Until about eight years ago, when a red spot appeared over a bony area on a patient's skin, nurses would rub the area gently to improve circulation, said Patricia Rowell, Ph.D., RN, senior policy fellow in nursing practice and policy for the American Nurses Association. Such treatment seemed to be common sense. But then along came studies that showed exactly the opposite to be true. Rubbing the skin actually damaged the tissue, and nurses stopped the practice.

"That's the result of research," Rowell said.

Evidence-based practice-basing methods of patient care on scientific research rather than relying on tradition or habit-is not a new concept in nursing. Since the days of Florence Nightingale, nurses have applied and conducted research in their practices.

But within the last two decades, evidence-based practice has taken on a new importance as nurses, physicians and other health care professionals have started questioning even the most basic care procedures and proposing improvements based on the latest research.

The advent of the Internet and large research clearinghouses such as the Cochrane Library and the Agency for Healthcare Research and Quality have put huge amounts of information at the fingertips of caregivers and researchers. Nursing practice, which focuses on patient safety and quality of care, has caught the attention of hospitals and other sponsors of research.

Coming into vogue
"We're seeing it come into vogue," Rowell said. "They are realizing more and more that nursing practice is a major contributor to patient outcomes."

Pain management, falls, skin care, bed rest vs. mobility after surgery and patient self-care techniques have fallen under scrutiny in a number of hospitals, health care systems and nursing associations. Journals on evidence-based practice, such as The Online Journal of Knowledge Synthesis for Nursing, offer reviews or digests of research on topics such as "Agitation in Older Patients with Dementia" and "Effects of Head of Bed Positioning on Pulmonary Artery Pressure Measurements."

Many large hospitals, such as the Cedars-Sinai Medical Center in Los Angeles, have their own resource departments devoted to helping multidisciplinary teams of health care workers-physicians, nurses, pharmacists, therapists-research a particular area or practice. Many hospitals have clinical educators or clinical nurse specialists who are responsible for interpreting and implementing pertinent nursing research and then working with a team to develop changes in practice.

Nursing schools include course content on the importance of evidence-based practice and introduce students to the rudiments of evidence analysis during their clinical experience.

Although most nursing leaders, advanced practice nurses, researchers, educators and quality-improvement departments, have embraced evidence-based practice, many clinical nurses' eyes still "glaze over" when they hear the words, said Lisa Sams, MSN, RN, president of Clinical Linkages Inc., a Virginia-based company that works with hospitals to improve patient outcomes.

It's hard to blame them. The language of research is filled with jargon-RCTs, evidence synthesis, meta-analysis. Nurses who work at the bedside for 10 or 12 hours rarely have the time to evaluate complicated studies on dressing changes or emergency management of pediatric asthma. Not all nurse managers see the importance of their nurses leaving patients to attend a session on the latest pain management techniques.

Making it work
But those who advocate the use of evidence-based practice say bedside nurses must be involved if the concept is to work. "Every nurse needs to make a commitment to being a consumer of knowledge for practice," said Nancy Donaldson, DNSc, RN, director of the UCSF Stanford Center for Research and Innovation in Patient Care at the University of California, San Francisco School of Nursing and co-principal investigator for the California Nursing Outcomes Coalition Project.

Nurses are perhaps the most vital members of any clinical improvement team in a hospital, said Andy Kosseff, MD, physician consultant to the SSM Health Care Quality Resource Center in St. Louis. "By far and away, the most effective people in implementing evidence-based practices are nurses," he said, in part because nurses must deal with variations in care prescribed by physicians. "They have a tremendous interest and enthusiasm for seeing if some of that care can be standardized," he said.

Evidence-based medicine, the foundation for evidence-based practice, was born in England in the 1970s, when physician Archie Cochrane made a presentation asserting that medicine wrongly disregarded research and based most of its practices on habit rather than lifelong learning, Sams said.

"He kind of threw the gauntlet down," she said, and spawned a movement that called for the organized, systematic use of evidence in medical practice. Cochrane advocated that medical practice be based on randomized, control trials-the so-called "gold standard" of research.

But later proponents of evidence-based medicine have included other types of evidence as well, including long-term uncontrolled tests on a population and, as a last resort, expert opinion. When all the evidence on a particular topic is reduced to a document of a few pages, it is called a synthesized review or a digest.

Evidence-based practice can be as simple as a single nurse reading a synthesized review of a practice-say, the effect of exercise on arthritis patients or whether ice is effective for relieving muscle pain-and using that information in his or her work. Or it can be a three-year study, like the one conducted by the Association of Women's Health, Obstetric and Neonatal Nurses on the effect of specific pelvic exercises on reducing incontinence in new mothers.

For that study, the association assembled a team of nurse researchers and clinicians, said Carolyn Sampselle, Ph.D., RN, FAAN, a Carolyn K. Davis collegiate professor of nursing at the University of Michigan in Ann Arbor and a member of the research team. For the first year, the team looked at and evaluated all the available and relevant information on the topic. Then the researchers created a protocol that nurses could use.

The association sent out a call for volunteers whose institutions would send them for training in Washington, D.C. Those nurses, a variety of advanced practice nurses and RNs who worked in outpatient settings, went back and began teaching patients. The research team monitored the clinicians and gathered feedback from them. In the third year, the team analyzed the data and found a measurable decrease in incontinence.

Hospital implementation of a policy based on evidence may follow a similar pattern, but on a much smaller scale and over a much shorter period of time.

For instance, at Sunrise Hospital and Medical Center in Las Vegas, a multidisciplinary team that included physicians and nurses looked at reducing the cesarean rate by using intrauterine pressure catheters to measure labor in women who showed no cervical changes during contractions.

The practice was advocated by the Association of Women's Health, Obstetric and Neonatal Nurses, said Eloise Keeler, RN, clinical applications specialist at the hospital, and research supported it. After assessing the available information, the team developed a way of putting the procedure into practice and collecting feedback that would allow them to measure the outcome.

Researchers still are interpreting the results of that study, Keeler said. Meanwhile, the hospital is participating in similar studies with other hospitals on reducing falls and pressure ulcers, she said.

The challenges
Implementing what research demonstrates as the "best practice" isn't always a matter of announcing a change, then sitting back and waiting for it to happen.
For example, research shows that giving children antibiotics for otitis media, an infection of the middle ear, does not shorten the length of infection, said Kathleen Stevens, Ed.D., RN, FAAN, professor at the University of Texas Health Science Center at San Antonio School of Nursing and editor of The Online Journal of Knowledge Synthesis for Nursing.

But the research doesn't tell caregivers how to placate worried parents who demand medicine for their children, she said.

According to a 1999 editorial in the online journal, studies show that the greatest barriers to nurses using evidence-based practice include lack of time, no administrative support, limited access to research journals, opposition from physicians, difficulty in understanding reports and resistance to change.

Sampselle said that some nurses in her study reported difficulty convincing physicians of the value of the self-care teaching, even after they showed them the evidence.

In Los Angeles, at Cedars-Sinai Medical Center, clinical nurse specialists worked with multidisciplinary teams to research and improve pain management, said Brigitte Failner, MS, RN, an orthopedic clinical nurse specialist and orthopedic unit manager at Cedars-Sinai. After examining the evidence, the nursing team decided to make it a policy to offer pain medication to patients round-the-clock.

Most units have adopted the policy without problems, Failner said. But feedback shows a few nurse have resisted for one reason or another, and some do not feel their immediate supervisors support the practice change.

Hospitals and health care systems need to support nurses in the use of evidence-based practice by giving clinicians time to do research and to work on committees to improve practice, said Nancy Dickenson-Hazard, MSN, RN, FAAN, CEO of the Sigma Theta Tau International Honor Society of Nursing, based in Indianapolis. "That says that the system values evidence being placed into practice and values giving nurses the opportunities to do that," she said.

But Rowell fears the nursing shortage may make it more difficult for nurses to spend time on research or education about best practices. Clinical nurse specialists, who form the backbone of evidence-based practice in hospital nursing, are in short supply, she said. Also in demand are nurse researchers, who are desperately needed to fill the still-shallow font of information about many nursing practices, she said.

Despite the obstacles, the use of evidence-based practice in nursing is more important now than ever, said Esther Acree, MSN, RN, director of the Sycamore Nursing Center and associate professor of nursing at the Indiana State University School of Nursing.

"To me, it shows that nurses are just not handmaidens anymore," she said. "Over the years, I think we've fought battles to get respect from many different groups, to show that the things we do are based on research that nurses can do. Without evidence-based practice, we could be slipping back into the adage that 'nurses don't really know anything.' "