What is Evidence-Based Practice?

Article Outline

• Copyright

There is not a day that goes by that the words “evidence-based practice” are not heard in the neonatal intensive care unit (NICU). The difficulty is, however, that the words invoke a variety of feelings such as fear, confusion, resentment, and the perception that the practice is reserved for a select few that usually excludes nurses. Furthermore, the words evidence-based practice imply that clinical judgement has no place in the NICU, and decisions are in someway driven by large randomized control studies with evidence presented in the form of statistical values and multiple references. These myths, however, are far from the truth and require a concerted effort by clinicians, researchers, and educators to dispel their existence. Evidence-based practice is the conscientious, explicit, and judicious use of current best evidence in making decisions about patient care. The practice does not exclude clinical expertise but rather challenges professionals to integrate their knowledge with the best available research. Evidence-based practice has existed for decades, and the emergence of workshops, teaching programs, undergraduate courses, and journals specific to evidence-based reviews suggest that the interest is growing. It is therefore essential that health care professionals understand what evidence-based practice is and what it is not.

Evidence comes in a variety of formats depending on the specific questions asked. The key is to determine how and when the evidence was derived, and how close the evidence is to the truth about the clinical situation. Not all studies have been executed without flaw, and the astute clinician needs to be critical in their interpretation of the results. Clinicians and specifically nurses must never lose sight of the clinical situation at hand. Extrapolating information from different populations may be appropriate when no information is available, such as what nursing interventions are required for an infant and family with a rare genetic disorder. However, the practice of extrapolation may be detrimental if the population is vastly different from the one of interest, such as managing pain of extremely low-birth-weight infants based on data derived from term infants. Evidence-based practice, traditionally based on medical research, has been categorized into different types of evidence and ranks them according to their strength. Level (I) evidence is derived from a systematic review or at least one properly designed large randomized controlled trial, level (II) evidence is derived from nonrandomized cohort studies, level (III) evidence is derived from case-control studies preferably from more than one center or research group, level (IV) evidence is derived from case series, and lastly, level (V) evidence comes from expert opinion based on physiology, bench research, or consensus statements. Although these levels are considered the gold standard for evidence-based practice, they do not apply to different types of research nor are they relevant to the many clinical issues that arise in the NICU.

Nurses are in an optimal position to identify clinically relevant questions and have the knowledge and skills to determine the best approach to management. As experts, we need to ask ourselves what is the best evidence? If the best evidence to a specific clinical issue is derived from a qualitative study, then the information should be considered as valuable as results from drug trials determining the optimal dose of a certain antibiotic. The growing appreciation for different types of research (qualitative, survey, population-based) and the recognition that interdisciplinary research yields important results suggests that a new level of ranking evidence is required. There is no doubt that certain questions must be addressed by well-designed large randomized control studies and decision making surrounding these issues should reflect the results as they apply to the clinical situation. Some examples of evidence-based practices that have now become standards of care include the promotion of nonnutritive sucking for weight gain and the administration of sucrose for procedural pain relief. If nurses are to be in a position to promote evidence based care, they must be provided with opportunities to understand the evidence-based review process. Nurses need to know how to (a) find these studies, (b) interpret the results, and (c) apply them to daily practice. As long as the myths that evidence-based practice is reserved for an elite group are perpetuated, nurses will be at a disadvantage. More important, clinical issues that do not fall into the traditional levels of care are at risk for being overlooked. As key members of the health care team, nurses can combine their art of nursing with an appreciation of many different types of evidence. A systematic approach to reviewing the evidence is the most important mandate for evidence-based practice. The level of evidence is only as important as the clinical situation and related management question.

This journal is dedicated to evidence-based practice related to the care of high-risk infants. Each article focuses on nursing interventions to minimize immediate and long-term morbidity. Practice guidelines for the management of the infant with necrotizing enterocolitis or those exposed to selective serotonin reuptake inhibitors or human immunedeficiency virus during pregnancy are reviewed. As well, approaches to feeding high-risk infants and providing bereavement care in the NICU are presented within the context of best evidence. It is our hope that the enclosed articles provide neonatal nurses with the courage to ask the difficult questions and challenge practices that have little or conflicting evidence. We believe that we should not abandon the discussion of evidence-based practice simply because the level of evidence was not derived from large studies. We believe that it is the responsibility of all nurses to determine if the level of evidence is sufficient for the clinical situation and whether further research is required before evidence-based care can be touted. A thorough review of the existing literature coupled with clinical judgement should always be considered in the determination of best evidence.

Poll question: Does your unit provide opportunities for nurses to understand the research process including where to find the results, how to interpret the results, and how to conduct research if interested?