Evidence-based nursing

Assistant Editor-In-Chief: Michelle Lew

Overview
Evidence-Based Nursing or EBN is a method of identifying solid research findings and implementing them in nursing practices to further increase the quality of patient care.

Evidenced-based nursing/evidence based practice (EBN/EBP) is a nursing process that entails reviewing and instilling the most reliable and updated research in patient care. The goal of EBN is to provide the highest quality and most cost efficient nursing care possible. EBN is a process founded on the collection, interpretation, and integration of valid, important, and applicable patient-reported, clinician-observed, and research-derived evidence. The best available evidence, moderated by patient circumstances and preferences, is applied to improve the quality of clinical judgments." Some define EBN as "the synthesis and use of scientific findings from randomized clinical trials only." Others see it as "the use of information from case reports and expert opinion" . EBN must use the best research evidence with clinical expertise and patient values. Nurses want to use EBN to improve the quality of care and create new and exciting questions to be addressed through the research.  EBN is not easily achieved and requires a conscious effort to practice and participate. In order to practice evidence based nursing one must understand the concept of research, know how to accurately evaluate research and decide which research is measurably valid and reliable.

EBP Meets Nursing
"Registered Nurses are expected to access, appraise, and incorporate research evidence into their professional judgment and decision-making as well as to consider preferences and values of their patient population." Associate degree graduates will demonstrate an awareness of the value or relevance of research in nursing. Registered nurses help identify problem areas in nursing practice within an established structured format, assist in data-collection activities, and, in conjunction with the professional nurse, appropriately use research findings in practice (Geri LoBiondo-Wood, Judith Haber pg.9) Thus, incorporating EBP into their nursing careers. "When enough research evidence is available, it is recommended that the evidence base for practice be based on the research." EBP is a growing trend in nursing. As more research is done in a specific area, the research evidence can be used to update and refine guidelines. "As we are exposed to new scientific knowledge, we need to use integrative review of literature, formulation of a new theory, or generate new hypotheses. Use of knowledge in this way is referred to as cognitive application" 1. It is not to be overlooked however, that the nursing approach to evidence based practice may differ from the standard medical approach. This is typically due to nurses' commitment to providing holistic care; treating and working with patients rather than working on them.

The difficulties associated with EBP in nursing is due to the wide range of meanings and uses associated with the term and the failure to clarify them in the context of a nursing discussion. "The science of nursing is based on a critical thinking framework, known as the nursing process, composed of assessment, diagnosis, outcomes identification, planning, implementation, and evaluation. These steps serve as the foundation of clinical decision-making and are used to provide evidence- based practice." Because EBP originated in medicine, the assumptions associated with it may or may not apply to nursing and must be identified and addressed. Specifically, the assumptions equate practice decisions with medical interventions and evidence with quantitative research. Is the definition of EBP--along with these underlying assumptions--congruent with nursing practice? Prior to adopting EBP in nursing, clinicians must determine what constitutes evidence and what an effective nursing intervention is. ''It is important to distinguish how these concepts of evidence and intervention differ'' when applied in fields other than medicine. Any discussion of the application of EBP within nursing must be accompanied by a clarification of these terms and consideration of how they fit into the nursing discipline. According to Sackett et al', evidence-based practice is the "conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients." Gibbs- takes this idea further, stating, "Placing the client's benefits first, evidence-based practitioners adopt a process of lifelong learning that involves continually posing specific questions of direct practical importance to clients, searching objectively and efficiently for the current best evidence relative to each question, and taking appropriate action guided by evidence."

Challenges of EBN for Nurses
Professional nurses are constantly challenged to be aware of new information to provide the highest quality of patient care (Barnsteiner and Prevost, 2002; IOM, 2001). Nurses are challenged to expand their "comfort zone" by offering creative approaches to old and new health problems and designing new and innovative programs. Nursing research provides a specialized scientific knowledge base that empowers the nursing profession to anticipate and meet these shifting challenges and maintain our societal relevance. The best available evidence--moderated by patient circumstances and preferences--is applied to improve the quality of clinical judgements and facilitate cost-effective health care (Sackett, Straus, Richardson, Rosenberg, and Haynes, 2000)

In order to be the best possible patient advocate, a nurse must be willing to continually evaluate and change his or her practice methods. Health care is constantly changing. New information on how to provide better care for patients is discovered every day; and old practices are being improved. Now, health care practices are being implemented after research is done to prove their effectiveness. Accurate research provides health care workers with the evidence needed to change their practice. However, not all research is valid. Many studies are biased or have low external and internal validity. These studies cannot be trusted because nurses cannot be sure if the intervention is really beneficial. Therefore, these new methods should not be put into practice. That is how research, theory, and practice all come together. Nurses must realize how important research is in patient care. He or she must then learn to become a wise interpreter and evaluator of research, and continually evaluate current research to provide the highest quality patient care.

History
Evidence based nursing started in the 1800s with Florence Nightingale. Her concepts of promoting health, prevention of disease, and care of the sick were central ideas of her system (LoBiondo-Wood, Haber pg. 11). Nightingale served in the Crimean War during the 1850s in which she organized a unit of 38 nurses. In 1856, when she returned to London, she spread the word of how important sanitation was in nursing care. Florence Nightingale believed that infection arose spontaneously in dirty and poorly ventilated places. This mistaken belief nevertheless led to improvements in hygiene, healthier living, and working environments. Nightingale did not know the scientific facts of germs and bacteria, though she knew that if materials used to treat the patients were clean, patients healed faster. Therefore if doctors and nurses washed their hands, patient deaths decreased dramatically. She fought the established medical practices of the day, insisting that it was not enough to rest on ungrounded theories, even if their proponents were prominent physicians of the time. She stated, "What you want are facts, not opinions...The most important practical lesson that can be given to nurses is to teach them what to observe-how to observe-what symptoms indicate improvement-which are of none-which are the evidence of neglect-and what kind of neglect." This is evidence based nursing.  In the 1960s, research priorities began to be reordered and practice-oriented research was targeted. These priorities were supported by nursing's major organizations. Nurses soon were attaining educational preparation in research design in order to teach research and conduct their own research courses. Nurses primarily worked with others from related disciplines that had the expertise to teach these courses (LoBiondo-Wood, Haber pg. 12-14). Today, the definition of evidenced based nursing came as a response to the push for efficiency in the 1970s and 1980's. While efficiency was certainly a worthy goal, the decision makers who impacted health-care policy were managers and businessmen rather than nurses or doctors who actually interacted with patients. What these managers and businessmen lacked was the ability to evaluate nursing and medical diagnosis, interventions, and clients' plans of care. We are striving to do this with EBN.

Future
The continuation of nursing knowledge provides various opportunities for a nurse to study research questions while promoting health, preventing illness, and optimizing patient outcomes. The increasing number of doctoral level programs in and outside of the United States will contribute to a large number of nurse researchers who are prepared to bring research-based knowledge to life. Nurse researchers are focused on developing programs that incorporate quantitative and qualitative study outcomes to form a foundation for evidence based practice. This practice is being incorporated in order for the nurses to give patients the best care.

In the near future, information may be available online through electronic communications such as a dedicated list server, a Virtual Hospital System, or another form of electronic media. Such a center could facilitate networking among health care professionals working on similar EB topics and provide helpful consultants and educational materials. This center also would provide data regarding the interventions/strategies that have been tested to translate research into practice and provide a "tool kit" of these interventions for use by all types of health care agencies. Education of Nurses must include knowledge and skills in using research evidence in practice. Nurses are increasingly being held accountable for practices based on scientific evidence and tradition. Therefore, we must communicate and integrate into our profession the expectation that it is the professional responsibility of every nurse to communicate with nurse scientists the numerous clinical problems for which we do not yet have scientific base. Nursing has risen to the challenge of improving health care, and will continue to research and implement new nursing based practices in the future.

Step 1: Select a Topic
The first step is to select a topic. Ideas come from different sources but are categorized in two areas: Problem-focused triggers and Knowledge focused triggers(see below). When selecting a topic, nurses should formulate questions that are likely to gain support from people within the organization. An interdisciplinary medical team should work together to come up with an agreement about the topic selection. The priority of the topic should be considered as well as the severity of the problem. Nurses should consider whether the topic would apply to many or few clinical areas. Also, the availability of solid evidence should be considered because providing proof of the research will increase staffs' willingness to implement into nursing practice.

Problem & Knowledge Focused Triggers
Problem focused triggers are identified by health care staff through quality improvement, risk surveillance, benchmarking data, financial data, or recurrent clinical problems. Problem focused triggers could be clinical problems, or risk management issues. Example: Increased incidence of deep vein thrombosis and pulmonary emboli in trauma and neurosurgical patients.

Deep Vein Thrombosis (DVT) is a blood clot in the deep venous system in the legs. Many things can contribute to a clot forming in the legs such as impaired mobility and bed rest. A thrombosis in the leg is not a huge problem but becomes a very dangerous situation when a piece of the clot breaks off and is free to travel in the bloodstream. In most situations, the thrombosis will travel into the right heart and then into the pulmonary circulation and become wedged in the lungs. This creates a pulmonary embolism which is a very serious situation.

Diagnosis and proper treatment of a DVT (Deep Vein Thrombosis) is a very important task for health care professionals and is meant to prevent pulmonary embolism. This is an example of an important area that more research can be conducted to add into Evidence Based Practice.

Knowledge focused triggers are created when health care staff read research, listen to scientific papers at research conferences or encounter EBP guidelines published by federal agencies or organizations. Knowledge based triggers could be new research findings that further enhance nursing, or new practice guidelines. Example: Pain management, prevention of skin breakdown, assessing placement of nasogastric and nasointestinal tubes, and use of saline to maintain patency of arterial lines.

It is important that individuals work closely together to reach the optimum outcome for the chosen topic. Some things that would ensure collaboration are working in groups to review performance improvement data, brainstorming about ideas, and achieving consensus about the final selection.1

Step 2: Form a Team
Some might become overwhelmed when they first learn about EBP and apply it for reasons other than improvement of patient care. Forming a team increases the chance of EBP being adopted. A team becomes paramount in implementation, and evaluation of the EBP. It is important to have representatives of the team from authority members of the organization and also grassroot members. It is also important to consider interdiscipline involvement to decrease  rejection, and for all to have an understanding of the project. All these individuals have a great impact on the possibility of successful implementation. Other factors to put into consideration include power figures in the organization who may directly or indirectly sabortage the efforts if they are not consulted, and fully included in EBP implementation. The EBP team should have explanations that clearly define the types of patients, setting, outcomes, interventions and exposures. This should be in simplified language that is comprehensible to a lay person.

The role of the practitioners is remarkable in any meaningful gains, they are therefore inevitable and their role becomes pivotal. The approach they adopt and their ability to educate the coworkers, answer their questions, and clarify any misconceptions greatly improves the outcomes.

Step 3: Evidence Retrieval
One of the most challenging issues in using EBP in the clinical setting is learning how to adequately frame a clinical question so that an appropriate literature review can be performed. When forming a clinical question the following should be included: the disorder or disease of the patient, the intervention or finding being reviewed, possibly a comparison intervention, and the outcome. An acronym used to remember this is called the "PICO" model:


 * P = Who is the Patient Population?
 * I = What is the potential Intervention or area of Interest?
 * C = Is there a Comparison intervention or Control group?
 * O = What is the desired Outcome?

Once the topic is selected, the research relevant to the topic must be reviewed, in addition to other relevant literature. It is important that clinical studies, integrative literature reviews, meta-analyses and well-known and reliable existing EBP guidelines are accessed in the literature retrieval process. With the internet at one’s fingertips, a plethora of research is just a few clicks away. However, just because you found it in a respectable journal does not signify high quality research. When reviewing any article for evidence retrieval read it very closely. Articles can appear to be precise and factual on the surface but with further and much closer examination, flaws can be found. The article can be loaded with opinionated and/or biased statements that would clearly taint the findings, thus lowering the creditability and quality of the article. Use of rating systems to determine the quality of the research is crucial to the development of EBP. There are several rating systems available online. The National Guideline Clearinghouse is a database of published EBP guideline abstracts at (http://www.guideline.gov). These and others will help to guide your way through the perils of research review.

Time management is crucial to information retrieval. Nurses making their way through the vast amount of research available may find it helpful to read research articles or critical reviews instead of clinical journals. To maintain high standards for EBP implementation, education in research review is necessary to distinguish good research from poorly conducted research. Equally important is that the materials being reviewed, consider if they are current.

Links to article sources
 * 1) Cinahl Information Systems Home Page
 * 2) British Medical Journal
 * 3) Medline Industries, Inc
 * 4) Pubmed

To learn more about the PICO go to  this is an excellent resource.

Once the literature is located, it is helpful to classify the articles as either conceptual (theory and clinical articles) or data-based (systematic research reviews). Before reading and critiquing the research, it is useful to read theoretical and clinical articles to have a broad view of the nature of the topic and related concepts, and to then review existing EBP guidelines.

Step 4: Apply the Evidence
After determining the internal and external validity of the study, a decision is arrived at whether the information gathered does apply to your initial question. Its important to address questions related to diagnosis, therapy, harm, and prognosis. The information gathered should be interpreted according to many criteria and should always be shared with other nurses and/or fellow researchers.

Step 5: Decision to Change the Practice
When the studies are completed, and the EBP outcomes are evaluted, a decision is reached on whether to use this in practice. Several factors are put into consideration. First the relevance of evidence for practice and second the  consistency in findings across studies and/or guidelines; a significant number of studies and/or EBP guidelines with sample characteristics similar to those to which the findings will be used; consistency among evidence from research and other nonresearch evidence; feasibility for use in practice; the risk/benefit ratio risk (risk of harm;potential benefit for the patient). Putting together results from other studies may end up supporting what is currently in practice rather than changing practice. Using a focus group is a great way to provide discussion about the EBP standard and to point out key areas that may cause problems during the implementation phase.

Qualitative Research Process
One method of research for Evidence based practice in nursing is Qualitative Research. "The word implies a focus on qualities of a process or entity and meanings that are not experimentally examined or measured in terms of quantity, amount, frequency, or intensity." With qualitative research, researchers learn about patient experiences through discussions and interviews. The point of qualitative research is to provide beneficial descriptions that allow insight into patient experiences. "Hierarchies if research evidence traditionally categorize evidence from weakest to strongest, with an emphasis on support for the effectiveness of interventions. That this perspective tends to dominate the evidence-based practice literature makes the merit of qualitative research unclear;" 1   Some people view qualitative research as less beneficial and effective, with its lack of numbers, the fact that it is "feeling-based" research, makes the opponents associate it with bias. Nevertheless, the ability to empathetically understand an individual's experience (whether it be with cancer, pressure ulcers, trauma, etc.), can benefit not only other patients, but the health care workers providing care. For qualitative research to be reliable, the testing must be unbiased. To achieve this, researchers must use random and non-random samples to obtain concise information about the topic being studied. If available, a control group should be in use, if possible with the qualitative studies that are done. Evidence should be gathered from every available subject within the sample to create balance and dissolve any bias. There should also be several researchers doing the interviewing to obtain different perspectives about the subject. Researchers must also obtain negative information as well as the positive information gathered to support the data. This will help to show the researchers were unbiased and were not trying to hide negative results from readers, and actually makes it posible to objectively understand the phenomenon under investigation. The inclusion of this negative information will strengthen the researchers initial study, and may actually work in favor to support the hypothesis. Any data that has been gathered must be appropriately documented. If the data collected was obtained from interviews or observation, it must all be included. Dates, times and gender of the sample may be needed, providing background on subjects, such as breast cancer in women over thirty-five. Any pertinent information pertaining to the sample must be included for the reader to judge the study as worthy.In addition, the current evidence-based practice (EBP) movement in healthcare emphasizes that clinical decision making should be based on the "best evidence" available, preferably the findings of randomized clinical trials. Within this context qualitative research findings are considered to have little value and the old debate in nursing has been re-ignited related as to whether qualitative versus quantitative research findings provides the best empirical evidence for nursing practice. In response to this crisis qualitative scholars have been called upon by leaders in the field to clarify for outsiders what qualitative research is and to be more explicit in pointing out the utility of qualitative research findings. In addition, attention to "quality" in qualitative research has been identified as an area worthy of renewed focus. Within this paper two key problems related to addressing these issues are reviewed: disagreement not only among "outsiders" but also some nursing scholars related to the definition of "qualitative research", and a lack of consensus related how to best address "rigor" in this type of inquiry. Based on this review a set of standard requirements for qualitative research published in nursing journals is proposed that reflects a uniform definition of qualitative research and an enlarged yet clearly articulated conceptualization of quality. The approach suggested provides a framework for developing and evaluating qualitative research that would have both defensible scholarly merit and heuristic value. This will help solidify the argument in favor of incorporating qualitative research findings as part of the empirical "evidence" upon which evidence-based nursing is founded.

How to Critique a Research Article
The critiquing process is the building block and foundation for the multiple steps that are to follow in the successful implementation of EBP. This is so because you must first ensure that the material and research that you are trying to convince others to accept is reliable and accurate. By taking the time to thoroughly critique a study you can point out both the strengths and weaknesses of the findings and weigh them accordingly. Successful completion of this vital step will help "weed out" the material lacking the needed proof of effectiveness, therefore minimizing useless, or even harmful, implementation of new practices in the healthcare field. Critiquing criteria are the standards, evaluation guides, or questions used to judge (critique) an article. In analyzing a research report, the reader must evaluate each step of the research process and ask questions about whether each step of the process meets the criteria. Remember when you are doing a critique, you are pointing out strengths, as well as the weaknesses. To critique an article you must have some knowledge on the subject matter. There is no replacement for reading the article many times. The reader must search the article for contradictions, illogical statements, and faulty reasoning. It is important to evaluate every section of the research article. Each section has different criteria to meet, in order to be considered a well-written addition to the article. Sometimes the harder you try the harder something becomes, locating hard core evidence that people will relate to may be a difficult task that you may face in future situations. The attached web site is an excellent tool that can help diminish your uncertainty about the decision making process. This handy little tool kit will make you a "connoisseur of evidence" and will give you the insight into how to focus and prepare to approach EBP research and to express yourself to the public accurately and be heard. 

Another site to check out would be  Very interesting reading if the Research field is in your heart.

Keys to critiquing a research article
In order to correctly critique a research paper you have to have some idea of what you are looking for in the article. Articles can be very deceiving at first glance, filled with persuasive wording, unneeded information, or downright false claims. In order to successfully decipher through the fog of deception you must take on the persona of an investigator. It is solely up to you to deem the material worthy of your seal of approval. The following paragraphs contain criteria that you as the reader want to be watchful for. These criteria will help guide you in knowing exactly what it is you are looking to examine.

It is recommended that you read the article several times, each time looking for more answers to the criteria listed below. It is helpful to write out notes as you go.

1. The first section of the article to be analyzed is the problem statement and purpose. The following are questions that must be answered by you the reader. The first question that you must ask yourself is whether or not the purpose of the research is made clear. Then you need to keep an eye out for a relationship between two or more testable variables. Next, you need to see if the article specifies the nature of the population being studied, and if a problem has been identified.

2. The next section of the article to be analyzed is the review of the literature and the theoretical framework. You must ask yourself what concepts are included in the review. You must separate the concepts that belong to the independent variable, and the dependent variable. Next, ask yourself if the literature review makes the relationship among the variables clear. Identify any gaps, or conflicts in the knowledge, if so read to see how this study intends to fill those gaps, or resolve those conflicts. You will want to focus on the references, noting whether they are primary or secondary sources.

3. The next section of the article to be analyzed is the hypothesis, or research question. The first question that needs answering is whether or not the hypothesis, or research question is appropriately stated. If research questions were used, are they in addition to a hypothesis, or are they used to guide an exploratory study? Next, it needs to be determined whether or not the hypothesis is null or research, and last it needs to be determined if the hypothesis is testable.

4. The next section for analysis is the sample. It is here where you want to figure out how the sample was selected, what type of sampling method was used, if it reflects the population as stated in the study, if it is appropriate, and if it can be generalized.

5. The next section to be analyzed is research design. In this section you will want to determine what type of method was used, and whether or not the design fits the research problem, theoretical framework, literature review, and hypothesis.

6. The last section for analysis is the internal and external validity. You will want to note if the threats to internal validity are discussed, and if there are controls for the threats to internal validity. When it comes to external validity you will want to note any threats to external validity.

Introduction, Purpose, and Hypothesis
Introductions need to at least include a literature review and a purpose statement, but they may also contain a theoretical framework, a research question, and a hypothesis. The research question presents the idea that is to be examined in the study and is the foundation of the research study.

A well developed research question guides a focused search for scientific evidence about assessing, diagnosing, treating, or assisting patients with understanding of their prognosis related to a specific health problem. The hypothesis attempts to answer the research question.

A hypothesis is a declarative statement about the relationship between two or more variables that predicts an expected outcome. Characteristics of a hypothesis include a relationship statement, implications regarding testability, and consistency with a defined theory base. They can be formed by either a directional or nondirectional method.

The literature review needs to explain the reason the study was conducted and why it was important for the study to be conducted now. The theoretical framework and the literature review should also work together.

The purpose statement needs to explain what the study wants to accomplish. The purpose, aims, or objectives often provide the most information about the intent of the research question and hypothesis and suggest the level of evidence to be obtained from the findings of the study.

The introduction should cover these topics, and should not throw in a lot of excess, useless knowledge. The research question, hypothesis, and the study should all correlate together. You have to be careful when critiquing research articles because sometimes researchers will try to cover up a poor study with lots of information that does not belong. It may look good to the reader at first glance so it is always a good idea to reread the articles a few times to fully understand it and to see if there are any discrepancies.

Methodology
The methodology section must start off by gathering a sample. There are a few definitions you must understand first. 'Population' is the group that you want you study findings to apply to. A 'sample frame' is the target population, in which the study will affect''. There are three different ways to select a population. The researchers can choose who they want in the study, the participants can choose if they want to be in the study, or it can be a random selection in which neither the researcher or the participant chooses.

The study must either have external validity or internal validity. If the study has external validity then the study's findings have different settings, procedures, and participants. External validity will also question what types of subjects and conditions in which the same results can be expected to occur. If the study has internal validity then the findings are held true within the sample. The researchers will rule out factors or threats as rival explanations of the relationship between the variables that are present. Be careful with internal validity and external validity because there are a number of threats for both that can affect the outcome of the study. These should be considered by the researchers who are planning the study and by consumers before implementing the results into practice.

Phenomenological method

In qualitative research phenomenological methods are used to learn and construct the meaning of the human experience through intensive dialogue with persons who are living the experience. The researcher's goal is to explain the meaning of the experience to the participant. This is achieved through a dialogic process, which is more than a simple interview.

Results and Discussion
The results section puts forth the findings of a study in a clear, logical, and unbiased manner. It presents the findings according to the variables studied without extrapolating beyond what those variables yielded. Qualitative studies do not contain statistical tests. Therefore, the themes, concepts, observational or print data are described in the "Methods" or "Data Collection" subtitles and are reported in the "Results" or "Findings" section.

A good results section should also make use of descriptive statistics. Descriptive statistics are used to summarize, reduce, and organize the data and characteristics of the data into an easily understood, manageable format. Finding data's mode, median, and mean are three techniques used to easily recognize central tendency. Techniques such as range and standard deviation are used to measure variability and scatter plots are used to measure correlation. After analyzing the data and finding central tendency, variability, and correlation, this information should be worked into an easily understood format such as a frequency distribution table, chart, or graph.

The reader should be able to easily recognize and interpret the data. However, the reader must be on alert to recognize that this may yet be another opportunity for the author of the study to make the results appear more grandiose than they are. Always look at what the actual numbers amount to instead of just looking at how significant the graph or chart makes the data look.

In a good results section, the author will not try to make insignificant data look significant, but simply show the results. If the numerical data of a study does not show the same claims that the researcher stated then this is a major flaw in the study and raises significant concerns about the study's validity and reliability; therefore, a nurse and other healthcare providers should not only stay current on new research but should be able to decipher the research in order to determine its true value to the medical practice.

Inferential Statistics
The very last section of a research study is known as the discussion section. Here, the researchers draw all the pieces from the study together to present the whole picture. The researchers review the literature and discuss how the results compare and contrast previously completed studies. The researchers often present biased opinions in the discussion section but these should always be supported by the research and not just the interpretation of the researchers. This overview of the study serves to make a comparison with the background literature.

The results and discussion sections can sometimes be combined into one by the researcher, but normally, the researcher will report the findings into separate "results" and "discussion" sections. One way is not better than the other when it comes to combining or dividing the findings into sections. Any new or unexpected results are usually described in the discussion section as well.

Evaluating The Conclusion
A conclusion can be identified as paragraphs that state the main claims that came out of the findings that were read earlier in the article. It should have a summary of the findings (strengths and weaknesses), status of the hypothesis, limitations, and recommendations, implications, or applications. In each section the best and worst needs to brought forth. In a quality conclusion section the author will only state what has been found, or not, without adding anything extra.

The hypothesis will be proven true or false and nothing in between. Limitations will be discussed such as the statistical framework or design errors made in the beginning. The researcher should also present the limitations or weaknesses of the study. This presentation is important because it effect's the studies generalizability.

The generalizations or inferences about similar findings in other samples also are presented in light of the findings. Recommendations will be few in quality research. If no loop holes or oversights are made at the beginning then these will not have to be expressed at the end. When all of these come together in a simplified manner then a conclusion can be considered strong.

A limitation is an admission of how certain aspects of the study, such as the sampling, were not as unbiased as they should have been. This lets the reader know that improvements can be made from what was accomplished in the article.

The last thing the conclusion should do is give the reader a recommendation. This recommendation should be derived from the results gathered earlier in the article. Based on the results, the reader will be able to judge whether the data and hypothesis should be applied to nursing practice.

Legal and Ethical Issues of Research
The big issues concerning research today are the legal and ethical issues surrounding it. The American Nurses Association (ANA) has set up five basic human rights for patient protection which are: 1. Right to self determination 2. Right to privacy and dignity 3. Right to anonymity and confidentiality 4. Right to fair treatment 5. Right to protection from discomfort and harm. You must also ask yourself questions such as: Were the study participants subjected to any physical harm, discomfort, or psychological distress? Did the researchers take appropriate steps to remove or prevent the harm? Did the benefits to participants outweigh any potential risks or actual discomfort they experienced? Did the benefits to society outweigh the costs to participants? Was any type of coercion or undue influence used in recruiting participants? Were vulnerable subjects used? Were participants deceived in any way? Were they fully aware of participating in a study, and did they understand the purpose of the research? Were appropriate consent procedures implemented? Were appropriate steps taken to safeguard the privacy of participants? Was the research approved and monitored by an Institutional Review Board or other similar ethics review committee? (Polit, Beck and Hungler: Essentials of Nursing Research (5th Edition).

These rights apply to both researchers and participants. Informed consent is one area that nurses must be familiar with in order to complete research. Informed consent is "the legal principle that governs the patients ability to accept or reject individual medical interventions designed to diagnose or treat an illness". Without informed consent research is at a halt and informed consent can only be obtained after the entire procedure and potential risks have been explained to the participant. Only then can the participant decide if they still want to participate. When dealing with the ethical portion of Evidence based practice, the Institutional Review Boards (IRB) review research projects to assess that ethical standards are being followed. The institutional review board is responsible for protecting subjects from risk and loss of personal rights and dignity. The IRB also come into play when deciding on which populations can be included in research. Vulnerable groups such as children, pregnant women, physically disabled or elderly maybe excluded from the process. Fraud is also a problem that has been associated with research. These days just about anyone could publish falsified information causing millions of people to be misinformed and any practices that decide to follow this incorrect information could be causing harm to their patients. Nurses must keep a watch out for articles that may look suspicious and notify the IRB to make sure that these individuals receive the appropriate attention and review.

It is important to be up to date on all the appropriate state laws and regulations regarding vulnerable populations. This may mean consulting with lawyers, clinicians, ethicists, as well as the affiliatedd IRB. It is imperative that researchers act as advocates for these vulnerable persons that cannot do so for themselves.

In order for Evidenced Based Nursing to continue to improve, all of these issues must be addressed and these problems must be resolved.

Barriers to promoting Evidence Based Practice
The use of evidence based practice depends a great deal on the nursing student's proficiency at understanding and critiquing the research articles and the associated literature that will be presented to them in the clinical setting. According to, Blythe Royal, author of Promoting Research Utilization in nursing: The Role of the Individual, Organization, and Environment, a large amount of the preparation requirements of nursing students consists of creating care plans for patients, covering in depth processes of pathophysiology, and retaining the complex information of pharmacology. These are indeed very important for the future of patient care, but their knowledge must consist of more when they begin to practice. Evidence based nursing in an attempt to facilitate the management of the growing literature and technology accessible to healthcare providers that can potentially improve patient care and their outcomes. Nancy Dickenson-Hazard states, "Nurses have the capacity to serve as caregivers and change agents in creating and implementing community and population-focused health systems." There is also a need to overcome the barriers to encourage the use of research by new graduates in an attempt to ensure familiarity with the process. This will help nurses to feel more confident and be more willing to engage in evidence based nursing. A survey that was established by the Honor Society of Nursing and completed by registered nurses proved that 69% have only a low to moderate knowledge of EBP and only half of those that responded did not feel sure of the steps the process consists of. Many responded, "lack of time during their shift is the primary challenge to researching and applying EBP." There is always and will always be a desire to improve the care of our patients. The ever increasing cost of healthcare and the need for more accuracy in the field proves a cycle in need of evidence based healthcare. The necessity to overcome the current issues is to gain knowledge from a variety of literature not just the basics. There is a definite need for nurses, and all practitioners, to have an open mind when dealing with the modern inventions of the future because these could potentially improve the health of patients. There are many barriers to promoting evidence based practice. The first of which would be the practitioner's ability to critically appraise research. This includes having a considerable amount of research evaluation skills, access to journals, and clinic/hospital support to spend time on EPN. Time, workload pressures, and competing priorities can impede research and development. The causes of these barriers include nurse's and other professional practioners lack of knowledge of research methods, lack of support from professional colleagues and organizations, and lack of confidence and authority in the research arena. Another barrier is that the practice environment can be resistant to changing tried and true conventional methods of practice. This can be caused because of reluctance to believe results of research study over safe, traditional practices, cost of adopting new practices, or gaining momentum to rewrite existing protocols. . It is important to show nurses who may be resistant to changes in nursing practice the benefits that nurses, their patients, and their institutions can reap from the implementation of evidence-based nursing practice, which is to provide better nursing care. Values, resources and evidence are the three factors that influence decision-making with regard to health care. All registered nurses and health care professionals should be taught to read and critically interpret research and know where to find articles which relate to their field of care. In addition, nurses need to be more aware of how to assess the information and determine its applicability to their practice.

Another barrier to implementing EBN into practice is lack of continuing education programs. Practices do not have the means to provide workshops to teach new skills due to lack of funding, staff, and time; therefore, the research may be tossed dismissed. If this occurs, valuable treatments may never be utilized in patient care. Not only will the patients suffer but the staff will not have the opportunity to learn a new skill. Also, the practitioners may not be willing to implement change regardless of the benefits to patient care.

Another barrier to introducing newly learned methods for improving treatments or patients' health is the fear of "stepping on one's toes". New nurses might feel it is not their place to suggest or even tell a superior nurse that newer, more efficient methods and/or practices are available.

The perceived threat to clinical freedom offered by evidence-based practice is neither logical nor surprising. Resistance to change and to authority is part of human nature. When we make decisions based upon good quality information we are inconsistent and biased. Human nature offers many challenges to evidence-based practice. Can we do a better job of promoting evidence-based practice? And even if we find and use the evidence, will we make consistent unbiased decisions?

Even if clinicians do act consistently it is possible that their decisions are consistently biased. People put different values on gains and losses. Tversky and Kahneman gave people the two identical problems (with the same probabilities of life and death outcomes - see fig 1) but framed the outcome choices as either lives saved or as deaths.10 Most people wanted to avoid taking risks with gains which could be safeguarded, but would take risks with losses which might be avoided; this is a framing effect. If people are given identical options but different words are used to emphasize a gain rather than a loss, then a different response is given by a large proportion of the population under study. Such a change in response appears to be inconsistent. (Health Education Authority. Oral Health Effectiveness Review No 7. Effectiveness of oral health promotion. London: HEA, 1998).

How is an EBP sample population chosen: Nonprobability Sampling vs. Probability Sampling
The sampling strategies are grouped into two main categories: nonprobability sampling and probability sampling. The difference between nonprobability and probability sampling is that nonprobability sampling does not involve random selection and probability sampling does. Does that mean that nonprobability samples aren't representative of the population? Not necessarily. But it does mean that nonprobability samples cannot depend upon the rationale of probability theory. At least with a probabilistic sample, we know the odds or probability that we have represented the population well. The major drawback to nonprobability sampling is there is no way of estimating each element's probability of being included in the samples; there is NO way of ensuring that every element has a chance of being included in the nonprobability sampling. Nonprobability sampling tends to produce less representative samples unless the researcher thoroughly thought through the inclusions and exclusions of the study.

Nonprobability sampling
The three major nonprobability sampling methods that are used are: convenience, quota and purposive. The convenience sample is when the researcher chooses the sample population at his/her convenience. Convenience sampling has the largest risk of bias due to the sample population being self selected by the researcher. Quota sampling is easy to draw a sample population as well and does contain an unknown source of bias which greatly affects the external validity of the study. In a purposive sampling, the risk of bias increases with greater heterogeneity of the population; conscious bias is also a danger with this study. All three samples are not fully representative of the population because of small generalizability. Bias is a major problem with nonprobability sampling.

Probability sampling
Probability sampling consists of four major sampling strategies: simple random, stratified random, cluster, and systematic sampling.
 * Random sampling has a significant lower risk of bias than nonprobability sampling, but the ease of drawing the sample population is much more difficult.
 * Simple random sampling is constructed when the researcher defines a specific population (i.e. sampling frame) and then selects a sample to be studied within the population through randomization (i.e.: assigning each person of a population with a specific number then randomly choosing 100 of those numbers).
 * Stratified random sampling is done by dividing the population into subgroups. An example:  5000 registered nurses are split up into three different groups depending on the type of degree that was received (group1:  diploma school graduates, group2:  Associate degree graduates, and group3:  baccalaureate graduates).  As one can determine these three groups were composed of random factors.
 * Cluster sampling involves a successive random sampling of clusters that progress from large to small and meet sample eligibility criteria. An example: if a sample of nurse practitioners is desired, the first sampling unit would be a random sample of hospitals.  The second step consist of a list of pediatric nurse practitioners practicing at each hospital from the hospitals selected in the first group. The third stage consist of inclusion or exclusion criteria that the NPs had to meet to be eligible for the study.
 * systematic sampling refers to a sampling strategy that involves the section of every "kth" case drawn from a population list at fixed intervals. An example: every 15th person from the phone book is chosen to participate.

Conclusion
In conclusion it is very important to know how the sample population was chosen in a study in order to determine the reliability and validity of a study. Without accurate sampling, EBP is botched from the beginning.

The Star Model of Knowledge Transformation
The Star Model of Knowledge Transformation uses a five point model to explain the major steps of “knowledge transformation” Those are: 1. Discovery 2.Evidence summary 3.Translation into practice recommendations  4.Integration into practice 5.Evaluation These guidelines were developed in 2005 to fill in the missing pieces of EBP. Until this time, there were no national competencies for EBP in nursing. The researchers at the University of Texas Health Science Center at San Antonio, who developed the Star Model, define Knowledge Transformation as the “conversion of actual findings from research studies, through a series of stages, to impact on health outcomes.” They are sure to mention that before integration into practice can happen, changes must occur at the individual, organizational, and environmental levels. It is not enough to just change our own beliefs and practices. It is the individuals responsibility to present the knowledge to others for changes to happen on all levels.

EBP Example and Graph
When healthcare providers are considering adopting a new practice they want to clearly see the results. Charts and graphs are a good way to show statistical results of a study. In 1997 an article was published about a study performed by Professor Richard Gray, a distinguished epidemiologist. Professor Gray studied and documented the effects of aspirin on mortality related to acute myocardial infarctions. Professor Gray made a graph using the results he obtained from the study. By looking at the graph, one can see immediately that mortality rates are much lower when patients were given aspirin as opposed to a placebo.

Nurses are more likely to catch the attention and gain support from other healthcare providers when they have statistical graphs. Other nurses may not have time to sit and read about results from a study. The researching nurse needs to present the evidence in a simple, concise manner. This is not to say, however that the evidence should not be backed up. All charts and graphs used in research should be accompanied with enough information to fully explain how the researchers arrived at those particular numbers and figures. Charts and graphs can also contain hidden information and the nurse must then dig deeper into the text to uncover things the researchers may not have wanted anyone to notice. Therefore, visual charts and graphs can have a profound influence on the acceptance of a new intervention, but must first be carefully screened for any faulty claims.

Further Information
If you would like to learn more about evidence based nursing practice, and see some real-life examples of its use and importance, please check out these websites. They are all excellent sources for nurses, other health professionals, instructors, or anyone interested in evidence based nursing and its application to practice.


 * "Indiana Center for Evidence Based Nursing Practice", a collaborating center of The Joanna Briggs Institute, located at Perdue University Calumet’s School of Nursing: http://www.ebnp.org/
 * "University of Minnesota Libraries", a tutorial on evidence based nursing: http://www.biomed.lib.umn.edu/learn/ebp/
 * "Centre for Evidence Based Medicine", University Health Network: http://www.cebm.utoronto.ca/syllabi/nur/intro.htm
 * "Academic Center for Evidence Based Practice", The University of Texas Health Science Center at San Antonio: http://www.acestar.uthscsa.edu/
 * "Medscape Today", online nursing resource and a source of CEU credit articles: http://www.medscape.com/viewarticle/514532