Building Capacity for Evidenced-Based Practice at the Unit Level Using Oncology Nursing Society Putting Evidence Practice.

“It is evident that leadership in nursing … is of supreme importance at this time. Nursing has faced many critical situations in its long history, but probably none more critical than the situation it is now in, and none in which the possibilities, both of serious loss and of substantial advance, are greater. What the outcome will depend in large measure on the kind of leadership the nursing profession can give in planning for the future and in solving stubborn and perplexing problems … if experience is any criterion, little constructive action will be taken without intelligent and courageous leadership.”—Isabel Maitland Steward (1943). The Education of Nurses: Historical Foundations and Modern Trends. Macmillan Nursing Education Monographs Series. New York: The Macmillian Company.

Much is written about evidence-based practice (EBP) in nursing and its use in clinical practice. For oncology nurses, it is especially important to use the principles of and knowledge about EBP since cancer care is becoming increasing complex. This care complexity places increasing demands on oncology nurses around the world. Although EBP should be imbued throughout a health care organization, the emphasis must be placed at the unit level be it bedside or chairside. Institutionalizing EBP requires oncology nurses to be knowledgeable about the available evidence and its usefulness. This should not difficult given the resources developed by and available to oncology nurses.

Oncology nurse researchers developed much of the scientific knowledge, the evidence, concerning cancer symptom management, cancer symptom clusters, and cancer care interventions. Oncology nurses lead the way in building EBP capacity. Yet, an ongoing concern is how nurses at the bedside or chairside practice using EBP principles. The purpose of this article is to provide some basic EBP principles and resources for oncology nurses to build EBP capacity at the unit level.

Evidence-Based Practice

EBP is an interdisciplinary approach to clinical practice. It is grounded in principles of clinical decision making combined with the best evidence available, along with the clinical expertise of the nurse, and includes the patient's preference. Clinical decisions should be based on research studies offering conscientious, explicit and judicious use of research to make decisions about patient care. Integrating clinical expertise with the best available external clinical evidence from systematic research while including the patient in the decision-making about their care are the essential components of EBP.[12345]

It is important to note that EBP should be considered a problem-solving approach to health care delivery integrating the best evidence from studies [Figure 1][6] with patient care data, combined with nursing expertise and patient preferences and values. This integration of best available research evidence, clinical expertise, and patient needs results in the best patient outcomes.

Figure 1

Levels of evidence.

Results of research studies comprise the evidence making up EBP. In Figure 1 levels of evidence are specified beginning at the base of a triangle. This evidence includes expert opinion, background information, along with descriptive, theoretical, and qualitative studies. These studies are considered low-level evidence. There are many of these types of studies found in published literature. Whereas at the top of triangle there are fewer studies on a given topic yet these studies are considered the best available evidence found in the literature. These studies use a specific methodology and are called meta-analyses, meta-syntheses, systematic reviews, and other studies that consolidate a given body of research on a specific topic. Reading and using these studies in practice constitute the best available evidence.

In addition to conducting literature searches for meta-analyses, meta-syntheses, and systematic reviews on a given clinical topic, there are many organizations that provide such summaries. Table 1 contains a list of resources where oncology nurses can find summaries of evidence on a variety of topics by a variety of organizations. Some of these evidence-based guidelines are fee-based, but others are open access and available on the internet. One such open access evidence-based oncology symptom database is Oncology Nursing Society's (ONS) Putting Evidence into Practice (PEP) (http:ONS.org/pepresources).

Table 1

Evidenced-based practice resources (selected)

Guideline source	Guideline internet address
National Guideline Clearinghouse	http://www.guideline.gov/
National Comprehensive Cancer Network	http://www.nccn.org/
Agency for Healthcare Research and Quality	http://www.ahrq.gov/
Clinical Trials.Gov (NIH)	http://clinicaltrials.gov/
Center for Evidence-based Medicine	http://www.cebm.net/
Turning Research into Practice Database	http://www.tripdatabase.com/index.html
National Institute for Health and Clinical Excellence	http://www.nice.org.uk/
Cochrane Database of Systematic Reviews	www.cochrane.org
Campbell Systematic Reviews	http://www.campbellcollaboration.org
British Medical Journal Clinical Evidence	www.clinicalevidence.com
Evidence matters
Web of Science	www.isiknowledge.com
Scopus	www.scopus.com/home.url
Medline/PubMed
EMBASE	http://www.ncbi.nlm.nih.gov/pubmed?term=EMBACE
Bandolier	www.jr2.ox.ac.uk/Bandolier
Cumulative Index of Nursing and Allied Health Literature	www.ebscohost.com/nursing/products/cinahl-databases/cinahl
Joanna Briggs Institute	www.JoannaBriggs.edu
ONS Pep — Putting Evidence into Practice	http://www2.ons.org/Research/PEP
ONS EBP Toolkit	https://www2.ons.org/Research/EBPRA/Toolkit
The National Comprehensive Cancer Network	www.nccn.org

Oncology Nursing Society Putting Evidence into Practice

The ONS PEP guidelines are resources available in a ready to use format designed to provide evidence-based interventions for oncology patient care including teaching. One could think of ONS PEP guidelines as fitting into the top of the triangle of evidence [Figure 1]. The ONS PEP topic teams of nurse scientists, advanced practice nurses, and staff nurses summarize and synthesize the available evidence in PEP topic areas.

These resources can be used to plan patient care, patient education, nursing education, quality improvement, and research. The ONS PEP can be embedded into cancer care interventions or incorporated into telephone triage protocols. They could be included in oncology policies and procedures, quality/performance improvement activities, standards of care, and physician order sets. The ONS PEP information can be integrated into orientation, educational programs, nursing grand rounds, and ONS PEP resources ideal activity for use in journal clubs.

The ONS PEP topics are patient-centered outcomes, such as symptoms that are selected by a survey of ONS members and determination of availability of evidence in the topic. The ONS PEP evidence synthesis answers the question of what interventions are effective in preventing or treating the outcome of interest. The ONS topic teams categorize interventions by consensus application of the ONS PEP Classification Schema into the categories.[7]

Cultivating a Spirit of Inquiry and an Evidence-Based Practice Culture at the Unit Level

Creating a culture of inquiry regarding EBP begins by encouraging staff to ask questions about patient-centered nursing care. The question that is asked when discussing EBP is called a PICO question. The term PICO is a mnemonic used to describe the elements of a clinical question. A PICO question always starts with the patient and the clinical problem/s that are being observed or a PICO question can arise from the patient care being prescribed by the health care provider or the care determined by the nurse. A PICO question is as follows:

Patient, Population or Problem: What are the characteristics of the patient or population? What is the condition or disease you are interested in?

Intervention or Exposure or Interest Area: What do you want to do with this patient? (e.g. treat, diagnose, observe)?

Comparison intervention or group: What is the alternative to the intervention? (e.g. placebo, different drug, surgery)?

Outcome: What are the relevant outcomes (e.g. morbidity, death, complications)?

The clinical question is delineated in such a way that the topic can be searched using best available literature. As the literature is searched it is important to determine the best type of study to use that addresses the PICO question and search the literature using the appropriate source(s). Oncology nurses at the bedside or chairside are encouraged to search for the best evidence. Integrating this evidence with clinical oncology nursing expertise while taking into consideration patient preferences makes the best clinical decision for the oncology patient. The final steps in cultivating a spirit of inquiry and creating organizational culture change include evaluating outcome(s) of the proposed practice change and disseminating theses outcome(s). This evaluation and dissemination process should be part of every change that an oncology nurse attempts at the unit level.

Conclusion

The focus of the paper is building capacity for EBP practice at the unit level. Using ONS PEP guidelines is one way to begin a culture and practice change, but there are limitations on their feasibility, use, and effectiveness in a global context.

There are a few caveats when it comes to using the published evidence available for oncology clinical practice. One size does not fit all when it comes to using the research. Be aware of the context where the evidence was developed and think about the cultural influences to cancer care. Consider the research and think about what this evidence means in a specific country. Think about the practice environment and the differences between the practice environments and the specific cultural clinical environment. Ponder the origin of best evidence. If the evidence originates in a high resource country, there will need to be an adaptation to the cultural context of clinical practice in a lower resource country. Engage local and regional oncology nurses to help critique and adapt the published evidence.

This paper began with a quote from a nurse leader written more than 70 years ago. Yet, the notion of nursing leadership still stands today and nurses are leaders and change agents who want the best for their cancer patients. The best care can be found in the published evidence and then tailored to the country and the health care system. Nurses will be leading the change to EBP at the unit level.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.