If it ain't broke, don't fix it.

In a previous column, "EBP by Any Other Name Is Still a Rose" (Levin, 2008), I briefly mentioned the need to describe the practice problem that clinicians observe, intuit, or otherwise believe exists. I will devote this column to a greater explication of describing the practice problem, first from a conceptual point of view and then from a reality-based point of view, providing an actual example. Evidence-based practice (EBP) as a decision-making process originated with the medical profession to be used by physicians to diagnose and treat patients' medical problems (see Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). In this situation a clinical question arose when there was a lack of knowledge about a specific patient problem, for example, "In patients with suspected pneumonia, are any clinical findings sufficiently powerful to confirm or exclude pneumonia all by themselves, or is a chest radiograph necessary for the diagnosis (p. 16)?" This question then led to a search for relevant evidence (external data or literature on the topic). In their 2000 book, Evidence-Based Medicine: How to Practice and Teach EBM, Sackett and colleagues outlined the five steps of EBM: 1. Developing the answerable clinical question 2. Looking for the best evidence to answer the question 3. Critically appraising the evidence for validity, significance, and applicability to practice 4. Integrating the results of step three with clinical expertise and patients' values and circumstances 5. Evaluating the effectiveness of implementing the process (steps 1 through 4). Nursing in general appears to have adopted this model without considering the more organizational nature of nursing as it compares to the medical profession, though The Iowa Model of EBP did put EBP into the larger context of practice improvement within an organization (Titler et al., 2001). What I mean is that physicians have traditionally been able to change their approach to patient care as individuals or as a group, whereas the majority of nurses are employed by an agency with policies and protocols to guide their practice. One nurse or even a few nurses working together cannot independently change practice without going through administrative approvals and subsequently making organizational rather than individual practice changes. Even though the Iowa Model asks the question, "Is this (the practice issue or question) a priority for the organization?" it does not clearly address the gathering and critique of internal data that would support and further clarify the practice problem and its relative importance. Some thought needs to be given to how the EBP process as described initially by Sackett and colleagues (2000), and later by Melnyk and Fineout-Overholt (2004) and Levin and Feldman (2006), actually applies to organizational nursing practice changes or improvements. I suggest that the first step in the EBP process needs to be a description of the practice problem, using both external (background literature) and internal organizational data. If this step is not taken, the clinical question arising from the experiential observation or intuition of clinicians may not really be a significant problem for the organization. Although Titler and colleagues (2001) addressed the organizational relevance of the problem, they did not address the search for and understanding of internal evidence. I have learned through examples such as the one that follows that this is an essential ingredient. Recently I worked with a hospital on integrating an EBP approach to nursing practice improvement. One of the topics the agency wanted to address was how pain was being managed by nurses. The first assumption was that nursing was not appropriately managing or assessing pain, and something needed to be done about that. Internally published and disseminated data about patient satisfaction indicated a positive overall rating of over 90% with respect to pain management. …