Introduction
Traditionally，nursing has been viewed as a profession that depends on the medical profession for its direction in providing patient care.Nurses were characterized as the“angels of mercy”who soothed the fevered brows of the sick and carried out the orders of the physicians.Comfort measures for patients，like those designed to reduce fevers，or even decisions about when patients could get up out of bed after a surgical procedure were left to the physician to order and the nurse to implement.The timing for administration of medications，taking of vital signs，measuring of the patient's intake and output were based on physician's orders，not nursing judgment.Nurses were not expected to question the scientific rationale for the physician's orders，they were just expected to carry out the written or verbal instruction of the physician.However，in North America and in many other countries，those expectations have changed dramatically.
As nurses have become better educated，it is clear that patient outcomes have improved.Yang，Hung，et al.（2012）reported that attention to the most effective staffing mix of professional nurses and auxiliary personnel in acute care respiratory units contributed to improved patient outcomes.In a seminal article that looked at the influence of hospital nurse staffing，patient mortality，nurse burnout and job dissatisfaction，the authors identified that patient mortality was directly linked to nurses'job satisfaction and staffing patterns（Aiken，L.H.，Clark，P.，Sloane，D.M.，＆Silber，J.H.，2002）.What was most influential about Aiken's research was that nurses who are educated at higher levels and those who had autonomy in practice were better able to care for patients and avert life－threatening complications during hospitalizations.Nursing research was supporting the theme that it was no longer advisable or safe to allow nursing to rely on just written orders and their implementation.Nurses had to develop their own body of scientific knowledge for safe and effective practice.Nurses who were educated in programs that are longer than the traditional twenty or thirty month program were better prepared to function in an environment where inquiry and testing was an essential part of practice.
The late twentieth century and the beginning of the new millennium was the time when the foundation for evidence－based nursing practice was laid in North America and Great Britain.Numerous articles were published about the need to have scientific evidence as a basis for nursing care.However，there was no well－crafted methodology to achieve this goal.Further，nurses were not well prepared accurately interpret statistics that were generated in their practice settings，nor was there user friendly technology designed to gather and manage such data.There was also resistance to the scientific investigation of the quality of patient care.
While Quality Improvement Departments were essential in every accredited healthcare institution，the data gathered emphasized the occurrence of mistakes and finding variations of protocols rather than on the generation of evidence to support the efficacy and appropriateness of the protocols.Many believed that if a protocol had“worked”for a long time，it was appropriate to continue to do it even if there was nothing to support that the procedure had any scientific validity in practice.Thus，the concept of“sacred cows”was often found in nursing practice.This is a term for a procedure that has been used for a long time without scientific validation，but with which people were comfortable.For example， the admission protocols in place for a woman who was admitted to the labor and delivery unit in a hospital included an enema，shaving of the pubic area and putting the patient to bed.The patient's significant other，either husband，female relative or other important person was guided to a waiting area where they spent hours waiting for the birth to occur. In another instance，visiting hours for hospitalized patients were strictly enforced and limited.There was a vague sense that this practice increased safety from infection and“comfort”for the patient.There was never any real evidence to support this notion. Rather，this practice developed as a convenience to the staff rather than for the welfare of the patient.To change practice to eliminate a“sacred cow”was seen as threatening and even detrimental to the nursing care of the patient.
The implementation of Evidence－based practice has helped to change these practices and improve patient outcomes as well as improving working conditions for nurses.But what does evidence－based practices in an environment that is resistant to evidence－based protocol development？In the following sections of this chapter，we will attempt to answer some of these questions.
What Is Evidence－Based Nursing Practice in North America？
Melnyk and Fineout－Overholt（2011）state the that origins of the evidence－based practice movement began in the acceptance of the work of the British epidemiologist，Dr. Archie Cochrane，who actively campaigned for effective and efficient health care.In 1972， he challenged the medical profession to provide extensive and careful reviews of medical practices so that policy makers and users could make the best possible decisions about health care alternatives.As a result of his efforts，the Cochrane Center was instituted in England in 1992.There are now fourteen Centers all over the world that facilitate the work of the Cochrane Collection（US Cochrane Center，2012）.The Chinese Cochrane Center is located in the West China Hospital，Sichuan University，No.37，Guo Xue Xiang，Chengdu 610041，Sichuan，China.Its web page is www.ebm.org.cn.The Cochrane Center's mission is to assist individuals in making well informed decisions by promoting systematic review of interventions.All of these reviews are available to the public.This underscores that the patient is considered an essential part of the evidence based process and that the results of EBP are not just for clinicians.
There are several definitions of evidence－based practice（EBP）in the literature in the United States.EBP relies on the integration of clinical applications and the most current and best available published evidence（Porter－O'Grady，2006）.The evidence tested in real life clinical practice is not just a blind application of published literature to a patient's care. Practical clinical experience that has resulted in excellent patient outcomes is also a facet of EBP.However，lest this practical clinical experience become a“sacred cow”that experience needs to be tempered with a critical analysis of the applicability of published research that is pertinent to the situation.Another facet for EBP centers on the patient.In nursing，it is a core precept that the patient is not just a vehicle of disease，but the patient is viewed as a whole being and an essential element in the care that needs to be delivered.Melnyk and Fineout－Overholt's（2011）definition has three clusters that make up the foundation of EBP.The first cluster is that of external evidence，evidence－based theories，opinion leaders and expert panels.The second cluster is clinical expertise that is also defined as internal evidence.The third cluster is that of Patient preferences and values.The inclusion of patient preferences and values moves EBP beyond just an amassing of the results of clinical trials and expert opinion，but rather solidifies EBPs essential role in nursing care.
Indeed，a classic definition of nursing in the United States is the one that is published by the American Nurses'Association（2012）.It states：
Nursing is the protection，promotion，and optimization of health and abilities， prevention of illness and injury，alleviation of suffering through the diagnosis and treatment of human response，and advocacy in the care of individuals，families， communities，and populations
Nowhere in this comprehensive ethical obligation for nursing does the statement indicate that nurses are those traditional“order takers”.Indeed，in order for a nurse to fulfill the requirements of the profession，the nurse must combine elements of critically appraised research findings，clinical process and outcome data，communication of solid clinical experience，recognition of best practices and a careful diagnosis of a patient's priorities. Indeed，evidence－based practice in nursing provides a framework for professional nursing practice that is current and requires continuous synthesis of the elements described by Porter－O'Grady，Melnyk and Fineout－Overholt.
How Does Evidence－Based Practice Modify Decision Making？
In the North America，as in many places in the world，nurses often accepted nursing protocols because it had always been done that way.There was little，if any，exploration of the efficacy of the protocols especially in the area of what was best for patient healing. Many protocols were set for the convenience of the staff，or to assure that there was some data available for the physician when they conducted rounds or for change of shift report to other nurses.What seemed to be intuitive，like suctioning protocols，were established because they sounded as if it was a good idea，but the protocol was never tested against the three clusters that comprise evidence base practice.In fact，it was not unusual for a nurse to be met with resistance from other nurses as well as from hospital executives when the protocols were questioned.However，with the increasing emphasis on scientific development of nursing science，with the the formation of the Cochrane Institute，the repository of research results from Sigma Theta Tau International（the international nursing honorary organization）and an emphasis on rigorous research implementation from the National Institute of Nursing Research（NINR）and Tri－Service Nursing Research （TSNRP）many clinical questions have been explored and a rich resource for evaluating protocols has been developed.
As the scientific sophistication of nursing has developed，a unique aspect of evidence based nursing is that gathers evidence from many different professional disciplines as well as its own to make decisions about practice approaches.Certainly，medical evidence about the most effective medications and treatments is essential in framing nursing care. Pharmacology offers evidence about the pharmacokinetics and pharmacodynamics of medications that are essential in decisions about the best time to administer the medications. Literature from psychology points to the best ways to structure the patient's activity and rest cycles as they recover from surgery or cardiac events.Evidence from sociology helps nursing design the best approaches to helping families create healing environments for the patients as they deal with the life changes that are imposed by illness.Nursing is very active in synthesizing information from other professions and forming important nursing research questions to determine how nursing can make the most effective impact on the patient's healing processes.Transprofesional literature has played an important role in the development of meaningful nursing protocols.The development of nursing theories and the testing of those theories as frameworks for caring protocols have opened a new and exciting resource for the development and testing of nursing science.Nursing is also a leader in the concept that synthesis of the science of many professions can be effectively developed into a body of scientific knowledge to benefit those committed to our care.
Screening Protocols As An Example of the Use of EBP in Modern Practice
Florence Nightingale said that it was nursing's objective to“obtain among the well as among the sick”（Nightingale，1859）.In this discussion，she was exhorting her readers to understand that it was our job to keep people well as much as to nurse them when they are ill.Although this has been our birthright obligation as nurses for over 100years，it seems that it is only lately that our health care system has come to recognize that prevention of serious disease is an essential part of being healthy.Concurrent with this recognition of health promotion is a developing industry for screening.In a 2004survey，87％of respondents（n＝500）indicated that“routine cancer screening tests for healthy persons is almost always a good idea（Schwartz，Woloshin，Fowler，Welch，2004）.Recent use of the evidence base has called into question this maxim，however.Mammograms，PSAs，routine EKGs and routine use of hormone replacement for menopause have all come under scrutiny （Journal Watch，2012）and labeled as“not recommended”.
In order for screening to be cost effective and a good indicator of the potential for disease，there are principles that must be considered：
The disease must be relatively common and have a significant impact
There should be an effective treatment for the disease
The condition should have an asymptomatic period and during which the detection and treatment can improve patient outcomes
Treatment in the asymptomatic period should be superior to treatment once the symptoms occur
The test should be safe，affordable and possess adequate sensitivity and reliability
The screening modality should be acceptable to the patient and to society
There should be evidence of continued effectiveness over time（Jackson，Berbano， O'Malley，2007）.
Imaging has become a significant tool in the screening armamentarium，indeed，the full body CT has become popular and is widely marketed to church groups，civic organizations and unions even though the cost（from＄65—＄2，000USD）is not usually covered by insurance.The evidence is still being gathered about the effectiveness of this modality and how well it fulfills the criteria for effective screening，however many entrepreneurial groups are seeing this as a profitable commercial use of screening.
Another use of imaging is the screening of asymptomatic individuals for coronary artery calcification.It is hoped that the results of the CTs will allow people to have information that will lead to life style changes and decrease the number of cardiac events.To date，there are many questions about the effectiveness of this screening and its specificity for different groups.Further，it has not been determined whether this method is superior to careful history and analysis of risk factors.The axiom that careful and complete history will yield more information than any tests is still supported by the evidence.
The risks associated with screening need to be considered.If a screening test leads to a false positive，aggressive intervention is expensive，can be life－threatening and cause emotional suffering for both the patient and the family.In the case for full body CT （FBCT），false positives are far more common than true positive results.In a study of coronary CT screenings，8％of the patients were deemed positive for at least one abnormal finding.Of those 37％has a recommendation for further evaluation.The study did not indicate how these evaluations affected patient outcomes（Furtado，Aguirre，Sirlin，2005）.
What are the consequences for these false positives？The most common is over diagnosis，meaning that the conditions that are not really clinically significant are diagnosed and treated unnecessarily.Any time intervention is instituted，there are risks of harm from the intervention such as reaction to anesthesia，infection，permanent anatomical changes that affect the quality of life，not to mention the increased expense.With the new Affordable Care Act，pre existing condition as a way of denying coverage is illegal. However，the issue of premiums is still apparent.There is also the question of unnecessary radiation exposure.Although many of these companies suggest that the exposure is minimal，which is true，the risk must be balanced against the value of the screening outcomes.In addition，there is an unknown although actual psychological impact of having a false positive or negative result of any screening to be assessed.
There is the issue of determining the optimal time for screenings.One only has to read the literature about Pap screenings to see the controversy in this area.For many years，the British have been using a two to five year interval for Pap testing.The United States healthcare community has only recently adopted guidelines for this testing that relate to age，frequency and the time at which the testing should be stopped.While mammograms are still recommended as a yearly screening for adult women，the age at which the screening should start and stop is changing.
The evidence－base literature makes recommendations based on different criteria.One way of looking at the test is to determine the efficacy of the test in finding new cases， another is the decreased mortality as a result of screening，still another is the issue of stage of disease at time of detection and its ability to be amenable to treatment，for instance，in the detection of prostate cancer in older men.None of this is clear cut and the practitioner must make a reasonable judgment based on the best and most sensible evidence available.
The last issue is the problem of technology.Screening tests usually require some kind of technologic equipment in order to accomplish the test.How is the equipment maintained？How is it calibrated？Think about the blood pressure kiosks in the pharmacies and supermarkets as an example.Further，there is the problem of the approval of the equipment by the FDA.Did the equipment have an appropriate testing cycle before it was put on the market？Do newer modifications actually increase the sensitivity？Most importantly，does this test make a difference in the life of the patient？
The reader is directed to a large volume of material that talks about the screening of various groups for various diseases that are available in data bases like Up To Date，the CDC and WHO websites as well as the recommendations by various specialty colleges and associations for specific timetables.Often too，Journal Watch，Pharmacist's Letter， Clinical Practice Guideline Watch，United States Preventive Services Task Force （USPSTF）website，and daily email updates like the AANP e newsletters can give the practitioner valuable updates for the efficacy of screening patterns.
This screening example illustrates that EBP is not something that is confined to a hospital unit or even just to primary care.Evidence－based practice is a dynamic and powerful tool for improving patient outcomes.It needs to be formulated thoughtfully and consistently evaluated.Old norms may not be the best when applied to current practice. New ideas need to be evaluated for efficacy and appropriateness in application to practice. The data base must be kept fresh and manageable so that important information can be retrieved.
The Availability of the Evidence Base
Managing the evidence base so that useful information is retrievable has been the subject of much discussion.It is no longer necessary to physically visit a library building to garner the information needed to test assumptions for actual practice.Access to the world wide web has opened amazing vistas for nursing professionals.Quick access to research conducted in other countries，government sponsored evidence based sites like the United States Preventive Services Task Force，and reliable consumer information sites like Web MD，（http：／／www.webmd.com）patient information sites that are sponsored by some of the largest health care agencies in the United States are all rich sources of evidence－based material.
The proliferation of electronic health records（EHR）has also assisted in the availability of data to support research to answer practice questions（Malloch and Porter O'Grady，2006）.Although these computerized systems are costly to implement，the benefit for the implementation of evidence based decision making is considerable.At a large Midwestern US health system，the EHR that was implemented in 2011has some striking components.When a provider（aphysician，pharmacist，advanced practice nurse or physician assistant）has an appointment with a patient，the patient's entire health history is available to the provider even before the encounter with the patient.Health history， medications，allergies and concurrent diagnoses are all gathered into one place in the record. As the patient's diagnosis is entered，a section of the record entitled“Best Practices”is available.In this section，the provider can quickly review the current evidence base and make a decision about the approach selected for that patient.The approach is individualized and specific for that patient.Although“Best Practice”does not dictate the decision，it does offer the provider effective choices for therapies.The patient becomes the beneficiary of the most current information available.
Lack of universally available clinical information is an impediment to both in hospital and out－patient care.In a recent report of system barriers associated with the care of diabetic patients，the providers who were included in the study cited that lack of access to patient information that is generated by providers to whom the patients were referred for specialty care，increasing demands of third party payers for documentation of implementation of evidence based protocols and the lack of ability to track the unmet health care needs of patients was a barrier to effective primary care（Zhang，J.，Van Leuven，K.， Neidlinger，S.，2012）.EHRs are seen as one way to address these problems，but for the private primary care practice，these systems are expensive and difficult to implement.That being said，weighing the cost and benefits of having Best Practices readily available in EHRs is an area that has to be evaluated.
Use of evidence based decision making has become a key element in evaluating patient outcomes and has become essential in the economics of health care.Insurers are now beginning to provide levels of reimbursement for practices according to the strength of the evidence based decisions of the provider.Treatments that have strong evidence base to support use are paid at better reimbursement rates and payment is being denied if sound evidence based rationales are not evident in the treatment plan（Melnyk and Fineout－Overholt，2011）.Nursing practice is also profoundly important in health economics. Hospitals are now subject to greater costs if evidence based nursing is not implemented to address preventable sequellae like pressure ulcers，failure to ambulate，preventable falls and nosocomial infections.The hospitals will not be reimbursed my Medicare for patients who are readmitted to the hospital as a result of these injuries.
Most hospital systems now have developed unit based teams of nurses to review and revise nursing protocols that are based on the evidence base.It is nursing that generates these protocols and is accountable for their implementation.It has been logically assumed hat translating available evidence into practice should be a smooth process that benefits all parties.This is not the case，however.Practice recommendations are only the first step of a much larger systematic approach to evidence－based implementation protocols and their application to practice（Harrison and Graham，2012）.
The Barriers of Including the Evidence Base in Nursing Practice
The gap between the publishing of evidence based information and its inclusion into actual nursing practice has been estimated to take seventeen years（Balas and Boren，2000）. Needless to say，in the years after this sad estimate，the tempo of inclusion of evidence based practice into actual implementation has been pressed to shorten.Although use of the evidence base is generally acknowledged to be important，many front line nurses are still slow in adopting these factors into actual care.Inquiry into why this is so has revealed several insights.Gerris，Nolan et al.（2012）identified four groups of influencing factors in the adoption of EBP into practice.They are：
Personal attributes of the FLN（Front line nurses）and the Advanced Practice Nurses（APNs）
Knowledge and skills in EBP
Clinical credibility with FLNs
Relationships with stakeholders including level of support from managers and medical colleagues
Aspects of the nursing role in their sphere of responsibility and workload
Organizational culture，workload，professional networks and available resources
These findings support what many nurses“know”from experience.If there is no support for the inclusion of EBP in practice，or the workload is such that it makes the inclusion of EBP difficult，or there is no support from leadership and professional colleagues in other disciplines，it takes too much energy to constantly look at“something new”.If the FLNs were not well educated in the essential nature of EBP's presence in safe and effective practice，the incentive to include EBP in professional protocols is severely minimized. Further，if resources are not made readily available so that EBP can be documented and included in protocols，the incorporation of EBP is impeded.
Leadership in the inclusion of EBP into practice is a huge component of success. Nursing executives，head nurses on units，and nursing supervisors are key to the success of EBP implementation.As one nurse in Gerris'study said：
For any change，if I've help from the top，from my executive nurse，it makes a big difference.Like the oral care guidance I've developed，once the committee has passed it，it'll be cascaded jointly.I'll take it forward，but（executive nurse）will be the driver，saying‘this is what we are going to do’.
Key issues in the implementation of EBP into nursing practice have been the availability of internet resources to the FLNs on the unit as well as the leadership style of the executives in the system.Heavy workloads，competing organizational demands and work patterns that did not promote the investigation and use of EBP are important cultural issues.The results of these barriers are increased frustration on the part of nurses，lack of engagement in unit protocols and a decrease in patient safety on the units.Indeed，ensuring that all nursing practice is based on the components of evidence－based practice is essential for improving outcomes（Gerrish，Nolan，et al.）.The literature does reveal that when nurses and their colleagues use EBP as a cornerstone of practice，their autonomy for decision making rises，a higher level of job satisfaction ensues（Melnyk，et al.）and engagement increases（Minor， 2010）.
Models Used in North America for Implementation of EBP into Nursing Practice
In reviewing the literature about the incorporation of EBP into nursing practice， connectivity to the internet and the ability to search large data bases is considered essential. It is no longer acceptable just to review a medical data base.Nurses must learn，as part of their education，techniques that allow them to mine the evidence for appropriate application to the clinical question they are asking.If the nurse graduated from nursing education programs that did not include this information，it is imperative that their workplace provide them with opportunities to learn these essential skills.
In the opinion of many nursing leaders in North America（Melnyk，Fineout－Overholt， Stillwell and Williamson，2009，Facchiano and Snyder，2012，Harrison and Graham，2012， Rycroft－Malone，2012）improvement in clinical practice in the reality of a very complex health care environment depends on the skill of nurses to develop a spirit of inquiry and then know what to do to transform that inquiry into evidence based practice.The importance of using the evidence base for practice decisions cannot be underestimated.The Institute of Medicine has set a goal that 90％of health care decisions will be made on the basis of the evidence base by 2020.This chapter has presented powerful barriers to implementation of EBP as well as even more powerful mandates for its inclusion as key to health care decision making.
Now we need to consider what models work and how nursing can change the face of its practice to improve patient outcomes.Melnyk，et al.（2003）published a paradigm of the merging of science and art within the context of caring and an EBP culture.The combination of research evidence and evidence based theories，clinical expertise and patient preference and values when encircled by the context of caring，combined to energize clinical decision making，resulted in high quality patient outcomes.Melnyk，et al.（2009）have developed a step by step method for integrating EBP into nursing practice.
This method starts with Step Zero－The Spirit of Inquiry.This is the base from which all other steps are derived and why the authors term it‘step zero’.Its importance can be summed up in one word，“WHY？”Nurses are curious about what works the best.They are equally curious about why things don't work.Mobilizing and rewarding that curiosity is a fundamental element of EBP implementation.Other spurs to seek out the evidence include the need to answer a patient's question，or to present new approaches to colleagues in journal clubs，or being asked to present a poster or podium presentation at a professional meeting（Facciano and Snyder）.
Asking colleagues and yourself the following questions can be a part of developing that spirit of inquiry：
Whom can I ask to help me be better at EBP？
What am I doing in practice that doesn't have evidence to support its effectiveness？
When should I ask the questions？
Where can I find the best evidence？
How can I work with others to enhance my EBP skill set？（Melnyk，et al.）
In the United States and Canada，measures that support this development have included posting posters with the questions and posting them prominently in the nurses'station have served as a consistent reminder that looking for the evidence is a core value of the unit. Another strategy that was used by this author was to link the accomplishment of strategic initiatives to evidence based rationales.If a unit believed that a certain piece of equipment or participation in a professional meeting was important to the patient outcomes of the unit， the application for approval had to include evidence that this was a positive action.In actuality，not having any evidence to support the request was equally powerful.If the data bases didn't reveal evidence to support the action，development of a project to evaluate efficacy was also a strong rationale for support.The key was stimulation of thinking and inquiry.We often used the sentence，“Curiosity didn't kill the cat，it made it a smartercat”to stimulate critical thinking and application of evidence in practice and also to communicate system support of inquiry.
Melnyk，Fineout－Overholt and their colleagues have published the seminal literature on the development and implementation of Evidence Based Practice in nursing.Their seven step procedure is very helpful when contemplating a move toward EBP as a foundation for modern practice.After acceptance of Step Zero Cultivate the Spirit of Inquiry，the next step is Asking the Clinical Question by using a format that reflects organization，thoughtful inquiry and a targeting of the issue so that one is able to use the data bases to the best advantage.This format is known by the acronym PICOT where P＝population of interest，I＝intervention or area of interest，C＝comparison or intervention group，O＝outcome and T＝Time Frame（Melnyk，Fineout－Overholt）.Writing PICOT question takes some practice.Providing a chart with the PICOT legend clearly stated can be helpful to post on a unit alongside the spirit of inquiry poster.An example of an evidence based inquiry using the PICOT format is：
In Primary Care（patient population），how does（Intervention）inspecting the feet of a patient with diabetes at every visit compared with doing it once a year（comparison） affect the detection of neuropathies（outcome）during a three year period（time frame）？
The response to this question may be intuitively answerable，but in order to assure that outcomes are the best they can be AND to get paid for the action the nurse is performing， evidence must be presented to support the procedure.
Step 2 is Search for the Best Evidence.The PICOT format helps to identify key words in the data base search.It is important to remember that each scientific data base has search protocol and a focus.Some data bases are more user friendly than others.This is where the help of a skilled medical librarian is most useful.These professionals are skilled at mining data bases and are excellent teachers when one is learning how to use data bases most effectively.There are four criteria for the mining of a data base that are helpful to keep in mind during the search.One is the soundness of the evidence based approach of the data base（here a librarian is extremely helpful）.The second is the comprehensiveness and／or specificity of the resource.Is it pertinent to the clinical practice or patient population you are exploring？Third，the ease of use.This is particularly important for busy professionals who are looking for evidence，but don't have the resources to spend time with complicated decision trees to find the specific piece of evidence to answer the query.Fourth is Availability（Facciano and Snyder）.Data bases should be available for searching using the resources provided by the organization or educational facility with which the practice has an affiliation.In the modern world，linkage to world wide sources of evidence are crucial to our EBP process.
Step 3 is Critically appraise the evidence.Just because something is in print doesn't mean it's sound evidence.Using the PICOT criteria，one can evaluate the relevance of the articles and studies.They should then be reviewed for validity，reliability and applicability. These are called“keeper studies”（Melnyck，Fineout－Overholt，Stillwell and Williamson， 2010）.Issues of the types of instruments used to obtain the data in the studies，did the authors accurately identify and evaluate the key points of the outcomes，was the design of the study appropriate are all questions to ask.Probably the most important question in this step，though，is are the results important and will they help me in my practice？There is a difference between statistically significant results and those that really matter in practice. Many findings can be both，but beware of those that are statistically significant，but won't have a positive impact on actual practice protocol development.
Step 4 of the Melnyk et al.formula is Integration of the Eidence With Clinical Expertise and Patient Preference and Values.Here is where the judgments of experienced clinicians are very helpful.If there is a protocol that is evidence based but it violates the ethical or moral framework of the patient，than all the evidence in the world is not going to cause the patient to agree to the action.Patient preference for，say the number of treatments that are desired，is going to have a profound effect on the adherence of the patient to the protocol. In another instance，suppose the evidence based protocol suggests that an optimum outcome for a pregnant patient is to have certain screenings done before 12weeks of gestation has occurred.If those screenings are not available because of financial or environmental constraints，then the protocol is not helpful in that particular practice.However，that information can always be used as leverage when seeking additional resources for practice.
Step 5 is Evaluate the Outcomes of the Practice Decisions or Changes Based on the Evidence.It's not enough to just institute a change.The nursing profession is dynamic.The changes in the evidence base are constant.What was accepted practice in 2000at the turn of the century may no longer be appropriate.Screening protocols are a good example here.Remember what was discussed about Pap smears or hormonal therapy for menopause？On a hospital based unit note，once the new protocol has been put in place and its use has been tried，it is essential to use some retrospective data（that's another reason why EHRs are so helpful）to determine if the change in protocol is really making apositive difference. For example，if patient protection from falls was a strategic initiative of the unit and an EBP protocol was established and used for say，six months，it would be important to see if the protocol could be linked to the reduction in falls.If that protocol did demonstrate positive results，then good，it can be maintained.But，if there was another factor that was not linked to the protocol and that factor had a larger effect on the number of falls，then the protocol needs revision.It is essential resist the urge to view any protocol as engraved in granite and unchangeable.
Step six is to Disseminate the Results.If one thinks back to the beginning of the EBP process and remembers what it was like to ask the question and then find out if anyone had answered it，it will become obvious why dissemination is so important.As nurses，we are not just interested in the health and well－being of those patients with whom we come in contact in our practice.Remember that Florence Nightingale was the first nurse in modern memory to use principles of epidemiology to demonstrate the effectiveness of clean environments on the mortality rate of wounded soldiers.Her concern was not just the survival of the soldiers in the Crimea，but a concern about patients she'd never encountered.Her results were used as justification for changes in protocols in India and in the United States.Even in the nineteenth century，nurses'concerns for patients'welfare was global in scope.It is our modern day obligation as professional to communicate with our colleagues and present posters，podium presentations and publish articles in peer reviewed journals so that the evidence base can be kept vibrant and up to date.
Conclusion
This chapter has the goal of introducing you to Evidence Based Practice as it is used in North America.Some discussion of why it is a nursing role to seek evidence base for protocols in every area that nursing functions has been presented.Screening，primary care and in hospital settings have been used to illustrate EBPs contribution to improving patient outcomes at all levels.The economic and strategic use of EBP has also been considered. The mandate for internet connectivity and the essential nature of international communication to improve patient outcomes has been discussed.The author welcomes comments or questions about the material.
（Elizabeth Barker）
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