Research Article

iMedPub Journals Health Systems and Policy Research 2018

www.imedpub.com Vol.5 No.3:75
ISSN 2254-9137
DOI: 10.21767/2254-9137.100094

Evidence Based Practice: A Concept Analysis

Catherine Haulesi Chiwaula1*, Mabel Chinkhata1, Hilda Kamera1 and Clara Haruzivishe2
1Department of Post Graduate Studies, Kamuzu College of Nursing, University of Malawi, Malawi
2Department of Nursing Science, College of Health Sciences, University of Zimbabwe, Zimbabwe
*Corresponding author: Catherine Haulesi Chiwaula, Department of Post Graduate Studies, Kamuzu College of Nursing, University of Malawi,
Malawi, Tel: +265995522960; E-mail: [email protected]
Received date: December 5, 2018; Accepted date: December 10, 2018; Published date: December 17, 2018
Citation: Chiwaula CH, Chinkhata M, Kamera H, Haruzivishe C (2018) Evidence Based Practice: A Concept Analysis. Health Syst Policy Res Vol. 5
No.3: 75.
Copyright: ©2018 Chiwaula CH, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

the identified attribute to reduce the research-practice

gap.
Abstract
The merits of evidence based practice (EBP) in nursing Keywords: Concept analysis; Evidence based decision
care practice cannot be underscored and has the making; Evidence based practice; Evidence informed decision
potential to improve quality of care and produce desired making; Methods of concept analysis
benefits for patients, nurses and midwives, and the
health-care system. The purpose of this concept analysis
was to clarify the concept of EBP to achieve a better Introduction
understanding of the concept among nurses in relation to
nursing care delivery and drive them to embark on EBP In recent years, the emphasis has been on delivery of
journey. Walker and Avant’s strategic method of concept evidence based practice (EBP), to direct improvement in
analysis was used to analyze the concept. The framework clinical nursing care decisions and improves patient outcomes.
comprised of eight steps: selecting a concept; determining Yet there is low implementation of EBP. Most nursing care
the aims or purpose of analysis; identification of all uses decisions and actions are not evidence based, they are mostly
of the concept; determining the defining attributes; derived from: work experience, information from nurse’s
constructing a model case; constructing borderline, observations and colleagues, guidance from experts, basic and
related, contrary cases; identifying antecedents and post-graduate education, rather than formal sources of
consequences; and defining empirical referents. The evidence based knowledge like information from scientific
operational definition of EBP according to this analysis, articles or research studies [1-3].
“EBP is a problem solving approach which involves nurse
practitioners asking clinical relevant questions, accessing Low implementation of EBP among nurses and midwives is a
evidence from research and contextual factors, huge problem in many places worldwide: In the United States
interpreting the evidence (appraising and synthesizing), 65.5% of the nurses could not consistently implement EBP in
combining the evidence with experiences of practitioner, treating patients; in Norway nurses practice EBP to a lesser
patients or target group, and applying what has been extent and most nurses rarely utilized research evidence in
learned from evidence in making decisions to improve care provision; in Iran research evidence is also not applied in
nursing care practice. EBP comprises of the following nursing practice [1,2,4-7]. Similarly in Africa, EBP
attributes: asking a relevant clinical question, use of best implementation is very low: In Ethiopia only 15.7% of the
current research evidence; integrating with practitioner nurses use research evidence in clinical practice; in Kenya, 92%
expertise and experiences; patient preferences, values of the nurses do not fully utilize research evidence when
and concerns; and applying the evidence in making providing nursing and midwifery care [8,9]. In Malawi,
nursing care decisions. Antecedents of EBP are availability available literature indicates low implementation of EBP. There
of: gap in nursing care practice; evidence and necessary is poor utilization of research findings in decision making in
resources; nurses with necessary knowledge, skills, and
health and nursing practice, policy formulation and programs
confidence on EBP; and supportive leaders. This will
[10-12].
eventually lead to anticipated consequences like: safe,
effective, cost-effective, quality care which can lead to The concept of EBP was chosen for analysis because EBP is a
desired patient outcomes. In conclusion, this analysis has priority agenda in nursing care delivery and EBP is considered
clarified the definition, the approach to EBP and further the most effective strategy that can lead to improvement of
studies are needed to test of the process of EBP guided by clinical and patient outcomes. Through implementation of EBP
patients are expected to receive the most effective care based

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on the best available research evidence [13]. In addition, generated through the above methods before being used in
nursing care is provided in an environment which is changing decision making.
daily which necessitates application of research evidence to
The word “based” on the other hand, means a foundation.
discard in effective practices. As such, the purpose of this
In case of EBP delivery, it means that evidence should be used
concept analysis was to achieve a better understanding of the
as the foundation or the center of all nursing operations. In
EBP concept among nurses. Specifically, the analysis was
contrast, a “practice” is defined as the act of doing [19]. In EBP
meant to: provide a precise operational definition for EBP in
delivery, practice entails the act of performing evidence based
nursing care delivery; determine the defining attributes for
nursing actions. To sum up, EBP definitions were examined.
EBP; construct models for borderline, related, contrary cases;
Newhouse and Dearholt et al. defined EBP as “a problem-
identify antecedents and consequences; and define empirical
solving approach to clinical decision making that combine
referents for EBP.
research evidence with experiential evidence, practitioner and
patient’s experiences”[20]. This definition comprises of five
Methods key components: problem solving; evidence; practitioner
experiences; patients experiences and decision making.
Walker and Avant’s eight step concept analysis method was Newhouse et al. further defined EBP as “a problem solving
used. These steps involved selecting a concept; determining approach to clinical decision making in a healthcare
the aims or purpose of analysis; identification of all uses of the organization that integrates the best available scientific
concept; determining the defining attributes; constructing a evidence with the best available experiential (patient and
model case; constructing borderline, related, contrary, cases; practitioner) evidence, considering internal and external
identifying antecedents and consequences; and defining influences on practice, and encourages critical thinking in the
empirical referents [14]. Literature was sought from judicious application of such evidence to care of the individual
dictionaries, PubMed, Google, Google scholar and Hinari using patient, patient population, or system” [21]. In this definition,
the search terms: Concept Analysis, Evidence Based Practice the scope of EBP was broadened and it included factors
(EBP), Evidence Based Decision Making (EBDM), Evidence influencing implementation of EBP and practitioners’ capacity
Informed Decision Making (EIDM), methods of Concept to think and apply EBP. Hmurovich also, defined EBP as a
Analysis. Articles containing information related to the search practice of making decisions about health care action,
terms from 2005 to 2018 were accessed and analyzed. The program, practice, intervention or a policy based on best
research articles, books, web pages and dictionaries in English research evidence, experiential evidence from clinical practice
language, in nursing and other health related fields were and contextual evidence [22]. This definition further
analyzed. Sixty seven (67) articles were accessed and 30 acknowledges contextual contributors to EBP implementation.
articles did not specifically discuss EBP and were discarded.
Thirty seven articles were considered relevant for analysis and Melnyk et al., gave a broad definition of EBP; It was defined
were used. They comprised twenty two research articles, six as “a paradigm and life-long problem solving approach to
eBooks, seven web pages and two dictionaries. 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
Results a clinical question, with one’s own clinical expertise and
patient values and preferences with the aim of improving
Definition of EBP and related definitions outcomes for individuals, groups, communities and systems”
[23,24]. In addition to the key components identified by
EBP has three distinct words with different connotations:
Newhouse et al., this definition adds three important elements
“evidence”, “based” and “practice”. Evidence is defined as
like: lifelong approach, process of evidence identification
facts, information and knowledge which has been proved,
(appraise of literature), and availability of a clinical question,
believed or justified as true [15]. Evidence is also seen as data
this also offers more guidance on the process. Therefore, after
on which a decision or a conclusion can be based [16]. Basing
critically analyzing EBP definition the operation definition of
on these definitions alone does not give true picture of
EBP is “a problem solving approach where the practitioners
evidence, because these definitions overlook other factors
need to ask a clinical question, then gather/access evidence
which rate a claim or a fact or the data or the information to
(from research, contextual factors), interpret evidence
be true evidence, especially evidence that can be used in
(appraising and synthesizing), combines evidence with
health or nursing care practice. For facts to qualify as true
experiences (of practitioner and target group), and applying
evidence which can be used in clinical decision making in
what has been learned from evidence in making nursing care
health or nursing care setting, the definitions should
decisions.
comprised the information on the methods of evidence
generation and how it was rated as true evidence. For Literature also presents two related concepts to EBP: EIDM
instance, evidence from well-designed studies, well executed and EBDM. EIDM is defined as a process of gathering and
systematic reviews, meta-analyses research studies with sharing information on what works from research, work
appropriate controls or comparison groups are considered true setting and experience to inform and improve care provision
evidence [17,18]. Research evidence or facts are justified as decision [1]. This shows that EIDM is only concerned with
true evidence for health and nursing care decisions if they are sharing evidence, best practices and experiences and misses

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out two important components in EBP like: use of clinical education and clinical skills in making care decisions [29].
expertise in decision making and integration with patients’ Incorporating patient Preferences in care decision entails using
desires. As such EBP and EIDM are different. patient-centered approach where patients views, onions,
values, beliefs, priorities, expectations are included in
EBDM on the other hand is defined as the process of using
decision-making process [31]. All these will help the nurse to
best scientific evidence integrated with the clinician’s
produce a plan of care that enlist commitment from the
experience and judgment, the patient’s concerns, values and
practitioner and that is best to patients and family interest;
desires when making patient care decisions [25]. This
this facilitates patients’ adherence for optimal recovery.
definition has similar elements presented in the EBP definition
like: best research evidence, clinician’s expertise and a
patient’s expectations, preferences and values. Critically Constructing a model case
analyzing how EBP and EBDM concepts have been used in A model case is developed to represent a real life example
literature, the concepts appear similar and inseparable. EBDM of use of the concept that includes all the critical attributes of
has been used as standalone concept or subsumed under EBP. the concept [14]. Agatha is a medical-surgical nursing nurse
In most research studies and articles, EBDM is discussed specialist and the in charge of male medical ward. There are 15
interchangeable with the EBP. Mostly it has been used within nurses taking care of 56 patients with various medical
the definition of EBP. For instance, the study by Stevens found diagnoses and there are four nurses per shift always. Nurses
that the frameworks that guide the design and organize their work in response to the urgency of the task at
implementation of EBP approaches strengthen the EBDM hand and nursing routines and patients were rarely included in
process [26]. It was argued that in order to instill the culture of planning of their care. On each shift the head nurse of the day
EBP in Education, there was need to use EBDM approach [27]. assigns specific tasks to each nurse to be performed for all
EBDM has also been described as an approach of EBP, while patients and report to the head nurse after completing the
another study used both concepts and found nurses had tasks. For example, a nurse is assigned to administer
positive attitude towards EBP, but could not implement EBDM medication, take specimens, order drugs and supplies, bath
[25,28]. Forest and Miller discussed EBDM as a stand-alone patients, feed patients, take vital signs, conduct ward rounds
concept through conducting a study of translating EBDM into with physicians or discharge patients etc. One day during
practice, but critically analyzing the article, EBP is mentioned matron’s ward rounds guardians complained that their
as a supporting concept [25]. In conclusion, critically reviewing patients were not examined thoroughly by nurses, nurses do
the ideas in EBP and EBDM definitions, it can be concluded not have time to be with patients and listen to their
that their scope appears to be the same. For instance, complaints and some nurses are not approachable. This was
dominant to these definitions are the following concepts: ‘use confirmed by reviewing what nurses had documented on the
of best research evidence’, integration with ‘clinical expertise/ care of the patients: only tasks done were documented and
experiences’ and inclusion of patient’s preferences and values’. documentations relating to the nursing process were not done
The way EBP and EBDM have been presented in literature they (the assessment, nursing diagnosis, holistic implementation of
appear similar and hence often used interchangeably. This nursing actions, and the evaluation of the care given). After
analysis clearly shows that these are two different concepts the matrons round, Agatha gathered her colleagues to discuss
though related. about problem and to conduct a critical analysis of the current
nursing delivery in the wards (the task oriented approach). It
Determining defining attributes of EBP was found that the task oriented approach to nursing care
delivery they were using lead to: Impersonal relationship with
Attributes are components and key features that
their patients such that nurse-patient relationship did not
differentiate and clarify the meaning of one concept from
flourish; fragmented and poor management of patients which
another similar concept [14]. Following the analysis of
resulted in delayed recovery of patients. It also limits the
literature, five main attributes were identified to characterize
professional growth of the nurses since the nurse only
EBP: availability of a clinical question; use of best current
performed one task, which limits a holistic application of
research evidence; practitioner expertise and experiences;
theory to practice. It was agreed that there was a need to
patient preferences, values and concerns and application of
change the approach to nursing care delivery.
evidence. As seen in literature EBP requires full integration of
the five components into clinical decisions to enhance patient Then three nurses: Yankho, Julia and Hana who were well
safety, quality of life and optimal patient’s outcomes [29]. This versed and skillful in initiation of change were tasked to lead
suggests that for nurses as providers of nursing care to provide the process of change to improve delivery of nursing care in
EBP they need to possess complex level of thinking or the ward. They started leading the team by asking a clinical
understanding in order to ask a clinical question; read critique guiding question organized in a PICO (population, intervention,
and select the best research evidence for decision making [30]. comparison, and outcome) format: “In male medical ward with
They also need to correctly isolate relevant contextual issues 56 adult patients, what is the effective nursing care approach
that influence utilization of research evidence when making that can improve patient care delivery compared to the task
nursing care decisions and plan of care. In addition, decision oriented approach?” Then they planned on what resources
making requires possession of necessary expertise and they would need and to review literature to find the best
experiences. Clinical expertise refers to the integration of evidence based approach to nursing care that can improve
accumulated knowledge, care experiences; information from their situation. They checked in the hospital library and found
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that there were no up to date books and research articles and

they asked the in charge and management to support them
Borderline Case and Other Cases
with computers, internet packages and allow them create time
in the afternoon to search literature (Google, Google scholar, Borderline
PubMed, Hinari) in order to identify the best evidence based A borderline case contains most of the critical attributes of
nursing care approach. They searched for three days utilizing the concept but not all of them [14]. Mphatso is a principal
keywords like nursing approach, methods of nursing care, and nursing officer and in charge of surgical ward. During matrons
strategies for nursing care provision. Fifteen (15) articles were rounds she discovers that there is poor documentation of
identified and five articles were critically appraised and nursing care which leads to poor continuity of care. Then she
synthesized. The patient centered approach was identified as conduct ward meeting to discuss with nurses in the wards her
an approach that would redress imbalances in nursing care findings and how to improve documentation. They discus to
provision in the wards and represented a shift from the task adopt electronic documentation because in charge had
oriented approach that focused on duties not the patient. The already gathered, appraised and synthesized research
goals of patient centered approach were to provide holistic evidence on electronic documentation which shows that it is
care to address all needs of the patient. Then guidelines, an effective way to improve documentation. They identified a
implementation and monitoring plan were developed based registered nurse who has necessary expertise and experienced
on evidence on the patient centered approach and nurses to lead the process of applying what was learned from
were oriented to the approach. Nurses were encouraged to evidence to ensure good documentation. The electronic
integrate the evidence with one’s clinical expertise and documentation software was introduced with support from
experiences. information technology personnel and management provided
On each shift the head nurse of the day assigned a number computers. Nurses were oriented to the electronic
of patients under the care of each nurse to provide for their documentation. Management monitored the process and
holistic needs (physical, psychological, social and spiritual). evaluated whether documentation is done properly and has
Implementation of the new the patients centered approach improved. After three months of documenting electronically
started by the nurses establishing nurse patient working the process was evaluated and found that documentation was
relationships with patients. At each encounter with their easy, properly done, patient information properly stored which
patients, nurses established or maintained nurse-their patient can be reviewed anytime and promoted continuity of care.
relationship, patients’ values were acknowledged and patients’ Analysis: This is borderline case because it is only
engagement was enhancing their care. Then nurses engaged in demonstrating the three attributes of EBP: gathering evidence
assessing, diagnosing, planning, implementing, and evaluating and integrating provider experiences and applying/introducing
individual patient care. Nurses provided information to the new documentation approach.
patients they need to make decisions and were also
supporting them in decision-making processes. This led to
identification of patient concerns, preferences and respecting Contrary case
patients’ choices. Nurses advocated for their patients’ choices. A contrary case is an example of what a concept are not
There were also collaborative partnerships in care provision [14]. Yanjanani is a registered nurse with Bachelor of Science in
with other health workers in order to meet all needs of nursing and has been working as a nurse for five years. In her
patients and improve the care provision. five years of working her care decisions are based on
The wards-in-charge with support from management knowledge from pre-service education, in-service education,
monitored the process and evaluated the outcomes. After existing practice guidelines and consultations with senior
three months, there was utilization of the patient centered nurses and clinicians. The matron during one of her
approach in delivery of nursing care in medical ward which supervision visits to her ward pointed out that standard of
lead to; improved nurse-patient relationships; nurse- nursing care in her wards has gone down. Some of the nurses
colleague’s interaction which lead to addressing in her ward pointed out to her that they can use EBP to
comprehensive needs of the patients; improved nursing and improve the standard of nursing care. Although she learned
patient outcomes (provision of holistic care, quick recovery, about EBP in her pre service education she seems not
patient satisfaction). In addition patients complain relating to interested and she pointed out to them that with the workload
nurses behavior decreased. The results were disseminated to in their ward they don’t have time for EBP and it’s a long
their colleagues through presentation during nurses and process. What they can do is to make sure that they are
hospital meeting, in-service education and journal clubs. implementing the problem solving approach thoroughly:
identifying a problem, analyzing a problem, identifying
Analysis: This is a model case because it fully demonstrates decision criteria, developing multiple solutions and choosing
the five attributes of EBP: problem identification; gathering the optimal solution
evidence (literature, routine service monitoring and
interacting with subordinates); integrating provider Analysis: This is a contrary case because it does not contain
experiences; and patient’s preferences and applying the all attributes of the EBP like gathering evidence; integrating
evidence based approach when they were introducing the new provider experiences; patient’s preferences and applying to
approach to nursing care provision. improve care provision.

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Related case Discussion

A related case has similar defining characteristics to the The merits of EBP in nursing care practice cannot be
concept [14]. Agnes is a registered nurse who uses the nursing underscored. EBP has the potential to improve quality of care
process to assess, diagnose, plan, and evaluate nursing care and produce benefits for patients, nurses and midwives, and
provision. the health-care system. For patients, EBP leads to delivery of
Analysis: This is a related case because although the nursing improved patient-centered care because patient preferences
process is a systematic process of problem solving, it does not are included in decision-making; this reduces length of stay,
have some important steps found in EBP like: gathering, increased patient safety and result in better patient outcomes.
accessing, synthesizing literature; integrating provider For nurses, EBP increases job satisfaction, empowerment and
experiences; patient’s preferences and applying what has been improved skills to integrate research evidence and patient
learned in literature (evidence) into clinical decision making to preferences into practice. Eventually it supports professional
improve care provision growth and continuous career development through
developing expert roles. Health systems benefits include
improvements in: decisions making capacity of practitioners;
Antecedents and Consequences delivery of effective, efficient, quality of care at a reduced cost
and health care outcomes [37]. This makes EBP to be highly
Antecedents associated with improved patient and care delivery outcomes.
Thus, should be a priority agenda and a driving force for
Antecedents are proceedings or occurrences before a changes in health and nursing care delivery in order to ensure
concept occurs [14]. In this analysis, the antecedents that the long awaited benefits of EBP: patient safety, quality, and
takes place before EBP occurs and enables EBP to take place effective care. Nurses are at the center of delivery of EBP, they
are: identifying gap in nursing care practice; availability of are well positioned to move good evidence into practice to
evidence and necessary equipment’s (resources: computers, optimize patients’ outcomes because they stay with patients
internet Wi-Fi, stationery); presence of nurses with necessary 24 hours a day. That’s why this concept analysis was done to
knowledge, skills, and confidence on EBP to be able to access, achieve a better understanding of the EBP concept among
interpret and utilize evidence; availability of supportive leaders nurses so that they can understand EBP in relation to nursing
and mentorship [26,32-34]. Availability of these antecedents care delivery and drive them to embark on EBP journey.
will enable nurses to effectively continue with the next steps in
EBP process: asking a relevant question; gathering, appraising The analysis has highlighted important issues that can guide
and synthesizing evidence, integrating provider and patients the nurses to effectively move towards EBP nursing care
experiences, applying best evidence as well as evaluating the delivery. Walker and Avant framework for concept analysis
process and performance. provided an approach which enabled breaking down of the
concept into understandable units and understand its
Consequences attributes. This helped to arrive at a precise definition of EBP.
Antecedents are essential elements which nurses should bear
If nursing care decisions are based on research evidence, in mind prior to planning an EBP intervention while
nurses have the capacity to select the best option from a range consequences are benefit which acts as a driving force for EBP.
of choices. This results in nursing practice being likely to be Inclusion of a model case “in the analysis illustrated the ideal
safer, more effective, cost-effective and producing the use of the attributes of EBP and use of borderline and contrary
intended patient [26,35].The consequence of EBP are patients cases highlights areas to be improved or dealt with in order to
safety, effectiveness, cost-effectiveness, quality care because make the EBP process successful”. Use of empirical referents in
interventions are based on true evidence. the analysis was to demonstrate on how EBP can be measured
in practice, and can guide in developing of indicators for
Empirical referents observable behavior which can provide highlights to
occurrence and nonoccurrence of EBP in nursing practice [30].
Empirical referents are measurable ways to demonstrate
occurrence of a concept [14]. In this case, empirical referents
demonstrate how EBP can be measured in practice. EBP can Conclusion
therefore be measured using its attributes through following In nursing care delivery, things are changing daily, thus,
the key stages of EBP in nursing [22]. The stages include: requires changing methods of nursing care provision. EBP
Asking a relevant clinical question; searching, appraising, offers nurses an opportunity to use research evidence,
synthesizing and selecting the best evidence; integrating integrated with their capacity (expertise and experiences) and
practitioner and patients experiences; developing a plan, patient’s preferences to be able to select the best care option
guidelines and protocols; implementing the plan to apply from a range of choices. Therefore the analysis of the concept
evidence and evaluating results [36]. This can be of EBP is a first step toward understanding implementation of
demonstrated in reports, minutes and documentation. EBP. It offers an operation definition for nurses and
researchers; and practical application of the concept in nursing
practice. However, further studies are needed to try of the

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