Moving Nursing Beyond Ritualistic Practice

Appeared in: Nurse Together

By: Karen Anne Wolf

NursingNursing practice is rooted in traditions, ritualistic care and institutional policies.  Over the past decade, nurses have been challenged to answer the question, "why do they do what they do" or "show the evidence that nursing practices are effective."  The concern over outcomes of care grew in response to escalating cost of care and questions about the quality and safety our care provided.  The growing demand for health care providers to use best practices in their care, is also aimed at improving the safety of that care.  This is an international challenge to nurses, physicians and other health care providers faced with a demand for new accountability for their practice (Dicenso, Guyall and Ciliska 2006, Sackett, 1996).  Research supports that evidence based practice adds to the quality and safety of care as well as to the satisfaction of patients.  Evidence based practice by nurses is a central factor in designation of Magnet Status to health care organizations.

Evidence based nursing practice requires that nurses systematically use the best current evidence in making decisions about patient care.  In this conscious approach at applying best practices, nursing remains patient centered, building not only on the nurse's expertise, but also on the patient preferences and values.  There is a growing body of nursing research that explores nursing practice and examined alternative approaches to care.  The question is how to evaluate such research and decide which research should be used and when to use it.  Too often, nurses have attempted to apply research prematurely to practice issues.  One study alone most likely does not provide the necessary evidence to change practice.  The challenge is to weigh the strength of the evidence in terms of number and types of studies, populations of patients as subject and rigor of the methods, analysis and findings.

For example, asking a simple question such as "what is the best way to get an accurate temperature reading on a given population of patients" can pose a challenge. There is a wide range of equipment choices available in some settings. Patient populations may vary by age, conditions or treatments and these factors may affect the outcome of a simple temperature measure.  Evidence based nursing practice begins with asking a concise question about the practice issue.  This is referred to as a PICO Analysis.

P = Population

I = Intervention

C = Comparison

O = Outcomes

A PICO analysis helps clinician to have clear, well thought out, questions to guide them in their search for evidence.  The search for answers is becoming easier as more resources are now available.  In order to make sound evidence-based decisions, nurse's need to critically appraise or examine the evidence from research studies.  Luckily for nurses, there is a growing body of evidence-based literature, from critical appraisal of single research article to a systematic review of large groups of studies.  This professional effort has resulted in more available systematic reviews of evidence and that brings together "best practice" evidence for implementation. Systematic reviews and critical appraisals help nurses to separate out the "best" evidence from the larger body of health care research.  According to PDQ Evidence-Based Principles and Practice (McKibbon 1999), only a small percentage of published literature contains evidence that is ready for clinical application; it is estimated that only 1 in 5000 ideas eventually makes it through all of the trials and the research stages to produce evidence with clinical outcomes. 

As stated in the AHRQ handbook, "Patient Safety and Quality: and Evidence-based Handbook for Nurses:

"Nurses play a vital role in improving the safety and quality of patient care-not only in the hospital or ambulatory treatment facility, but also of community-based care and the care performed by family members. Nurses need know what proven techniques and interventions they can use to enhance patient outcomes" (Hughes 2008).  


DiCenso, A., Guyatt, G., & Ciliska, D. (2005). Evidence based nursing: A guide to clinical practice. St. Louis, Mo.: Elsevier Mosby.

Hughes, R.  2008. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Washington DC: AHRQ retrieved from September 4, 2009 from

McKibbon, A (1999). PDQ Evidence-Based Principles and Practice. Hamilton-London-St.Louis: B.C. Decker Inc.,

Sackett, David L, William M C Rosenberg, J A Muir Gray, R Brian Haynes, and W Scott Richardson. "Evidence Based Medicine: What It Is and What It Isn't." BMJ 1996; 312: 71-72. Available:


About the Author: Karen Anne Wolf PhD, RN, ANP-BC, FNA is Associate Professor at Samuel Merritt University in Oakland, CA.  She was formerly Associate Director of the Nursing Program at the MGH Institute of Health Professions and an adult  nurse practitioner in the Cambridge Health Alliance Senior Health Center.  A writer and editor of a variety of article and books on nursing trends, politics, practices and history including, "A History of Nursing Ideas" and the "The Selected Work of JoAnn Ashley".  She enjoys writing for lay audience and urges her nursing colleagues to share their stories.


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