evidence-based nursing evidence-based nursing evidence-based nursing (ebn) is an approach to making quality decisions and providing nursing care based upon personal clinical expertise in combination with the most current, relevant research available on the topic. this approach is using evidence-based practice (ebp) as a foundation. ebn implements the most up to date methods of providing care, which have been proven through appraisal of high quality studies and statistically significant research findings. the goal of ebn is to improve the health and safety of patients while also providing care in a cost-effective manner to improve the outcomes for both the patient and the healthcare system. ebn is a process founded on the collection, interpretation, appraisal, and integration of valid, clinically significant, and applicable research. the evidence used to change practice or make a clinical decision can be separated into seven levels of evidence that differ in type of study and level of quality. to properly implement ebn, the knowledge of the nurse, the patient's preferences, and multiple studies of evidence must all be collaborated and utilized in order to produce an appropriate solution to the task at hand. these skills are taught in modern nursing education and also as a part of professional training. part of a series onevidence-based practices assessment design management research scheduling dentistry medical ethics medicine nursing pharmacy in developing countries toxicology conservation education legislation library and information practice policy policing prosecution muriel skeet, a british nurse, was an early advocate for the development of the evidence base for health care. she produced studies and surveys including waiting in outpatients (1965) which received widespread publicity and resulted in the introduction of appointment systems, while marriage and nursing, with gertrude ramsden (1967), resulted in staff creches for nurses cultivate spirit of inquiry a spirit of inquiry refers to an attitude in which questions are encouraged to be asked about existing practices. cultivating a spirit of inquiry allows healthcare providers to feel comfortable with questioning current methods of practice and challenging these practices to create improvements and change. a culture that fosters this should have a philosophy that incorporates ebp, access to tools that can enhance ebp, and administrative support and leadership that values ebp. key elements to foster ebp always question current practices as nursing professional. integrate ebp as higher standard/mission/philosophy and include competencies for ebp. ebp mentors for skills and knowledge availability to others to provide and help. tools to enhance ebp (e.g. meetings, educational/classroom time, access to, etc.). higher level support and ability for leaders to model valued ebp skills. recognition of use of ebp often ask clinical question (picot) picot formatted questions address the patient population (p), issue of interest or intervention (i), comparison group (c), outcome (o), and time frame (t). asking questions in this format assists in generating a search that produces the most relevant, quality information related to a topic, while also decreasing the amount of time needed to produce these search results. an example of an intervention focused picot question would be: in total knee arthroplasty patients (population), what is the effect of nerve blocks (intervention) compared to opioid pain medication (comparison) in controlling post-operative pain (outcome) within the first 24 hours after surgery (time)? an example of an issue of interest focused picot question would be: how do post-rehab chronic obstructive pulmonary disease (copd) patients (population) with stage 3 (issue of interest) perceive their ability to perform activities of daily living (outcome) after first month (time) of rehabilitation? . search for and collect relevant evidence to begin the search for evidence, use each keyword from the picot question that was formed. once results have been found on the intervention or treatment, the research can be rated to determine which provides the strongest level of evidence. there are seven levels of evidence, with a level i being of the strongest quality and a level vii being of the weakest quality: level i: evidence from systematic reviews or meta-analysis of randomized control trials level ii: evidence from well-designed randomized control trials level iii: evidence from well-designed control trials that are not randomized level iv: evidence from case-control or cohort studies level v: evidence from systematic reviews of descriptive or qualitative studies level vi: evidence from a single descriptive or qualitative study level vii: evidence from expert opinions the strongest levels of evidence, systematic reviews and meta-analyses, summarize evidence related to a specific topic by finding and assessing studies that specifically relate to the question being asked. meta-analyses are systematic reviews that also use quantitative measures such as statistics to summarize the results of the studies analyzed. pyramid framework. thinking of the information resources used to obtain evidence as a pyramid can help determine what the most valid and least biased evidence is. the top of the pyramid is just that. this is where decision support can be found, which is found within the medical record. the middle of the pyramid is the reviews of the evidence. this includes systematic reviews, practice guidelines, topic summaries, and article synopses. the bottom of the pyramid is the original studies. the bottom is also considered the foundation of the pyramid and where evidence begins. this includes research articles. those who look for evidence here need special knowledge and skills to not only find the evidence itself but how to evaluate its worthiness. critically appraise the evidence to begin the critical appraisal process, three questions need to be asked to determine the relevance of evidence and if evidence applies to population being cared for. the three questions are: are the results of the study valid? what are the results? will the results be applicable in caring for patients? question 1 measures the validity. in order to be valid, the results of the study must be as close to the truth as possible. also, the study must be conducted using best available research methods. question 2 measures the reliability of the study. if it is an intervention study, reliability consists of: whether the intervention worked, how large the effect was, and whether a clinician could repeat the study with similar results. if it is a qualitative study, reliability would be measured by determining if the research accomplished the purpose of the study. question 3 measures the applicability. the study may be used in practice when caring for patients if the subjects are similar to the patients being cared for, the benefit outweighs the harm, the study is feasible, and the patient desires the treatment. after asking these three questions, evidence appraisal continues by creating an evidence synthesis. this synthesis compares multiple studies to see if they are in agreement with each other. integrate the evidence after appraising the evidence, it is necessary to integrate it with the provider's expertise and patient's preferences. the patient is encouraged to practice autonomy and participate in the decision-making process. therefore, even if the study had successful outcomes, the patient may refuse to receive a treatment. assessment findings and patient history may reveal further contraindications to a certain evidence-based treatment. lastly, availability of healthcare resources may limit the implementation of a treatment even if it is found to be effective in a study. evaluate outcomes the next step in the evidence-based practice process is to evaluate whether the treatment was effective in terms of patient outcomes. it is important to evaluate the outcomes in a real-world clinical setting to determine the impact of the evidence-based change on healthcare quality. disseminate outcomes the last step is to share the information especially if positive outcomes are achieved. by sharing the results of evidence-based practice process, others may benefit. some methods to disseminate the information include presentations at conferences, rounds within one's own institution, and journal publications. qualitative research process one method of research for evidence-based practice in nursing is 'qualitative research': "the word implies a entity and meanings that are not experimentally examined or measured in terms of quantity, amount, frequency, or intensity." with qualitative research, researchers learn about patient experiences through discussions and interviews. the point of qualitative research is to provide beneficial descriptions that allow insight into patient experiences. "hierarchies of research evidence traditionally categorize evidence from weakest to strongest, with an emphasis on support for the effectiveness of interventions. that this perspective tends to dominate the evidence-based practice literature makes the merit of qualitative research unclear;" 1 some people view qualitative research as less beneficial and effective, with its lack of numbers, the fact that it is "feeling-based" research, makes the opponents associate it with bias. nevertheless, the ability to empathetically understand an individual's experience (whether it be with cancer, pressure ulcers, trauma, etc.), can benefit not only other patients, but the health care workers providing care. for qualitative research to be reliable, the testing must be unbiased. to achieve this, researchers must use random and non-random samples to obtain concise information about the topic being studied. if available, a control group should be in use, if possible with the qualitative studies that are done. evidence should be gathered from every available subject within the sample to create balance and dissolve any bias. there should also be several researchers doing the interviewing to obtain different perspectives about the subject. researchers must also obtain negative information as well as the positive information gathered to support the data. this will help to show the researchers were unbiased and were not trying to hide negative results from readers, and actually makes it possible to objectively understand the phenomenon under investigation. the inclusion of this negative information will strengthen the researchers' initial study, and may actually work in favor to support the hypothesis. any data that has been gathered must be appropriately documented. if the data collected was obtained from interviews or observation, it must all be included. dates, times and gender of the sample may be needed, providing background on subjects, such as breast cancer in women over thirty-five. any pertinent information pertaining to the sample must be included for the reader to judge the study as worthy. in addition, the current evidence-based practice (ebp) movement in healthcare emphasizes that clinical decision making should be based on the "best evidence" available, preferably the findings of randomized clinical trials. within this context qualitative research findings are considered to have little value and the old debate in nursing has been re-ignited related as to whether qualitative versus quantitative research findings provides the best empirical evidence for nursing practice. in response to this crisis qualitative scholars have been called upon by leaders in the field to clarify for outsiders what qualitative research is and to be more explicit in pointing out the utility of qualitative research findings. in addition, attention to "quality" in qualitative research has been identified as an area worthy of renewed focus. within this paper two key problems related to addressing these issues are reviewed: disagreement not only among "outsiders" but also some nursing scholars related to the definition of "qualitative research", and a lack of consensus related how to best address "rigor" in this type of inquiry. based on this review a set of standard requirements for qualitative research published in nursing journals is proposed that reflects a uniform definition of qualitative research and an enlarged yet clearly articulated conceptualization of quality. the approach suggested provides a framework for developing and evaluating qualitative research that would have both defensible scholarly merit and heuristic value. this will help solidify the argument in favor of incorporating qualitative research findings as part of the empirical "evidence" upon which evidence-based nursing is founded. legal and ethical issues of research both legal and ethical issues are important in considering patient-based research. the american nurses association (ana) has set up five basic rights for patient protection: right to self-determination right to privacy and dignity right to anonymity and confidentiality right to fair treatment right to protection from discomfort and harm. these rights apply to both researchers and participants. informed consent is one area that nurses must be familiar with in order to complete research. informed consent is "the legal principle that governs the patient's ability to accept or reject individual medical interventions designed to diagnose or treat an illness". informed consent can only be obtained before the procedure and after potential risks have been explained to the participant. when dealing with the ethical portion of evidence-based practice, the institutional