Translation of Evidence into Nursing Practice

• OBJECTIVES
1. Understand translational science and closely related terminology.
2. Identify tools supporting the translation of evidence at the data, information, knowledge,
and wisdom meta-structure levels.
3. Describe evolution of evidence-based practice and evolving trends in the translation of
evidence into practice.
4. Describe how informatics is used as a tool to promote and facilitate knowledge
generation and translation in practice.
5. Describe models and frameworks connecting critical thinking to processes that support
the use of evidence into nursing practice.
6. Discuss how informatics tools serve to promote the use of evidence and the application
of knowledge in practice.
7. Identify professional nursing groups and networks that help expand and improve
resources to assist in translating evidence into nursing practice.
8. Discuss how professional nurses might engage in advancing the next steps and how
informatics tools can be used to deliver evidence into nursing practice.
• KEY WORDS
 Evidence
 Knowledge generation
 Clinical practice guidelines
 Evidence-based practice tools
 Meaningful use
 Performance metrics
 Quality and safety of patient care

Introduction
1. Overview
a. The nursing discipline has evolved from the days when research was left to those in
academe
(1) An increased emphasis on evidence- to be “evidence,” the profession is rapidly
based practice (EBP) now requires nurses at learning together how human and
all levels to engage in EBP electronic information resources as well as
(2) For a nurse practicing across inpatient, print information resources contribute to
ambulatory, home, and other settings as well improved outcomes
as education, administration, and research, it (5) Informatics facilitates this journey by
can be challenging to keep up with both the strengthening the merger of evidence with
latest technology as well as new scientific technology in convenient, yet
publications transformative, ways
(3) Yet staying current is central to safe and (6) This chapter focuses on the translation
high-quality care even though care based on of evidence into practice and how
evidence is not always the norm translation intersects with technology
(4) Although nurses in different settings
may consider different types of information

Defining Evidence, Implementation and Translational

Sciences
1. Overview
a. EBP adds action to the use of evidence
(1) EBP provides processes for using evidence to generate knowledge
(2) It is a widely used term that is easier to define than to operationalize
(3) When defining EBP, Melnyk and Fineout-Overholt highlight the importance of using
evidence to support decisions by saying that EBP is a “problem solving approach to clinical
decision-making that involves the conscientious use of the best available evidence (including
a systematic search for and critical appraisal of the most relevant evidence) to answer a
clinical question with one’s own clinical expertise along with patient values and preferences
to improve outcomes for individuals, groups, communities and systems”
(4) EBP has many siblings and the distinctions can be confusing
(5) Implementation science is the study of methods to promote the integration of research
findings and evidence into healthcare policy and practice
(6) Implementation science is a growing field that is both multifaceted and complex
(7) It is especially relevant to nurses and others who work directly with patients since it
focuses on what is needed to improve outcomes
b. EBP is also central to what Titler and Everett define as “translational research,”
which tests the effect of interventions to facilitate the rate and extent to which evidence
based practices are adopted
(1) Translational research and implementation science, both capture the significance of key
variables that influence EBP
(2) These variables are part of the local environmental context that so often complicates the
implementation of evidence, such as introducing a new intervention based on a current
clinical practice guideline recommendation with the goal of assimilating the intervention into
routine clinical practice
(3) Since there is no one standard international terminology that conclusively defines
translation, sorting out the definitions can be overwhelming
(4) Yet understanding the commonly used terms associated with evidence-driven care are
potentially valuable since adhering only to one way of thinking about evidence misses what
these terms have in common
(5) The collective actions associated with terms like EBP, implementation science,
translational research, knowledge translation, and related terms share a goal to move science
close to what makes a difference for patients and populations
(6) These actions can be simplified into the term “translation”
(7) Although defined in different ways, translation emphasizes processes such as
dissemination and implementation of empirical, patient-centered findings that have been
rigorously tested in broad populations and subgroups before deemed ready for
implementation in clinical practice
(8) Feedback and evaluation often follow implementation
(9) As evidence moves through dissemination, implementation, evaluation, and other stages,
evidence-driven care is fostered through iterative and interactive processes
(10) Although there is growing awareness of the importance of evidence uptake, we are in the
early stages of knowing how to systematically operationalize translation and sustain
improvements after safety- and quality-related interventions end
(11) But much is being learned and technology offers momentum
(12) Struggling with what it takes to apply evidence in ways that promote lasting, safe, cost
effective, and high-quality care is gradually leading to measurable outcome improvements

Tools Used for Supporting Translation of Data to

Information to Knowledge to Wisdom
1. Overview
a. Nursing is an information-based discipline
(1) Nursing informatics unites nursing science, computer science, and information science in
ways that transform what this means
(2) The evolution of nursing as an information-based discipline changes how data,
information, and knowledge are managed in nursing practice
(3) The actions occurring as data are transformed into information, knowledge, and wisdom
are dynamic and iterative
(4) What is learned through research, evaluation, quality improvement, and safety activities
contributes to wisdom
(5) Once wisdom is achieved, feedback contributes to ongoing improvements and to generate
new hypotheses
b. In an evolving healthcare system, nurses’ information needs are fluid and evolve. The
development of knowledge accompanies the use of evidence
(1) But only recently the scientific knowledge base relevant to translational research and
implementation science has been strong enough to support use of specific evidence-based
tools and strategies during translation as well as address how local factors, such as attitudes
toward EBP, influence translation
(2) Measurement of the impact of using a specific evidence-based tool aids in ongoing
understanding of the barriers and facilitators that influence sustained improvements
(3) Peer-reviewed publications reporting the results of measuring impact adds to the relevance
of the scientific knowledge base
(4) Nurses are in the early stages of identifying best practices as well as gaps in the body of
knowledge related to Health Information Technology (HIT) implementation
(5) As innovations spread, more will be known about how to tailor HIT tools to a local
setting, including better understanding about how to adjust implementation strategies based
on factors associated with the nursing

2. Evolution of evidence
a. How evidence is generated?
(1) Research results can be used to address important clinical questions after being accepted
as part of the evidence base for a clinical question
(2) Research results become part of the evidence base for a disease or condition only after
going through rigorous and explicit processes designed to find, compare, and combine data
(3) Reviews of research findings involve critical appraisal using explicit and objective
inclusion and exclusion criteria
(4) Such criteria identifies studies to be considered when trying to answer a clinical question,
such as which nursing interventions for reducing pain are the most effective and scientifically
grounded
(5) An organized approach is used to identify valid and reliable peer-reviewed publications to
be considered further
(6) Rigorous methods determine the efficacy of specific interventions and their effectiveness
when used with real patients outside of tightly controlled conditions
b. Advanced statistical analysis, using Bayesian or other methods, helps understand how
best to combine findings
(1) Through these techniques, systematic reviews pull together what is known about the
benefits and harms of the interventions surrounding a clinical question
(2) Credible methodology helps reveal the trade-offs associated with key treatment,
diagnostic, or prevention interventions
(3) The cumulative findings associated with specific questions can then be reviewed and rated
by unbiased experts
(4) Typically, ratings are accomplished by a multidisciplinary expert team
(5) A team’s systematic review often results in rated recommendations about what does and
does not contribute to improved outcomes
c. Evidence is rated by experts using one of several methods
(1) The methods used by USPSTF and other credible groups are revised over time as methods
evolve
(2) The USPSTF assigns an A, B, C, D, or I letter grade to signify the strength of each
recommendation that comes from synthesizing research findings
(3) The graded recommendations produced through this process can be used as the basis for
evidence-based tools, such as clinical practice guidelines
(4) During 2012, the USPSTF updated its definition for grade C recommendations, which can
be the most complex for clinicians to implement
(5) The basic meaning of the C recommendation indicates that the net weight of benefits and
harms is very close and needs to be considered within the context of conditions,
circumstances, and preferences
(6) While the statistical magnitude of net benefit for a C recommendation is considered small,
it may or may not seem small to an individual patient or family or in the eyes of the providers
caring for the patient or to the community as a whole
(7) Values can influence how a specific clinical choice is viewed
(8) In these cases, the USPSTF recommends “selectively” providing the service—meaning
that patient and community preferences, clinician input, and costs may rise in importance
(9) In these instances, it is especially important to guard against the potential for bias
(10) Bias arises from conflicts of interest or other avenues that risk the integrity of the
processes involved with synthesizing evidence and using this evidence to create evidence-
based tools
(11) Bias can influence ultimate credibility of the final products and can occur at any point
between the selection of research findings through translation and evaluation
d. The availability of evidence and evidence-based tools is only the beginning. The US
Centers for Disease Control and Prevention (CDC) provides a representation showing
the convergence of evidence synthesis with expert judgment
(1) A nurse can apply this model by rating the quality/strength of evidence as weak, moderate,
strong, or rigorous
(2) This rating is associated with the potential impact of applying the EBP in a clinical setting
(3) The quality of the evidence is interpreted with consideration given to impact
(4) Impact is quantified in terms of effectiveness, reach, feasibility, sustainability, and
transferability
(5) Within this framework, the term “impact” goes beyond traditional ideas of clinical
significance or clinical importance, which focus on whether a nurse or other
clinician would alter their practice based on the statistical significance of research findings
(6) Frameworks of this kind make it easier to communicate about the potential use or
rejection of the interventions identified as “best practices” when evidence and judgment are
combined
(7) The use of a framework and common terms aids accountability and transparency about
how decisions were reached
(8) Early in the application of a framework, such as CDC’s conceptual framework, nurses
way want to discuss how terms like “impact” and “clinical significance” are defined by
members of the clinical team and by the patients and family members involved

3. The origins of Evidence-Based Practice

a. EBP employs a systematic approach to clinical decisionmaking using the best
evidence
(1) Although nurses have long promoted rational choice based on current research findings,
the use of a systematic approach to finding and applying evidence as the basis for decisions
has only been emphasized over the past 25 years
(2) Throughout the 1990s, ideas about how to find and use research results evolved
(3) The term EBP became popular after 1992 when first used by Gordon Guyatt and a group
he led at McMaster University
(4) David L. Sackett described EBP as the best use of current best evidence in making
decisions about the care of individual patients
(5) Over time, EBP came to describe a systematic approach to organizing, collecting, and
using research findings in ways that contribute to the best possible outcomes
(6) As this occurred, nursing roles were revitalized as informatics brought clinical decision
support and other tools closer to the bedside
b. As methods for synthesizing evidence improved, literature searches and reviews,
meta-analysis, evidence reviews, and evidence-based tools proliferated
(1) Such synthesized evidence in the form of review papers and similar formats are of
growing relevance to nurses since multiple studies and multiple applications are included
Knowledge Generation of Evidence
1. Overview
a. With approximately 80% of Americans now having regular Internet access evidence
is often sought through Webbased resources
(1) Nurses help themselves, their students, patients, professional nursing groups, and their
clinical team understand whether the information commonly downloaded
about a specific condition or disease is accurate (valid and reliable) while pointing out
potential benefits and harms
(2) Caution may be needed if information is being used without critical review
(3) A nurse can generate (and regularly update) lists of credible online evidence-based
resources to suggest to patients, families, and other providers
(4) Because evidence becomes outdated, nurses can monitor to be sure that their teams and
patients have current information, including understanding any legal and ethical concerns or
privacy issues
b. Criteria to evaluate health-related information found online has been developed and
disseminated by several organizations including HON Code, American Medical
Association, Internet Healthcare Coalition, Hi-Ethics, and MedCertain
(1) However, criteria developed by these groups vary in scope and scale and have not been
shared in a systematic way
(2) In addition, most of these criteria were designed for evaluating health and medical
information, not necessarily nursing
c. Youth, young adults, and increasingly the rest of us are using mobile and portable
devices, including tablets, portable computers, and smartphones to seek the evidence
and engage with actual automated interventions (such as online counseling)
(1) Web-based screening, prevention, outreach, and intervention tools help patients to access
valid and reliable evidence about fundamental public health issues, such as obesity, stress
management, and tobacco cessation, while also helping patients track, reinforce, and manage
healthy choices and gain online support
d. E-mail, evidence, and twitter alert systems involve voluntary registration based on
clinical interest in order to receive alerts or updates related to interventions
(1) They are ideal for receiving information about new evidence or to send alerts about a
safety concern, such as spreading information that a medication has been found dangerous
(2) Alerts are often linked to resources that allow access to the scientific literature matched to
a specific clinical interest
(3) Alerts also deliver information that has already been rated
(4) However, the credibility of the informant often needs to be appraised
e. Assessments and interventions provided via a technology platform may occur without
a provider
(1) Some of these tools allow for tracking and feedback about the patient’s use of the tool to a
nurse or other clinician
(2) Some of these tools are interactive and Web-based or may be run from a DVD, local
computer, or flash-drive
(3) Mobile tools, such as phones and tablets, are also used
(4) Nurses help by addressing what is lost (in terms of nonverbal interactions, cues, and
physical assistance) versus what is gained (through access and convenience)
when a technology-based intervention works with other non-nursing clinicians
(5) Nurses can then tailor these tools to the needs of specific patients

Models and Theoretical Frameworks Connecting Critical

Thinking to Processes that Support the use of Evidence
in Nursing Practice
1. Overview
a. Models and frameworks help link critical thinking to stepwise processes that promote
the use of evidence, including accounting for factors that lead to safe and lasting
outcome and organizational improvements
(1) Because translation involves implementing evidence and evidence-based tools outside
tightly controlled situations, such as Randomized Controlled Trials (RCT),
theories help nurses critically examine the contextual factors, assumptions, and influences
surrounding implementation
(2) Using models and frameworks helps nurses prepare a cogent plan for translation within
complicated situations, such as the implementation of an EBP when change and disruption are
anticipated
(3) Nursing leaders across countries have contributed to theories about translation and quality
improvement
(4) These theories include Donabedian’s structure, process, and outcomes framework, which
focus on problem solving
(5) Other theories directly relevant to translation are found in
 Rogers’ Diffusion of Innovations model
 The Funk Model
 The PRECEDE Model
 The Chronic Care Model
 The PARiHS Model
 The Stetler Model
 The Iowa Model and Translation Research Model
 Russworm’s and Larrabee’s Model
 The ARCC Model
 Kitson’s Framework
 Melnyk and Fineout-Overholt’s Model of EBP
 The Lean Framework
 The PICOT Model
 The QUERI model
 Rossworm and Larrabee’s Model
 The Institute for Healthcare Improvement’s
 breakthrough model
(6) Some of these models are briefly described below
b. Exploring how nurses conceptualize translation helps nurses
learn from each other
(1) Specific contributions include Roger’s understanding of “attributes” (including
complexity) and Alison Kitson’s emphasis on understanding the environment, including the
importance of a clearly articulated collaborative Knowledge Translation (KT) approach that
can be embedded into the research design
(2) The Promoting Action on Research Implementation in Health Services (PARIHS)
framework helps define and measure key factors leading to successful implementation and
has been widely used, including by Squires et al. who designed strategies to implement
researchbased policies and procedures
(3) Dr. Marita Titler provided leadership for AHRQ’s TRIP initiatives and has also studied
the context in which EBPs are translated
(4) Important influences found include
 i. The nature of the innovation (such as the strength of evidence)
 ii. The manner it is communicated to nurses and physicians
(5) Dr. Carole Estabrooks described the importance of considering the significant needs found
in complex care environments, such as nursing homes
(6) Dr. Cheryl Stetler evolved her practitioner-oriented Stetler Model of Evidence-Based
Practice in ways that have shaped the evolution of EBP and also synthesized literature on
use of the PARIHS framework, including development of a companion guide to assist
researchers using PARIHS
(7) The PARIHS framework is widely used internationally
(8) Bergstrom, Peterson, Namusoko, Waiswa, and Wallin used PARIHS as a framework for
knowledge translation in Uganda
c. As new technologies combine with novel approaches to measuring the complex
factors affecting outcomes, theories and frameworks are being customized, including
tailoring them to the workflow of nurses and the needs of developing nations
(1) Melnyk and Fineout-Overholt adopted EBP competencies for nurses and advanced
practice nurses (APNs) working in real-world clinical situations
(2) Rycroft-Malone et al. and McCormack et al. described a new approach known as realist
review and synthesis, which focuses on understanding the mechanisms by which an
intervention works or does not work
(3) Hynes et al. used the QUERI model to demonstrate how HIT approaches could be
characterized as facilitators or barriers to implementation
(4) Three pathways were found to contribute to translation:
 Compliance and collaboration with information technology policies and procedures
 Operating within organizational policies and building collaborations with end users,
clinicians, and administrators
 Obtaining and maintaining research resources and approvals
(5) Harrison et al. emphasized the importance of planning support in development of a
framework called CAN-IMPLEMENT
(6) In Canada, The Queen’s University Research Roadmap for Knowledge Implementation
(QuRKI) is being used to highlight mutually supporting/interconnected cycles of research
studies supporting implementation
(7) In Australia, multidisciplinary Health Networks were used as a framework to
collaboratively develop evidence-based policies and drive implementation

Informatics Tools that Promote the use of Evidence and

Apply Knowledge to Practice
1. Overview
a. Adoption of evidence is now understood far beyond passively providing access to a
single clinical practice guideline or Webinar
(1) The attention has shifted to understanding the conditions that foster ongoing and lasting
change once the evidence is found and introduced, often using multiple implementation
strategies
(2) Increasingly, not only is the intervention being tested based on the best available evidence
but the implementation strategies being used to apply the evidence are also grounded in
science
(3) Boulet, Bourbeau, Skomro, and Gupta authored one of many studies focusing on the
complex barriers that cross the patient, provider, and healthcare system boundaries and
suggested innovative, multifaceted approaches to implementation(4) Young et al.
demonstrated how complicated such investigations can become
(5) Although home telehealth programs can be tailored to facilitate older adults’ access to
care, collecting data was challenging during this study because the patients did not want to be
critical
(6) But sustained improvement depended on understanding patient perspectives about the
benefits and challenges of care coordination and home telehealth
(7) Ultimately, it was documented that patients were frustrated by equipment problems, as
well as slow response, and care coordinator inaccessibility
(8) Understanding the influence of patient perceptions assured that expectations could be met.
This facilitated translation
b. The information explosion presents challenges to healthcare providers who seek new
evidence on an ongoing basis
(1) Evidence-based clinical or point-of-care resources, especially literature reviews, make it
easier to access information
(2) Easy access helps nurses avoid making decisions based on experience alone or on the
advice of a colleague or teacher
(3) Evidence-based tools help by organizing evidence and aiding cognition in evidence
selection, interpretation, implementation, and evaluation
(4) When coupled with technology, evidence-based tools become central to practice
(5) Yet this occurs within a climate of constant change and new incentives

c. Decision support includes integrating experience with the

evidence
(1) Evidence-based tools are not “cookbooks”
(2) When implementing a clinical intervention using an automated evidence-based tool,
clinical judgment is needed
(3) Because translation and decision support overlap, each is inherently multidisciplinary
(4) Nursing joins public health, medicine, and other health disciplines in seeking better
understanding of the conditions needed to successfully apply evidence to decision support in
real situations, then measure the impact and feed data back after evaluation
(5) As evidence brokers, computer-literate nurses bring to their teams knowledge of how to
identify and then critically appraise the best available evidence or use the evidence-based
tool(s) to support decisions
(6) This includes knowing how to explain evidence to clinicians, families, and teams with
varying degrees of scientific expertise and computer literacy
(7) Explaining evidence includes understanding the “unintended consequences” that
accompany translation and dealing with uncertainty when evidence is incomplete, misleading,
or contradictory
d. Decision support now occurs within the context of
change
(1) Fueled by healthcare reform, HIT supports EBP by making it easier to access and use
evidence and evidence-based tools, such as automated reminders
(2) The US Center for Medicaid and Medicare Services (CMS) defines the “meaningful use”
provision in the Affordable Care Act (ACA) legislation in ways that promote the use of
evidence to drive improved outcomes, quality, and safety
(3) The implications and pace are staggering
(4) Within this environment, there are incentives that promote automated systems facilitating
advances in HIT
(5) Such advances promote EBP but also reveal gaps in quality and safety as well as
disparities
(6) Carefully planned use of HIT contributes to new and restructured systems that address the
overuse, under use, and misuse of healthcare
(7) Understanding the context in which HIT and EBP merge means studying what works and
does not work during translation
(8) This sometimes means feeding data back as the intervention is being implemented using
methods such as formative evaluation
(9) Although nurses are in the early stages of investigating factors associated with
organizational context, such as explaining variation in the use of HIT during translation, there
are a growing number of studies seeking to understand what makes a difference

2. The use of Electronic Health Records (EHRs)

a. Automated tools are often linked to computerized health records, such as EHRs,
which refer to patient records collected across settings, ideally to support care along the
continuum of an individual’s lifespan
(1) As a result of the proliferation of electronic health data, clinical intelligence and other uses
of aggregated data promote the conversion of meaningful information into knowledge
(2) EHRs can be especially powerful if the data is standardized and copied into data
warehouses or datamarts where data can be easily exchanged for follow-up purposes
b. Because EHR promotes meaningful use of technology and enhances information
exchange, it plays a growing role in the translation of evidence into practice
(1) EHR provides a vehicle to transmit evidence by embedding evidence-based tools into
routine nursing functions
(2) In doing so, EHR impacts quality and safety, hopefully in positive ways
(3) Later, these data may become part of the body of evidence used to update the next version
of a clinical practice guideline
(4) Poe, Abbott, and Pronovost used peer coaches to build and sustain competencies needed
by nurses using EHR in clinical settings
(5) Both satisfaction and confidence increased through the use of an evidence-based coach
intervention
(6) Nurses are cautioned, however, to actively participate in the development, monitoring,
implementation, and use of their EHRs
(7) Ongoing diligence is needed to assure the timeliness of updates, the accuracy of input, as
well as the usefulness and safety of output
3. Applying evidence in informatics to improve safety and
quality of care
a. Nurses seeking to improve the safety and quality of care within their organizations can
often find literature reviews, systematic reviews, meta-analyses, or evidence-based tools that
address their specific goals or are relevant to their areas of practice
(1) Technology-based tools can be used within an organization in ways that make it easier and
faster to implement evidence-based tools while also making it harder
to harm a patient
(2) Evidence-based tools such as electronically available clinical practice guidelines, clinical
decision support, automated performance measures, and computerized reminders, can be
embedded into routines of care with feedback provided “just in time” to impact processes,
intermediate outcomes, outcomes, and sometimes influence costs, patient and provider
satisfaction, and even workforce issues

(3) The impact of electronic tools like these needs to be carefully evaluated prior to, during,
and after implementation
(4) Such evaluations may reveal characteristics of the organization and staff that will promote
lasting use of an evidence-based tool
b. A dynamic high-functioning quality and safety culture requires that nurses
continually examine the conditions needed to foster ongoing learning
(1) It is important that data resulting from quality and performance measures not be used to
punitively punish providers when targets or goals are not reached
(2) Ongoing improvements in performance, quality, and safety based on the best available
evidence are aided through evidence-based tools combined with an open environment where
the cause of errors or poor performance can be explored outside a climate of fear
(3) Performance, quality, and safety does not come through the technology alone but is
influenced by those who implement, monitor, and use the technology
(4) Innovation and progress are impeded by fear
(5) The tools associated with implementing bar-coded patient wrist bracelets that match
automated records to prevent patients from receiving the wrong medication or surveillance
systems designed to detect healthcareacquired infections are only useful when safely
implemented and maintained
(6) It is difficult to build a performance-driven culture when fear of reprisal is the norm
(7) Although this can seem overwhelming, simulation and similar tools increasingly are used
to help understand and prepare nurses for complex procedures, especially when the margin
for error is small and options for training are limited
4. Evidence embedded into Clinical Decision Support
(CDS) tools
a. Evidence is often embedded in CDS tools
(1) CDS captures the processes used to enhance healthrelated decisions and actions with
pertinent, organized
(1) As a result of the proliferation of electronic health data, clinical intelligence and other uses
of aggregated data promote the conversion of meaningful information into knowledge
(2) EHRs can be especially powerful if the data is standardized and copied into data
warehouses or datamarts where data can be easily exchanged for follow-up purposes
b. Because EHR promotes meaningful use of technology and
enhances information exchange, it plays a growing role in
the translation of evidence into practice
(1) EHR provides a vehicle to transmit evidence by embedding evidence-based tools into
routine nursing functions
(2) In doing so, EHR impacts quality and safety, hopefully in positive ways
(3) Later, these data may become part of the body of evidence used to update the next version
of a clinical practice guideline
(4) Poe, Abbott, and Pronovost used peer coaches to build and sustain competencies needed
by nurses using EHR in clinical settings
(5) Both satisfaction and confidence increased through the use of an evidence-based coach
intervention
(6) Nurses are cautioned, however, to actively participate in the development, monitoring,
implementation, and use of their EHRs
(7) Ongoing diligence is needed to assure the timeliness of updates, the accuracy of input, as
well as the usefulness and safety of output
3. Applying evidence in informatics to improve safety and
quality of care
a. Nurses seeking to improve the safety and quality of care within their organizations
can often find literature reviews, systematic reviews, meta-analyses, or evidence-based
tools
that address their specific goals or are relevant to their areas of practice
(1) Technology-based tools can be used within an organization in ways that make it easier and
faster to implement evidence-based tools while also making it harder to harm a patient
(2) Evidence-based tools such as electronically available clinical practice guidelines, clinical
decision support, automated performance measures, and computerized reminders, can be
embedded into routines of care with feedback provided “just in time” to impact processes,
intermediate outcomes, outcomes, and sometimes influence costs, patient and provider
satisfaction, and even workforce issues
(3) The impact of electronic tools like these needs to be carefully evaluated prior to, during,
and after implementation
(4) Such evaluations may reveal characteristics of the organization and staff that will promote
lasting use of an evidence-based tool
b. A dynamic high-functioning quality and safety culture
requires that nurses continually examine the conditions
needed to foster ongoing learning
(1) It is important that data resulting from quality and performance measures not be used to
punitively punish providers when targets or goals are not reached
(2) Ongoing improvements in performance, quality, and safety based on the best available
evidence are aided through evidence-based tools combined with an open
environment where the cause of errors or poor performance can be explored outside a climate
of fear
(3) Performance, quality, and safety does not come through the technology alone but is
influenced by those who implement, monitor, and use the technology
(4) Innovation and progress are impeded by fear
(5) The tools associated with implementing bar-coded patient wrist bracelets that match
automated records to prevent patients from receiving the wrong medication
or surveillance systems designed to detect healthcareacquired infections are only useful when
safely implemented and maintained
(6) It is difficult to build a performance-driven culture when fear of reprisal is the norm
(7) Although this can seem overwhelming, simulation and similar tools increasingly are used
to help understand and prepare nurses for complex procedures, especially when the margin
for error is small and options for training are limited
4. Evidence embedded into Clinical Decision Support (CDS) tools
a. Evidence is often embedded in CDS tools
(1) CDS captures the processes used to enhance healthrelated decisions and actions with
pertinent, organized clinical knowledge and patient information, to improve health and
healthcare delivery
(2) CDS comes in many forms and interactive automated programs that assist clinicians with
decisions, usually at the point-of-care
(3) Decision analysis and CDS tie the probability of a specific clinical option to the likely
results
(4) The probability of alternative strategies can then be quantified
(5) Many decision support tools are part of an EHR and promote the timeliness of a diagnosis
or treatment intervention
(6) CDS includes automated templates for orders and referrals that link to reminders or other
forms of evidence
b. Computerized pathways, flow charts, algorithms, and critical paths are CDS tools
that facilitate implementation in ways that reduce errors and promote compliance
(1) Checks and triggers are embedded to guide clinicians through diagnostic and treatment
interventions based on guideline recommendations
(2) Algorithm-based decision systems can be used, for example, to prompt clinicians about
the correct interval for a laboratory test

5. Evidence integrated into care coordination and continuum of care mapping

a. Case management and care coordination are key roles for nurses who follow a panel
of patients, including assuring that evidence-based diagnostic and treatment
interventions are completed
(1) Communication and information sharing are promoted electronically across providers
throughout the flow of their work so that the patient benefits from coordinated care
6. Cognitive aids (clinical business intelligence, automated GIS, big data, visual
analytics, clinical analytics) and advanced informatics to support evidence in practice
a. Cognitive aids help nurses use data and link it to evidence by expanding the ability to
quickly process, compare, and interpret large volumes of complex data
(1) Automated tools that help make sense of the growing abundance of structured and
unstructured data are growing in popularity and availability, and are sometimes now used at
the point-of-care
(2) These tools can be used to retrospectively look back using data to support performance
measurement or to support population health gating the data then using it to predict and offer
guidance for future care
b. Pathways can be developed to foster variance analysis, which compares patients to a
group using aggregated data
(1) Geographic Information Systems or Geographic Information Science (GIS) refers to Web
sites or services that connect data from different sources in order to share, remix, repurpose,
and reconnect them
c. Clinical and Business Intelligence takes data from large healthcare databases in order
to analyze and feed it back in ways that aid interpretation and inform decisions
(1) Visualization of multiple data sets can be integrated using a common format that enhances
how much information is needed to support a decision
(2) Such tools are transformative in their ability to interactively engage nurses and patients as
they combine data with experience as well as generate new hypotheses
7. Trigger tools, bundles, and rapid cycle testing
a. The Institute for Healthcare Improvement (IHI) and other groups use many different
automated tools that often work in tandem with quality and safety efforts
(1) “Triggers” measure harm through retrospective review of records using clues about
adverse events
(2) A bundle is a group of three to five evidence-based practices linked together
(3) A bundle is used to promote adoption of specific interventions. Impact can then be
measured and the data fed back
8. Automated performance measures
a. Quality and safety measurement is an efficient way to promote the use of evidence
and move it quickly into practice
(1) Clinical quality measures as well as performance measures related to quality and safety
quantify differences in the care provided to individuals, organizations, plans, facilities, or
networks
(2) Performance measures and indicators are often based on clinical practice guidelines or
other synthesized (credible) evidence
b. A performance measure or indicator is derived using administrative or clinical data,
often pulled from automated records
(1) Such measurement assesses provider and organizamarking, quality improvement efforts,
and financial
(2) Patient safety indicators (PSI) use abstracted administrative data to help providers identify
risks
(3) Robust performance measures increasingly are developed, tested, and introduced,
including composite (combined) and “tightly linked” measures for specific
conditions. Poorly constructed measures can lead to bias or “gaming”
9. Emerging technologies and trends
a. Clinical analytics (previously described) holds exciting promise for advancing quality
and safety, for example, when coupled with Lean, Six Sigma, or a similar framework
(1) Using clinical analytics, high degrees of variation in outcomes can be identified at an early
point that may promote prevention, safety, and clinical improvements
(2) Automated tools used for EBP are evolving quickly
(3) Nurses lead by implementing and evaluating these tools, especially new ones, during
translation activities
10. Human communication principles still apply
a. Evidence is translated at the level understood by each
patient and by the providers in a clinical team
(1) When applying evidence, many factors associated with patients (and their families), as
well as other providers, require attention, including culture and literacy
(2) HIT interface designs need to support patient–clinician interactions and relationships
(3) As patients increasingly bring their own information into healthcare decisions and
articulate their preferences, the skills needed to foster the best possible choices expand
(4) Fuelled by technology, expectations are changing
(5) Patients and families often facilitate use of evidence by challenging their providers to
explain the options for care
(6) Rather than push technology onto patients, it may help to observe what the patient
understands about their own documentation and work with the patient
as a partner in adapting newer technologies
(7) Communication about why a specific test of intervention is being suggested requires
explaining the evidence
(8) E-mail, texting, and other electronic media can facilitate such communication
(9) Automated training materials can also be conveniently provided at a reasonable cost,
either by sending materials electronically or providing them at the point-of-care
(10) Patients may ask a nurse about evidence that does not exist
(11) Even when the evidence is strong, the factors related to its use in real settings are often
limited
Professional Nursing Groups and Networks that Provide
Resources to Translate Evidence into Nursing Practice
1. Overview
a. Nursing groups and networks help expand and improve
resources by creating, promoting, and assisting expansion
of the knowledge base surrounding EBP
(1) Key groups include
i. The Office of the National Coordinator for Health Information Technology (ONC)
ii. Healthcare Information and Management Systems Society (HIMSS)
iii. The Alliance for Nursing Informatics (ANI)
iv. The American Medical Informatics Association (AMIA)
v. v. The American Nursing Informatics Association (ANIA)
vi. ANIA’s sister organization, The Capital Area Roundtable on Informatics in Nursing
(CARING)
(2) The US Agency for Healthcare Research and Quality also provides a wide array of
resources, including
vii. Interactive tools for patients
viii. The US Health Information Knowledge base— which is a metadata registry of data
standards, and results from their Knowledge Transfer and Translating Research Into
Practice (TRIP I and TRIP II) programs
(3) Sigma Theta Tau International sponsors conferences, research, and resources to support
evidence-based information and implementation and translation into practice
(4) Sigma Theta Tau International sponsors a scholarly journal entitled: Worldviews on
Evidence-Based Nursing
(5) International Evidence Dissemination through the Cochrane Collaboration and Joanna
Briggs Institute
b. There is a growing list of notable international nursing, health services, and
informatics groups that contribute to our knowledge based about EBP, including The
Cochrane Collaboration, which hosts a library of evidence reviews, and The Knowledge
Translation+ (KT+) resources provided by McMaster University’s Health Information
Research Unit
(1) KT+ exemplifies the proliferating resources available to nurses seeking peer-reviewed
articles, systematic reviews relevant to safety and quality improvement, professional
education, automated clinical decision support, and patient resources
(2) The Cochrane Collaboration includes a Nursing Care Field (CNCF) since so many nurses
use the evidence available in nursing
(3) One of the nursing collaborators within the CNCF is the Joanna Briggs Institute
(4) Within Nursing the Joanna Briggs collaborative includes over 70 entities globally to also
engage in the development, dissemination, implementation, and translation of evidence to
improve care to patients delivered by nurses
(5) In the United States, Joanna Briggs Collaborative Centers are located in Indiana,
Louisiana, New Jersey, Oklahoma, Texas, and California
(6) Canadian collaborative centers are in Ontario, Canada

How Professional Nurses Might Engage in Advancing Evidence, Informatics Tools,

Integration and Translation into Practice
1. Overview
a. Nurses lead in a number of important ways related to the use of technology in
translation. Ideas for next steps as nursing moves forward include the need for nurses to
(1) Promote evidence-driven care aided by theories, such as QuRKI, that help find solutions
amidst the interconnected cycles of research and translation. The Queen’s Roadmap within
QuRKI is one of the useful approaches nurses can use, study, and report about as they
systematically improve quality and safety. Such roadmaps are useful in addressing the
complexity associated with translation. As QuRKI and other approaches are used,
nurses can share what they learn about the context in which the evidence is used. This
attention to context helps nurses identify and manage the facilitators and barriers needed to
translate a clinical practice guideline recommendation or other external evidence
(2) Clearly describe the choices and rationale surrounding implementation strategies. This
rationale links the choice of implementation strategies to determinants of change and helps
draw meaningful interpretations. Create research–practice alliances and other collaborative
relationships to use information about the local context in ways that help identify “best
practices” that foster change
(3) Explicitly address the limitations surrounding translation efforts, such as difficulty in
generalizing findings, the need for more advanced methods, little information about costs, and
the complexity of measuring disparities and involving patients
(4) Explicitly address the limitations surrounding technology applied to healthcare, such as
automating poor quality interventions that are not grounded in the best available
evidence. Implementing the wrong information can easily lead to faulty automated processes
that waste resources, cause frustration, and potentially harm patients
(5) Pursue conceptual clarity such that meaningful evaluations and comparisons are possible.
This may include use of existing classifications
(6) Identify security and privacy risks and help patients and others to address them
(7) Collaborate across education, administration, clinical care, research, and policy
boundaries to standardize terminology and expand the knowledge base about
effective solutions to complex healthcare problems. Nurses can foster teamwork across silos
in ways that address inconsistencies in terms such as “clinical signif
icance.” Many of the definitions relevant to EBP change over time and can be hard to
measure. Nurses can help define and standardize key definitions while promoting consensus
about how to measure a patient’s response to an intervention in ways that adhere to evidence
based standards or “best practices”
(8) Define clear goals for translation that capture the complex factors influencing nurses as
they strive to apply evidence in real situations
(9) Define methodological issues. For each one, explicitly define the state of the science,
study design, and measurement complexities in ways that advance translational research
(10) Build the skills needed to discuss evidence with patients who are computer literate as
well as those who do not use technology to access research findings and use them as the basis
for their questions
(11) Promote the inclusion and active participation of nurses as part of the multidisciplinary
teams that synthesize research findings and translate evidence into evidencebased tools
(12) Participate in the peer review of evidence-based tools and other expert review and
feedback
(13) Educate teams and organizations that performance and quality measurement are useful
and valuable but can also be harmful. Negative results (such as not reaching a target) can be
used to improve care and reduce risks but should only lead to punitive action when serious
issues, such as patient safety, reveal risk
(14) Explicitly address the risk of bias or other threats to the integrity of evidence-based tools.
Conflicts of interest are possible at any point, including the selection of “experts” who rate
the evidence or those who choose the recommendations to translate. Caution is needed so that
bias does not lead to underestimating potential risk, ignoring resource or costs (unless they are
intentionally ignored), or promoting overtreatment
(15) Promote active dialog within clinical teams and with patients to address
recommendations that lack conclusive net weight of benefits and harms
(16) Provide input from the beginning in the design and implementation of HIT projects and
offer caution that HIT can both help and harm patients
(17) Support patients to access accurate evidence by helping them use online tools believed to
contribute to positive outcomes, such as an automated self-check-in tool that encourages
patients to tailor their behavior to their goal as they pursue change. The nurse may want to
practice with the patient to help set up the automated messaging systems that accompany
some tools
(18) Provide expert advice or monitoring of text-based communication through e-mail, social
media, listservs, networks, forums, or a mobile format. While online groups and chat rooms
offer convenience, they also sometimes lead to exchange of misinformation. Nurses
can help by monitoring or serving as a resource