Evidence-based practice: AHRQ's role in generating and disseminating knowledge

AORN Journal,  Nov, 2007  by Margaret Coopey,  Mary P. Nix,  Carolyn M. Clancy

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Achieving evidence-based practice (EBP)--perhaps best defined as a problem solving approach to practice that involves the conscientious use of current best evidence in making decisions about patient care (1,2)--depends on a research-based body of knowledge. As in many settings and disciplines, evidence-based practice is being adopted and utilized in nursing.

The pursuit of knowledge driving EBP includes researching both what is efficacious and what is practical in the health care setting; to achieve evidence-based health care, research findings must be translated into information that can be implemented into care delivery and must be disseminated to the bedside clinician. Results from individual studies contribute to the overall body of knowledge, which provides the foundation for clinical practice guidelines and performance measures.

The Agency for Healthcare Research and Quality (AHRQ), as a federal funder of health services research, focuses on the development of evidence, synthesis of findings, dissemination and implementation of those findings, and evaluation of health care quality. The AHRQ also provides Internet-based repositories of clinical practice guidelines and performance measures. These components together comprise AHRQ's EBP endeavor, from generation of new knowledge to its practical application to evaluation of its effectiveness.

NEW KNOWLEDGE AND SYSTEMATIC REVIEWS

Since 1989 when the agency was established, the AHRQ has awarded more than 174 grants to nurse principal investigators engaging in original research that contributes to the evidence base of nursing. These grants reflect the diversity of nursing practice in areas such as workforce issues, clinical care, and knowledge dissemination. Systematic reviews developed under the AHRQ's EBP program since 1997 identify what we know about a clinical problem by evaluating existing evidence. The AHRQ's Evidence-based Practice Centers (EPCs) develop evidence reports and technology assessments on topics relevant to clinical, social, economic, and other health care organization and delivery issues--specifically those that are common, expensive, and/ or significant for the Medicare and Medicaid populations.

Many of these reports apply to nursing practice. Recently, the Nurse Staffing and Quality of Patient Care EPC report (3) was released. This report topic was proposed by the American Organization of Nurse Executives, the first nursing organization to submit an evidence topic to the EPC program. The report assesses the association of nurse-to-patient ratios and nurse work hours with patient outcomes in acute care hospitals, factors that influence nurse staffing policies, and nurse staffing strategies that improved patient care. (3)

TRANSLATING RESEARCH INTO GUIDANCE

Those who request reviews are expected to use EPC reports, disseminate them to their members, and develop guidelines or other quality tools with the research evidence identified and synthesized in the reports. Nursing guidelines specifically address issues of nursing practice that are directed toward improving patient care outcomes.

The AHRQ-sponsored National Guideline Clearinghouse (NGC) provides health care professionals with a readily available mechanism for obtaining objective, detailed information on clinical practice guidelines and for furthering dissemination, implementation, and use of the guidelines. The NGC uses the definition of clinical practice guidelines developed by the Institute of Medicine: "systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances." (4(p38))

The NGC currently contains 105 guidelines developed by 13 nursing organizations or departments. These guidelines cover a wide range of clinical topics, including family bereavement support, pressure ulcer prevention and treatment, and breast feeding.

LEARNING ABOUT EFFECTIVENESS THROUGH IMPLEMENTATION

To have an impact on health practice and patient outcomes, guidelines must be used. The Institute of Medicine report Keeping Patients Safe: Transforming the Work Environment of Nurses stresses the need for interdisciplinary collaboration and teamwork to achieve safe and effective health care. (5)

Unfortunately, guideline implementation, especially across disciplines and teams, is a complex endeavor. Applying guidelines to a specific practice setting presents challenges. Perhaps only part of the guideline is applicable. Considerable time and effort might be needed to adapt the guideline to a setting and population. Time and resources are needed to coordinate efforts with other disciplines. Shortages of nursing staff may limit the ability of nurses to engage fully in the task.

Of the 105 nursing-developed guidelines in the NGC, 81 include implementation strategies and tools to help guideline users apply the recommendations in practice. In addition to tools that assist in guideline implementation (eg, staff training presentations, competency checklists, chart documentation), some guideline developers prepare tools to assist in evaluating the effectiveness of the guideline recommendations in local settings. These tools include audit criteria and quality measures.