Evidence-based Nursing Practice With Persons With Intellectual And Developmental Disabilities

Joan Earle Hahn, PhD, APRN, BC, CDDN

Abstract

Evidence-based practice can be found in almost every professional arena in healthcare today. The term evidence-based nursing (EBN) has been used in nursing since the mid-1990s, although some researchers note its use as early as Florence Nightingale. The Honor Society of Nursing, Sigma Theta Tau International, defines EBN as "an integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families, and communities who are served." Nursing has a long history and is one of the earliest disciplines to provide services to individuals with intellectual and developmental disabilities (I/DD). This paper provides a brief historical overview of evidence-based practice (EBP), a review of EBN in the context of I/DD nursing, and an explanation of the five basic steps used in EBN. An overview of the literature on EBP in I/DD nursing and a clinical example of the use of EBN practice to promote positive outcomes for persons with I/DD are presented.

Keywords: developmental disabilities , intellectual disabilities , evidence-based practice , evidence-based nursing

INTRODUCTION

Evidence-based practice can be found in almost every professional arena in healthcare today. The term evidence-based nursing (EBN) has been used in nursing since the mid-1990s (1), although some researchers note its use as early as Florence Nightingale (2). The Honor Society of Nursing, Sigma Theta Tau International (STTI) defines EBN as "an integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families, and communities who are served" (3)

EBN practice prompts nurses to base practice "on evidence of 'what works'" (4) or to do the right thing in the right way in order to "do the best job possible with the clients / students / consumers / people we support" (5). EBN is a systematic process used to examine evidence using clinical expertise and consideration of patients', families', and communities' preferences to decrease clinical uncertainty, increase certainty that an intervention will lead to a desired outcome, or reduce harmful outcomes. EBN may confirm or support an existing intervention or practice; it may shed light on new practice or interventions (1). In addition, it may also provide interventions that improve health or quality of life, or assist persons with disabilities to gain participation in their communities.

The purpose of this paper is to provide a brief historical overview of EBP and provide basic steps to using and building EBN. This paper will provide examples from the literature to illustrate ways nurses are developing, using, and applying EBN to support practice with persons with intellectual and developmental disabilities (I/DD). A more specific example is included to illustrate the steps that I/DD nurses can follow to implement EBN to support persons with I/DD.

HISTORICAL OVERVIEW OF EBP

EBP is the result of a paradigm shift in the 1960s. The publication of numerous randomized control clinical drug trials (RCTs) prompted the need for strategies to summarize the research evidence using systematic reviews of the literature and meta-analysis, a statistical method used to summarize RCTs. This led to an outline of a process that searches for the "best" evidence, weighs the evidence, and reports the strength of the evidence, which in turn helps health providers make practice recommendations. This paradigm shift brought about a greater demand for providers to examine the evidence that supports and guides practice (6).

The shift to embrace a process that scientifically sorts through large quantities of evidence has its roots in medicine with early forerunners of the EBP movement such as Archie Cochrane, founder of the Cochrane Collaboration, and Dr. David Sackett and colleagues whose work (7) was later published as the Users' Guides to the Medical Literature (JAMA) between 1993 and 2000 (8). Clinical practice guidelines, which were sets of recommendations for practice based on summaries of existing scientific research, began to emerge. A recent search in an academic medical center library revealed a number of texts about EBP, most published after 2000, by multiple disciplines including nursing.

Nursing has a rich history of research that has provided evidence to guide nursing practice. During the 1970s, the use of research utilization (RU) moved to the forefront with the advent of a number of models that promoted a systematic process for applying nursing research in clinical practice. RU models assist nurses to critique, use, evaluate, and disseminate nursing interventions to improve patient outcomes (9). The model developed by Stetler has been updated to facilitate its use in EBP (10). In 1985, The National Institute for Nursing Research (NINR), one of 27 institutes and centers in the National Institutes of Health (11), was authorized by law to promote nursing research (12). Thus, in nursing in general, the focus on EBN practice since the mid-1990s (1) parallels the development of EBP in other healthcare arenas.

A greater focus on using EBN has occurred since the late 1990s. For example, data from a survey published in 1998 revealed that staff nurses most frequently obtained information to guide practice from 1) experience; 2) basic nursing education programs; 3) in-service programs and conferences; 4) policy and procedure manuals; 5) physician sources; 6) intuition; and/or 7) "what has worked for years." A more recent survey of U.S. nurses conducted by STTI revealed that 90% of nurses reported needing to find evidence at least occasionally and 64% of nurses using EBN at least weekly. Although the availability and accessibility of evidence was rated as fairly adequate, familiarity with EBP varied from low (24%), to moderate (45%), to high (31%)(13). Thus, evidence-based practice is increasingly being used in nursing in general, yet not all nurses may be familiar or confident with its use. Evidence-based practice in the field of I/DD is also being recognized as important (5). However, nursing – which was among the first healthcare disciplines to provide services to individuals with I/DD (14) – may be unprepared to meet the challenge of supporting persons with I/DD using EBN.

Survey results reported in 2000 gathered from nurses in Northern Ireland with a specialty in learning disabilities (LD) - an equivalent term for intellectual disabilities (ID) - about their use of research revealed that less than one out of five nurses believed that research is relevant in daily nursing practice. Only one in four nurses reported frequent use of research (which is often the basis of evidence). While limited in the ability to generalize to all I/DD nurses, these results led study authors to question LD (or I/DD) nurses' use of EBN in practice (15).

One factor contributing to the limited use of research specific to I/DD nursing may be the somewhat limited scope and depth of nursing research about practice with persons with I/DD, which falls short of the scope of nursing research in general. This was documented in a review of the research literature pertinent to learning disabilities nursing conducted in the UK by the Nursing Research Unit of King's College London. Most research is descriptive, based on small convenience samples, and lacks information about the effectiveness of nursing interventions or delivery of nursing care (16). However, since 2000, similar to the growth of EBN in nursing in general, the importance of EBN in I/DD nursing is gaining recognition.

Nurses practicing with persons with I/DD are publishing systematic reviews of evidence (17), participating in the development of nursing (18) or interdisciplinary clinical or best practice guidelines (19) to improve practice with persons with I/DD, and participating or teaching in conference sessions targeted toward nurses who practice to support persons with I/DD (20, 21, 22). Teaching nurses to use EBN is critical to helping nurses to use, develop, and embrace its use.

STEPS TO USING EBN

The five steps suggested for use to conduct EBP are also endorsed for use in EBN (23): 1) formulate an unanswered clinical question; 2) systematically search and retrieve the best evidence available; 3) critically evaluate or appraise the evidence in terms of validity, relevance to the clinical question, and applicability to the practice context and patients involved; 4) make decisions about practice using the evidence, clinical expertise, and the values and preferences of the patients involved; and 5) evaluate the evidence-based practice change for its effectiveness (23).

Step 1: formulating a clinical question

A clinical question is formulated to answer an unclear question about practice for which the practitioner lacks information about the best way to practice. A question may be formulated to seek information about a new intervention that is needed to guide practice. Two ways to formulate a question are based on the acronyms COPES (24) and PICO (25, 26).

Gibbs illustrates the use of Client Oriented Practical Evidence Search (COPES) on the website: Evidence-Based Practice for the Helping Profession. COPES questions are Client Oriented, Practical, and guide the Evidence Search for the following types of questions: prevention, assessment, description, effectiveness, and risk. The suggested elements for each question, based on the work of Sackett and colleagues, are: client type and problem, what might you do, alternate course of action, and what you want to accomplish. See www.evidence.brookscole.com/copse.html for additional sample questions (24).

The PICO model (25, 26) or Patient, Intervention, Comparison, and Outcome, suggests four categories that may be used to help formulate the clinical question (27). First, identify the population that is the focus of the question (i.e., nurse, patient/client, family, and community). Second, select an intervention or an area of interest. Third, choose a comparison, and fourth, select the outcome you wish to study. See Table 1 for sample PICO questions that were drafted based on three EBN reports that address EBP in I/DD.

Table 1. Formulating a Clinical Question using the PICO Format

Element of the clinical question/Type of question	Patient	Intervention (or cause, prognosis)	Comparison (optional)	Outcome
Prognosis	Children with autism	Is parental concern		a reliable predictor of the early identification of autism? 1
Description	Patients with FAS	What are the nursing interventions		for prevention of secondary disabilities? 2
Effectiveness of intervention	People with epilepsy	How effective is a specialist epilepsy nurse	standard vs. alternative care	in seizure frequency; appropriateness of medication prescribed; social or psychological functioning scores; knowledge about epilepsy scores; costs of care and adverse effects? 3

Step 2: searching and finding the evidence

Searching for the best available evidence is the next step in conducting EBP once the clinical question is established. The question should guide the search. A systematic search for the best evidence should be targeted to the population of interest, the intervention or area of interest, and the comparison and type of study being sought. It is important to document the search strategy, including search terms and any inclusion and exclusion criteria used to find the evidence to support practice.

Evidence can come from a number of sources, such as manufacturer's guidelines, expert opinion, RCTs and other types of qualitative and quantitative research, systematic reviews, and meta-analyses. The strongest level of evidence comes from a meta-analysis or a systematic review, followed by single or multiple randomized control trials (RCT). The lowest level of evidence is based on opinion or authoritative statements. See Figure 1 for a grading schema of evidence.

A systematic review of the evidence is a rigorous compilation of the existing research and other information about an intervention or practice of interest that supports or refutes the effectiveness of the intervention. A meta-analysis is a statistical method used in review of a comprehensive collection of studies or a systematic review that is focused on a particular intervention or specific area of interest to determine whether or not the intervention (as summarized using a statistical method combining all of these studies) made a difference. If a meta-analysis cannot be done statistically, then a systematic review may be the next best level of evidence. In some cases, a clinical practice guideline may have been developed using the best available evidence that is not based solely a systematic review, but is possibly a combination of systematic reviews, research studies, and expert opinion. Thus, one of the first places to find types of evidence from research would be a meta-analysis, followed by a systematic review and/or clinical practice guideline (27). Some sources for finding systematic reviews and/or clinical practice guidelines are:

1. The National Guideline Clearinghouse www.guideline.gov
2. The Agency for Healthcare Research and Quality (AHRQ) Clinical Practice Guidelines Online www.ahrq.gov/clinic/cpgonline.htm
3. The Cochrane Data Base for Systematic Reviews from the Cochrane Library www.cochrane.org/reviews/clibintro.htm
4. The American Association on Cerebral Palsy and Developmental Medicine (AACPDM) www.aacpdm.org/membership/members/committees/treatment_outcomes.php

Clinical practice guidelines, sometimes called "best practice" guidelines, for use in practice with persons with I/DD may be broad, discipline-specific, or designed specifically for nursing practice. In most instances, however, guidelines are written for a broad audience rather than for persons with developmental disabilities. The strength of the evidence used to build the guidelines varies from expert opinion to systematic reviews. Multidisciplinary teams and agency-appointed advisory committees (often driven by professional associations or governmental agencies), frequently develop the guidelines on topics relevant to developmental disabilities. Some guidelines are more long standing than others (i.e. Down syndrome guidelines that began in 1981 have been updated periodically). See www.downsyn.com/guidelines/healthcare.php).

A search for guidelines in the National Guideline Clearinghouse at www.guideline.gov using the term "intellectual disability" (or "mental retardation") revealed guidelines written and published by the Massachusetts Department of Mental Retardation, University of Massachusetts Medical School's Center for Developmental Disabilities Evaluation and Research. Called Preventive health recommendations for adults with mental retardation, these guidelines were developed by physicians, nurses, nurse practitioners, pharmacist, and occupational therapist in 2003 (19).

Other sources of clinical practice guidelines are from state agencies. The Autistic Spectrum Disorders: Best Practice Guidelines for Screening, Diagnosis and Assessment, which was developed with guidance from a state agency, provides professionals, policymakers, parents, and others with detailed "best practice" recommendations and rationale for screening, evaluating, and assessing individuals suspected of having autistic spectrum disorders. The guidelines were written to "elevate the knowledge of health care professionals, policy makers, parents and others to engage in the 'best practice' available for the goal of improving diagnosis of children with autism spectrum disorders to enhance their opportunity to get services early in their lives." These guidelines incorporate the use of "evidence-based" findings as noted by authors based on experts' use of "validated scientific evidence, clinical experience and clinical judgment" (28).

Another example of clinical practice guideline created by a state agency, Best Practice Guidelines Behavioral Health Services for Children and Adolescents (29), was created by a panel of experts for nurses and other health and service providers. This document covers screening, evaluation, identification, and treatment guidelines. It reviews a number of common DSM IV mental health diagnoses, including co-morbid psychiatric conditions and intellectual disability, as well as EBP treatment options and resources. Evidence is "well established," meaning that two or more studies have shown a treatment to be superior to other interventions, that it is equivalent to an already established treatment, or its equivalence or superiority is evident from nine single-subject case studies." In addition, these guidelines call for practice that considers the child's developmental changes as well as the child's family (29).

To explore the scope of EBP in systematic reviews in the Cochrane Collaborative database, a search was conducted using the search term "developmental disabilities AND nursing" to identify reviews that may be more pertinent to nursing. Fourteen systematic reviews were available. See Table 2 for a list of reviews. The majority of these reviews are targeted to practice prenatal or infant care and approaches that prevent developmental disabilities.

Table 2. Cochrane Database of Systematic Reviews
Nursing and intellectual disabilities or mental retardation or DD = 14

Pre-conception and antenatal screening for the fragile site on the X-chromosome Common antiepileptic drugs in pregnancy in women with epilepsy Treatments for toxoplasmosis in pregnancy Thyroid hormones for preventing neurodevelopmental impairment in preterm infants Developmental care for promoting development and preventing morbidity in preterm infants Iodine supplementation for the prevention of mortality and adverse neurodevelopmental outcomes in preterm infants Prophylactic postnatal thyroid hormones for prevention of morbidity and mortality in preterm infants Replacement of estrogens and progestins to prevent morbidity and mortality in preterm infants Prophylactic systemic antifungal agents to prevent mortality and morbidity in very low birth weight infants Cooling for newborns with hypoxic ischaemic encephalopathy Iodine supplementation for preventing iodine deficiency disorders in children Iodized salt for preventing iodine deficiency disorders Pharmacological interventions for clozapine-induced hypersalivation Rapid versus slow withdrawal of antiepileptic drugs

A search was completed using PubMed and CINAHL electronic databases to review the general scope of current EBN health and nursing literature about nursing practice with persons with I/DD. Search terms used for I/DD were "mental retardation," "intellectual disabilities," "developmental disabilities," and these terms were added to search terms, "nursing" and "evidenced-based practice." The search revealed 11 articles from PubMed and 1 from CINAHL for a total of 12 articles (11 articles without redundancy) during the last five years. Nine articles were excluded for failure to be specific to persons with I/DD or to nursing. Of the three articles that remained, each provided an evidence-based review (nursing interventions to prevent secondary disabilities for persons with FASD; effectiveness of a specialist nurse model in epilepsy management compared to usual care; and the components of community learning disability teams). Only one of the three articles reported the highest level of evidence (reviews of RCTs). Unfortunately, due to the lack of strong evidence, none were able to recommend definitive EBN interventions. See Table 3 for a summary.

Table 3. EBN and Persons with I/DD (past 5 years) from PubMed and CINAHL

Article	Title	Source of Evidence	Level of evidence	Conclusions/Recommendations
1	WITHDRAWN: Specialist epilepsy nurses for treating epilepsy.	3 randomized controlled or quasi-randomized trials to assess effectiveness of specialty nurse compared with routine care	I	Effectiveness is plausible - some patients may improve knowledge; need further research before EBP recommendations can be made.
2	Evidence-based review of nursing interventions to prevent secondary disabilities in fetal alcohol spectrum disorder.	2 descriptive (one with comparison non FASD group); 2 exploratory qualitative studies	V	Not sufficient evidence for EBN interventions to prevent secondary disabilities
3	Community learning disability teams: developments, composition and good practice: a review of the literature.	literature review conducted; - most literature theoretical or opinion based; not enough for a systematic review	VII	Lacks evidence-based interventions; Practice suggestions only

One of the strongest levels of single-study research is the RCT. Another search was done in PubMed (Medline) to query for RCTs using the terms: "developmental disabilities OR mental retardation OR intellectual disabilities OR learning disabilities AND nursing AND (randomized controlled trial [Publication Type] OR (randomized [Title/Abstract] AND controlled [Title/Abstract] AND trial [Title/Abstract]))". The search was used to seek a higher level of evidence that could guide nursing practice. The search revealed twenty-five articles. (See topics listed in Table 4.) Articles were published from 1965 to 2007. The topics included interventions in the various settings (e.g., NICU, early intervention, home) at various stages of development (e.g., prenatal, neonatal, early childhood, adults), for various health issues (i.e., communication, behavior, infant/child parental relationships, constipation, sexuality); and were targeted to various audiences (i.e., pre-term infants, parents, persons with mental illness, staff and residents). It was beyond the scope of this paper to review each article; however, this illustrates that the areas of interest in EBN in I/DD are broad in scope as is nursing practice. These RCTs can be reviewed to support EBN as relevant to a particular clinical question with a targeted population, interventions for a particular nursing or health issue, or a particular setting.

Table 4: EBP – Nursing – I/DD: RCTs (Medline)

Communication of a diagnosis of Down syndrome, Parenting intervention in neonatal intensive care Informed choice in antenatal Down syndrome screening Family-based intervention to enhance infant-parent relationships in the neonatal intensive care unit Paraprofessional home visitation in early intervention service delivery Increasing screening uptake using action plans Abdominal massage for adults Nonaversive behavior intervention Safer-sex education for persons with mental illness Follow-up in a trial of prophylactic volume expansion in preterm babies Stress-point intervention for parents of repeatedly hospitalized children with chronic conditions Communication between staff and residents who have severe or profound mental retardation Prophylactic early fresh-frozen plasma or gelatin or glucose in preterm babies Home intervention for children with failure to thrive HOME scores and income Prevention intellectual impairment and pregnancy smoking Home visitation for pregnant women and parents of young children Health care communication and persons with mental retardation Home care program – maternal training Parental counseling Nurse home visitation and child abuse and neglect Nursing intervention/behavior modification program for parents in the home Pipamperone Nurse intervention and behavior change Extendor [Extender] role for nurses

Evidence may be sought in the absence of meta-analysis, systematic reviews, or clinical practice guidelines using electronic databases of literature such as PubMed, CINAHL, MEDLINE, EMBASE, and PsychInfo. Research librarians can be helpful in conducting searches. Other sources of evidence and searching techniques may be found from professional association websites or publications, or from journals that are specific to EBP or EBN. Evidence that applies directly to persons with I/DD may be difficult to find since persons with I/DD may be excluded from general RCTs about new medications or procedures. Therefore, a broad sweep may be needed to find evidence that is applicable. Once all the evidence on the topic is collected and reviewed, data is then extracted to appraise the evidence.

Step 3: appraising the evidence

Appraising "best" evidence is based on knowledge of a hierarchy of what is considered the strongest level of evidence. Evidence is weighted based on type of evidence. A number of evidence-grading scales have been developed by various associations, organizations, and publishers to rate the strength of evidence used to make recommendations for practice. There is no consensus among professional organizations or across healthcare disciplines in methods used for denoting the type of evidence for a specific practice, or for the grading schemas to denote the quality of evidence, although some consensus is occurring (e.g., SORT guidelines) (30). One schema used in EBN has seven levels (23). The levels range from Level I, which includes meta-analysis and systematic reviews of all relevant RCTs or EBP clinical guidelines based on systematic reviews of RCTs, to Level VII, which is evidence from the opinion of experts or authorities. See Figure 1.

Figure 1. Evidence Rating Scale for EBN*

Level I:	Evidence from a systematic review or meta-analysis of all relevant RCTs or evidence-based clinical practice guidelines based on systematic reviews of RCTs.
Level II:	Evidence obtained from at least one well-designed RCT
Level III:	Evidence obtained from well-designed controlled trials without randomization
Level IV:	Evidence from well-designed case-control or cohort studies
Level V:	Evidence from systematic reviews of descriptive and qualitative studies
Level VI:	Evidence from a single descriptive or qualitative study
Level VII:	Evidence from the opinion of authorities and/or reports of expert committees

*This schema is reported by Melnyk & Overholt-Fineout 2005 (23).

It is important to record the search strategy and to extract the data from each study in order to critically appraise it and note commonalities and differences among the studies. Once extracted, it may be helpful to provide a summary evidence table (noting the strength of evidence) with sufficient detail from the studies to summarize the evidence, weigh the evidence, and make conclusions about practice recommendations based on the level of strength of the accumulated evidence.

Another helpful suggestion is to use a conceptual framework to guide interpretation of the findings. In light of the definition from Sigma Theta Tau, EBN interventions are meant to benefit individuals, caregivers, families, and communities. Interestingly, in developmental disabilities nursing, the role of the public health nurse is one of the more established roles for nurses in this field, following the role of nurses working in institutional settings, which has a longer history (14). A public health nursing model provided a means to describe the evidence in a systematic review of nursing interventions as they applied to nursing roles and interventions for individuals with Fetal Alcohol Spectrum Disorder (FAS). The nursing interventions found in the literature were categorized into 16 types of interventions at one of three population-based foci: individual focused, community focused, and systems focused (17).

Three questions will assist nurses in appraising each article from the literature when a systematic review is unavailable after the search and extraction is completed. The questions (31) can assist in determining whether the level of evidence is sufficient and applies to practice: 1) How valid are the studies? 2) How reliable are the studies? and 3) Can the studies be used? This may begin first with an evaluation of the validity of the evidence, then with an evaluation to determine whether the evidence is reliable, and finally with an evaluation of the importance of the results. It is also critical to verify that practice guidelines or systematic reviews are current and up to date, and that they work for the practice population (e.g., age, gender, type of condition).

Appraising research literature can be complex and takes skill. A set of guidelines called the CONSORT statement was developed to help standardize reviews of the quality of RCTs (32, 33). Similar guidelines or a review of basic research skills may prove helpful in reviewing other types of studies. Evaluation concludes with a determination of whether there is enough solid evidence to support the intervention's use. It is important, as well, to examine the presence, type, and magnitude of any adverse events or complications. Do benefits outweigh the risks? Are the risks so severe or intolerable to the patient that the particular intervention is not the right one to try?

Recommendations will be based on the critical evaluation of the evidence, the level of the strength of evidence reviewed, and the weight of the evidence. Is there good evidence to support or refute a recommendation(s) for practice? Is the evidence good, fair, or insufficient to make recommendations? If the results of the evidence-based search and conclusions about EBN recommendations lead to reliable, important, and applicable nursing practice recommendations for persons with I/DD, a next step would be to implement the intervention(s) into current practice and test effectiveness for the new practice population and setting.

For example, in the review of nursing interventions for FASD, Caley and colleagues assessed that insufficient evidence was available to make EBN recommendations for practice with persons with FAS. The majority of evidence is Level VII (expert opinion) and therefore lacks support as EBP nursing interventions to prevent secondary disabilities. However, the review does provide an extensive overview of nursing interventions to support persons with FASD that can be used to inform practice, including the strong need for case management for persons with FASD. Although these interventions lack a high level of evidence to support their use as evidence-based practice, they do fall into five key areas ("referral and follow-up, screening, case-finding, health teaching, and case management") and outline interventions that need to be researched in order to provide the evidence required to further guide practice (17). Nurses can begin to build evidence by seeking more information and researching the use of these interventions in practice to examine effectiveness and build EBN with individuals with FASD.

Step 4: decision-making and implementation into practice

The initial clinical question will help to guide implementation of evidence into practice. The specific population and intervention has been defined. The data and appraisal of evidence should be good, sufficiently strong, and without adverse effects to justify its use and further testing with persons with I/DD. The grading of the evidence as well as the strengths or weaknesses of the recommendations for practice can assist decision making about using and testing in practice (1). It is also critically important to use clinical expertise and consider the patients', families', and communities' values and preferences.

Patient considerations include the patient's health status as well as the patient's values and choices, family's input, practice setting, and clinical circumstances (34). Evidence obtained from qualitative studies can highlight the preferences of patients. For example, when asking a clinical question about the evidence about transitions in healthcare for adolescents with cerebral palsy, research shows that perceptions of success are related to "being believed by others, believing in yourself, and being accepted by others" (35). Adults with cerebral palsy report distaste for nurses who are patronizing or fail to respond to their communication in the hospital setting (36). One nursing research study looked at the carers' views and values about their work with persons with severe learning disabilities in promoting personal hygiene (37). This type of research is an important consideration when reviewing the literature for EBN with persons with I/DD so that the best evidence and nursing expertise work in concert with the patient's, family's and carer's values and preferences.

Once the decision is made that enough evidence with good recommendation for an EBP intervention is available, it is important to consider other factors, such as the climate in which the intervention or practice will take place and be tested. Questions that may be asked include: Will the intervention be viewed as having an important and needed impact? Will it involve greater resources than are available? Are the resources and supports needed to implement the intervention available (e.g., administrative and staff support), and Does it fit with the values and preferences of individuals with disabilities and/or their caregivers and families?

Step 5: evaluation of EBP change for effectiveness

Evaluation of effectiveness of an intervention requires objective measurement. Effectiveness can be measured by looking at change pre- and post-intervention, by looking at change between a group that receives the intervention and a group that does not, or by examining objective pre- and post-intervention findings. Measuring effectiveness of interventions also involves measuring whether or not persons conducting the intervention have the skills and knowledge to administer it. Does the intervention change attitudes? Is satisfaction involved? What are the effects on the process (e.g., time to do the intervention, resources needed)? What are the effects on patient outcomes (decided prior to implementation and measured in a way that avoids bias and error)? Using a theoretical model can assist nurses in identifying outcomes such as improvement, maintenance, or prevention of decline in function, activities, and participation. How much change occurred? Is it statistically and clinically significant? A statistically significant difference may occur, but the clinical change may not be significant enough to have made a difference. Evaluation of results also includes assessing the factors involved in the change. Did change occur because of the intervention or because of other factors? If changes did not occur, was something else going on at the same time that prevented the change? Evaluating the implementation of a new practice intervention takes good planning. Partnering with researchers may assist nurses in developing a sound evaluation strategy.

Clinical EBN Example for Adults with I/DD

Formulating the question

Clinical research study results (38) prompted this author to identify an EBN practice issue - the noted high prevalence of cerumen ear impaction in a sample of adult participants with I/DD. The literature documents that persons with I/DD have a higher prevalence and reoccurrence of cerumen impaction (39). The following PICO components were identified: P (adults with I/DD); I (intervention to treat cerumen impaction); C (eardrops – cerumenolytics compared to no treatment), and O (resolution of cerumen impaction). The searchable question was: Is the use of a cerumenolytic effective in removing cerumen impaction in adults with I/DD?.

Searching and finding the evidence

The search strategy and the identified literature are outlined in Figure 2. The following sources were accessed to obtain evidence: Cochrane Database of Systematic Reviews, The National Guidelines Clearinghouse, PubMed, and CINAHL. The search term "cerumen impaction" revealed several systematic reviews and clinical practice guidelines as well as several clinical articles. When the terms for I/DD were added to the search, a paucity of articles were revealed in PubMed and CINAHL. These were excluded as they failed to be specific to the management of cerumen impaction. See Figure 2.

Figure 2. Table of Evidence – Intervention for Cerumen Impaction (I/DD)

Source	Search Term(s)	Literature	Level of Evidence
Cochrane Database of Systematic Reviews	Cerumen impaction	Burton MJ, Doree CJ. Ear drops for the removal of ear wax. Cochrane Database of Systematic Reviews 2003, Issue 3. Conclusion: any ear drop may help to remove ear wax; water and saline may be just as good. No adverse effects found. Individualize intervention – Quality poor; more research needed	I Systematic review
National Guidelines Clearinghouse	Cerumen impaction Initial Result (5) Exclusion: not specific to cerumen impaction management Final Result (2)	University of Texas at Austin School of Nursing, Family Nurse Practitioner Program - Academic Institution. Evaluation and management of obstructing cerumen. 2007 May. 17 pages. NGC:005674 Conclusion: no advantage of oil vs. water based; better than no treatment; water-based is cerumenolytic; oil-based softens. Evidence is fair to good; Recommendation is C = improves but benefits vs. harm balancer is too close to make general recommendation. Adams-Wendling L, Pimple C. Nursing management of hearing impairment in nursing facility residents. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center, Research Dissemination Core; 2007 Jun. 56 p. [172 references] Included section on cerumen management Conclusion: Cerumenolytics work to soften and loosen cerumen. Harm done with cerumenolytic is minimal (D). May be indicated when cerumen impaction reoccurs chronically (C). Docusate sodium (Colace) may make cerumen removal easier or eliminate need for irrigation, which is most effective next to Cerumenex and olive oil. (B) B=RCTS/consistent results; C =observational, correlational, descriptive or inconsistent results, D= expert opinion	I Clinical practice guideline I Clinical practice guideline
PubMed	cerumen impaction Initial Result (32) Exclusion: not specific to cerumen impaction management Final Result (4)	Roland PS, Smith TL, Schwartz SR, et al. Clinical practice guideline: cerumen impaction. Otolaryngol Head Neck Surg. 2008139(3 Suppl 2):S1-S21. Conclusion: Use of cerumenolytic is one method (in addition to irrigation or manual removal). Evidence does not support one "superiority of one therapeutic option vs. another . . . Cerumenolytics can be used alone or in combination with irrigation or manual removal" (p. S10). "Any type of cerumenolytic agent tends to be superior to no treatment but lacks evidence that any particular agent is superior to any other." (p. S13). Evaluate need for intervention in patient who cannot express himself and has cerumen impaction. Safe. Potential harm: otitis externa, allergic reactions, otalgia. Patient values: cost and safety concerns. Patient preferences- role for shared decision-making. Grade C evidence quality = Observational studies (case-control and cohort design) McCarter DF, Courtney AU, Pollart SM. Cerumen impaction. Am Fam Physician. 2007 Jul 1;76(1):32. Conclusion: longer use of cerumenolytic is more effective; and its use may make irrigation more effective. However, cerumenolytic alone may not always remove the wax. Shorter use of a cerumenolytic may be just as effective as using one for several days prior to irrigation. No one cerumenolytic is superior to any other or saline.(B) Jabor MA, Amedee RG. Cerumen impaction. J La State Med Soc. 1997 Oct;149(10):358-62. Conclusion: management of cerumen impaction includes the use of cerumenolytics Meador JA. Cerumen impaction in the elderly. J Gerontol Nurs. 1995 21(12):43=5. Conclusion: cerumenolytic agents provide one option for removing cerumen impactions	I Systematic review and clinical practice guideline (expert panel) V Systematic review of lower quality studies VII Opinion of authorities VII Opinion of authorities
CINAHL	Cerumen impaction Initial Result (32) Exclusion: not specific to cerumen impaction management or older than 1995 Final Result (1)	Neno R Holistic ear care: cerumen removal techniques. Journal of Community Nursing, 2006 20 (9): 26, 28, 30-1. Conclusion: simple remedies may be just as effective as proprietary ear drops. Olive oil may be used two times a day for one week to help remove cerumen with out irritation or make irrigation easier. Insert ear drops with patient lying on his/her side with affected ear up. Insert 2 to 3 drops of olive oil into the ear canal at body temperature by pulling up and out on the pinna and ask patient to stay in that position for about 5 minutes. Do NOT occlude ear canal with cotton. (from expert/authority opinion)	VII Opinion of authorities

Appraising the evidence

No meta-analysis was available. The evidence in the search included three systematic reviews, two clinical practice guidelines, and three clinical articles. (See levels of evidence in Figure 2.) In general, the majority of the evidence was Level I, the highest level of evidence, and the lowest was Level VII. The clinical practice guidelines and systematic reviews were valid. A nurse practitioner group wrote one of the clinical practice guidelines. The latest systematic review, published in 2008, was compiled and reported by experts convened by the American Academy of Otolaryngology-Head and Neck Surgery Foundation.

The results reported in all of the literature supported using ceruminolytics, either alone or in conjunction with other methods, for removal of cerumen impaction. The results were mixed as to which cerumenolytic was better, but all reports agreed that some type of drops are better than none for cerumen removal. Only one article (nurse authored) discussed the method by which a cerumenolytic agent should be administered. This report was ranked as the lowest level of evidence (expert or authority opinion). The greatest flaw in the reviewed evidence was the lack of attention to studies that included persons with I/DD. However, the latest guidelines clearly indicated the need to address interventions when cerumen impaction is present in persons who cannot express themselves. This would be inclusive of some persons with I/DD and communication impairments who may experience disability in the healthcare setting. Other comments included the need to individualize, to note when the cerumenolytic is not effective, and to list the reasons a person should be referred to a specialist.

Decision-making and implementation into practice

Although the guidelines did not address effectiveness for persons with disabilities, they did provide fair to good evidence to support a recommendation to use cerumenolytics to treat cerumen impaction. However, what remained unknown definitively was which of the cerumenolytics would have been best to use as well as compatible with individual preferences. Persons with developmental disabilities have varying levels of tolerance for medical procedures. To implement this EBN intervention, the preferences of patients, caregivers, and families needed to be assessed, and the variety of settings and health care providers needed to be considered. One set of guidelines did recommend that a registered nurse under the supervision of a physician should conduct these assessments.

Evaluation of EBP change for effectiveness

The practice recommendation for the use cerumenolytics for cerumen impaction was based on fair to good evidence. However, no evidence was available to document the effectiveness for persons with I/DD. Given the potential of this practice recommendation to make a difference, testing the use of cerumenolytics with individuals with I/DD with cerumen impaction would add to the evidence nurses need to engage in EBN practice. This intervention has the potential to produce a good outcome in terms of loosening and removing a cerumen impaction, but it also may have other positive outcomes, such as decreasing symptoms that might be barriers to people's ability to interact and participate in their environment and increasing quality of life.

The steps in this example provide a start for looking at the EBN practice of an important clinical issue for persons with I/DD. Further research is needed to test its efficacy and effectiveness for persons with I/DD for removal of cerumen impaction.

SUMMARY

EBP evolved from the need for practitioners to look at large amounts of accumulated research and develop a process for examining the evidence and determining which intervention or interventions might best assure good patient outcomes or reduce risks. As in other disciplines, nurses are now using EBP; however, some nurses still need knowledge and support to use EBN in practice. EBN, which is grounded in evidence, combines the best knowledge of practice and nursing expertise to support persons, families, carers, and communities while considering their values and preferences. The steps are basic, yet the process is complex. Supports to foster EBN's use and to value its implementation are needed. By using the five basic steps that form the structure of EBP, nurses who support individuals with I/DD have a role to play in reviewing, developing, implementing, and testing EBP to improve outcomes for the individuals, families, and communities they serve.

EBP in nursing with persons with I/DD is not without its challenges (40). Evidence that applies to persons with I/DD and nursing in I/DD may be problematic. Evidence-based randomized trials are lacking because persons with disabilities are often excluded from randomized clinical trials. This is a barrier to the accumulation of evidence to support evidenced-based practice (41). Nurses may also need to rely on evidence as it applies to other persons and then use their clinical expertise and knowledge of the values and preferences of persons with I/DD to propose EBN practice that can be evaluated.

Nurses may need education to understand the EBN process. Working with others who are more skilled, such as researchers, librarians or EBP teams, may assist nurses to develop skills needed to critique and appraise the literature and apply EBN. System changes may be needed to foster a climate that accepts and supports the use of EBN. The nurse in intellectual and developmental disabilities can be at the forefront of building and testing EBN in this practice specialty.

CONCLUSION

The push is on to use EBP. "All health care professionals need to understand the principles of EBP, recognize EBP in action, implement evidence-based policies, and have a critical attitude to their own practice and to evidence" (42). This includes nurses who provide services to support individuals with I/DD to use and develop EBN to foster positive outcomes and promote the ability of the persons they serve to fully participate in their lives and communities.