Introduction to Nursing Knowledge & the Quantitative Research Critical Appraisal Process

Healthcare settings are constantly involved in quality improvement initiatives to ensure they offer high-quality and evidence-based care to their patients. These settings often rely on both internal and external evidence to inform quality improvement initiatives. However, evidence must be appraised to ensure that the evidence being used is credible and relevant for the said quality improvement initiative. Dagne and Beshah (2021) note that nurses play a vital role in identifying and appraising research evidence used to inform quality improvement initiatives in their practice settings. It is therefore necessary for all nurses to have the appropriate skills and knowledge required for evidence appraisal. This discussion explores the differences between internal and external evidence, describing how each type of evidence can be utilized for quality improvement in a clinical setting.

Internal evidence is defined as the data and information that are generated within a particular healthcare institution (McGill & Speech Pathology Australia, 2022). Examples of internal evidence include information metrics like patient outcomes, quality improvement reports, electronic medical records data, incident reports, infection rates, readmission rates, and data from patient satisfaction surveys. Internal evidence is often institution-specific, reflecting how the institution, or a department in the institution, performs in a particular area over time. Moreover, internal evidence highlights the effectiveness of current interventions in the institution and helps identify practice gaps.

Conversely, external evidence in the context of evidence-based practice refers to the information obtained from systematic research that has been carried out outside a particular organization (McGill, 2023). Examples of external evidence include findings from peer-reviewed journals, clinical practice guidelines, meta-analyses, randomized controlled trials, and other primary studies whose results are generalizable and can be applied in the organization seeking to implement evidence in quality improvement initiatives. External evidence to inform quality improvement initiatives can also be obtained from credible repositories and organizations such as the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), or the National Institute for Health and Care Excellence (NICE). However, external evidence requires robust analysis and critical appraisal before use in quality improvement initiatives (McGill, 2023).

Internal evidence can be utilized for quality improvement in a clinical setting in several ways. It can be used to identify performance gaps, understand the unique characteristics and needs of a particular clinical setting, and evaluate outcomes of already implemented interventions. The quality improvement staff can assess and evaluate current and past internal data, such as staffing patterns, nurse-to-patient ratios, and documentation workflows, to identify performance gaps and the root causes of issues that need to be addressed. In addition, internal data can be used to understand the specific needs of the clinical setting, hence tailoring quality improvement interventions to meet these needs. Internal evidence, such as intervention outcomes, can be used to determine whether current quality improvement initiatives are effective.

Furthermore, external evidence can be utilized for quality improvement in a clinical setting to ensure that decisions are based on generalizable and scientifically validated findings (Dunlap et al., 2025). External evidence can justify the need to address concerns using quality improvement initiatives and inform proposed interventions using studies that have applied similar interventions and had positive outcomes. Additionally, well-presented external evidence can be used to gain buy-in and support from administrators in a clinical setting for quality improvement initiatives.

Both internal and external evidence are essential for driving continuous quality improvement. Internal evidence provides institution-specific context, helping identify problems and evaluate change, while external evidence offers scientifically validated solutions drawn from broad research. Utilizing both in clinical settings ensures that quality improvement initiatives are not only effective but also relevant and sustainable within the specific clinical settings.

References

Dagne, A. H., & Beshah, M. H. (2021). Implementation of evidence-based practice: The experience of nurses and midwives. PloS One, 16(8), e0256600. https://doi.org/10.1371/journal.pone.0256600

Dunlap, J. J., Waldrop, J. B., Brewer, T. L., & Mainous, R. O. (2025). Differentiation and integration of research, evidence-based practice, and quality improvement. The Journal of Nursing Education, 64(6), e44–e47. https://doi.org/10.3928/01484834-20240514-01

McGill, N. (2023). What is the evidence? The four components of contemporary evidence-based practice, Part 4: External evidence. Journal of Clinical Practice in Speech-Language Pathology, 25(1), 27–32. https://doi.org/10.1080/22087168.2023.12370385

McGill, N., & Speech Pathology Australia. (2022). What is the evidence? The four components of contemporary evidence-based practice, Part 3: Internal evidence. Journal of Clinical Practice in Speech-Language Pathology, 24(2), 100–103. https://doi.org/10.1080/22087168.2022.12370364

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Discussion Question:

Explain the difference between internal and external evidence. How can each of these types of evidence be utilized for quality improvement in the clinical setting?

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