Melnyk's rapid critical appraisal tools

Critical Appraisal

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Fourth edition

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Third edition © 2015 Wolters Kluwer Health. Second edition © 2011 Lippincott Williams & Wilkins, a Wolters Kluwer business. First edition © 2005 by Lippincott Williams & Wilkins. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com, or via our website at lww.com (products and services).

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Library of Congress Cataloging-in-Publication Data

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 resources available online can be found below.

ORGANIZATION OF THE BOOK

As in prior editions, the Table of Contents is structured to follow the steps of EBP:

Chapters 1 to 3 in Unit 1 encompass steps 0, 1, and 2 of the EBP process. This unit gets learners started by building a strong foundation and has significant content updates in this new edition. Chapters 4 to 8 in Unit 2 delve deeply into step 3 of the EBP process, the four-phased critical appraisal of evidence. In this edition, Chapters 7 and 8 were moved into Unit 2 to better align the steps of the EBP process with the chapters, including the important consideration of patient concerns, choices, clinical judgment, and clinical practice guidelines in the recommendation phase of critical appraisal. In Unit 3, Chapters 9 to 12 move the reader from recommendation to implementation of sustainable practice change. To facilitate understanding how to implement evidence-based change, Chapter 11 was added to describe the context, content, and outcome of implementing EBP competencies in clinical and academic settings. Unit 4 promotes creating and sustaining a culture of EBP. In this unit, we included new content and resources in the chapters on teaching EBP in educational and healthcare settings (Chapters 16 and 17, respectively). Educators can be most successful as they make the EBP paradigm and process understandable for their learners. Unit 5 features a new Chapter 19 on health policy. In today’s political climate, nurses and healthcare professionals need to understand how to ensure sustainable change through influencing the formulation of policies governing healthcare, fully supported by the latest and best evidence. This new chapter joins Chapter 20 on disseminating evidence. In Unit 6, Chapter 21 now combines two previous chapters’ content on generating evidence through qualitative and quantitative research, greatly streamlining the material for enhanced understanding of important concepts and making the information more accessible to learners. Chapter 23 provides updated information on ethics in EBP and research generation. The glossary is one of the best resources within this book. Readers are encouraged to use it liberally to understand and master EBP language, and thereby enhance their fluency.

Often, educators teach by following chapters in a textbook through their exact sequence; however, we recommend using chapters of this fourth edition that are appropriate for the level of the learner (e.g., associate degree, baccalaureate, master’s, doctoral). For example, we would recommend that associate degree students

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benefit from Units 1, 3, and 4. Curriculum for baccalaureate learners can integrate all units; however, we

recommend primarily using Units 1 to 4, with Unit 5 as a resource for understanding more about research terminology and methods as readers learn to critical appraise evidence. Master’s and doctoral programs can incorporate all units into their curricula. Advanced practice clinicians and doctorally-prepared clinical experts will be able to lead in implementing evidence in practice, thoughtfully evaluate outcomes of practice, and move to sustainable change, whereas those learning to become researchers will understand how to best build on existing evidence to fill gaps in knowledge with valid, reliable research that is clinically meaningful.

An important resource for educators to use as a supplement to this EBP book is the American Journal of Nursing EBP Step-by-Step series, which provides a real-world example of the EBP process from step 0 through 6. We recommend this series as a supplement because the series was written to expose readers to the EBP process in story form, but used alone it does not provide the level of learning to establish competence in evidence-based care. In the series, a team of healthcare providers encounters a challenging issue and uses the EBP process to find a sustainable solution that improves healthcare outcomes. If educators choose to use this series, we caution on using it as the sole source for learning about EBP. Rather, assigning the articles to be read before a course begins or in tandem with readings from this book that match the article being read provides a complete learning opportunity, including context and adequate content for competence—the goal of learning about EBP, regardless of the learner’s level of education or clinical practice. For example, the first three chapters of the book could be assigned along with the first four articles, in an academic or clinical setting. The learners could use discussion boards or face-to-face group conference-type settings to discuss how the team used the content the learners studied within the chapter, allowing educators opportunity for evaluation of content mastery (see suggested curriculum strategy at this book’s companion website on , http://thepoint.lww.com/Melnyk4e). Multiple approaches are offered for educators and learners to engage EBP content, and, in doing so, we believe that this book continues to facilitate changes in how research concepts and critical appraisal are being taught in clinical and academic professional programs throughout the country.

UPDATED FEATURES

This edition of Evidence-Based Practice in Nursing & Healthcare includes many features that readers have come to expect. These features are designed to benefit both learners and educators:

Quotes: As proponents of cognitive-behavioral theory, which contends that how people think directly influences how they feel and behave, we firmly believe that how an individual thinks is the first step toward or away from success. Therefore, inspirational quotes are intertwined throughout our book to encourage readers to build their beliefs and abilities as they actively engage in increasing their knowledge and skills in EBP to accomplish their desired learning goals. Clinical Scenarios describe a clinical case or a supervisory decision clinicians could encounter in clinical practice, prompting readers to seek out best evidence and determine a reasonable course of action.

Web Tips: With the rapid delivery of information available to us, web tips direct readers to helpful Internet resources and sites that can be used to further develop EBP knowledge and skills. EBP Fast Facts act as a chapter-closing feature, highlighting important points from each chapter. Reviewing these pearls can help readers know if they retained the important concepts presented within the chapter. Making EBP Real: A successful real-world case story emphasizing applied content from each unit. NEW: Learning Objectives: Each unit and chapter now begins with learning objectives, to help learners focus on key concepts. NEW: EBP Terms to Learn: Each unit and chapter also now includes a list of the key terms discussed or defined in the chapter that are to help students build familiarity with the language and terminology of EBP.

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NEW: Making Connections: An EBP Exemplar: Opening each unit, this new feature walks the learner through the EBP process in an unfolding case study that is applicable to a real-time important practice issue.

ADDITIONAL RESOURCES ON

Evidence-Based Practice in Nursing and Healthcare, fourth edition, includes additional resources for both learners and educators that are available on the book’s companion website at http://thepoint.lww.com/Melnyk4e.

Learner Resources Available on Learners who have purchased Evidence-Based Practice in Nursing and Healthcare, fourth edition, have access to the following additional online resources:

Appendices D, E, F, G, H from the book Learning Objectives for each chapter Checklists and templates in MS Word format include checklists for rapid critical appraisal, conducting an evidence review, or holding a journal club; sample templates for PICOT questions and for evaluation and synthesis tables; an ARCC model EBP mentor role description; and more. A searching exercise to help develop mastery of systematic searching. Journal articles corresponding to book chapters to offer access to current research available in Wolters Kluwer journals. The American Journal of Nursing EBP Step-by-Step Series, which provides a real-world example of the EBP process as a supplement to learning within the EBP book. An example of a poster (to accompany Chapter 20). A Spanish–English audio glossary and Nursing Professional Roles and Responsibilities

See the inside front cover of this book for more details, including the passcode you will need to gain access to the website.

Educator Resources Available on

Approved adopting instructors will be given access to the following additional resources: An eBook allows access to the book’s full text and images online. Test generator with updated NCLEX-style questions. Test questions link to chapter learning objectives. Additional application case studies and examples for select chapters. PowerPoint presentations, including multiple choice questions for use with interactive clicker technology. An image bank, containing figures and tables from the text in formats suitable for printing, projecting, and incorporating into websites. Strategies for Effective Teaching offer creative approaches. Learning management system cartridges. Access to all learner resources.

COMPREHENSIVE, INTEGRATED DIGITAL LEARNING SOLUTIONS

We are delighted to introduce digital solutions to support educators and learners using Evidence-Based Practice in Nursing & Healthcare, Fourth Edition. Now for the first time, our textbook is embedded into an integrated digital learning solution that builds on the features of the text with proven instructional design strategies. To learn more about this solution, visit http://nursingeducation.lww.com/, or contact your local Wolters Kluwer representative.

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Lippincott CoursePoint is a rich learning environment that drives academic course and curriculum success to prepare learners for practice. Lippincott CoursePoint is designed for the way students learn. The solution connects learning to real-life application by integrating content from Evidence-Based Practice in Nursing & Healthcare with video cases, interactive modules, and evidence-based journal articles. Ideal for active, case- based learning, this powerful solution helps students develop higher-level cognitive skills and asks them to make decisions related to simple-to-complex scenarios.

Lippincott CoursePoint for Evidence-Based Practice features:

Leading content in context: Digital content from Evidence-Based Practice in Nursing & Healthcare is embedded in our Powerful Tools, engaging students and encouraging interaction and learning on a deeper level.

The complete interactive eBook features annual content updates with the latest evidence-based practices and provides students with anytime, anywhere access on multiple devices. Full online access to Stedman’s Medical Dictionary for the Health Professions and Nursing ensures students work with the best medical dictionary available.

Powerful tools to maximize class performance: Additional course-specific tools provide case-based learning for every student: Video Cases help students anticipate what to expect as a nurse, with detailed scenarios that capture their attention and integrate clinical knowledge with EBP concepts that are critical to real-world nursing practice. By watching the videos and completing related activities, students will flex their problem-solving, prioritizing, analyzing, and application skills to aid both in NCLEX preparation and in preparation for practice. Interactive Modules help students quickly identify what they do and do not understand so they can study smartly. With exceptional instructional design that prompts students to discover, reflect, synthesize, and apply, students actively learn. Remediation links to the eBook are integrated throughout.

Curated collections of journal articles are provided via Lippincott NursingCenter, Wolters Kluwer’s premier destination for peer-reviewed nursing journals. Through integration of CoursePoint and NursingCenter, students will engage in how nursing research influences practice.

Data to measure students’ progress: Student performance data provided in an intuitive display lets instructors quickly assess whether students have viewed interactive modules and video cases outside of class, as well as see students’ performance on related NCLEX-style

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quizzes, ensuring students are coming to the classroom ready and prepared to learn.

To learn more about Lippincott CoursePoint, please visit: http://nursingeducation.lww.com/our- solutions/course-solutions/lippincott-coursepoint.html

A FINAL WORD FROM THE AUTHORS As we have the privilege of meeting and working with clinicians, educators, and researchers across the globe to advance and sustain EBP, we realize how important our unified effort is to world health. We want to thank each reader for your investment of time and energy to learn and use the information contained within this book to foster your best practice. Furthermore, we so appreciate the information that you have shared with us regarding the benefits and challenges you have had in learning about and applying knowledge of EBP. That feedback has been instrumental to improving the fourth edition of our book. We value constructive feedback and welcome any ideas that you have about content, tools, and resources that would help us to improve a future edition. The spirit of inquiry and life-long learning are foundational principles of the EBP paradigm and underpin the EBP process so that this problem-solving approach to practice can cultivate an excitement for implementing the highest quality of care. As you engage in your EBP journey, remember that it takes time and that it becomes easier when the principles of this book are placed into action with enthusiasm on a consistent daily basis.

As you make a positive impact at the point of care, whether you are first learning about the EBP paradigm, the steps of the EBP process, leading a successful, sustainable evidence-based change effort, or generating evidence to fill a knowledge gap or implement translational methods, we want to encourage you to keep the dream alive and, in the words of Les Brown, “Shoot for the moon. Even if you miss, you land among the stars.” We hope you are inspired by and enjoy the following EBP rap.

Evidence-based practice is a wonderful thing, Done with consistency, it makes you sing. PICOT questions and learning search skills; Appraising evidence can give you thrills. Medline, CINAHL, PsycInfo are fine, But for Level I evidence, Cochrane’s divine! Though you may want to practice the same old way “Oh no, that’s not how I will do it,” you say. When you launch EBP in your practice site, Remember to eat the chocolate elephant, bite by bite. So dream big and persist in order to achieve and Know that EBP can be done when you believe!

© 2004 Bernadette Melnyk Bernadette Mazurek Melnyk and Ellen Fineout-Overholt

Note: You may contact the authors at bernmelnyk@gmail.com ellen.fineout.overholt@gmail.com

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http://nursingeducation.lww.com/our-solutions/course-solutions/lippincott-coursepoint.html
mailto:bernmelnyk@gmail.com
mailto:ellen.fineout.overholt@gmail.com
Acknowledgments

This book could not have been accomplished without the support, understanding, and assistance of many wonderful colleagues, staff, family, and friends. I would first like to acknowledge the outstanding work of my coeditor and cherished friend, Ellen—thank you for all of your efforts, our wonderful friendship, attention to detail, and ongoing support throughout this process; I could not have accomplished this revised edition without you. Since the first edition of this book, I have grown personally and professionally through the many opportunities that I have had to teach and mentor others in evidence-based practice across the globe—the lessons I have learned from all of you have been incorporated into this book. I thank all of my mentees for their valuable feedback and all of the authors who contributed their time and valuable expertise to this book. Along with my wonderful husband John and my three daughters, Kaylin, Angela, and Megan, I am appreciative for the ongoing love and support that I receive from my mother, Anna May Mazurek, my brother and sister-in-law, Fred and Sue Mazurek, and my sister, Christine Warmuth, whose inspirational words to me “Just get out there and do it!” have been a key to many of my successful endeavors. I would also like to thank my wonderful colleagues and staff at The Ohio State University for their support, understanding, and ongoing commitment to our projects and their roles throughout this process, especially Dr. Margaret Graham and Kathy York. Finally, I would like to acknowledge the team at Wolters Kluwer for their assistance with and dedication to keeping this project on track.

Bernadette Mazurek Melnyk

Now is the time to join together to ensure that EBP is the paradigm for clinical decision making. Healthcare providers and educators have made tremendous strides across the years to establish that EBP is an expectation of providers, educators, and systems. I am grateful to the American Nurses Credentialing Center (ANCC) for the impact of the Magnet movement as well as educational accrediting agencies (e.g., Commission on Collegiate Nursing Education [CCNE], National League for Nurses Accreditation Commission [NLNAC], Liaison Committee on Medical Education [LCME], Accreditation Council of Pharmacy Education [ACPE]) for putting forward standards that have had an impact on adoption of the EBP paradigm and process in education, practice, and policy. As a result, all of us across the wonderful diversity of providers who make up the healthcare team are supported as we choose the EBP paradigm as the foundation for daily clinical decisions. Thank you to the students, clinicians, healthcare leadership, clinical educators, faculty, and researchers for demonstrating the ownership of practice that is the key to placing EBP at the center of healthcare transformation. We are at a tipping point . . . let’s see it through to fruition!

To those of you who have shared with me personally the difference this book has made in your practice, educational endeavors, and teaching, I heartily extend my deepest thanks. The value of our work is measured by the impact it has on advancing best practice in healthcare and how it helps point-of-care providers and educators make a difference in patients’ and students’ lives and health experiences. You help us know that we are making progress on achieving our dream of transforming healthcare—one client–clinician/learner–

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educator relationship at a time. Bern, almost 30 years ago, we started our work together—not knowing where our path would take us. Thank you for seeing the potential and taking the chance—I have enjoyed the wonderful privilege to work alongside you to bring our dream to life. To my colleagues at University of Texas at Tyler, thank you for the privilege of joining the family—you are the best!!

With the writing of this fourth edition, my life experiences, and those of contributors to the book, have helped me recognize more completely how blessed I am to have the support of my precious family and friends and to have wonderful people in my life who are committed to this often-arduous journey toward best care for all patients. My sweet family has trekked with me across these four editions. With the first edition, our eldest daughter wasn’t yet one year old; now, she is a senior in high school. Our youngest daughter was a dream who is now is in eighth grade. Every day, these sweet young ladies inspire me to continue to strive to achieve the goal of evidence-based care as the standard for healthcare. Their gift of love and laughter delivered in packages of hugs is invaluable—Thank You, Rachael and Ruth! Thank you to my steadfast husband, Wayne, who faithfully offers perspective and balance that are so important to me—your support for this work is invaluable! Thank you to my mother, Virginia (Grandginny), who continues to help me see the best and not best in healthcare as she experiences it as an older old adult (now 87). Her encounters remain a reminder that advocating for evidence-based consumers is an imperative. Thank you to my brother John, and his family, Angela, Ashton, and Aubrey—your music lifts my spirits; your healthcare experiences serve as fodder for this work. To those of you who have prayed for me during this writing adventure—thank you so very much! During my extenuating health issues that have flavored this fourth edition, my Savior and Friend’s continual care for me has been profound. I am eternally grateful. Healthcare should serve all of us well. Let us all strive to ensure that every encounter is an experience in excellent care.

Finally, I am grateful to each of you who choose to read this book, take the knowledge contained in its pages, and make the EBP paradigm and process come alive in your work. You make our dream of healthcare transformation through EBP live! The Wolters Kluwer team with whom we have had the privilege to work has been so helpful to make this fourth edition the best yet!! Thank you so much! This book is not written by one person—or even two. It is written by many people who give of their expertise and wisdom so that readers can have such a wonderful resource. I am very grateful for each of the faithful contributors to this work and their decision to join us in advancing EBP as the solution for improving healthcare.

Ellen Fineout-Overholt

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Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

Chapter 6

Chapter 7

Chapter 8

Chapter 9

Chapter 10

Chapter 11

Chapter 12

UNIT 1

UNIT 2

UNIT 3

Contents

Steps Zero, One, Two: Getting Started Making the Case for Evidence-Based Practice and Cultivating a Spirit of Inquiry Bernadette Mazurek Melnyk and Ellen Fineout-Overholt

Asking Compelling Clinical Questions Ellen Fineout-Overholt and Susan B. Stillwell

Finding Relevant Evidence to Answer Clinical Questions Tami A. Hartzell and Ellen Fineout-Overholt

Unit 1 Making EBP Real: A Success Story. Using an Evidence-based, Autonomous Nurse Protocol to Reduce Catheter- Associated Urinary Tract Infections in a Long-term Acute Care Facility

Step Three: Critically Appraising Evidence Critically Appraising Knowledge for Clinical Decision Making Ellen Fineout-Overholt and Kathleen R. Stevens

Critically Appraising Quantitative Evidence for Clinical Decision Making Dónal P. O’Mathúna and Ellen Fineout-Overholt

Critically Appraising Qualitative Evidence for Clinical Decision Making Mikki Meadows-Oliver

Integration of Patient Preferences and Values and Clinician Expertise into Evidence-Based Decision Making Ellen Fineout-Overholt, Lisa English Long, and Lynn Gallagher-Ford

Advancing Optimal Care With Robust Clinical Practice Guidelines Doris Grinspun, Bernadette Mazurek Melnyk, and Ellen Fineout-Overholt

Unit 2 Making EBP Real: A Success Story. Intradermal Lidocaine Intervention on the Ambulatory Unit: An Evidence- Based Implementation Project

Steps Four and Five: Moving From Evidence to Sustainable Practice Change Implementing Evidence in Clinical Settings Cheryl C. Rodgers, Terri L. Brown, and Marilyn J. Hockenberry

The Role of Outcomes and Evidence-Based Quality Improvement in Enhancing and Evaluating Practice Changes Anne W. Alexandrov, Tracy L. Brewer, and Barbara B. Brewer

Implementing the Evidence-Based Practice Competencies in Clinical and Academic Settings to Ensure Healthcare Quality and Improved Patient Outcomes Bernadette Mazurek Melnyk, Lynn Gallagher-Ford, and Cindy Zellefrow

Leadership Strategies for Creating and Sustaining Evidence-Based Practice Organizations Lynn Gallagher-Ford, Jacalyn S. Buck, and Bernadette Mazurek Melnyk

Unit 3 Making EBP Real: A Success Story. Improving Outcomes for Depressed Adolescents With the Brief Cognitive Behavioral COPE Intervention Delivered in 30-Minute Outpatient Visits

Creating and Sustaining a Culture and Environment for Evidence-Based Practice

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Chapter 14

Chapter 15

Chapter 16

Chapter 17

Chapter 18

UNIT 5 Chapter 19

Chapter 20

Chapter 21

Chapter 22

Chapter 23

Appendix A

Appendix B

Appendix C

Appendix I

Appendix J

Appendix K

UNIT 4 Chapter 13

UNIT 6

Innovation and Evidence: A Partnership in Advancing Best Practice and High Quality Care Kathy Malloch and Tim Porter-O’Grady

Models to Guide Implementation and Sustainability of Evidence-Based Practice Deborah Dang, Bernadette Mazurek Melnyk, Ellen Fineout-Overholt, Jennifer Yost, Laura Cullen, Maria Cvach, June H. Larabee, Jo Rycroft-Malone, Alyce A. Schultz, Cheryl B. Stetler, and Kathleen R. Stevens

Creating a Vision and Motivating a Change to Evidence-Based Practice in Individuals, Teams, and Organizations Bernadette Mazurek Melnyk and Ellen Fineout-Overholt

Teaching Evidence-Based Practice in Academic Settings Ellen Fineout-Overholt, Susan B. Stillwell, Kathleen M. Williamson, and John F. Cox III

Teaching Evidence-Based Practice in Clinical Settings Ellen Fineout-Overholt, Martha J. Giggleman, Katie Choy, and Karen Balakas

ARCC Evidence-Based Practice Mentors: The Key to Sustaining Evidence-Based Practice Ellen Fineout-Overholt and Bernadette Mazurek Melnyk

Unit 4 Making EBP Real: A Success Story. Mercy Heart Failure Pathway

Step Six: Disseminating Evidence and Evidence-Based Practice Implementation Outcomes

Using Evidence to Influence Health and Organizational Policy Jacqueline M. Loversidge and Cheryl L. Boyd

Disseminating Evidence Through Presentations, Publications, Health Policy Briefs, and the Media Cecily L. Betz, Kathryn A. Smith, Bernadette Mazurek Melnyk, and Timothy Tassa

Unit 5 Making EBP Real: A Success Story. Research Projects Receive Worldwide Coverage

Generating External Evidence and Writing Successful Grant Proposals Generating Evidence Through Quantitative and Qualitative Research Bernadette Mazurek Melnyk, Dianne Morrison- Beedy, and Denise Cote-Arsenault

Writing a Successful Grant Proposal to Fund Research and Evidence-Based Practice Implementation Projects Bernadette Mazurek Melnyk and Ellen Fineout-Overholt

Ethical Considerations for Evidence Implementation and Evidence Generation Dónal P. O’Mathúna

Unit 6 Making EBP Real: Selected Excerpts From A Funded Grant Application. COPE/Healthy Lifestyles for Teens: A School-Based RCT

Question Templates for Asking PICOT Questions

Rapid Critical Appraisal Checklists

Evaluation Table Template and Synthesis Table Examples for Critical Appraisal

ARCC Model Timeline for an EBP Implementation Project

Sample Instruments to Evaluate EBP in Educational Settings

Sample Instruments to Evaluate EBP in Clinical Settings

Glossary

Index

APPENDICES AVAILABLE ON

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Appendix D

Appendix E

Appendix F

Appendix G

Appendix H

Walking the Walk and Talking the Talk: An Appraisal Guide for Qualitative Evidence

Example of a Health Policy Brief

Example of a Press Release

Example of an Approved Consent Form for a Study

System-Wide ARCC Model Evidence-Based Practice Mentor Role Description

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UNIT

1 Steps Zero, One, Two: Getting Started

To accomplish great things, we must not only act, but also dream; not only plan, but also believe.

—Anatole France

EBP Terms to Learn Background questions

Bibliographic database

Body of evidence

Boolean connectors

Clinical inquiry

Critical appraisal

EBP competencies

Evidence-based practice (EBP)

Evidence-based quality improvement (EBPI)

External evidence

Foreground questions

Grey literature

Internal evidence

Keywords

Meta-analysis

Outcomes management

PICOT format

Point-of-care resources

Preappraised literature

Proximity searching

Randomized controlled trials (RCTs)

Reference managers

Search strategy

Subject headings

Yield

UNIT OBJECTIVES

Upon completion of this unit, learners will be able to:

Identify the seven steps of evidence-based practice (EBP).

Describe the differences among EBP, research, and quality improvement.

Explain the components of a PICOT question: population, issue or intervention of interest, comparison of interest, outcome, and time for intervention to achieve the outcome.

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Discuss basic and advanced strategies for conducting a systematic search based on the PICOT question.

Describe a body of evidence based on the evidence hierarchy for specific types of clinical questions.

MAKING CONNECTIONS: AN EBP EXEMPLAR On the orthopedic unit of a tertiary hospital in the Eastern United States, a nurse manager, Danielle, and the unit EBP Council representative, Betsy, were discussing recent quality improvement (QI) reports in the staff lounge. Danielle noted that the unit’s patient satisfaction rates had dropped as their fall rates had increased.

To help provide context, Betsy, who has a passion for fall prevention (Step 0: Spirit of Inquiry), shared the story of Sam, an elderly patient who sustained a fall with injury during the last quarter, despite the fact that he was not a high fall risk. As Sam’s primary nurse, Betsy had initiated universal fall prevention precautions as recommended by the Agency for Healthcare Research & Quality in their Falls Prevention Toolkit (AHRQ; https://www.ahrq.gov/sites/default/files/publications/files/fallpxtoolkit.pdf). Betsy hoped that Sam’s story would help illuminate some of the issues that surround falls that are more challenging to predict.

Sam had awakened from a deep sleep and needed to void. He was oriented when he went to bed, but upon waking he became confused and couldn’t locate his call light because, although it was placed close to him, it had been covered by his pillow. In an interview after he fell, Sam told Betsy that he had to go so badly that he just didn’t think about looking under the pillow. He also forgot that there was a urinal on the bedside table. He simply focused on getting to the bathroom, and when he tried to get out of bed with the rails up, he pinched his wrist, causing a hematoma and soft tissue injury.

Danielle had more information that shed light on the rising fall rates. All of the falls during the past quarter occurred during the night shift. Over a period of several weeks, a number of the night nurses had been ill, leading to per-diem and float staff covering those positions. Staff had documented rounding, but Betsy and Danielle wondered whether introducing regularly scheduled rounding could prevent future falls like Sam’s.

Danielle and Betsy discussed some tools that they had heard could help structure regular rounding; both agreed that staff would need more than just their recommendation for the implementation of any tool to be successful. They gathered a group of interested staff who had reviewed the fall data to ask about their current regular rounding habits. The nurses indicated that they rounded on a regular basis, but sometimes up to three hours might pass between check-ins with more “stable” patients like Sam, particularly if there were other urgent needs on the unit. One of the newer nurses, Boqin, mentioned that in nursing school he had written a paper on hourly rounding and perhaps that may be a solution.

All of the unit nurses agreed that the outcome of a rising fall rate required evaluation and that hourly rounding may help, so Betsy guided the group in crafting a properly formatted PICOT question (P: population; I: intervention or issue of interest; C: comparison intervention or condition; O: outcome to see changed; T: time for the intervention to achieve the outcome or issue to be addressed). After reviewing the QI data, discussing the context of the clinical issue, and looking at case studies for clues about why the outcome was occurring, the question that the group posed was, In elderly patients with low risk for falls with universal precautions in place, how does hourly rounding at night compared to no hourly rounding affect preventable fall rates within 3 months of initiation? (Step 1: Ask a Clinical Question in PICOT Format).

The nurses became excited about answering the question and asked Betsy about the next steps in the EBP process. Betsy already had a great relationship with their hospital librarian, Scott, who was well versed in EBP and had demonstrated his expertise at systematic searching when helping with previous EBP Council projects. Betsy e-mailed the group’s PICOT question to Scott and asked him to conduct a systematic search (Step 2: Systematic Searching). Scott knew that his initial search terms had to come from the PICOT question, so he carefully considered what the nurses had asked. He knew a great start would be finding a systematic review that contained multiple studies about the impact of hourly rounding on fall rates within elderly patients who were at low risk for falls, so he began his search with the O: fall rates. In addition, all studies Scott would consider including in his body of evidence would need to have the outcome of preventable fall rates; otherwise, the studies could not answer to the clinical question.

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https://www.ahrq.gov/sites/default/files/publications/files/fallpxtoolkit.pdf
Figure 1: Systematic search of Comprehensive Index of Nursing and Allied Health Literature (CINAHL) database. (Source: EBSCO Information Services)

A systematic search using the advance search interface of the Cochrane Library to find systematic reviews that included the terms hourly rounding AND falls yielded no hits. The term hourly rounding yielded one hit, a systematic review focused on the impact of hourly rounding on patient satisfaction. Scott decided to keep that review, since Betsy had mentioned that their patient satisfaction had varied at the same time as their fall rates. Using the same approach, Scott continued the systematic search in the Comprehensive Index of Nursing and Allied Health Literature (CINAHL) database, beginning with the same terms, hourly rounding and falls and their associated subject headings. Scott used the focus feature in CINAHL for each subject heading to make sure the topic was the major point of the article. This search yielded 22 articles. A systematic search of PubMed with the same approach yielded 12 studies (see Figures 1 and 2 for details of these searches).

Figure 2: Systematic search of PubMed database. (From National Library of Medicine, www.pubmed.gov)

Now that all three databases had been searched, the total yield of 35 studies were available for Scott’s review to see if they were keeper studies to answer the PICOT question. Eight hits were found to be redundant among databases and were removed from the yield (N = 27). When inclusion criteria of fall preventions as the outcome was applied, 14 more were removed (N = 13). One article was proprietary and could not be accessed through interlibrary loan or via the Internet (N = 12). Three articles were not owned by the library and were requested through interlibrary loan (N = 15). Finally, two relevant articles, one of which was a master’s thesis, were found by hand searching, which resulted in 17 articles to enter into the critical appraisal process. After review of the study designs, the final cohort of studies that Scott currently had (i.e., the body of evidence) included one systematic review, no single randomized controlled trials, four quasi-experimental studies, eight evidence-based or quality improvement projects, and one expert opinion article (see Table 1). He knew he had three more articles to add to the body of evidence when they came in from interlibrary loan; however, Scott thought it was important to discuss the current body of evidence with Betsy and Danielle, who decided to take the current articles to the EBP Council.

Join the group at the beginning of Unit 2 as they continue their EBP journey.

TABLE

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http://www.pubmed.gov
1 Synthesis: Levels of Evidence

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1, Brown; 2, Callahan; 3, Dyck; 4, Goldsack; 5, Hicks; 6, Krepper; 7, Leone; 8, Lowe; 9, Mitchell; 10, Olrich; 11, Stefancyk; 12, Tucker; 13, Waszynski; 14, Weisgram.

References Brown, C. H. (2016). The effect of purposeful hourly rounding on the incidence of patient falls. Nursing Theses and Capstone Projects. Retrieved

from http://digitalcommons.gardner-webb.edu/nursing_etd/246 Callahan, L., McDonald, S., Voit, D., McDonnell, A., Delgado-Flores, J., & Stanghellini, E. (2009). Medication review and hourly nursing

rounds: An evidence-based approach reduces falls on oncology inpatient units. Oncology Nursing Forum, 36(3), 72. Daniels, J. F. (2016). Purposeful and timely nursing rounds: A best practice implementation project. JBI Database of Systematic Reviews and

Implementation Reports, 14(1), 248–267. doi:10.11124/jbisrir-2016-2537.* Dyck, D., Thiele, T., Kebicz, R., Klassen, M., & Erenberg, C. (2013). Hourly rounding for falls prevention: A change initiative. Creative

Nursing, 19(3), 153–158. Goldsack, J., Bergey, M., Mascioli, S., & Cunningham, J. (2015). Hourly rounding and patient falls: What factors boost success? Nursing,

45(2), 25–30. Hicks, D. (2015). Can rounding reduce patient falls in acute care? An integrative literature review. MEDSURG Nursing, 24(1), 51–55. Jackson, K. (2016). Improving nursing home falls management program by enhancing standard of care with collaborative care multi-

interventional protocol focused on fall prevention. Journal of Nursing Education and Practice, 6(6), 85–96.* Krepper, R., Vallejo, B., Smith, C., Lindy, C., Fullmer, C., Messimer, S., . . . Myers, K. (2014). Evaluation of a standardized hourly rounding

process (SHaRP). Journal for Healthcare Quality, 36(2), 62–69. doi:10.1111/j.1945-1474.2012.00222.x Leone, R. M., & Adams, R. J. (2016). Safety standards: Implementing fall prevention interventions and sustaining lower fall rates by promoting

the culture of safety on an inpatient rehabilitation unit. Rehabilitation Nursing, 41(1), 26–32. Lowe, L., & Hodgson, G. (2012). Hourly rounding in a high dependency unit. Nursing Standard, 27(8), 35–40. Mitchell, M. D., Lavenberg, J. G., Trotta, R. L., & Umscheid, C. A. (2014). Hourly rounding to improve nursing responsiveness: A systematic