An Evidence-Based Practice Outcome Measure: Analysis of Nurse Authored Hospital Policy and Procedure Documents

Monday, 9 November 2015: 3:35 PM

Kathy J. Fatkin, PhD, RN, AHIP
Eastern Idaho Regional Medical Center, Idaho Falls, ID, USA
Mary Anne Hales Reynolds, PhD, RN, ACNS-BC
School of Nursing, Northern Arizona University, Flagstaff, AZ, USA

An Evidence Based Practice Outcome Measure: Analysis of Nurse-Authored Hospital Policy and Procedure Documents


Evidence Based Practice (EBP) is an approach to making health care decisions that integrates best evidence from research with the provider’s clinical expertise, the patient’s preferences and values with available resources within a health care system.  Evidence from current research is considered the primary basis of EBP and the strength of the evidence varies depending on the quality, quantity, and consistency of the available research. When EBP directs decision-making, the quality of patient care improves and health care costs decrease (Melnyk, 2012).  It is expected that hospital nurses utilize current research-based evidence to guide patient care decisions (IOM, 2001).

Patient care within a health care system is often directed and communicated by written protocols for managing various patient care needs.  These documents describe the standards and expectations for nurses in performance of particular nursing activities along with the nurse’s roles and responsibilities.  Written policy and procedure documents ensure safe and consistent care to patients around the clock (Long, Burkett, & McGee, 2009).  These documents may reflect generic policy and procedure manuals or may be created or updated by nurses within the organization.  Nurse authors are often directed to cite the “source of information at the end of the policy” (Pape, 2003, p. 154).  There are very few studies that specifically look at the sources of evidence, in this case, policies and procedures, nurses use to support patient care decisions.

The purpose of this study was to investigate the use of EBP through an examination of nurse-authored hospital policy and procedure documents.  This study answered the following questions: 1.What are the information sources nurses cite when creating or updating nursing policies and procedures?  2.  Are there variations of source citations between rural and urban, and small and large hospitals?


This bibliometric study used citation analysis of nursing policy and procedure documents from full member National Network of Libraries of Medicine (NN/LM) hospitals with staffed medical libraries in the intermountain west region of the U.S.  A purposive sample of 22 hospitals was selected for the study.  Ten hospitals voluntarily shared their nursing policy and procedure documents; seven of the hospitals were located in Idaho, and three were located in Utah.  Seven of the participating hospitals were located in urban (>50,000 population) centers and three were located in rural areas; three participating hospitals were small (under 100 licensed beds) and seven were considered large (100 or more licensed beds). 1,581 policy and procedure documents that had been updated or created by a nurse over the previous 12 month period were examined. References to published literature were collected by printing or recording the list of citations from these documents.  These citations were the major units of analysis.


Of the 1,581 documents examined, 1,172 (74%) had no citations.  The 409 documents with citations yielded 1,285 individual citations.  These citations were evaluated based on the types of sources and year of publication.   Analysis of the data found that citations came from the following sources:  27% books, 26% journals, 20% websites, 19% government documents, and 8% from other resources including product manuals, point-of-care summary databases, and meeting minutes.  Each type of resource was further analyzed to determine the type of evidence represented.  Textbooks, many available electronically, were frequently written by nursing specialty groups publishing their standards of practice and reflected current copyright dates.  Journal citations reflected primary research articles, systematic research reviews from medical and nursing journals and clinical practice articles. High quality websites and links to reliable government agencies or well-recognized professional organizations were also cited.  EBP summary databases such as the Cochrane Library which is considered the highest level of evidence for practice were rarely cited.

Variations between hospitals, specifically urban and rural, and small and large were determined.  It was found that citation types varied between large and small hospitals. Small hospitals cited government documents more often than the larger hospitals.  Larger hospitals cited more websites. When compared to urban hospitals, rural hospitals cited more books and the average age of the cited resources was older compared to urban hospitals.


It is recognized that this study looked at a small and unique population of documents, yet it provides an important “snap shot” of information sources as a measure of the utilization of EBP.  Important findings from this study include: first, the majority of the initially reviewed nursing policy and procedure documents did not include any citations to any published sources (74%). This study did not look at nor can it speculate about, the preparation of the nurses or the process used in developing the policy and procedures, yet if nursing practice is to be based on “evidence” that evidence needs to be documented. Second, of the resources cited, there was a large variation of type of resources being used, as well as strength of the evidence within individual documents and between hospitals.  Finally, it is important to note that all of the hospitals in this study had on-site medical librarians. Medical librarians are educated in evidence based practice principles and process, and also have access to most published sources. They have the expertise in finding and evaluating the evidence and are important resources to other health care providers in using EBP.

Nursing Implications

EBP is foundational for quality nursing care (Melnyk, 2012) and policy and procedure documents require current, research-based evidence (Pape, 2003; Turkel, 2004).  It is well documented that hospital nurses are utilizing EBP based on measurable patient outcomes, however, this study clearly shows that in this population, policy and procedure documents are not reflecting the best evidence. There is clearly a need for nursing curriculums in practice, education, and leadership to revisit evidence based practice concepts in terms of strength of the evidence or best sources, where to find the evidence, and finally, how to document the sources of evidence. There is also a need for nurses in hospitals to work as a team with medical librarians. Medical librarians bring to the table important knowledge about evidence based practice as well as the expertise to the access and evaluate many different resources. This study is important to nursing in that it has looked at the application of EBP from a unique perspective and has identified the need to document what sources of evidence support care decisions detailed in nursing policy and procedure documents.


Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the   21st century. Retrieved from http://www.nap/edu/catalog.php?record_id=10027

Long, L. E., Burkett, K., & McGee, S. (2009). Promotion of safe outcomes: Incorporating evidence into policies and procedures. Nursing Clinics of North America, 44(1), 57-70.

Melnyk, B. M., Fineout-Overholt, E., Gallagher-Ford, L., & Kaplan, L. (2012). The state of evidence-based practice in U.S. nurses: Critical implications for nurse leaders and educators. Journal of Nursing Administration, 42(9), 410-417.

Pape, T. M. (2003). Evidence-based nursing practice: To infinity and beyond. Journal of Continuing Education in Nursing, 34(4), 154-161.

Turkel, M. C. (2004). Magnet status: Assessing, pursuing, and achieving nursing excellence. Marblehead, MA: HCPro.