How to Create an Evidence-Based Nursing Policy

How to Create an Evidence-Based Nursing Policy image of nurse
How to Create an Evidence-Based Nursing Policy image of nurse

It wasn’t that long ago that people attributed common illnesses to the malefic hands of witches and fairy folk, and as you might expect, treatments based on these beliefs left a great deal to be desired. Fortunately, medicine has evolved a great deal over the past century thanks in large part to evidence-based policy. Hospital policies and procedures provide important guidance for staff and should be rigorously observed, yet they are also living documents, which need to accommodate changes as new evidence that can improve patient outcomes arise. This progressive, adaptive care model requires smart, autonomous nurses who are comfortable taking on leadership roles—the kind of nurses we train in the Carson-Newman RNBSN online program.

Today we’re going to look at what constitutes evidence-based practice in nursing, evidence-based policy, and the factors to keep in mind as you consider developing such policies.

Evidence-Based Practice in Nursing

Evidence-based practice in nursing is quite simply an approach to making decisions and providing patient care based upon clinical expertise and the latest evidence-driven research available on the topic. Establishing effective policy is the first step towards practicing evidence-based nursing (EBN).

As nurses Susan Blankenship, Amy Lucas and Sandy Sayre note in their Nursing 2013 article, “Anatomy of an Evidence-Based Policy,”

When [hospital] policies are outdated or inadequate to guide an important aspect of patient care, nurses should step up to fill the void. No nurse should hesitate to voice questions and initiate changes to current practice in order to create a better, safer enviornment for patients.

These policies are crucial to help nurses deal with unfamiliar health needs. Blankenship and her colleagues use the example of a nurse receiving an operating room patient with a lumbar drainage device (LDD) and having no idea how she should proceed with care. The complexity of modern medicine means that no nurse can be expected to be familiar with every possible illness or treatment, which is why the absence of a specific policy could potentially have endangered the patient.

Formulating an Evidence-Based Nursing Policy

Formulating a new policy requires careful planning, teamwork and diligent research, which is part of the reason that many hospitals now require nurses to demonstrate an academic background (BSN) as well as hands-on technical training. In many cases, a team or committee will be assigned to divide the work and discuss findings. The best place to start is with the resources available in your own hospital:

  • consult nurses, doctors and other staff with relevant expertise
  • reach out to your health system’s librarian (if available) for guidance in finding peer-reviewed research
  • if the new policy is responding to a new piece of technology, contact a representative of the manufacturer for support documentation and to answer questions

This is where your academic critical thinking skills come in. How do you know which sources are reliable? Blankenship and company recommend multiple randomized clinical trials as the best source of evidence.

As you move forward, make sure that major stakeholders are involved in the process from the outset. New evidence-based policies can affect multiple departments and patient populations, so it’s wise to consult them early so they can troubleshoot glaring problems before you’ve strayed too far in the wrong direction. It’s also important to secure the support of managers, as you will need approval for the hours you put into writing and research, as well as the institutional will to enact recommended changes that can be wide-ranging in nature.

When it comes time to write the policy itself, it can be helpful to look to existing hospital procedures as a model. The more consistent your hospital’s documentation is, the easier it is for staff to read and understand. It’s wise to appoint one person as the primary writer, allowing others to contribute as editors. In this way, the resulting document will have a consistent voice, and will also have been rigorously vetted before it’s ever submitted for administrative approval. After any necessary revisions, your new evidence-based policy can take its place among your facility’s guiding documents, helping to improve patient outcomes and advance the cause of medicine for years to come.

Learn more about how to expand your role as a nurse through our online RN to BSN program for Nurses.


Susan Blankenship, Amy Lucas, and Sandy Sayre. “Anatomy of an evidence-based policy” in Nursing2013. Wolters Kluwer Health | Lippincott, Williams & Wilkins