Chapter 10: Evidence-Based Practice

1. A nurse executive is implementing evidence-based practice at a community nursing center that serves a large Cuban immigrant population. Which of the following actions would be the most helpful for the nurse?

a.
Review clinical policies with cultural competency experts from the local university.
b.
Conduct weekly staff meetings to discuss which methods work best when helping immigrants.
c.
Invite Cuban immigrants from the community to serve on the center’s advisory board.
d.
Send personnel to conferences and seminars that focus on treating Hispanic immigrants.

ANS: C

Although all of these options are good, to determine whether practice is serving the needs of the population, the nurse will need to consult the population served. This means that evidence should be applied with input from the community. For example, decisions related to the services to be offered in a nurse-managed clinic should be made with input from the clinic’s advisory board, which should include community leaders and consumers of the clinic’s services. Cuban immigrant needs may not be the same as those of Hispanic immigrants from other places such as Mexico or Spain.

DIF: Cognitive Level: Apply (Application) REF: p. 176

2. A community health nurse is determining the best way to address an outbreak of a new infectious disease using evidence-based practice. Which of the following actions would the nurse most likely take?

a.
Review policies and procedures
b.
Review outcomes of clinical trials
c.
Review several nursing textbooks
d.
Review reputable sites on the Internet

ANS: B

Research findings, knowledge from basic science, clinical knowledge, and expert opinion should be considered sources of evidence for EBP. The problem with nursing textbooks is that many are not grounded in evidence-based practice, because the concept is relatively new to the United States (as mentioned in the section of the chapter on historical perspectives of EBP). Scanning the Internet for ideas is helpful only if evidence-based practice sites are accessed, and most Internet sites are not EBP sites.

DIF: Cognitive Level: Apply (Application) REF: p. 176, 181

3. A nursing administrator wants to develop a work environment conducive to the implementation of evidence-based practice (EBP). Which of the following actions would best achieve this goal?

a.
Conducting market research to determine customer satisfaction with EBP
b.
Eliciting opinions from nurses on how EBP will affect workload
c.
Purchasing computers and Internet access for use by employees
d.
Sending staff to conferences related to incorporation of EBP into practice

ANS: C

A lack of computers and Internet access can create a barrier to implementation of EBP in community-based nursing agencies. If these are provided, nurses can quickly access current evidence-based findings and recommendations.

DIF: Cognitive Level: Analyze (Analysis) REF: p. 178

4. A busy school health nurse concerned over the rising incidence of obesity wants to implement evidence-based practice (EBP) but faces barriers because of time constraints. Which of the following actions should the nurse take first?

a.
Identify students who are obese so that they may be closely monitored for weight control success or failure.
b.
Evaluate best practices to determine those that have the highest success rates for weight control in children.
c.
Schedule physician appointments for obese children.
d.
Develop an obesity management program for children whose body mass index exceeds normal.

ANS: B

The first step of the seven-step EBP process is step zero, which involves a curiosity about the interventions that are being applied; this is not described in any of the topic descriptors. Step one requires asking questions in a “PICOT” format; this is not described in any of the topic descriptors. Step two involves searching for the best evidence to answer the question. This is done through evaluating best practices.

DIF: Cognitive Level: Analyze (Analysis) REF: p. 179

5. The nurse has been reading everything she can find on a particular clinical problem, using both the closest medical library and the Internet. Which of the following would be the most helpful source?

a.
A journal with a whole issue devoted to research on that clinical problem
b.
A randomized controlled clinical trial related to that clinical problem
c.
A researcher who has built a career on studying that clinical problem
d.
A systematic review related to the clinical problem

ANS: D

A systematic review is an approach to identifying, appraising, and synthesizing research evidence to evaluate and interpret all available research that is relevant to a particular research question. Systematic reviews can be accessed from most databases. Systematic reviews require more rigor and contain less opinion of the author than typical reviews of the literature.

DIF: Cognitive Level: Apply (Application) REF: p. 179

6. A school health nurse plans to use evidence-based practice (EBP) to guide the development of health education programs most likely to increase retention of learning in elementary schoolchildren. Which of the following would be the best way to use EBP in this situation?

a.
Ask other school health nurses what they included in their own education programs.
b.
Compare and contrast randomized clinical trials related to learning in elementary schoolchildren.
c.
Develop a series of games to accompany the programs developed to promote health.
d.
Seek out and examine health education programs for elementary school children on the Internet.

ANS: B

Randomized clinical trials are the gold standard of evidence gathering in EBP.

DIF: Cognitive Level: Apply (Application) REF: p. 182

7. After finding several studies related to the clinical problem, a nurse knows the studies must be evaluated. Which of the following characteristics should be present in the literature?

a.
Federally supported multiagency clinical studies
b.
Multiple high-quality studies with large sample sizes and consistent findings
c.
Research studies done by multidisciplinary teams in multiple settings
d.
Controlled clinical trials

ANS: B

The Agency for Healthcare Research and Quality (AHRQ) reviewed 40 systems used to evaluate the quality of studies and strength of evidence. The report identified three domains for evaluating systems that grade the strength of evidence: quality, quantity, and consistency. The quality of a study refers to the extent to which bias is minimized. Quantity refers to the number of studies, the magnitude of the effect, and the sample size. Consistency refers to studies that have similar findings, using similar and different study designs.

DIF: Cognitive Level: Apply (Application) REF: p. 181

8. A nurse is familiar with evidence-based practice (EBP) and wants to implement it into the care of clients. Which of the following would present the biggest challenge?

a.
Assessing one’s current practice and accessing evidence-based resources
b.
Convincing administration that EBP is beneficial
c.
Distinguishing EBP from practice based on old standards
d.
Showing clients that EBP will improve their health outcomes

ANS: A

The first step toward implementing evidence-based practice in nursing is recognizing the current status of one’s own practice and believing that care based on the best evidence will lead to improved client outcomes. The challenge for the clinician is how to access the evidence and integrate it into practice, thus moving beyond practice based solely on experience, tradition, or ritual.

DIF: Cognitive Level: Apply (Application) REF: p. 182

9. Which of the following groups is pressuring clinicians the most to use evidence-based practice (EBP)?

a.
Administrators
b.
Insurance companies
c.
Nurses
d.
Physicians

ANS: B

Much of the pressure to use evidence-based practice comes from third-party payers and is a response to the need to contain costs and reduce legal liability.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 183

10. A nurse implements an education program that incorporates computer games to reinforce learning for a group of older adults. Although the research demonstrates evidence of improved retention of this information, the nurse experiences exactly the opposite with this group. Which of the following is the most likely cause of such poor outcomes?

a.
Failure to consider client and setting differences
b.
Inadequate incorporation of evidence into practice
c.
Inferior quality of the available research evidence
d.
Lack of skills when evaluating the evidence

ANS: A

EBP cannot be applied as a universal remedy without attention to client differences. When EBP is applied at the community level, best evidence may point to a solution that is not sensitive to cultural issues and distinctions and thus may not be acceptable to the community. For example, computer games may be excellent for younger groups but are often poorly suited for older Americans who may face challenges with learning new technology.

DIF: Cognitive Level: Apply (Application) REF: p. 183

11. A health care provider is concerned about the high number of clients with type 2 diabetes mellitus who have poor glucose control. What would be the best reference for the provider to implement evidence-based practice (EBP) in the management of this problem?

a.
Published protocols
b.
Current research findings
c.
Opinions of colleagues
d.
Nursing journals

ANS: B

EBP in community-oriented nursing challenges nurses to integrate outcomes of the best evidence into their clinical practice. Current research findings will explicate evidence of most successful interventions. (Randomized clinical trials are the gold standard of research for EBP.) Protocols and opinions often reflect tradition rather than the most current scientific evidence. Although many nursing journals are peer reviewed, many are not and, even if peer reviewed, many are not research based or focused on scientific evidence. Similarly, information from the Internet may or may not be reliable, because the goal of many websites is to sell products rather than to serve as an unbiased source. Determining when the website was last updated would also be helpful in evaluating the site’s usefulness.

DIF: Cognitive Level: Apply (Application) REF: p. 183

12. Staff members have agreed to implement evidence-based practice; they have chosen a specific problem and searched the literature. The group has selected the interventions that seem the easiest to implement. Which of the following actions would the staff take next?

a.
Assess the quality of the evidence in the literature.
b.
Decide how best to orient the staff and community to the proposed changes.
c.
Eliminate all nursing interventions that are not evidence based.
d.
Choose another specific problem for the next literature search.

ANS: A

After the group has chosen the topic and evaluated the literature for approaches that seem feasible, specific interventions are chosen. The quality of the evidence must be assessed before recommending specific changes or writing a protocol to resolve the problem. Grading the strength of evidence or determining the quality, quantity, and consistency of research studies must be done before making recommendations for practice.

DIF: Cognitive Level: Apply (Application) REF: p. 179

13. A school nurse is developing a primary prevention strategy for school-aged children. Which of the following interventions would the nurse most likely implement?

a.
Developing individualized exercise programs for overweight children
b.
Drafting policy for increases in noncompetitive physical activity programs
c.
Monitoring body mass index in children to identify elevations before they become difficult to manage
d.
Notifying parents and/or guardians of their child’s height-weight scale in comparison with national norms

ANS: B

At the primary prevention level, campaigns to support regular exercise, greater emphasis on school-based physical education programs, and environmental and policy initiatives to create or enhance places for physical activity in communities can make significant contributions to improving the lifestyle of sedentary children. Exercise programs are an example of tertiary prevention. Monitoring BMI in children is an example of secondary prevention. Notifying parents of their children’s height-weight scale increases family awareness but does not meet the definition of a preventive measure.

DIF: Cognitive Level: Apply (Application) REF: p. 183

14. Which of the following is the best way to increase the number of persons who come to their screening test appointments?

a.
Reminding clients via telephone, e-mail, or mail
b.
Emphasizing long life and happy family when conditions are caught early and treated successfully
c.
Pointing out how inexpensive and convenient screening tests are
d.
Stressing the dangerousness of the condition if not caught early

ANS: A

Client reminders and recalls via mail, telephone, or e-mail—or a combination of these strategies—are effective in increasing compliance with screening activities such as those for colorectal and breast cancer.

DIF: Cognitive Level: Understand (Comprehension) REF: p. 183

15. A nurse manager wants to facilitate incorporation of evidence-based practice (EBP) in the clinical setting. Which of the following would be the best strategy to accomplish this goal?

a.
Eliminate all protocols and standards that are not evidence based
b.
Encourage group reflection on the ideals and expectations of nursing care
c.
Refer agency nurses to Internet sources of research findings
d.
Support nurses using practice-oriented research findings in decision making

ANS: D

EBP demands changes. It requires incorporating more practice-oriented research and more collaboration between clinicians and researchers. Emphasis should be on decision making using the varied sources of evidence. The environment and climate must be supportive in order to implement EBP.

DIF: Cognitive Level: Analyze (Analysis) REF: p. 184

MULTIPLE RESPONSE

1. A nurse has decided to increase the evidence base of current nursing practice in an agency. Which of the following describes a barrier that could be encountered by the nurse? (Select all that apply.)

a.
Colleagues who don’t know how to search the literature or critique research
b.
Dedication to the history and tradition of the agency
c.
Little or no research published in the clinical area of concern
d.
Several meta-analyses in the literature with inconsistent results

ANS: A, C

Barriers to evidence-based practice exist when the following are limited or lacking: time, access to journal articles, search skills, critical appraisal skills, and an understanding of research terminology. Other barriers include miscommunication about the process; inferior or unavailable research or other evidence; unwillingness of organizations to fund research or make decisions based on evidence; and concern that evidence-based practice will decrease emphasis on individual client needs or the nurse’s clinical decisions.

DIF: Cognitive Level: Apply (Application) REF: p. 178