The APRN’s Secret Weapon: Evidence-Based Practice for Superior Care

EVIDENCE-BASED PRACTICE AND THE APRN

The Four-Step Process of Identifying Evidence

Historically, the process of identifying and determining evidence-based practice (EBP) has been defined by a formal, four-step approach. This model continues to be the cornerstone of EBP, offering a structured path for APRNs to integrate current best evidence into their practice. The steps are as follows:

1. Formulation of a Clinical Question: APRNs begin by identifying a clinical issue or query that requires evidence-based intervention. This involves pinpointing specific questions that need answers to guide patient care decisions.

2. Identification and Retrieval of Pertinent Research Findings: After formulating the question, the next step involves a thorough literature review to identify relevant studies and evidence. This step is crucial as it forms the foundation of the EBP process.

3. Critical Appraisal and Data Extraction: Once relevant studies are identified, APRNs must critically appraise the evidence to determine its validity and applicability to their practice. Data is extracted from these studies to inform clinical decisions.

4. Clinical Decision-Making Based on Evidence: Finally, APRNs use the appraised evidence to make informed clinical decisions. This involves integrating research findings with clinical expertise and patient preferences to ensure the best outcomes.

These steps act as a template for incorporating current best evidence into practice and are essential for developing clinical practice guidelines and related EBP resources.

Principles Guiding Clinical Decision-Making

The principles of EBP serve as a guide for APRNs in making clinical decisions for individual patients, creating policies and procedures that influence practice on a broader level, and determining care policies for large patient groups. Despite the widespread acceptance of EBP, the adoption of best evidence in daily practice remains limited.

For instance, a study on the adherence to the American College of Cardiology and American Heart Association Guidelines for perioperative assessment of patients with hip fractures found that over 90% of clinicians overscreened patients for cardiovascular comorbidities. This practice led to delays in surgery, increased perioperative complications, and early mortality (Smeets et al., 2020).

Similarly, a study involving 850 children from school-based health centers revealed that key health indicators like body mass index and blood pressure were often not recorded, despite recommendations from a multidisciplinary expert panel (Gance-Cleveland et al., 2015). These examples highlight the gap between evidence-based guidelines and actual practice, emphasizing the need for greater integration of EBP into clinical routines.

Levels of Advanced Practice Nurse Competency in EBP

APRN competency in EBP can be divided into three levels, each reflecting a different degree of involvement in evidence-based practice.

Level I: Use of Evidence in Individual APRN Practice

• Fundamental Level: APRNs at this level incorporate EBP principles into their individual clinical practice, ensuring that patient care decisions are informed by the best available evidence.
• Expanded Level: At this level, APRNs extend their use of EBP principles beyond individual practice to influence policies on a unit, clinic, department, facility, or health system level. This may involve participating in interdisciplinary teams to formulate best practice guidelines.

Level II: Use of Evidence to Change Practice

• Fundamental Level: APRNs incorporate best practice changes according to EBP principles into their practice or mentor front-line staff in implementing these changes.
• Expanded Level: At this level, APRNs design and implement processes to change practice beyond the scope of individual care, influencing unit-wide, clinic-wide, or even national practice standards.

Level III: Use of Evidence to Evaluate Practice

• Fundamental Level: APRNs identify benchmarks to evaluate their own practice or participate in the evaluation of front-line nursing and other clinical staff practices.
• Expanded Level: APRNs design and implement processes to evaluate outcomes of practice on a broader scale, such as group APRN practice or interdisciplinary team practice across facilities or health systems.

Interpretation and Use of EBP in Clinical Decision Making

At the most fundamental level, APRNs must apply the four-step EBP process to individual patient care decisions. This involves not only formulating a clinical question and identifying pertinent studies but also integrating the best evidence with an understanding of patient-specific factors.

For example, an APRN in a urology department might frequently encounter questions about the efficacy of cranberry juice or supplements in preventing urinary tract infections (UTIs). By conducting a systematic literature review and critically appraising the evidence, the APRN can make an informed decision. Although recent studies have questioned the efficacy of cranberry products, the absence of harm and patient preference for natural remedies might lead the APRN to continue recommending cranberry juice as part of a broader UTI prevention strategy.

This example underscores the importance of staying current with emerging evidence and recognizing the role of patient preferences in clinical decision-making.

EBP and the Creation of Policies for Patient Care

At a more advanced level, APRNs use EBP to create policies and protocols that prevent adverse events and improve patient outcomes. For instance, the implementation of rapid response teams in hospitals has been guided by evidence showing their effectiveness in reducing cardiac arrests and unplanned ICU admissions.

To develop such policies, APRNs must engage stakeholders, secure administrative support, and educate staff about changes in care protocols. This process illustrates the translation of research-based evidence into practical, facility-wide interventions that enhance patient care.

Evaluation of EBP to Determine Standards of Care

The highest level of EBP competency involves participating in interdisciplinary teams to evaluate and determine standards of care. This often requires APRNs to develop evidence-based clinical practice guidelines that address broad areas of patient care.

For example, an APRN task force might be charged with creating an algorithm for the use of compression in managing chronic venous insufficiency (CVI) and venous leg ulcers (VLUs). This process would involve generating clinical questions, conducting a comprehensive literature review, and developing guidelines that incorporate both evidence-based and best practice recommendations. The resulting guidelines would be validated by a multidisciplinary team and adapted for use in various clinical settings.

FAQs on Evidence-Based Practice and the APRN

What is the role of APRNs in evidence-based practice? APRNs play a crucial role in integrating evidence-based practice into patient care. They are responsible for formulating clinical questions, critically appraising research, and applying evidence to guide clinical decisions and develop policies.

Why is evidence-based practice important for APRNs? EBP ensures that patient care is informed by the best available evidence, leading to better patient outcomes. It also encourages continuous learning and improvement in clinical practice.

How do APRNs stay updated with the latest evidence? APRNs can stay updated by regularly reviewing literature from reputable sources such as the Cochrane Database of Systematic Reviews and professional society guidelines. Attending conferences and participating in continuing education also helps APRNs keep abreast of new evidence.

What are the challenges in implementing evidence-based practice? Challenges include limited access to up-to-date research, time constraints, and resistance to change among healthcare providers. Additionally, there may be a lack of resources or support for implementing EBP in some settings.

How can APRNs overcome barriers to evidence-based practice? Overcoming barriers requires a commitment to lifelong learning, collaboration with colleagues, and advocacy for resources and support. APRNs can also mentor other healthcare providers in EBP principles and processes.