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EBP in Nursing Practice
For research topics there first needs to be a gap in information apparent. Disease management has been a particular component focused upon to improve health statuses and control “chronic illness through the use of risk stratification, targeted nurse outreach, telephonic nurse advice, and evidence-based guidelines in managing illness” (Roby et al., 2008, p. 421). A distinct focus from Disease Management & Health Outcomes, was upon Medicaid (Roby et al., 2008). There were noted barriers for Medicaid recipients such as access difficulties of description of services, community support limitations, decrease interest for financial assistance from providers, housing issues, difficult access to pharmacies, primary care, and medical equipment. Since the barriers of the designated topic are found, there can then be a creation of a positive impact program for disease management for those with Medicaid. Once a researcher reviews the barriers followed by the current approaches and programs present, a change approach or need can be discussed. By research providing strategies for this vulnerable population, such as a needs assessment, provide non-medical support, and language barriers, it can provide a framework for an evidence-based practice creation. A careful design would need to be created for Medicaid patients for disease management (Roby et al., 2008). However, with this information, is it beneficial to create an evidence-based practice or are there more drawbacks?
Focus on Good of EBP
To review the favorableness of evidence-based practices (EBPs) in nursing practice, it can bring forth positives to further indicate improvements for patients, providers, and healthcare agencies. For healthcare agencies various evidence-based practices are supported because of high promotion of quality and cost-effectiveness of care. Magnet status for healthcare agencies shows a level of excellence for a nursing agency. This status does require promotion of research and recognizes that EBPs are a way to improve quality of patient care (Gray et al., 2017). EBP is a problem-solving approach to allow insights upon delivery of care (Fineout-Overholt et al., 2011). Lastly, when reviewing nursing practice, the education of nursing students is to be considered. EBPs bring a demand to change education of students to view the continual changes in healthcare. Nursing requires keeping pace with the latest technological discoveries and newer conditions and treatments (Youngblut & Brooten, 2001).
Focus on Drawbacks of EBP
Controversially, EBPs can be viewed with some drawbacks. The transfer of research is being completed towards a population base. This shows increase focus to promote EBP guidelines to individual patients, rather than an entire population (Gray et al., 2017).  EBPs can be helpful for treating conditions with biological etiologies, but less helpful in understanding and treatment for conditions whose etiology is social, psychological, or spiritual. Lastly, EBPs have been viewed as “introducing rationing rather than rationality into health services” (Nolan & Bradley, 2008, p. 389). They mainly utilize methods such as randomized controlled trials (RCTs), systematic reviews, and meta-analyses. RCTs are noted to not be free from bias and do not look to review how the treatments work (Nolan & Bradley, 2008).
Fineout-Overholt, E., Williamson, K., Gallagher-Ford, L., Melnyk, B., & Stillwell, S. (2011). Following the
evidence: Planning for sustainable change. The American Journal of Nursing, 111(1), 54-60.
Gray, J.R., Grove, S.K., & Sutherland, S. (2017). Burns and Grove’s the practice for nursing research:
Appraisal, synthesis, and generation of evidence (8th ed.). St. Louis, MO: Saunders Elsevier.
Nolan, P. & Bradley, E. (2008). Evidence-based practice: Implications and concerns. Journal of Nursing
Management, 16, 388-393. doi: 10.1111/j.1365-2834.2008.00857.x
Roby, D., Kominski, G., & Pourat, N. (2008). Assessing the barriers to engaging challenging populations in
disease management programs: The Medicaid experience. Disease Management & Health Outcomes, 16(6), 421-428.
Youngblut, J. & Brooten, D. (2001). Evidence-based nursing practice: Why is it important? Advanced
Critical Care, 12(4), 468-476.


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Why would a focus on EBP be good for advanced nursing practice?

Evidence-based practice should be a focus for advanced nurses because it strives to promote excellence in care delivery and patients outcomes, which is a goal of the nursing profession (Thorne, 2009). EBP is a cyclical process that resembles nursing care: assessing existing evidence, planning, or developing guidelines, implementing them into practice, evaluating the outcomes.
 Generating EBP includes a systematic review of existing knowledge that helps distinguish between common practice or opinions and the data gained through the vigorous research (Freeman, Lara, Courts, Wanzer & Bibb, 2009). Sometimes, authors can provide a meta-analysis by summarizing statistics from different studies that result in robust objective data (Gray, Grove & Sutherland, 2017, p. 466). Qualitative research data is synthesized usually in meta-synthesis or meta-summary, which are still in the process of evolving (Gray, Grove & Sutherland, 2017, p. 476). This process can present difficulties to the advanced nurses due to the need to align scientific knowledge and unique human experiences (Thorne, 2009). Another setback mentioned by Kleinpell, Gawlinski, and Burns (2006), is the nurses’ lack of research experience evaluating existing research. The final review or guidelines of EBP summarizes the best data available that ideally should be implemented in practice.  
EBP implementation is the next step that bridges the knowledge and practice gap. Unfortunately, there are many barriers to the implementation of the best knowledge to practice.  Moor (2010) points out that adherence to ritualistic practices and lack of resources are some. Furthermore, there many steps that need to be meticulously followed in the implementation plan (Fineout-Overholt, Melnyk, Stillwell, & Williamson, 2010). One of the essential steps in the implementation process is gaining support from the administration, stakeholders, and colleagues. Some models can be used for EBP implementation. For example, Freeman et al. (2009) used the Settler Research Utilization Model and Bibb- Wanzer Identifying, Organizing Strategy (IOS) to evaluate existing infection control policies, revise and implement them.
Finally, EBP needs to be disseminated broadly in the health care system to be useful in improving health care outcomes. For example, the nutritional guidelines are available, but 1/3 of the US adult population is obese (Koh, 2010). Moreover, the rate of obesity in the US continues to grow. A positive example of EBP guidelines implementation is the JNC 8 in the treatment of HTN (Gray, Grove & Sutherland, 2017, p. 488).  
Overall, generating and implementing EBP is a complicated and time-consuming process, but it results in improved outcomes for patients, nurses, and healthcare.  

What are some drawbacks?

Some of the EBP drawbacks were mentioned before and will be summarized in this section. First, it is inadequate existing knowledge and nurses’ lack of experience working with research literature and statistics to review existing literature adequately. Second, nurses face difficulties in placing nursing research into the EBP hierarchy due to the resonance of empirical knowledge generated by RCTs with the nursing paradigm of the unique and subjective human being (Thorne, 2009). Additionally, some nurses still adhere to the existing ritualistic practices and consider the EBP threatening. Finally, and the most profound barrier to the implementation of the EBP is the lack of resources. It is inadequate stuffing pointed out by Moore (2010) to implement the best guidelines in pressure ulcer prevention. There are also many barriers existing in the disadvantaged population that prevent implementation of the disease management programs described by Roby, Kominski & Pourat (2008). 
Finally, the lack of resources is evident in my everyday practice as a primary care NP. No matter how strict my adherence to the EBP is, there is no way to improve healthcare outcomes if the patients cannot afford medications. For example, some diabetic patients are “stretching” their insulin use by injecting a smaller number of units daily because they cannot afford it. Many patients cannot obtain steroid inhaler because their insurance does not cover it and use only albuterol for their asthma maintenance, which is against current guidelines. Therefore, the EBP successful implementation depends on the health care’s affordability, and assessment of recourses should be the essential step in the implementation process.    
Gray, J.R., Grove, S.K., & Sutherland, S. (2017). Burns and Grove’s the practice of nursing research: Appraisal, synthesis, and generation of evidence (8th ed.). St. Louis, MO: Saunders Elsevier.
Fineout-Overholt, E., Melnyk, B., Stillwell, S., & Williamson, K. (2010). Critical appraisal of the evidence: Part III the process of synthesis: Seeing similarities and differences across the body of evidence. American Journal of Nursing, 110(11), 43–51. doi: 10.1097/01.NAJ.0000390523.99066.b5
Freeman, S. S., Lara, G. L., Courts, M. R., Wanzer, L. J., & Bibb, S. C. G. (2009). An Evidence-Based Process for Evaluating Infection Control Policies. AORN Journal, 89(3), 489.
Kleinpell, R. M., Gawlinski, A., & Burns, S. M. (2006). Searching and critiquing literature essential for acute care NPs. Nurse Practioner, 31(8), 12–13.
Koh, H. (2010). A 2020 vision for healthy people. The New England Journal Of Medicine, 362(18), 1653–1656.
Levin, Rona, PhD, RN, Fineout-Overholt, Ellen, PhD, RN, FNAP, FAAN, Melnyk, Bernadette, et al. (2011). Fostering Evidence-Based Practice to Improve Nurse and Cost Outcomes in a Community Health Setting: A Pilot Test of the Advancing Research and Clinical Practice Through Close Collaboration Model. Nursing Administration Quarterly, 35, 21-33.
Moore, Z. (2010). Bridging the theory-practice gap in pressure ulcer prevention. British Journal of Nursing, 19(15), S15–S18.
Roby DH, Kominski GF, & Pourat N. (2008). Assessing the barriers to engaging challenging populations in disease management programs: the Medicaid experience. Disease Management & Health Outcomes, 16(6), 421–428.
Thorne, S. (2009). The role of qualitative research within an evidence-based context: Can metasynthesis be the answer? International Journal of Nursing Studies, 46(4), 569–575. doi: 10.1016/j.ijnurstu.2008.05.001

I agree with your summary about the importance of utilizing EBP in nursing. As you correctly noted, EBP is directed to improve patients’ outcomes by integrating research into practice, implementing a proactive approach, and reducing cost. The EBP model is often pictured as a pyramid with the weakest level of the evidence on the bottom (expert opinion) and the most substantial level of evidence on the top (systematic reviews and metanalysis) (Gray, Grove & Sutherland, 2017). The problem with nursing research is the inadequate number of RCT and metanalyses that are the most robust evidence. The nurses tend to develop more qualitative studies. The nursing paradigm of the human body’s unique personal experience and wholeness is not easily fitted in the empirical evidence model (Thorne, 2009).
Your point about some managers using the EBP protocols to cut costs by hiring cheap labor and training them to use those protocols was surprising to me. The managers still need to use licensed professionals, aren’t they? I always thought that EBP could lower expense by decreasing the time required to make decisions, and protocols are useful in the fast-pacing work environment. Thank you for sharing your point of view. 
  Gray, J.R., Grove, S.K., & Sutherland, S. (2017). Burns and Grove’s the practice of nursing research: Appraisal, synthesis, and generation of evidence (8th ed.). St. Louis, MO: Saunders Elsevier.
Thorne, S. (2009). The role of qualitative research within an evidence-based context: Can metasynthesis be the answer? International Journal of Nursing Studies, 46(4), 569–575. doi: 10.1016/j.ijnurstu.2008.05.001

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