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AACN Clinical Issues Volume 12, Number 4, pp. 468-476 @ 2001, AACN

Evidence-based Nursing Why Is It Important?

Practice:

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Evidence-basedpractice, or use of best practices, has gained momentum in a variety of disciplines--medicine, management, engineering, and sales, to name a few-and has attractedwidespread attention in nursing. The impetus for this movement has come from healthcaresystems, payers, accrediting bodies, government agencies, professional organizations, and the increasein malpractice litigation.I Each of these entities is interested in improving patient outcomes and decreasing costs by standardizing and streamlining care and using protocols that result in better treatment of acute health conditions and better control of chronic health conditions. In addition, with the vast amount of information easily accessible on the World Wide Web and disseminatedby the media, consumersare increasingly savvy about different available

From the School of Nursing, Florida International University, North Miami, Florida. Dr Youngblut and Dr Brooten are partners in The ResearchA-Team,LLC. The information in this article is taken from presentations given by the authors at severalconferencesand the Hirsh Institute's certificate programs in Implementing Best PracticesBased on Evidence, during the first author's tenure as Founding Director of the Hirsh Institute at the Bolton School of Nursing, CaseWestern Reserve University. Reprint requeststo JoAnne M. Youngblut, PhD, RN, FAAN,Florida International University,3000NE 151stSt., AC II Room 234A, North Miami, FL 33181 (e-mail: [email protected]). 468

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ation of all of the recent studies,6regardless of the discipline that conducted the research, is required before making a decision about practice. This evaluation must include accurate critique of the studies' methods, sample compositions, and statistical procedures; as well as reconciliation of discrepant findings. Rating systems sometimes are used to describe the quality of the researchliterature as a whole (see Table 1). Clinical judgment and knowledge about the population and the practice are important components of the .evaluation,s although they are rarely included in formal rating systems. Randomized controlled trials (RCTs)have. long been considered the gold standard in establishing cause and effect.9 An important feature of an RCT study is that participants are assignedrandomly to either the treatment or the control group. Randomization is the method of assigning participants to group 0 The Evidence that is most likely to result in equivalent groups at the beginning of the study. RanEvidence-based practice varies by what is dom assignmentalso breaks the relationships considered evidence and how the evidence between preexisting characteristicsor factors is used. Different categories of evidence inand the outcomes of the study, increasing clude findings from research, knowledge one's confidence that the observed outcomes from the basic sciences, and clinical knowlare the result of the intervention being tested. edge. Practices based on research evidence However, many of the phenomena imrather than those based on other types of evportant to clinicians are not amenable to idence are more likely to be best practices, randomization for ethical, political, cultural, especially when the research findings have or practical reasons.lO.llFor example, ranbeen replicated in different geographic areas domizing pregnant women to preterm and with more heterogeneous samp,ies.. full-term birth, or adults to head injury is Research findings almost universally are not possible or ethical. Therefore, studying considered to be appropriate sources ofevithe effect of preterm birth, a very fragile dffice, although there is some disagreement preterm infant, or an adult with newly susabout the necessary number of studies and tained brain damage on a family system retypes of research designs considered.3.4In quires a different research design with difmany areas, there are research studies that ferent types of controls. Findings from support a particular practice and others that nonexperimental research can be very userefute that same practice. Because of this ful in identifying risk factors for specific variation in findings, it is imprudent and conditions and characteristics of those least sometimes dangerous to base practice on likely to follow their treatment regimens, or only one study. For example, there is conthose most likely to benefit from a particuflicting evidence about the efficacy of helar approach. For example, research can parin for prolonging patency and decreasing identify characteristics of patients with diaphlebitis of peripheral intravenous (IV) betes or cardiac disease who are less likely lines.5 If the fmdings of one of these studies, to follow their diet and. exercise prescripin isolation from the other studies, are impletions, and take their medicines as ordered. mented in the clinical setting', patients may Omitting findings from these studies would receive heparin with its concomitant risks ignore knowledge that is important for unnecessarily or experience the side effects nursing practice and may paint a misleadof IV lines (pWebitis or subsequent attempts ing picture of the phenomenon.l2 to restart the IV) needlessly. Rigorous evalu-

TABLE I-Ratin g Sc"y Level

, Definition

Levell

Evidence obtained from a systematic randomized controlled trials.

Level II

Evidence obtained from at least one properly designed randomized controlled trial.

Level 111.1

Evidence obtained from well-designed randomization.

Level 111.2

Evidence obtained from well-designed cohort or case control analytic studies, preferably from more than one center or research group.

Level 111.3

Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments.

Level IV

Opinion of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

review of all relevant

controlled trials without

"From: The Joanna Briggs Institute for Evidence Based Nursing & Midwifery. Appraising tematic reviews. Changing Practice 2000; 1(1):1-5.

Knowledge from the basic sciences most often is bench research that provides background information for understanding physiologic processes and responses. Findings from bench research are very important for designing new approaches or treatments for clinical conditions. However, these new approaches and treatments must be tested in clinical researchwith human participants before being widely implemented in practice.13 Clinical knowledge generally refers to experience, anecdotal accounts, case histories, and expert opinion. Clinical knowledge is an important source of information for practice in areas where there is little or no research or the quality of the researchis poor.14,15 Experiential knowledge is affected by where the experience is obtained: geographic region; urban or rural setting; teaching or community hospital; and primary care, acute care, long-term care, or home care setting. Experiential knowledge also is affected by memory and the selective recall that often goes with it.16As nurses, we tend to remember the best and the worst cases,the patients who had outstanding outcomes despite lots of adversity and those who had poor outcomes despite our most intensive and creative efforts. These extreme cases do not representthe majority of patientswe see and are the cases most likely to be published as anecdotal accounts or case histories. Thus, practice based on experience, anecdotal ac-

sys-

counts, and case histories may fit the extreme cases but not the more usual patient situations, and may not provide a complete picture of the phenomenon. The quality of the evidence from expert opinion depends on who the "experts" are and the basis of their opinions.12 Quality of the evidence is improved when the experts are nationally or internationally recognized for their expertise in the area, have conducted high-quality research on the topic, and published their results in well-respected peer-reviewed journals. In addition, it is important that the panel of experts has representatives from different geographic areas with expertise in complementary areas. Evidence-based practice also differs by how the evidence is used. Practice supported by evidence and practice based on evidence differ.12Practice supported byevidence often means that the practice protocol is defined and then evidence is sought to support the practice. For example, if the practice in a particular healthcare facility has been to use intermittent heparin flushes to maintain IV line patency, at least one researcharticle could be found to support the practice. In this case, evidence maintains and supports the status quo. .conversely, when practice is based on evidence, the evidence is reviewed first, then recommendations suggested by the evidence are identified and the practice protocol is defined

Vol. 12, No.4 November 2001

based on those recommendations. After looking at all of the research conducted on the use of intermittent heparin flushes for IV lines, the healthcare facility might change its procedures from intermittent flush to addition of low-dose heparin to continuous peripheral IV infusions.5 Using evidence in this way encourages practice change and helps practice remain contemporary and relevant to current patient populations, phenomena, and technologies. Clinical pathways often are cited as evidence-based practices. However, in many cases,clinical pathways are designed by local "experts" and based on their own clinical experiences rather than on researchevidence. Clinical pathways rarely are tested empirically to see if they result in the desired patient outcomes. When the decision points and interventions in clinical pathways are guided by the research, they are appropriately considered "evidence-basedpractices."lZ Evidence-based practice does not eliminate the need for professional clinical judgment.17,lS As always, the nurse perfomlS the assessmentof the patient's condition and needs, and decides what observations, actions, or interventions are indicated.19When clinical pathways, hospital policies, and proceduresare based on findings from the body of applicable research, the nurse selects interventions and actions from among those supported by research and performs these interventions and actions in a way that is consistent with the recommendations from the body of research findings.ZO,zl Evidence-basedpractice also does not ignore patient preference.1So22 As always, patients' preferences are solicited and considered in the choice of actions and priorities whenever possible. The difference is that the options are from a slate of interventions that have been supported by research, and the procedures for those interventions are designed from the findings of the body of research. Indeed, research may broaden the repertoire of interventions or programs the patient has to consider. Evidence-based practice is critically important in today's clinical settings becauseof its potential to save both nursing time and healthcare dollars.z3 Using the evidence to guide practice streamlines nursing care. Practices that are not necessary are elimi-

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nated, and ineffective practices are replaced with practices that result in the desired out-comes. Using research also decreases the need for trial-and-error methods for finding what works best. In each case, nursing time is not spent on ineffective procedures or trying numerous interventions before finding the "right" one, and nursing time is spent where it can be most effective. 0 Sources

of Evidence-based

Practices Institutions and individual nurses can develop their own evidence-basedpractices, or they can use those developed by others.l2 Developing evidence-basedpractices takes a considerable amount of time in identifying and obtaining appropriate research articles, reading and critiquing each research report, synthesizing the findings, and reconciling discrepant fmdings. Accurate critique requires expertise in research methods and data analysis, and an understanding of the clinical phenomenon. For many, developing their own evidence-based practices is a daunting task. However, when a suitable evidence-basedpractice is not available, it may be an unavoidable effort. Using evidence-based practices developed by others savesthe institution's and individual's time, money, and energy. However, it is important to evaluate the quality of the evidence-based practice before implementing it.l2 This evaluation includes the process used in creating the guideline or practice protocol, the type and amount of evidence used, the completeness and objectivity of the review, and the feasibility, acceptability, and cost of the resulting recommended practice. Sources of evidence-based practices include journals, specialty organizations, US government organizations, and commercial organizations. Journals publish a variety of articles relevant to evidence-based practice, including literature reviews, reports of research with practice recommendations, and guidelines, protocols, or clinical pathways. Some clinical journals now include columns devoted to evidence-based practice. Although these articles generally undergo peer review before publication, the Quality of the

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AACN ClinicalIssues

evidence for practice varies considerably. In Clearinghousedoes not provide a ranking or addition, literature reviews are often written rating of the quality of these guidelines,25it to convey a specific point of view rather can be difficult and confusing for healthcare than to critically evaluate the state of the reprofessionals to evaluate them and choose search, so the findings of these literature rethe guideline to implement. The Clearingviews are not always consistent.7 house Web site, however, contains syntheses Many specialty organizations are developof selectedguidelines and allows the user to ing their own practice guidelines. Most of conduct online comparisons of two or more these are based on evidence and are develguidelines.26The Clearinghouse does not oped by a nationally constituted panel of exown the copyright for the guidelines it warepert clinicians, educators, and researchers. houses;some of the copyright owners charge The American Association of Critical-Care a fee for obtaining the full guideline. Other Nurses (AACN), for example, has supported governmentalagencies, such as Health Care a variety of publications that describe protoFinancing Administration and the Centersfor cols for practice.24Some organizations, such DiseaseControl and Prevention, also provide as the AACN, also conduct national research specific guidelines germane to their mission. studies to provide the evidence for practice Guidelines from these government agencies generally are provided free of charge to the change. The most prominent US government user. source of bestpracticesis the National GuideCommercialorganizationsthat develop evlines Clearinghouse(www.guidelines.gov)opidence-basedpractices include the Cochrane erated by the Agency for Healthcare Research Collaboration (www.cochrane.org), the and Quality in partnership with the American Joanna Briggs Institute for Evidence Based Medical Associationand the AmericanAssociNursing & Midwifery (wwwjoannabriggs. ation of Health Plans.25The National Guideedu.au), and the Sarah Cole Hirsh Institute lines Clearinghouseis a Web site designed "to for Best Nursing PracticesBased on Evidence provide... an accessible mechanism for ob(www.hirshinstitute.com). Eachof theseorgataining objective, detailed information on nizations offers a variety of servicesand prodclinical practice guidelines and to further their ucts to facilitate and enhance evidence-based dissemination and use."25Any organization practice. Potential users of their evidencecan submit guidelines to the Clearinghouse based practices must either join the organizafor evaluation with the minimum inclusion tion or purchase a publication to obtain the criteria set by the Agency for Healthcare Reinformation. search and Quality and its partners, and subThe Cochrane Collaboration is the oldest sequent inclusion on the Web site. Each of these evidence-based practice organizaguideline in the Clearinghouse has a brief tions. Its basic aim is "to help people make summary and a complete summary;26both well informed decisions about healthcare by contain the guideline's source, developer, enpreparing, maintaining and ensuring the acdorsers, availability, and major recommenda- cessibility of systematicreviews of the effects of health care interventions."28 Although tions. The complete summary contains more heavily focused on medicine, the Cochrane information about the production of the Collaborationhas quickly become the leading guideline, including methods used to collect, international organizationto produce systemevaluate, and synthesize the evidence in seatic, up-ta-date reviews of all relevantRCfs in lected research reports. Healthcare profeshealthcare.The Cochrane Collaboration prasionals can searchthe databaseby diseaseor duces and maintains its systematic reviews condition, treatment or intervention, and the through international collaborative review creating or sponsoring organization. Howgroups. Members of these groups are trained ever, in many instances,there are numerous with Cochrane-developed training materials guidelines for each specific disease or treat-.ment. A search of the guidelines for asthma and ~orkshops. The Cochrane Library houses both The Cochrane Databaseof Sysmanagement, for example, fmds 22 guidetematic Reviews, which contains the lines; five of these describe asthma manageCochrane reviews, and The Cochrane Conment and the rest describeguidelines for controlled Trials Register,a bibliographic dataditions related to asthma.27Because the

Vol. 12,No.4 November2001 base of RCfs. Its ConsumerNetwork provides a mechanism for consumer involvement in the CochraneCollaboration'sactivities.28 Summaries of the Cochrane reviews are available online and free to the public. These summaries contain brief descriptions of the background on the topic, objective of the review, strategy used to search for appropriate studies, selection criteria for including studies in the review, data collection and analysis of the researchreports, main results of the review, reviewers' conclusions about the state of the evidence, and the citation for the full review. For example, the review on "Aminosteroids for Acute Traumatic Brain Injury," focused on the use of aminosteroids for acute traumatic brain injury.29The reviewers found two RCfs, including one whose findings have not yet been reported, and concluded that the data are insufficient to either support or refute the use of aminosteroids with this group of patients. The Joanna Briggs Institute for Evidence Based Nursing & Midwifery was established in 1996 by the University of Adelaide Department of Clinical Nursing and the Royal Adelaide Hospital to be the leading center in Australasia, South EastAsia, and the Pacific Region.30Its mission is "to improve the effectiveness of nursing practice and health care outcomes"30through a variety of practiceoriented research activities. The Joanna Briggs Institute accomplishes its mission through collaborating centers in Australia, Hong Kong, and New Zealand; member institutions that include hospitals, residential aged care facilities, educational institutions, libraries, and corporate bodies; and individual members. It produces "Practice Information Sheets" based on its systematic review of the research, conducts multi-site RCfs where evidence is lacking, and disseminates its findings to the profession, all levels of the healthcare system,governments, and service provider units. The Joanna Briggs Institute has recently added both consultation services to facilitate the implementation of evidence-based praCticesin healthcare organizations and short courses on evidence-based practice for nurse clinicians, educators, researchers,and administrators.30 The Sarah Cole Hirsh Institute for Best Nursing PracticesBased on Evidence was established in 1998 at the Frances Payne

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Bolton School of Nursing, Case Western Reserve University, to improve patient outcomes and nursing care by moving research fmdings into practice.31The Hirsh Institute developed a three-pronged approach to accomplish this mission: 1) a certificate program in Implementing Best Practices for administrators, advanced practice nurses, quality managers, and staff development personnel focused on implementing research-based practice changes; 2) State of the Evidence Reviews that provide easy-toread descriptions of the most current research findings with recommendations for nursing practice based on these fmdings; and 3) consultation services to help individual healthcare facilities implement a specific protocol.32 The Hirsh Institute worked with University Hospitals of Cleveland to implement a protocol on medication self-administration with cognitively intact elders33found to be effective in several studies in its skilled nursing facility. Although the skilled nursing facility unit's staff nurses had some reservations about the time involved with using the new protocol, they found that the extra time spent with patients early in their skilled nursing facility unit stay to teach them about their medications was more than offset by the time savings and satisfactionthey experienced at patient discharge. In addition, patients were excited about the increased control and decision making in their care resulting from this change in practice.34

0 Demands and Opportunities Evidence-basedpractice provides many opportunities for the future of nursing and improvement of patient outcomes, but it also places demands on clinicians, educators, and researchersto make changes in practice, education, and the focus of programs of research.35Each of these changes is critical to improvement of patient outcomes through the use of evidence to guide practice. Evidence-based practice demands that clinicians look"critically at the foundation of their practice and identify which practices are based on research evidence, which are based on clinical knowledge, and which are based on tradition.35With the pace of today's

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acute and critical care inpatient units, basing practice on evidence may seem like an impossible task. Although nurses in a fastpaced unit may not be able to use evidence as a basis for every decision, it is possible and necessaryto use evidence in developing the clinical pathways and the policy and procedure manuals that guide nursing practice. The AACN's Thunder Projects-to identify whether using heparin helped with maintaining arterial pressure monitoring lines36and whether saline installation with endotracheal suctioning was beneficial37were designed to identify which practices lead to improved patient outcomes and reduced costs. Evidence-based practice also demands that clinicians be committed to excellence in providing care and to being open to change.35Clinicians have a responsibility to help researchers identify practice areas where research findings are needed and to join researchteams to bring clinical reality to the research.38 Evidence-based practice places demands on nurse educators to stay current with the newest research findings in their areas and to base their teaching on researchfindings at both the basic and advanced practice levels.35,38 Because it often takes years to write and publish a teXtbook, the most up-to-date practice information is contained in reports of research published in journals. Thus, teaching for evidence-based practice requires educators to rely less heavily on teXtbooks for their classroom content and assignments, and to incorporate research reports in their assigned readings. Preparing students for evidence-basedpractice also requires educators to foster a spirit of inquiry, critical thinking, and a philosophy of lifelong learning.35Although these ideals can be enhanced through assignments and classroom discussions, role modeling is a much stronger and more effective way to foster their adoption.38 Evidence-based practice also places demands on nurse researchersto ask clinically important questions, to study these issues with a variety of clinical populations, to use the most sophisticated and appropriate designs, and to disseminate their findings in a timely way.35,38 This places the responsibility on the researcherto be current in their practice areasand to include clinicians in the re-

AACN Clinical Issues searchprocess so that the researchstaystrue to the ever-changingrealities of clinical prac'tice.38More than ever before, it is critical that researchers disseminate their fmdings widely,39to go beyond the researchaudience to target forums that will bring researchfmdings to clinicians and educators. Including clinicians and educatorson the researchteam and in the dissemination of the findings allows the researchto be more broadly disseminated. It is also critical that these research fmdings be conveyed to the policy makers and accrediting and credentialing bodies so that those who impose the restrictions on clinical practice are aware of new developments in knowledge that affect practice.35,38 Evidence-basedpractice also provides opportunities to improve nursing care and patient outcomes. Developing protocols based on research evidence eliminates ineffective or unnecessarypractices and can streamline care. Additionally, evidence-based practice promotes a dynamic and exciting practice that is able to take advantage of new knowledge and new technology.35 Using research to guide practice means that nursing interventions and approaches can be highly individualized based on patient characteristicssuch as age, gender, race or culture, stage of health condition, and genetic makeup or family predisposition, as well as environmental and healthcare delivery conditions. In considering the stages of quitting now identified during smoking cessation, for example, different approaches, interventions, and supports are required for different stages. It may also be that different characteristicsof healthcare delivery systems are effective for patients with specific personal characteristicswhen they are at different stages of their conditions. Researchhas provided the knowledge to tailor nursing care much more precisely than was possible prior to these studies. The other opportunity that evidencebased practice affords is the ability to maximize the effect of nurses' clinical judgment on patient outcomes.17-19 Most research is done with somewhat homogeneous samples, and its findings and recommendations are most appropriate for individuals with similar characteristics.In addition, research may increasethe number of available care options. Thus, to identify the most appropriate inter-~

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vention or approach for a specific patient at a given time, nurses will need to consider the many combinations of factors germane to the patient's condition; plan and conduct appropriate and timely physical, psychological, family, and social assessments;correctly interpret their findings; and select the most effective strategiesfrom a slate of possible interventions and approaches. Despite concerns to the contrary,40 evidence-based practice actually increases the need for nurses to use well-developed, finely tuned, sound clinical judgment. And, it will increase awareness of the role that nurses' clinical judgment plays in patient outcomes.

0 Conclusion In summary, using research evidence as a basis for practice is important for improving patient outcomes, decreasing or containing costs, and for keeping pace with new technologies and knowledge developments. The growing interest in evidence-based nursing practice is particularly timely in light of the impending nursing shortage and the increasing emphasis on improved patient outcomes and practice efficiencies to decrease costs. Researchconducted by those in other disciplines is often germane to issues important to nursing and cannot be ignored. However, nursing research that describes clinical phenomena and then develops and tests interventions to address the most pressing clinical problems must increase substantially to produce the knowledge necessary to guide practice and improve patient outcomes. More than ever before, it is critical that clinicians, educators, and researchers work together to accomplish these aims.

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5. Randolph AG, Cook DJ, Gonzales CA, Andrew M. Benefit of heparin in peripheral venous and arterial catheters:systematicreview and meta-analysis of randomised controlled trials. BMJ.1998;316:969-975. 6. Cook DJ, Greengold NL, Ellrodt AG, Weingarten SR. The relation between systematic reviews and practice guidelines. Ann Intern Med. 1997;127:210-216. 7. O'Mathuna DP. Evidence-basedpractice and reviews of therapeutic touch. Image J Nurs Sch.2000;32:279-285. 8. Rosswurm MA, Larrabee JH. A model for change to evidence-based practice. Image J Nurs Sch. 1999;31:317-322. 9. Cook ill, Campbell DT. Quasi-experimentation: design and analysis issues for field settings. Boston: Houghton Mifflin; 1979. 10. Black N. Why we need observational studies to evaluate the effectiveness of health care. BMJ. 1996;312:1215-1218. 11. Cook D], Levy MM. Evidence-based medicine: a tool for enhancing critical care practice. Crit Care Clin. 1998;14:353-358. 12. Hirsh Institute. Implementing Best Nursing Practices Based on Evidence: A Certificate Program. Cleveland, Ohio: CaseWestern Reserve University; 2000. 13. Clinical ResearchSummit. Breaking the Scientific Bottleneck.Clinical Research:A National Call to Action. Washington, DC: Association of American Medical Colleges and American Medical Association; 1999. 14. Ellrodt G, Cook DJ, Lee ], Cho M, Hunt D, Weingarten S. Evidence-baseddisease management.JAMA.1997;278:1687-1692. 15. Stetler CB, Brunell M, Giuliano KK, Morsi D, Prince L, Newell-Stokes V. Evidence-based practice and the role of nursing leadership.J Nurs Adm. 1998;28:45-53. 16. EstabrooksCA. Will evidence-basednursing practice make practice perfect? Canadian Journal of Nursing Research. 1998;30:15-36. 17. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, RichardsonW5. Evidence based medicine: what it is and what it isn't: it's about integrating individual clinical expertise and the best external evidence. BMJ. 1996;312:71-72.

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18. Closs 5J, Cheater FM. Evidence for nursing practice: a clarification of the issues.J Adv Nurs.1999;30:10-17. 19. Regan]. Will current clinical effectivenessinitiatives encourage and facilitate practitioners to use evidence-basedpractice for the benefit

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20. Madigan EA. Evidence-basedpractice in home healthcare: a springboard for discussion. Home HealtbcareNurse. 1998;16:411-415. 21. Beyea SC,Nicoll LH. Developing clinical practice guidelines as an approach to evidencebased practice. AORN]. 1998;67:1037-1038. 22. Feinstein AR, Horwitz RI. Problems in the "evidence" of "evidence-based medicine." Am] Med. 1997;103:529-535. 23. Goode C], Piedalue F. Evidence-basedclinical practice.] NursAdm. 1999;29:15-21. 24. Available at: www.aacn.orgiMemship.nsf/ Files/1pt/$file/ProceduresTOC.pdf. Accessed May 11,2001. 25. Available at: www.guidelines.gov/FRAMESETS/ static_fs.asp?view=about.rnission.AccessedMay 11,2001. 26. Available at: www.guidelines.gov/FRAMESETS/static_fs.asp?view=about.overview .views. AccessedMay 11,2001. 27. Results of guideline search for asthma management. Available at: www.guidelines.gov. AccessedMay 11,2001. 28. Available at: www.cochrane.org/cochrane/ cc-broch.hrm. AccessedMay 11,2001. 29. Available at: www.cochrane.org/cochrane/ revabstr/abOO1527.hrm.Accessed May 11,2001.

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AACN Clinical Issues 32. Available at: www.hirshinstitute.com/about/ default.htm. AccessedMay 11,2001. 33. Hirsh Institute. Helping elders manage their medications. Cleveland, OH: Case Western ReserveUniversity, 2000. 34. Musil C, Vanderboom C, Youngblut JM. Medication self-managementin older adults: an empirically based best nursing practice. Presented at the 25th annual MNRS March 2-4, 2001; Cleveland, Ohio.conference'' 35. Youngblut JM. The future of evidence-based nursing practice. Paperpresented at the Nursing Practice Based on Evidence: Approaches, Strategies,Applications workshop; November 17, 2000,Padua,Italy. 36. American Association of Critical-CareNurses. Evaluation of the effects of heparinized and nonheparinized flush solutions on the patency of arterial pressure monitoring lines: the AACN Thunder Project. Am] Crit Care. 1993;2:3-15. 37. Available at: www.aacn.org. Accessed March 17,2001. 38. Brooten D. Nursing interventions DO effect outcomes. Keynote paper presented at Evidence-Based Nursing Practice conference, March 23, 2001,Ann Arbor, Mich. 39. Brooten D, Youngblut JM, Roberts BL, et al. Disseminating our breakthroughs: enacting a strategic framework. Nursing Outlook. 1999; 47:133-137. 40. Hampton JR. Evidence-basedmedidne, practice variations and clinical freedom. ] Eval Clin Fract. 1997;3:123-131.