Evaluating the evidence: web sites

AORN Journal,  Jan, 2008  by Brenda Hoss,  Diane Hanson

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The Institute of Medicine advocates the use of evidence-based practice (EBP) as a means of improving patient safety, efficiency, and the effectiveness of health care, (1) but researchers are discovering significant gaps in practicing nurses' skills in identifying, accessing, retrieving, evaluating, or utilizing published evidence. (2) The 2004 National Sample Survey of Registered Nurses showed that more than 60% of practicing nurses graduated from their initial nursing education program prior to the 1990s when desktop computer access became common in health care settings. (3) In addition, nearly two-thirds of nurses received their initial nursing education in non-baccalaureate programs where research and informatics were not required components of the curriculum. (4)

According to Pravicoff et al, (5) the discipline of nursing demands professional practice that is based on up-to-date information. Health care providers, however, may be unprepared to meet this information demand. This creates a significant dilemma. This article will help bridge the gap between research and practice by helping perioperative nurses become effective and efficient users of Internet information resources.

LEVELS OF EVIDENCE

Currently, EBP is the dominant philosophical approach for quality medical care because empirical evidence suggests that EBP improves patient outcomes. It evolved during the 1990s from the work of British epidemiologist Archibald L. Cochrane, CBE, FRCP, FFCM, and a clinical learning strategy initiated at McMaster University School of Medicine, Hamilton, Ontario, Canada. (6) Evidence-based practice is a process quite similar to the nursing process with the addition of a step between assessment and planning that includes searching for, finding, and evaluating pertinent evidence to answer defined clinical questions. (5)

Evidence-based practice techniques create hierarchies to indicate the relative strength of published evidence. Medical evidence hierarchies usually include only research evidence. Meta-analysis of randomized clinical trials (ie, phase III trials) is placed at the top of the hierarchy, and nonexperimental research is placed at the bottom. This focus on research evidence exclusively is not without its critics. Currently, authors define EBP broadly, calling for integration of clinical expertise and patient values with the best research evidence. (7-9)

In comparison, when nurses develop scales for rating the strength of evidence, meta-analysis of randomized clinical trials also is placed at the highest tier of the hierarchy, but qualitative, experiential, and quality improvement (QI) evidence, is included on the lower end of the scale. (10) Evidence-based nursing thoughtfully considers anecdotal case reports, QI data, and the opinions of experts, especially when expertise is needed from another health care discipline or biomedical technology vendor. Table I shows an example of a strength-of-evidence hierarchy used by interdisciplinary content development teams.

[FIGURE 1 OMITTED]

OVERCOMING BARRIERS TO EBP

Research has identified multiple organizational barriers to EBP, including lack of administrative support, lack of time for integrative review of evidence, and lack of access to resources (eg, the Internet, library resources, librarians). (5,11-15) In the United States, these organizational barriers are being addressed by national efforts of the American Organization of Nurse Executives (16) (Figure 1) and the US Congress. (17) The evidence linking nursing care to quality patient outcomes is inspiring nurse executives to allocate resources to provide an information technology (IT) infrastructure in support of evidence-based nursing practice. Endorsing this trend, several bills advocating health IT as a method for reducing medical errors and improving patient safety were introduced in the 109th Congress of the United States. (17) If passed, these bills will provide significant sources of grant funding for decision-support software. It is anticipated, therefore, that IT infrastructure in the form of networked computer hardware and clinical decision-support software will be more commonly available to clinical staff members in ORs in the United States in the future.

INDIVIDUAL BARRIERS

Data published in 2005 indicate that approximately half of US clinical nursing staff members already have access to the Internet on nursing units; however, many nurses seldom or never use it to obtain nursing information. (5) Individual barriers limiting nurses' use of EBP techniques include

* lack of knowledge (eg, formal education in research and informatics);

* resistance;

* closed minds (eg, "we have always done it this way"); and

* lack of a mentor. (11)

In general, nurses educated before 1990 or nurses whose formal education ended with less than a baccalaureate degree have little experience conducting independent literature searches. (18)

With the aging nursing workforce and efforts to quickly educate new nurses to enter practice, (3) the barriers to using EBP are formidable. In a purposive study of older perioperative nurses, one respondent older than 50 years of age lamented the loss of the educator role in her workplace. She commented, "Our education programs are all [computer-based]. That's great, but who are these young girls going to ask a question of?" (19) The answer is clear: nurses must learn to use IT resources to efficiently search the published evidence.