Using Evidence to Address Clinical Problems

Submitter Information

Author: Pamela M. Ironside, PhD, RN, FAAN
Title: Associate Professor
Institution: Indiana University School of Nursing
Email: pamirons@iupui.edu

Competency Category(s)
Evidence-Based Practice

Learner Level(s)
New Graduates/Transition to Practice, Pre-Licensure ADN/Diploma, Pre-Licensure BSN, RN to BSN

Learner Setting(s)
Clinical Setting

Strategy Type
Independent Study

Learning Objectives

  • Differentiate clinical opinion from research and evidence summaries
  • Explain the role of evidence in determining best clinical practice
  • Identify gaps between local and best practice
  • Discriminate between valid and invalid reasons for modifying
    evidence-based clinical practice based on clinical expertise or
    patient/family preferences
  • Participate effectively in appropriate data collection and other research activities
  • Consult with clinical experts before deciding to deviate from evidence-based protocols.
  • Appreciate strengths and weaknesses of scientific bases for practice
  • Acknowledge own limitations in knowledge and clinical expertise
    before determining when to deviate from evidence-based best practices

Strategy Overview

In this exercise, students work collaboratively to explore current
practice on a unit where they are having clinical experience. In most
cases, not every student will complete every phase. Rather, students
will take turns investigating the problem and reporting results to the
group. While this exercise describes only a part of the quality
improvement process, you can expand it to be more inclusive as the
timeframe and situation allows. Similarly, this exercise can span a few
weeks or an entire semester. It is most helpful if the problem students
explore is specific to the unit on which they are currently having
clinical experiences so that they can look at their own practice over
time as well as that of the staff. You may specify the problem in
advance [i.e.: hospital acquired infections] based on your experience,
or you may make the process of coming up with the problem part of the
exercise [i.e.: after several weeks on the unit, students can
collectively decide on a problem (potential problem) they have
identified in the clinical setting].

Once the problem is identified, an assigned student investigates
staff perceptions of the problem. [For instance, do staff see this as a
problem? Why or why not? What initiatives have been tired (if any) by
the unit staff to address or prevent it? Is this problem addressed at
unit meetings/in-services?] Another student investigates the nursing
literature related to the problem. [i.e.: Looking at the last 5 years,
how many studies of this problem have been reported? What are the major
conclusions?] Another student may look at the health literature more
broadly [Who IS studying this problem? What does the literature
recommend? How and in what ways does this relate to nursing?] Another
student investigates the Cochrane Library and/or national benchmarks to
gather evidence and recommendations for practice. Discussion throughout
this part of the exercise focuses on the evidence related to the problem
– where it is, how the problem is (or is not) being studied, and what
questions remain for students. Simultaneously, another student may
review charts on the unit to identify the extent of the problem
(alternatively, each student may report relevant data related to the
problem for their assigned patients and construct a simple database to
look at incidence of the problem for their patients over time related to
national data). As the exercise nears completion, discussion may
include:

  1. When you think about the patients for whom you have been providing
    care this semester, what could possibly be wrong with the best evidence
    available to date?
  2. In what specific situation would you NOT use this evidence when planning care for this patient? Why?
  3. With whom would you consult (if anyone) in making this determination?
  4. Are there data sources that we have not yet explored that could be
    helpful in considering [this problem] or planning ways to alleviate it?
  5. What questions do you have (about this problem or nursing practice
    related to care of patients experiencing the problem) that aren’t being
    addressed by current researchers?

Submitted Materials

Additional Materials

Evaluation Description

This exercise can be used for discussion or as a group project that
is marked pass/fail. An important aspect of discussion is to engage
students in thinking about the practical use of evidence in its most
inclusive sense (i.e.: students immersed in exploring various data
sources may inadvertently discount other valuable sources such as
patient/family values and/or clinical expertise). As well, exploring
what’s missing is a great time to talk about the importance of ongoing
research and what to do when decisions must be made for which there is
little, no, or conflicting evidence. Differentiating between valid and
invalid reasons and the importance of backup from clinical experts can
also help students explore the limits and boundaries of their current
knowledge and experience.

Alternatively, you may ask each student to write and submit a one
page summary of their findings which you can mark using a rubric
consistent with those used at your school. (ie: A – work is clear,
complete and concise, demonstrates excellent command and critical use of
resources related to [the problem]. B – work is clear and concise,
reflects consistent and appropriate use of resources related to [the
problem]. C – work is incomplete and reflects non-critical or
superficial use of resources). The questions at the end, however, should
be for discussion only.