follow-up data to measure how the practice changes have been sustained. How were these projects accomplished? The teams functioned in a work environment that fostered EBP and encouraged nurses to question practice. Many institutions have advanced practice nurses to support the management of EBP projects and to guide clinical nurses eager to change practice in their organization. This type of data collection can and should be done by LPNs and LVNs, who work under the supervision of an RN or other healthcare provider. In long-term care facilities, the RN is often immersed in managerial tasks while the LPN performs most care for residents. LPNs/LVNs are a vital part of the healthcare team in an ever-changing healthcare environment, and whether working in long-term care, home care, or an acute care facility, they are on the front line to provide data that contribute to evidence-based practice.12 Steps to an evidence-based approach:
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Strategies for evidence-based practice
Activities to support EBP include forming journal clubs, conducting sessions to teach staff nurses about evidence-based practice, integrating evidence-based practice into the philosophy of nursing care and nursing job descriptions, and building policies and procedures to be evidence-based using both references and levels of evidence to document the strength of the evidence.

Orientation on evidence-based practice should be provided for new nursing employees, and all professional nurses should complete an annual evidence-based practice skill competency. Learning how to examine the evidence is an important aspect of patient care and deserves time spent on education. Engaging and involving clinical nurses, who represent their units and services, on evidence-based champion teams, such as pain, falls, palliative care, and skin care, leads them to become champions for best practices for these clinical issues. EBP newsletters can help to keep staff updated on EBP activities and projects. Research shows that administrative support is key to developing a work environment that supports EBP.17 Nurse managers need to provide time and resources to encourage research utilization activities.17

While evidence-based activities are critical to transforming the institutional culture, the most important change needs to be the individual nurse’s views about research and evidence. If nurses think reviewing literature and other sources of evidence to implement evidence-based practice is an “add-on” to their practice, they may never fully understand or accept important practice changes.

Many nurses, unfortunately, were taught that research is not part of clinical practice. Practice based on evidence is the foundation for professional nursing practice, not an activity reserved for specialists. Nurses’ actions make a difference daily in patient outcomes. Major regulatory agencies and healthcare payer groups are now examining nurse-sensitive indicators, such as pressure ulcers, falls, and restraint use, to benchmark outcomes of nursing care and use this data to determine institutional reimbursement.
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Levels of evidence
Level and quality of evidence
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Meta-analysis or a systematic review of multiple controlled studies or clinical trials
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Individual experimental studies with randomization
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Quasi-experimental studies, such as nonrandomized, controlled, single group, pre-post cohort, time series, or matched case-controlled studies
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Nonexperimental studies, such as comparative and correlational descriptive research, as well as qualitative studies
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Program evaluation, research utilization, quality-improvement projects, case reports (The Joint Commission’s sentinel event reports), or benchmarking studies (National Database of Nursing Quality Indicators data, University Health System Consortium reports)
Type of evidence
Opinions of respected authorities or the opinions of expert committees, including their interpretation of nonresearch-based information. This includes textbooks and clinical product guidelines.
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Sue handles this unusual medical order:
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Appropriately — all one can do is laugh with such a weird order
Less than adequately. Sue should have immediately refused to administer the gum because it was not in the drug manual or textbook used as a reference
Less than adequately. Sue should have at least asked the pharmacist if he or she knew why gum was ordered so she knew the rationale and what to expect post-administration
a.
b.
c.
d.
It doesn’t matter because gum is a harmless substance. It does not make a difference in outcome
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Sue receives a second postop patient with this diagnosis, who also has an order for gum to be chewed, with the same directions. She suddenly realizes there is a pattern of treatment here that she knows nothing about. The best action Sue can take is:
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a.
Ask her nurse manager
b.
Search for the evidence herself to take responsibility for learning about this treatment modality
c.
Ask peers if they have heard or read anything about gum being prescribed for patients
d.
Wait for another patient with that treatment because two patients really does not mean it is a pattern
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Sue finds an article in a journal about gum chewing and its effect on GI tract motility in patients with this diagnosis. The article informs her that chewing gum postoperatively can speed recovery by stimulating bowel motility. She realizes she and the staff have reacted the way they did because:
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a.
Chewing gum distracts patients so they don’t think about pain
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Gum chewing makes the patients feel more at home in the hospital
c.
They did not know the reason and acted like it was a joke
d.
Chewing gum is a fun order that brings some humor to patient care
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Sue realizes her peers need this information because they all thought the medical order was a joke, but she is not sure how strong the evidence is for this practice. The most effective way to evaluate the strength of the evidence is to:
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Send an email to peers telling them about the procedure, regardless of level of evidence
b.
Tell peers on a one-to-one basis about the new protocol
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Wait to gain approval from the physician before adding this to standards of care
d.
Search for more evidence, then organize journal clubs so staff can participate in evaluating the evidence, and then discuss the findings with the physician
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Answers
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ANSWERS:
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Evidence-based practice encourages participation of the nurse to search for the evidence. Whenever there is a question about an order, the nurse should gather information and share that information with other coworkers. Journal clubs are an excellent forum for sharing new findings with the other nursing staff.
b.
Nurses are instrumental in providing evidence-based care. Searching for the evidence will foster skills necessary to learn about new treatment modalities.
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Research can be fun and exciting. Although nontraditional treatment modalities may appear unusual, to provide evidence-based care, nurses must determine the reason behind the order.
d.
Determining the strength of the evidence is an important step in providing evidence-based care. Searching for evidence, organizing journal clubs, and evaluating the evidence helps determine whether the practice is supported by research. After involving the physicians, an informed decision can be made about the practice.
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Clinical vignette
Scenario:
Sue is a clinical nurse on a medical/surgical unit. One day she takes a physician’s order for a postop patient who had elective open sigmoid colectomy surgery. The order says, “Administer one stick of sugarless gum 3x qd; pt must chew gum for one hr.” Sue is puzzled: Why would the physician order gum to be chewed three times a day? The physician is not available for consultation.

She orders the gum from the pharmacy per hospital procedure after discussion with her charge nurse because they were not sure this should be considered a medication. She is truly puzzled; why would such an unusual order be written? She and her peers laugh, and it becomes a joke on the unit. When the patient asks the RN why he is receiving chewing gum, Sue is at a loss for words. She laughs, and says, “You’ll have to ask your physician.”
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How to earn continuing education
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THIS COURSE IS 1 CONTACT HOUR
1.
Read the Continuing Education article.
2.
Go online to Nurse.com/CE to take the test for $12. If you are an Unlimited CE subscriber, you can take this test at no additional charge. You can sign up for an Unlimited CE membership at Nurse.com/UnlimitedCE for $49.95 per year.
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If the course you have chosen to take includes a clinical vignette, you will be asked to review the vignette and answer 3 or 4 questions. You must answer all questions correctly to proceed. If you answer a question incorrectly, we will provide a clue to the correct answer.
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Once you successfully complete the short test associated with the clinical vignette (if there is one), proceed to the course posttest. To earn contact hours, you must achieve a score of 75%. You may retake the test as many times as necessary to pass the test.
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All users must complete the evaluation process to complete the course. You will be able to view a certificate on screen and print or save it for your records.
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Accredited
OnCourse Learning is accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME), to provide continuing education for the healthcare team.

OnCourse Learning is also accredited by the Florida Board of Nursing and the District of Columbia Board of Nursing (provider # 50-1489). OnCourse Learning’s continuing education courses are accepted by the Georgia Board of Nursing. OnCourse Learning is approved by the California Board of Registered Nursing, provider # CEP16588.
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editors-noteEDITOR’S NOTE: Mary Krugman, PhD, RN, FAAN, the original author of this educational activity, has not had an opportunity to influence the content of this version. Maureen Habel, RN, MA, and Margi J. Schultz, PhD, MSN, RN, CNE, past authors of this educational activity, have not had an opportunity to influence the content of this version. Anna Ver Hage, MSN, AGACNP, CCRN, CNRN, is a nurse practitioner in the division of stroke and neurological critical care at Banner Desert Medical Center in Mesa, AZ. She has authored numerous articles on stroke and coauthored national guidelines on the care of the neuroscience patient.
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Consumers expect that nurses will anticipate care problems to keep them safe and prevent adverse outcomes. A growing body of literature documents how medical response teams make a difference in patient morbidity and mortality by recognizing prearrest conditions and acting on a change in patient condition immediately.18,19 (Level B) Reducing errors and keeping patients safe is a national initiative. Care needs to be delivered using evidence combined with careful patient surveillance.
The role of the LPN/LVN in evidence-based care is especially apparent in the examples related to pressure ulcers, falls, and safety issues. The LPN/LVN is often the first to recognize signs of impaired skin integrity, confusion, incontinence, and other issues that affect the safety of the patient.

The LPN must observe, record, and report changes that may have a significant impact on patient outcomes. In fact, data collection is one of the primary roles of the LPN/LVN. It’s the responsibility of the LPN/LVN to participate in the development of policy change and new protocols to meet the needs of all patients. LPNs/LVNs are an integral part of the healthcare team and should participate in the changes that occur with evidence-based nursing care.20 Patients depend on us to deliver the best care possible. Nurses need to assume accountability for practice by continually learning to fulfill our professional responsibilities. Basing practice on evidence is essential for safe nursing practice and the future of our profession.
1. Identify a clinical problem or issue bothering you or other nurses
Good clinical problems to tackle are those involving patient populations that team members feel are clinically challenging or find difficult to care for safely. Nurses practicing in all settings have clinical issues they find frustrating. These are often called “burning clinical questions.”7
2. Search for the evidence, using databases applicable to your problem
Some databases are by subscription only, but Medline can be accessed easily and is available at www.nlm.nih.gov/portals/healthcare.html. Many hospitals offer employees free access to online resources such as PubMed or Up-to-Date. If you need help to search the literature and don’t have easily accessible resources, try a free online tutorial.
3. Start a journal club to analyze the evidence
Nurses can hold journal club sessions to review articles pertinent to their practice. Journal clubs are essential to keep professional practice current and to sustain the culture of EBP. Nurses should be encouraged to hold journal clubs monthly or quarterly to keep up on practice changes, with clinical staff nurses taking turns learning how to lead sessions under the guidance of clinical nurse specialists/educators and research nurse scientists. Float pool and off-shift nurses should be included in journal clubs. There is always a way to hold a journal club!

Encouraging a culture that embraces evidence-based practice requires education about how these practices can improve patient care and patient outcomes.13 Nurses can be taught about how to facilitate a journal club through an online program of instruction using PowerPoint, formal classes and written material.

Journal clubs have the advantage of bringing together nurses from a similar specialty who have multiple views and various years of clinical experience. Participants use quantitative and qualitative critique forms to sharpen their critical thinking skills when reviewing the literature to prepare for journal club discussions. Contact a local nursing college to help conduct journal clubs if this activity seems too challenging to tackle alone at your place of work.
4. Analyze the strength of the literature
Is the evidence sufficiently reliable and valid to change practice? Decisions based on journal club review need to be based on the strength of the evidence. This can be challenging. Five key questions one expert suggests asking are:2 (Level B)
  • Is the research relevant?
  • Can the research be applied to a broader population?
  • Did the intervention do more good than harm?
  • What outcomes were studied?
  • How large an effect did the study show, using statistical tests of significance?
An account of an outcome affecting one patient, such as a case study, will have far less strength than several studies with large sample sizes. A chart (such as the one below) can help determine the level of evidence.7,14
5. Use the strength of evidence to determine the next steps
If the evidence clearly supports a practice change, decide the best method for the change process. Who are the stakeholders? Who needs to become involved to “own” the change? If it’s a nursing practice change, such as flushing lines with saline rather than heparin, nurses can initiate change using the quality improvement process in their institutions.

Partners would include physicians and pharmacy. If analysis of the evidence indicates insufficient strength exists, it may be prudent to go back and re-review the evidence or consider broadening the scope to find resources to initiate your own institutional study of the problem. It may be helpful to consult an algorithm developed by research experts to help with the next steps.

In the above example of alcohol withdrawal and the sedation scale, the evidence was clear that these were valid and reliable assessment instruments that could be implemented for safer patient care. In a different example, a handful of nurses were interested in the issue of family presence during resuscitation procedures.

The nurses reviewed research articles, but some staff members were uncomfortable with having family members present during codes and other emergency procedures. Journal clubs were held (many of them multidisciplinary) across the hospital to discuss the evidence. Because of the degree of controversy, research was conducted by surveying nurses, physicians and families to assess their perceptions of family presence during resuscitation.

Based on this internal survey data, one unit then began to initiate the practice change as a pilot project. This was later implemented as a guideline across the institution. Units implementing the guideline reported excellent results.15 (Level B) This project demonstrates how the views of leadership influence the readiness to implement evidence, which is a challenge when creating an evidence-based practice environment.
6. Make the practice change
In the case of the alcohol withdrawal and sedation assessment evidence-based changes, when the preliminary nursing review of the evidence indicated enough strength for practice change, a team was formed, including physicians, pharmacists, and nurses, to plan practice changes. These changes included new standards of care, staff education with competency verification, and the development of preprinted medical orders.

The hospital quality model, FOCUS-PDCA (Plan, Do, Check, Act), was used to make and sustain the change.16,17 Evidence-based projects enhance nurses’ professional development, for they not only learn about evidence-based practice directly, but also exercise leadership skills by co-leading journal clubs, writing new evidence-based nursing standards of care, collaborating with physicians and other disciplines on draft orders, holding in-services to teach peers about the practice changes, coaching staff, and conducting audits.

Seeking collaborative partners to make EBP changes ensures that all team members reach consensus on the evidence and process.
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Follow the evidence
Earn 1 credit hour with this continuing education course
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Contents
HOME
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Get to the root of it
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Master the basics of EBP and learn how to start your own project.
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Research seeds practice
Turn a patient care idea into evidence-based practice by starting with solid research.
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Fuel career satisfaction
Rejuvenate your career with new evidence that transforms old practices.
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EBP blasts make an impact
A nurse who manages six clinics successfully expands healthcare access and relieve congestion.
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CE Catalog
Boost your knowledge of evidence-based practice processes in various settings with these education offerings.
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Self-care is a safety issue
Nurses who work nights or rotating shifts can suffer from sleep deprivation, which negatively impact their health and puts patients at risk.
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Create a dream team
Interprofessional collaboration and care has the potential improve outcomes and processes.
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Follow the evidence
You know EBP is important; now grasp the strategies and thought processes behind it by taking this CE module.
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Pregame practice for students
Nursing students are being taught the importance of providing high-quality care that’s supported by evidence.
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TeamSTEPPS improves communication
TeamSTEPPS was created as a nursing strategy to improve patient safety. Learn how the model took shape.
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Elevate your care
Learn why evidence-based practice is a must when it comes to quality patient care.
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Hold the power for change
Bedside nurses have the ability to make significant practice changes in the workplace.
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Making the grade
Use your critical thinking skills to continue to reevaluate evidence and adjust EBP, if necessary.
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Protect them from pain
Age-appropriate EBP helped nurses reduce pain levels in their young patients.
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The journey continues
Nurse leaders have the difficult task of increasing participationin EBP, but they know it’s worth the effort.
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An unacceptable risk
Perioperative nurses are striving to decrease the risk of hospital-acquired pressure ulcers.
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Training days
Managing the healthcare of specific patient populations using EBP to drive clinical decision making has become a necessity.
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Patient care gets revamped
Cancer center uses evidence-based studies and patient input to make changes to bedside reporting, elevate patient safety and improve care.
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