One of the most commonly heard phrases right from day one of nursing school is “critical thinking.” The common consensus is that everyone has to develop sound critical thinking in order to be a safe and effective, registered nurse (RN). This necessity is magnified when it comes to critical care areas where one decision by the RN can change the patient’s outcome. Nursing has changed from a simple caregiving job to a complex and highly responsible profession. Hence, the role of nurses has changed from being task-oriented to a team-based, patient-centered approach with an emphasis on positive outcomes. Strong critical thinking skills will have the greatest impact on patient outcomes.
So, what is critical thinking and how do we develop this? A precise definition was proposed in a statement by Michael Scriven and Richard Paul at the Eighth Annual International Conference on Critical Thinking and Education Reform during the summer of 1987. “Critical thinking is the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action. In its exemplary form, it is based on universal intellectual values that transcend subject matter divisions: clarity, accuracy, precision, consistency, relevance, sound evidence, good reasons, depth, breadth, and fairness,” reads the document.
Simply put, critical thinking in nursing is a purposeful, logical process which results in powerful patient outcomes. “Critical thinking involves interpretation and analysis of the problem, reasoning to find a solution, applying, and finally evaluation of the outcomes,” according to a 2010 study published in the Journal of Nursing Education. This definition essentially covers the nursing process and reiterates that critical thinking builds upon a solid foundation of sound clinical knowledge. Critical thinking is the result of a combination of innate curiosity; a strong foundation of theoretical knowledge of human anatomy and physiology, disease processes, and normal and abnormal lab values; and an orientation for thinking on your feet. Combining this with a strong passion for patient care will produce positive patient outcomes. The critical thinking nurse has an open mind and draws heavily upon evidence-based research and past clinical experiences to solve patient problems.
How does one develop critical thinking skills? A good start is to develop an inquisitive mind, which leads to questioning, and a quest for knowledge and understanding of the complex nature of the human body and its functioning. A vital step in developing critical thinking for new nurses is to learn from those with a strong base of practical experience in the form of preceptors/colleagues. An open-minded nurse can learn valuable lessons from others’ critical thinking ability and will be able to practice for the good of their patients.
Critical thinking is self-guided and self-disciplined. Nursing interventions can be reasonably explained through evidence-based research studies and work experience. A strong sense of focus and discipline is also important for critical thinking to work. If thinking is unchecked, nurses can be easily misguided and deliver flawed patient care. A constant comparison of practice with best practices in the industry will help guide a nurse to think critically and improve care. This makes it easier to form habits which continue to have a positive impact on patients and colleagues. Every decision a critical thinking nurse makes affects not only the patient but also his or her families, coworkers, and self.
In summary, the take-home message for nurses is that critical thinking alone can’t ensure great patient care. A combination of open-mindedness, a solid foundational knowledge of disease processes, and continuous learning, coupled with a compassionate heart and great clinical preceptors, can ensure that every new nurse will be a critical thinker positively affecting outcomes at the bedside.
Using evidence-based practice (EBP) to give patients the best possible care is one of the hottest topics in nursing today. Yet evidence-based nursing is not a new model of care. In fact, says Linda Burnes Bolton, DrPH, RN, FAAN, vice president and chief nursing officer at Cedars-Sinai Medical Center in Los Angeles, it is simply another way of looking at the traditional theme of nurses living up to their sacred trust with society.
“The sacred trust is based on the belief that nursing professionals will always act in the best interest of the patient,” Burnes Bolton explains. “We cannot do that without knowing what would best benefit and assist the patient. Part of that trust and commitment to patients is to give the very best care for each individual. We cannot be lulled into a false sense [of security] that it is OK to do something just because ‘this is the way we have always done it.'”
These days, it’s hard to open up a nursing magazine and not see an article about evidence-based practice. But because it’s a complex concept, many nurses still don’t completely understand what EBP is all about.
One of the best explanations of what EBP is and is not comes from Bernadette Melnyk, PhD, RN, PNP/NPP, FAAN, FNAP, dean of Arizona State University (ASU) College of Nursing & Healthcare Innovation in Phoenix. Three years ago, Melnyk founded the nursing school’s Center for the Advancement of Evidence-Based Practice (CAEP), one of a handful of university-based centers across the country dedicated to this paradigm of care.
Speaking at the 2006 National Black Nurses Association annual conference, Melnyk noted that “improving health care through EBP is a problem-solving approach that integrates the best research data with the nurse’s clinical expertise and the patient’s individual needs and preferences. It is not just research utilization or translating research into practice. It’s the process of synthesizing the best evidence across multiple studies to come up with what’s best for [that particular patient in that particular situation].”
With its emphasis on developing interventions based on sound clinical evidence and proven best practices, evidence-based practice is an ideal tool for nurses to use in their efforts to eliminate racial and ethnic health disparities. Yet using EBP in the specific context of improving minority health outcomes poses unique challenges—from where to find research data that is inclusive of minority populations to understanding how culture and language may influence a patient’s preferences.
Defining EBP: A Closer Look
David Sackett, MD, a Canadian physician, is considered the father of evidence-based practice, according to Cheryl Fisher, MSN, RN, program manager for professional practice development of nursing and patient care services at the National Institutes of Health (NIH) Clinical Center. Located in Bethesda, Md., the center is the nation’s largest hospital devoted entirely to clinical research.
Fisher has adopted Sackett’s definition of EBP. “He states that evidence-based practice is ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. . .[by] integrating individual clinical expertise with the best available external clinical evidence from systematic research.’ In our hospital setting, we also take into consideration the patient’s preference since our care is patient-centered.”
Searching the literature to find the best evidence doesn’t have to be an overwhelming or time-consuming process. To target their search and quickly find the relevant research, says Melnyk, nurses should formulate a clinical question using the PICO framework:
P = Patient, Population, Problem
I = Intervention
C = Comparison
O = Outcome
“When you phrase questions in that way [with these criteria in mind], you will not spend days and days searching for the evidence to answer your question,” she says. “You will know how to put key words from PICO into a database search and rebuild your answer in a short period of time.”
Once you have come up with the key words to focus your inquiry, the next steps in the EBP process are to:
1. Search for the best research studies relating to your question;
2. Do a rapid critical appraisal of the research findings;
3. Integrate the evidence with your clinical expertise as well as the patient’s circumstances and preferences; and
4. Evaluate the outcome in the context of your own practice setting and, if necessary, make changes to current practices to give the patient better care.
A rapid critical appraisal helps clinicians establish the validity, reliability and patient applicability of a study or group of studies and find the most important nuggets of evidence to use in their practice. “And then you have to make the decision as to whether or not you are going make a practice change and integrate Step 4,” Melnyk says.
For Adelita G. Cantu, PhD, RN, a clinical instructor in the Department of Family Nursing Care at the University of Texas Health Science Center at San Antonio School of Nursing and a researcher who focuses on Hispanic health disparities, EBP means looking at what clinicians are doing on a daily basis, looking at patient care and knowing it is based on research. “You need to know there is some evidence that says this is the way you should do it and why you are doing it,” she emphasizes. “[As nurses], we need to explain to the patient why something is being done and that there is a reason it is being done a particular way. That should translate into better patient compliance.”
Sandra Millon Underwood, PhD, RN, FAAN, American Cancer Society Oncology Nursing Professor at the University of Wisconsin-Milwaukee College of Nursing, is a researcher who has devoted much of her work to cancer prevention and early detection among medically underserved minority populations. She cautions against taking too narrow a view of what EBP can accomplish. All too often, Underwood says, when clinicians think about evidence-based practice they focus solely on using the data from research to guide decisions.
“I think in many ways that is short-sighted, because most evidence-based practice models expand that vision,” she explains. “The evidence and research is critical but so are the other domains of EBP in making decisions for individuals, for communities and for population groups at risk.”
Underwood believes there are six domains that come into play when using EBP: scientific evidence, clinical experiences, the resources that are available within the academic arena or clinical environment, patient preferences, patient condition and patient characteristics.
The Importance of Inclusive Research
One of the biggest challenges nurses face in using evidence-based practice to address minority health disparities is finding enough evidence that is relevant to the needs of minority patients. There are many areas of medical research where people of color are underrepresented in clinical studies, or not included at all.
Burnes Bolton stresses the need to use research that is based on minorities to treat these populations. She points to skin cancer as an example. Skin assessments for people with dark skin will be vastly different than those done on Caucasians. “Generally, you look for changes in a [mole or spot on the body] where the skin is a different color,” Burnes Bolton explains. “With African Americans, they may not be able to see that.”
To share resources in support of evidence-based projects for reducing Native American health disparities, nursing leaders from the National Institutes of Health, the Indian Health Service and the National Alaska Native American Indian Nurses Association teamed up to create a collaborative online community
The end result can be deadly. According to the American Academy of Dermatology, failure to recognize skin cancer in people of color can lead to late diagnosis and lower long-term survival rates—only 58.8% compared to 84.8% for Caucasians. Furthermore, many people are under the misconception that melanoma is not a threat for individuals with darker skin. And studies of African Americans who are diagnosed with melanoma highlight another relatively unknown fact: In African Americans the condition most often develops on areas of the body that are not exposed to the sun.
“You can’t only use skin texture as a factor,” Burnes Bolton says. “You have to ask patients questions in a culturally appropriate manner.”
Another example, she continues, is the effects medications may have on different populations. “Many of the research studies [of medications] have been conducted [only] on white males,” Burnes Bolton points out. “It is very important when someone is prescribing a medication to know if that drug was tested on diverse populations. When reviewing the research, you must make sure you know what is the best evidence [about the drug’s effect on different populations].”
What Underwood finds disheartening is that even when a research study does include racially diverse participants, often the results are not analyzed by subgroups. “Inclusion [of minorities in a study] is not sufficient if one is not looking carefully at the outcomes of the research to determine whether or not there are similarities or differences for minorities, or nuances that need to be addressed in nursing practice,” she says.
Another factor that must be taken into account is the diversity that exists within a particular racial or ethnic group, Cantu advises. She says it’s critical for nurses to analyze the data and make sure there was a good research design in place. “Hispanics living on the U.S./Mexican border are going to be different than those living in an upscale suburban setting. You have to ask yourself: Is the population [in the study] similar to the one you treat? Where do they live? Do they have a high economic status? Do they have a low economic status? Make sure you are looking at evidence that pertains to your population.”
Where to Find Data
There are a number of ways to gather research data. Searching Internet databases is one of the fastest. Some of the best evidence-based health care databases include:
• The Cochrane Collaboration
• MEDLINE COS
• Cinahl Information Systems
• Agency for Healthcare Research and Quality (AHRQ)
There are also some databases and EBP online communities that focus specifically on minority health and health disparities, such as:
• American Public Health Association (APHA) Health Disparities Community Solutions Database
• National Minority Quality Forum
• Health Disparities Collaboratives
The Office of Minority Health Resource Center (OMHRC), the nation’s largest repository of information on minority health issues, provides free customized database searches on request. This service can be obtained by calling (800) 444-6472 or emailing the center at [email protected].
Another valuable source of data and best practices is other nurses—both researchers and clinicians. Burnes Bolton suggests tapping into the resources of professional nursing organizations, such as the American Academy of Nursing, for information. AAN initiatives such as Raise the Voice, which showcases the work of nurse “Edge Runners” who have created successful interventions and care models, may offer insights, she says.
Cantu suggests tapping into national and regional minority nursing associations. In addition, she says, many hospitals have clinical nurse specialists and nurse educators on their units. “They are a resource to go to. Schools of nursing are another place to use as an information resource. Maybe you can partner with them. Using these community resources is very appropriate and saves time for the bedside nurse.”
Sharing EBP Resources Online
Fisher has been working with the National Alaska Native American Indian Nurses Association (NANAINA), the Indian Health Service (IHS) and the NIH to create an online virtual community that helps promote the use of EBP to advance the agenda for reducing American Indian/Alaska Native health disparities. The online community links NANAINA faculty mentors with nurse clinicians at remote IHS sites and research staff from the NIH Clinical Center to collaborate and share resources in support of evidence-based projects.
According to Fisher, the virtual community grew out of a series of face-to-face meetings held in 2006-07 to establish relationships between the three collaborating organizations and to define evidence-based projects the nurses would work on. She says the Web-based community was launched last fall to provide technical support for the project’s mission and to enable the mentors and mentees to collaborate in an online environment.
“The virtual community provides a way to communicate and collaborate with the Indian Health Service nurses to promote evidence-based practice in their work settings,” Fisher explains. “The goal of the community was to provide a way for us to stay in touch following face-to-face meetings in order to continue our work.”
The online community includes such features as a discussion board, a resource center, a links section to help members quickly find Web-based information that will support their work, and opportunities for live chat or real-time meetings between two or more members.
Although the community is less than a year old, it has already accomplished a great deal, Fisher reports. “We were able to develop a list of members with contact information, share resources and develop posters for national presentation utilizing the virtual community—which would have otherwise been very difficult, since we [are all physically located in different parts] of the country. The virtual community has provided us with a means for staying connected.”
Filling Evidence Gaps
Another challenge that can arise when using EBP as a model of nursing care is: What do you do if the specific research data you need to answer your clinical question just isn’t out there—or at least not yet? Finding enough minority-inclusive research is just one part of the problem. Another obstacle, says Melnyk, is that it currently takes an average of 17 years for the findings of a study to become a valid, accepted part of the nursing literature.
“That [time lag] is a huge issue,” she emphasizes. “There are many areas in nursing where we do not yet have good evidence-based interventions to improve health outcomes. There are a lot of gaps in the evidence. That is why we need outstanding nurse researchers to generate evidence where we do not have it. Then we need outstanding clinicians to take the evidence that is generated and [apply evidence-based nursing skills] to translate it into clinical practice.”
One strategy for filling evidence gaps, Melnyk adds, is for nurses to generate practice-based evidence in their own clinical site by using outcome management. “Collect data through your chart records, do a certain practice and then look at outcomes and look at the data you have available,” she says. “The message I want to get out is that you do not have to be a rigorous researcher to be able to do outcome management and generate some evidence to guide your own practice in your [clinical] setting.”
This do-it-yourself approach to evidence generation can also be extremely helpful for busy nurses who might otherwise not have time to sit down at a computer and search for research data. “I think that many nurses, particularly bedside nurses, are so involved in patient care that they do not have the time to review on their own or attend meetings, workshops or seminars where evidence-based practice is discussed,” says Cantu.
Using EBP Effectively
Ellen Fineout-Overholt, PhD, RN, FNAP, director of the Center for the Advancement of Evidence-Based Practice at ASU College of Nursing, believes that having open communication with patients and colleagues plays a key role in providing evidence-based care.
“If I am taking care of a patient of color and do not know anything about that [person’s] culture, it is incumbent upon me to find out, to ask some questions,” she says. “Then it is incumbent on the patient to tell me, to talk to me. We need to have a dialogue so we can come to understand and know one another better to get the best outcome. Nurses need to [look at patients’ cultural beliefs and values] to see what they want and what they may need [in terms of care].”
That isn’t to say every outcome will be positive. Sometimes patients may not be willing to make a change in their behavior, especially if it goes against their belief system. “Then you need to tell them, ‘This is what the evidence says might happen. If you still want to go ahead [with that behavior], be informed of what your outcome may be,” Fineout-Overholt explains.
To use EBP effectively, she continues, nurses must always keep two things in mind: Why are we doing this and what outcome are we trying to achieve? “[Whatever you’re doing, whether it’s] inserting a Foley catheter into a bladder or holding a dying patient’s hand during a procedure, if you can keep those [two questions] as your focus it will really help you to understand what aspects [of the evidence] to put into practice. With hand-holding, culture . What does it mean to comfort someone in certain situations? With putting in a catheter, what you are trying to accomplish depends on what kind of circumstances there are. Keeping patient care front and center is imperative.”
Nurses should question the research data if it does not seem to fit in with their own clinical experiences, Cantu says. “We teach critical thinking [at our university]. In your experience, if you have seen something different, you cannot discount that. Then you may need to ask, ‘How do I get [these two pieces] to fit together?'”
Melnyk stresses that nurses need to work in a culture that supports EBP. “[Buy-in from] upper management is critical. Nurse managers and nurse executives need to understand EBP, practice it and create a culture that [encourages their nursing staff] to implement it. Part of that culture is having a cadre of It is critically important for nurses of color to be in the forefront of the evidence-based practice movement, Fisher emphasizes. “Minority nurses can help pave the way through modeling and dissemination of their EBP projects, which was the goal of our work with NANAINA and the Indian Health Service. It is exciting to see the nurses get involved with EBP and use their creativity to improve patient care. Once EBP becomes [more widely accepted] as a new way of practicing and providing care on a daily basis, both nurses and patients will benefit.”
Want to Learn More About EBP?
Join the (Journal) Club!
Two years ago, Pattie Soltero, BSN, RN, MAOM, operations manager for 6 North, a pediatric rehab and med-surg unit at Childrens Hospital Los Angeles, was looking for a way to help introduce the unit’s nursing staff to evidence-based practice (EBP). So she started a journal club. Journal clubs—also known as research clubs—are so called because they involve reading and discussing research studies published in clinical journals.
Soltero was introduced to the concept of EBP when she went to a professional conference. “There was a group of critical care nurses from a hospital here in L.A. who wanted to develop [a procedure for] providing their intubated patients with the best oral care possible,” she says. “So they went and researched the best mouthwash, the best toothbrush or utensil, and all the things related to providing the best oral care for intubated patients. Then they went to their manager and said, ‘These are the items we need.’ It turned out that the hospital already had a contract with a supplier that had every single item they needed. Based on that, they were able to develop a package for every single intubated patient in the ICU based on the evidence and their practice. Now [this hospital system] uses it in all of their facilities.”
The nursing staff on 6 North have varying levels of education, which is another reason Soltero started the journal club. “We have nurses with advanced degrees who are nurse practitioners and we have other nurses who have two-year associate’s degrees,” she explains. “Nurses with a two-year degree have had [little or no exposure to nursing research]. So we have taught them how to read a research article. We have taught them that nursing research is not something to be afraid of: It is done by nurses, it is not in a foreign language and it is applicable to our practice.”
Attend an EBP Conference Focusing on Vulnerable Populations WHEN:
February 19-20, 2009 WHAT:
10th Annual Evidence-Based Practice Conference: “Translating Research into Best Practice with Vulnerable Populations” WHERE:
Renaissance Glendale Hotel & Spa, Glendale, Ariz. SPONSORED BY:
Center for the Advancement of Evidence-Based Practice at Arizona State University College of Nursing & Healthcare Innovation FOR MORE INFORMATION:
Amy Fitzgerald, [email protected]
When the club first started, Soltero picked a research article once a month, posted it for everyone to read and then scheduled a meeting to discuss the study. “Little by little, after about six or seven months, some nurses started to really enjoy the journal club, so the staff [eventually took it over themselves],” she says. “Now it is just positive peer pressure [that motivates them to participate], so they meet on the weekend to do the journal club. I am not involved in it.”
While approximately 75% of the children the hospital treats are Hispanic, the facility also serves a variety of other ethnic communities. “We have an Armenian community close by and a Chinese community close by. And the rest of [our patient population] is a very diverse mix,” Soltero says.
She feels the journal club has been an excellent vehicle for implementing evidence-based practice to better meet the nursing needs of children of color. “For example, we looked at the spiritual care of our kids and how we are meeting those needs [given] the diversity of our population. People think because you are Hispanic you are Catholic, but that is not always true,” she notes. “We found a research article that focused on the spiritual care that was delivered to pediatric patients. Based on that, we were able to talk about how important that aspect is to their care.”
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