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Names: Melnyk, Bernadette Mazurek, author. Title: Evidence-based practice in nursing & healthcare : a guide to best

practice / Bernadette Mazurek Melnyk, PhD, RN, APRN-CNP, FAANP, FNAP, FAAN, Vice President for Health Promotion, University Chief Wellness Officer, Dean and Professor, College of Nursing, Professor of Pediatrics & Psychiatry, College of Medicine, The Ohio State University, Editor, Worldviews on Evidence-Based Nursing, Ellen Fineout-Overholt, PhD, RN, FNAP, FAAN, Mary Coulter Dowdy Distinguished Professor of Nursing, College of Nursing & Health Sciences, University of Texas at Tyler, Editorial Board, Worldviews on Evidence-Based Nursing, Editorial Board, Research in Nursing & Health.

Other titles: Evidence-based practice in nursing and healthcare Description: Fourth edition. | Philadelphia : Wolters Kluwer Health, [2019] |

Includes bibliographical references. Identifiers: LCCN 2018032178 | eISBN 9781496386892 Subjects: LCSH: Evidence-based nursing—Practice. | Nurse

practitioners—Practice. Classification: LCC RT42 .M44 2019 | DDC 610.73—dc23 LC record available at https://lccn.loc.gov/2018032178

This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work.

This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data, and other factors unique to the patient. The publisher does not provide medical advice or guidance, and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments.

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I dedicate this book to my loving family, who has provided tremendous support to me in pursuing my dreams and passions: my husband, John; and my three daughters, Kaylin, Angela, and Megan; as well as to my father, who always taught me that anything can be accomplished with a spirit of enthusiasm and determination, and my sister Chris, who taught me to “just get out there and do it!” It is also dedicated to all of the committed healthcare providers and clinicians who strive every day to deliver the highest quality of evidence-based care.

Bernadette Mazurek Melnyk

For Rachael and Ruth, my precious daughters who are my daily inspiration. May you have the kind of healthcare you deserve—evidence- based with demonstrated reliable outcomes that is delivered by conscientious care providers who intentionally incorporate your preferences into your care. For my dear husband, Wayne, and my sweet Mom, Virginia Fineout, from whom I learn so much about how healthcare could/should be. Finally, this edition is dedicated to all care providers in primary care, community/public health, and at point of care in acute and long-term care who diligently seek to consistently deliver evidence-based care.

Ellen Fineout-Overholt

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Contributors

Anne W. Alexandrov, PhD, RN, AGACNP-BC, CNS, ANVP-BC, NVRN-BC, CCRN, FAAN

Professor of Nursing and Neurology Acute, Critical Care and Department of Neurology Chief Nurse Practitioner UTHSC Memphis Mobile Stroke Unit University of Tennessee Health Science Center at Memphis Memphis, Tennessee

Karen Balakas, PhD, RN, CNE

Retired Director of Research & EBP St. Louis Children’s Hospital & Missouri Baptist Medical Center St. Louis, Missouri

Cecily L. Betz, PhD, RN, FAAN

Professor Department of Pediatrics University of Southern California Keck School of Medicine General Pediatrics Children’s Hospital Los Angeles Los Angeles, California

Cheryl L. Boyd, PhD, MSN, RN

Adjunct Assistant Professor College of Nursing The Ohio State University Director Professional Development Nationwide Children’s Hospital Columbus, Ohio

Barbara B. Brewer, PhD, RN, MALS, MBA, FAAN

Associate Professor College of Nursing The University of Arizona Tucson, Arizona

Tracy L. Brewer, DNP, RNC-OB, CLC

Clinical Professor College of Nursing

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University of Tennessee-Knoxville Knoxville, Tennessee

Terri L. Brown, MSN, RN, CPN

Clinical Specialist Quality and Safety Texas Children’s Hospital Houston, Texas

Jacalyn S. Buck, PhD, RN, NEA-BC

Administrator Health System Nursing ACNO Medical Surgical and Women and Infants Nursing Health System Nursing Medical Surgical and Women and Infants Nursing The Ohio State University Wexner Medical Center Columbus, Ohio

Emily Caldwell, MS

Media Relations Manager University Communications/Office of the President The Ohio State University Columbus, Ohio

Katie Choy, DNP, RN, CNS, NEA-BC, RN-BC

Consultant Nursing Practice and Education San Jose, California

Denise Cote-Arsenault, PhD, RN, CPLC, FNAP, FAAN

Eloise R. Lewis Excellence Professor School of Nursing University of North Carolina Greensboro Greensboro, North Carolina

John F. Cox III, MD

Associate Professor of Clinical Medicine Department of Medicine Primary Care Physicians School of Medicine & Dentistry University of Rochester Internist, Clinton Medical Associates Rochester, New York

Laura Cullen, DNP, RN, FAAN

Adjunct Faculty

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University of Iowa College of Nursing University of Iowa EBP Scientist Office of Nursing Research, EBP and Quality Department of Nursing and Patient Care Services University of Iowa Hospitals and Clinics Iowa City, Iowa

Maria Cvach, DNP, RN, FAAN

Assistant Director Nursing, Clinical Standards The Johns Hopkins Hospital Baltimore, Maryland

Deborah Dang, PhD, RN, NEA-BC

Graduate School of Nursing Johns Hopkins University Director of Nursing, Practice, Education, & Research Central Nursing Administration The Johns Hopkins Hospital Baltimore, Maryland

Lynn Gallagher-Ford, PhD, RN, DPFNAP, NE-BC, FAAN

Senior Director Director, Clinical Core The Helene Fuld Institute for Evidence-based Practice in Nursing and Healthcare College of Nursing The Ohio State University Columbus, Ohio

Martha J. Giggleman, RN, DNP

Consultant Evidence-based Practice Livermore, California

Doris Grinspun, RN, MSN, PhD, LLD (hon), Dr (hc), O.ONT

Adjunct Professor Lawrence S. Bloomberg Faculty of Nursing University of Toronto Chief Executive Officer Registered Nurses’ Association of Ontario (RNAO) Toronto, Ontario

Tami A. Hartzell, MLS

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Senior Librarian Werner Medical Library Rochester General Hospital Rochester, New York

Marilyn J. Hockenberry, PhD, RN, PPCNP-BC, FAAN

Associate Dean for Research Affairs Bessie Baker Professor of Nursing Center for Nursing Research Duke University School of Nursing Durham, North Carolina

Robin Kretschman, HC-MBA, MSN, RN, NEA-BC

Vice President Clinical Business Strategic Operations Nursing Administration OSF HealthCare Peoria, Illinois

June H. Larabee, PhD, RN

Professor Emeritus West Virginia University and West Virginia University Hospitals Charleston, West Virginia

Lisa English Long, PhD, RN

Consultant Evidence-based Practice Cincinnati, Ohio

Jacqueline M. Loversidge, PhD, RNC-AWHC

Associate Professor of Clinical Nursing College of Nursing The Ohio State University Columbus, Ohio

Pamela Lusk, DNP, RN, PMHNP-BC, FAANP, FNAP

Associate Professor of Clinical Practice College of Nursing The Ohio State University Columbus, Ohio Psychiatric/Mental Health Nurse Practitioner Pediatrics Yavapai Regional Medical Center Prescott, Arizona

Tina L. Magers, PhD, MSN, RN-BC

Nursing Excellence and Research Coordinator

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Mississippi Baptist Medical Center Jackson, Mississippi

Kathy Malloch, PhD, MBA, RN, FAAN

Clinical Professor College of Nursing Ohio State University Columbus, Ohio

Mikki Meadows-Oliver, PhD, RN, FAAN

Associate Professor Department of Nursing Quinnipiac University School of Nursing North Haven, Connecticut

Dianne Morrison-Beedy, PhD, RN, WHNP, FNAP, FAANP, FAAN

Chief Talent & Global Strategy Officer Centennial Professor of Nursing College of Nursing The Ohio State University Columbus, Ohio

Dónal P. O’Mathúna, PhD

Associate Professor Fuld Institute for Evidence-based Practice College of Nursing The Ohio State University Columbus, Ohio Associate Professor School of Nursing & Human Sciences Dublin City University Glasnevin, Dublin 9, Ireland

Tim Porter-O’Grady, DM, EdD, APRN, FAAN, FACCWS

Clinical Professor School of Nursing Emory University Clinical Wound Specialist Street Medicine Program/Clinic Mercy Care of Atlanta Atlanta, Georgia

Cheryl C. Rodgers, PhD, MSN, BSN

Associate Professor Duke University School of Nursing

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Durham, North Carolina

Jo Rycroft-Malone, PhD, MSc, BSc(Hons), RN

Professor and Pro Vice-Chancellor Research & Impact School of Health Sciences Bangor University Bangor, United Kingdom

Alyce A. Schultz, RN, PhD, FAAN

Consultant Clinical Research and Evidence-based Practice Bozeman, Montana

Kathryn A. Smith, RN, MN, DrPH

Associate Professor of Clinical Pediatrics Department of Pediatrics Keck School of Medicine General Pediatrics Children’s Hospital Los Angeles Los Angeles, California

Cheryl B. Stetler, RN, PhD, FAAN

Retired Consultant

Kathleen R. Stevens, RN, MS, EdD, ANEF, FAAN

Castella Endowed Distinguished Professor School of Nursing University of Texas Health Science Center San Antonio San Antonio, Texas

Susan B. Stillwell, DNP, RN ANEF, FAAN

EBP Expert Mentor and Independent Consultant Vancouver, Washington

Timothy Tassa, MPS

Network for Excellence in Health Innovation Washington, District of Columbia

Amanda Thier, RN, MSN

Staff Nurse Specialty Care Unit Baylor University Medical Center Dallas, Texas

Kathleen M. Williamson, RN, PhD

Professor, Chair Wilson School of Nursing

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Midwestern State University Wichita Falls, Texas

Jennifer Yost, PhD, RN

Associate Professor M. Louise Fitzpatrick College of Nursing Villanova University Villanova, Pennsylvania

Cindy Zellefrow, DNP, MSEd, RN

Director, Academic Core and Assistant Professor of Practice The Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare at The Ohio State University

College of Nursing The Ohio State University Reynoldsburg, Ohio

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Reviewers

Ashley Leak Bryant, PhD, RN-BC, OCN Assistant Professor School of Nursing The University of North Carolina at Chapel Hill Clinical Nurse North Carolina Cancer Hospital UNC Healthcare UNC Lineberger Comprehensive Cancer Center Chapel Hill, North Carolina

Lynne E. Bryant, EdD, MSN, RN, CNE Professor Ron and Kathy Assaf College of Nursing Nova Southeastern University Fort Lauderdale, Florida

Mary Mites-Campbell, PhD Assistant Professor College of Nursing Nova Southeastern University Fort Lauderdale, Florida

Lisa Chaplin, RN, NP-C, DNP Assistant Professor Department of Advanced Practice Nursing School of Nursing and Health Studies Georgetown University Washington, District of Columbia

Karyn E. Holt, RN, PhD Director of Online Quality and Faculty Development and Clinical Professor College of Nursing and Health Professions Drexel University Philadelphia, Pennsylvania

Kathy James, DNSc Associate Professor of Nursing Department of Nursing University of San Diego San Diego, California

Lynette Landry, PhD, RN Professor and Chair, Nursing and Health Science Nursing Program California State University, Channel Islands Camarillo, California

Susan Mullaney, EdD

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Professor and Chair Department of Nursing Framingham State University Framingham, Massachusetts

Mary Ann Notarianni, PhD, RN Professor School of Nursing Sentara College of Health Sciences Chesapeake, Virginia

Doreen Radjenovic, PhD, ARNP Associate Professor School of Nursing, Brooks College of Health University of North Florida Jacksonville, Florida

Theresa Skybo, PhD, RN, CPNP Associate Professor Mt. Carmel College of Nursing Columbus, Ohio

Margaret (Peggy) Slota, DNP, RN, FAAN Associate Professor Director, DNP Graduate Studies School of Nursing and Health Studies Georgetown University Washington, District of Columbia

Ida L. Slusher, PhD (RN, PhD, CNE) Professor Baccalaureate & Graduate Nursing Eastern Kentucky University Richmond, Kentucky

Debbie Stayer, PhD, RN-BC, CCRN-K Assistant Professor Department of Nursing Bloomsburg University Bloomsburg, Pennsylvania

Ann Bernadette Tritak, RN, EdD, MA, BSN Professor and Associate Dean Department of Graduate Nursing Felician University Lodi, New Jersey

Supakit Wongwiwatthananukit, PharmD, MS, PhD Professor Pharmacy Practice The Daniel K. Inouye College of Pharmacy University of Hawai’i at Hilo Hilo, Hawaii

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Foreword

Like many of you, I have appreciated healthcare through a range of experiences and perspectives. As someone who has delivered healthcare as a combat medic, paramedic, nurse, and trauma surgeon, the value of evidence- based practice is clear to me. Knowing what questions to ask, how to carefully evaluate the responses, maximize the knowledge and use of empirical evidence, and provide the most effective clinical assessments and interventions are important assets for every healthcare professional. The quality of U.S. and global healthcare depends on clinicians being able to deliver on these and other best practices.

The Institute of Medicine (now the National Academy of Medicine) calls for all healthcare professionals to be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics. Although many practitioners support the use of evidence-based practice, and there are indications that our patients are better served when we apply evidence-based practice, there are challenges to successful implementation. One barrier is knowledge. Do we share a standard understanding of evidence-based practice and how such evidence can best be used? We need more textbooks and other references that clearly define and provide a standard approach to evidence-based practice.

Another significant challenge is the time between the publication of research findings and the translation of such information into practice. This challenge exists throughout public health. Determining the means of more rapidly moving from the brilliance that is our national medical research to applications that blend new science and compassionate care in our clinical systems is of interest to us all.

As healthcare professionals who currently use evidence-based practice, you recognize these challenges and others. Our patients benefit because we adopt, investigate, teach, and evaluate evidence-based practice. I encourage you to continue the excellent work to bring about greater understanding and a more generalizable approach to evidence-based practice.

Richard H. Carmona, MD, MPH, FACS

17th Surgeon General of the United States

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Preface

OVERVIEW OF THIS BOOK The evidence is irrefutable: evidence-based practice (EBP) is key to meeting the quadruple aim in healthcare. It improves the patient experience through providing quality care, enhances patient outcomes, reduces costs, and empowers clinicians, leading to higher job satisfaction. Although there are many published interventions/treatments that have resulted in positive outcomes for patients and healthcare systems, they are not being implemented in clinical practice. In addition, qualitative evidence is not readily incorporated into care. We wrote this book to address these issues and many others as well. We recommend that learners read this book, then read it again, engage in the online resources, the appendices, the glossary . . . then read it again. It is chock-full of information that can help learners of all disciplines, roles and educational levels discover how to be the best clinicians. We hope you find that EBP pearl that is just the right information you need to take the next step in your EBP journey to deliver the best care!

Purpose

The purpose of Evidence-Based Practice in Nursing and Healthcare has never changed. The purpose of this edition, as with the last three, is to incorporate what we have learned across the years to provide resources and information that can facilitate clinicians’ ready translation of research findings into practice, as well as their use of practice data to improve care and document important outcomes, no matter the clinician’s healthcare role. Each edition has provided additional features and resources for readers to use in their journey to become evidence-based clinicians. Since the first book was published, there has been some progress in the adoption of EBP as the standard of care; however, there is still much work to be done for EBP to the paradigm used in daily clinical decision making by point-of-care providers. Clinicians’ commitment to excellence in healthcare through the intentional integration of research findings into practice while including patients in decisions remains a daunting endeavor that will take anywhere from years to decades. Therefore, increased efforts across the healthcare industry are required to provide a culture that fosters empowered point-of-care clinicians with the knowledge, skills, attitudes, and resources they need to deliver care that demonstrates improved healthcare system, clinician, and patient outcomes.

We will always believe that anything is possible when you have a big dream and believe in your ability to accomplish that dream. It was the vision of transforming healthcare with EBP, in any setting, with one client– clinician encounter at a time and the belief that this can be the daily experience of both patients and care providers, along with our sheer persistence through many “character-building” experiences during the writing and editing of the book, that culminated in this user-friendly guide that aims to assist all healthcare professionals in the delivery of the highest quality, evidence-based care.

The fourth edition of this book has been revised to assist healthcare providers with implementing and sustaining EBP in their daily practices and to foster a deeper understanding of the principles of the EBP paradigm and process. In working with healthcare systems and clinicians throughout the nation and globe and

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conducting research on EBP, we have learned more about successful strategies to advance and sustain evidence-based care. The new material throughout the book, including new chapter material, a unit-by-unit EBP example, new chapters, EBP competencies, and tools to advance EBP, are included so that clinicians can use them to help with daily evidence-based decision making.

Worldview

A solid understanding of the EBP paradigm, or worldview, is the first mastery milestone for readers of this EBP book. The next milestone is using the paradigm as the foundation for making clinical decisions with patients. This worldview frames why rigorously following the steps of the EBP process is essential, clarifies misperceptions about implementing evidence-based care, and underpins practical action strategies that lead to sustainable evidence implementation at the point of care. It is our dream that the knowledge and understanding gained from thoughtfully and intentionally engaging the contents of this book will help clinicians across the country and globe accelerate adoption of the EBP paradigm until evidence-based care is the lived experience for clinicians, patients, and health professions students across various healthcare settings and educational institutions.

NEW FEATURES AND RESOURCES FOR THIS EDITION The book contains vital, usable, and relatable content for all levels of practitioners and learners, with key exemplars that bring to life the concepts within the chapters. Each unit now begins with “Making Connections: An EBP Exemplar.” This unfolding case study serves as a model or example of EBP in real-life practice. We recommend that learners read each unit exemplar before they engage in that unit’s content; the characters in the healthcare team in the exemplar use the information within the unit’s chapters to carry out the steps of EBP, leading to a real evidence-based change to improve the quality and safety of care. These characters may be fictional, but the exemplar is based on an important quality indicator (i.e., hospital falls) and an actual synthesis of published research that offers the opportunity for readers to better understand how they can use EBP in their clinical practice or educational setting to improve outcomes. Readers may wish to refer back to the exemplar as they are reading through the chapters to see how the healthcare team used the information they are learning. Furthermore, it is recommended that readers follow the team as they make evidence-based decisions across the units within the book. There are online resources as well as resources within the appendices of the book that will be used in the exemplar, offering readers the opportunity to see how the team uses these resources in evidence-based decision making.

Our unit-ending feature, “Making EBP Real: A Success Story,” has been updated and continues to provide real-life examples that help readers to see the principles of EBP applied. Readers can explore a variety of ways that the steps of the EBP process were used in real EBP implementations. Clinicians who desire to stimulate or lead change to a culture of EBP in their practice sites can discover in both of these unit-level features how functional models and practical strategies to introduce a change to EBP can occur, including overcoming barriers in implementing change, evaluating outcomes of change, and moving change to sustainability through making it standard of care.

To help recognize that knowledge and understanding of EBP terms and language is essential to adopting the EBP paradigm, in this edition, we added EBP Terms to Learn that features key terms at the beginning of

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each unit and chapter. Readers can review terms in the glossary before reading the chapters so that they can readily assimilate content. Furthermore, we have provided learning objectives at the unit and chapter level to continue to reinforce important concepts and offer the opportunity for readers to quickly identify key chapter content. When readers come across bolded terms within the chapter, they are encouraged to go to the glossary at back of the book to further explore that concept. EBP Fast Facts is an important feature at the end of each chapter that we retained for this edition, offering readers some of the most important pearls of wisdom from the chapter. These elements in our fourth edition will help learners master the terminology of EBP and identify important content for developing EBP competence.

Finally, for faculty, there is new content in the chapter on teaching EBP in academic settings that can help educators to parse teaching EBP across academic learning degrees. Educators are encouraged to review the online resources that can facilitate teaching EBP in both academic and clinical settings.

Further resources for all readers of the book include appendices that help learners master the process of evidence-based change, such as rapid critical appraisal checklists (be sure to check online on for Word versions of RCA checklists for readers to use), sample instruments to evaluate EBP in both educational and clinical settings, a template for asking PICOT questions, and more. Some appendices appear online only on

, including an appraisal guide for qualitative evidence, an ARCC model EBP mentor role description, and examples of a health policy brief, a press release, and an approved consent form for a study. More details about the great r