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D e f i n i t i o n s
! Evidence-based practice can be thought of as requiring
"the integration of the best research evidence with our
clinical expertise and our patient's unique values and
circumstances." (Straus, et al., 2005)
! "Fortunately, evidence-based practice (EBP) is an
approach that enables clinicians to provide highest
quality of care in meeting the multifaceted needs of their
patients and families." (Melnyk & Fineout-Overholt, 2005)
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Definitions
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Cllnlcal Lxperuse
auenL values
8esL avallable
research
evldence
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Goals of EBP
! rovlde pracuclng nurses wlLh evldence-based daLa
! 8esolve problems ln Lhe cllnlcal semng
! Achleve excellence ln care dellvery
! lnLroduce lnnovauon
! 8educe varlauons ln nurslng care
! AsslsLs wlLh emclenL and eecuve declslon-maklng
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K'20) =&'(L1C
! uslng besL evldence Lo lmplemenL Lhe regulauon of
nurses
! 8esolve regulaLory problems
! Achleve excellence ln regulauon
! lnLroduce regulaLory lnnovauon
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Why the rapid spread of
evidence-based practice?
Some of major reasons cited by Sackett et al (1997)
for the spread of the EBP movement have been :
" the lack of research-based information to support
clinical decision making
" the lack research-based guidelines and protocols to use
in clinical practice
" the overwhelming volume and variability of new journal
information
" the inadequacy of traditional sources of information (e.g.
textbooks out of date)
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What are the benefits of
evidence-based practice?
1. To patients/consumers
Patient typically accept recommended care
from health professionals with the unspoken
assumption that the practitioner know what
works
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What are the benefits of
evidence-based practice?
2. To nurses
! EBP allows a more structured and streamlined way of
keeping abreast of relevant new developments without
becoming over-whelmed by information overload
! EBP also allows nurse to communicate effectively with
their patients and with the healthcare team about the
rationales for decision making and care plans
! An EBP nurse is a confident professional, feeling
assured that they are providing care that is supported by
facts rather than habits, and can take legal
accountability for their practice
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What are the benefits of
evidence-based practice?
3. To the healthcare organization
! EBP philosophy allow healthcare organization to position themselves
in the market as quality institution.
! An EBP-compliant institution should be less likely to attract
litigation, or to successfully defend the care delivered.
! EBP allows the scrutinizing of practice for effectiveness.
! This process often results in practice changes that allow significant
cost savings, or alternatively justify necessary additional
expenditure
! This is attractive to organizations frequently struggling to meet
assigned budgetary limits, or lobbying government for additional
funds
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What are the benefits of
evidence-based practice?
4. 1o Lhe communlLy
! 1hrough Lhe uullzauon of L8, nlLe resources are
noL wasLed on Lhe dellvery of lneecuve
lnLervenuons.
! L8 llmlLs Lhe amounL of dlsablllLy and suerlng
LhroughouL Lhe communlLy by ensurlng Lhe mosL
currenL and eecuve care ls provlded.
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1. Ask or identify the important clinical question
2. Collect the best and more pertinent evidence
3. Critically analyze and rate the evidence
4. Integrate the evidence into clinical decisions
5. Implement best evidence in clinical practice
6. Evaluation
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1. Ask or identify the important
clinical question
! HOW?? PICO
! Patient
! Age, sex, ethnicity, etc.
! Condition, diseases, general health status
! Intervention
! Education, diagnostics, treatment plan, self-care, etc.
! Comparison Intervention
! Placebo, etc.
! Outcome
! Expected and actual effects on patient
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PICO
! The nurses want to know:
What is the best way of obtaining a urine specimen
culture, from a child?
Population: Children suspected of having UTI (Urinary
tract infection), who are not yet toilet training
Intervention: Bag-catch urine specimen, clean-catch urine
specimen
Comparison: Suprapubic aspiration
Outcome: Culture contamination
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PICO
The revised question:
In children suspected having of UTI, who are not yet toilet
training, what is the risk of culture contamination when
urine is obtained by bag-catch or clean catch, as
compared with urine obtained by suprapubic aspiration
directly from the bladder?
! Not all questions are of a clinical nature
! Intervention can be interpreted very broadly
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! Do nurse led tobacco cessation interventions
result in decreased smoking rates after hospital
admission for coronary heart disease?
! What are the factors, identified by mothers who
live in the deprived inner city areas, that
influences them to breastfeed or to bottle-feed
using infant milk formula
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2. Collect the best and more
pertinent evidence
Where is the evidence located?
! CINAHL (Cumulative Index to Nursing and the Allied Health Literature)
! Medline www.ncbi.nlm.nih.gov/PubMed/.
! Proquest
http://www.proquest.com/pqdweb
username: 0NQTKKWNKM& Password:brawijaya
! Ovid
http://gateway.ovid.com/
ID & Password : hsll199
! EBSCO
http://search.epnet.com/
user : cathedral & password : dc
NEW: http://search.ebscohost.com
Id: n5000145, passwords
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3. Critically analyze and rate the
evidence
! Critical Appraisal of the evidence
! Grading of the evidence
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Grading of research studies that measure the
effect of an intervention, treatment or therapy
Level of
evidence
Study designs
I Evidence obtained from a systematic
review or meta-analysis of all relevant
randomized controlled trials
II Evidence obtained from at least one
properly designed randomized controlled
trial
III-1 Evidence obtained from well-designed
pseudo-randomized controlled trials
Source : NHMRC 1999
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Grading of research studies that measure the
effect of an intervention, treatment or therapy
Level of
evidence
Study designs
III-2 Evidence obtained from comparative
studies with concurrent controls and
allocation not randomized (Cohort studies,
case-control studies or interrupted time-
series with control group)
III-3 Evidence obtained from comparative
studies with historical control, two or more
single-arm studies, or interrupted time-
series without a parallel control group
Source : NHMRC 1999
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Grading of research studies that measure the
effect of an intervention, treatment or therapy
Level of
evidence
Study designs
IV Evidence obtained from case series (either
post-test or pretest and post-test
Source : NHMRC 1999
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Levels of evidence of effectiveness
Level Evidence of effectiveness
1 Systematic review (with homogeneity) of experimental
studies, or one or more large experimental studies with
narrow confidence interval
2 Quasi-experimental studies (e.g without randomization)
3a Cohort studies (with control group)
3b Case-controlled
3c Observational studies without control groups
4 Expert opinion without explicit critical appraisal, or
based on physiology, bench research or consensus
Source:The Joanna Briggs Institute.Available at www.joannabriggs.edu.au/pubs/approach.php.
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TRIP = turning research into practice
Simultaneously searches evidence-based sources of systematic reviews, practice
guidelines, and critically-appraised topics and articles
QUALITY OF EVIDENCE
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4. Integrate the evidence into
clinical decisions
Key points:
Research evidence is, on its own, insufficient to ensure
the robust clinical decisions necessary for clinically
effective health care
Good clinical decisions require the sophisticated
application of research findings in the context of
clinical expertise, patient preferences and values, and
the individual decisions
The availability of resources influences how research
evidence is interpreted and applied
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4. Integrate cont
The seven rights of the clinical effectiveness
(Royal College of Nursing, 1996)
1. Right thing for the
2. Right patient from the
3. Right person at the
4. Right time in the
5. Right way to achieve the
6. Right outcome at the
7. Right cost
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4. Integrate cont
Influences on clinical decision making
Decision
making
Clinical
expertise
Intuition
Research
Available
Resources
Media
Experts
Values and
belief
Consensus
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4. Integrate cont
Clinical expertise:
The ability to use our clinical skills and past experience to rapidly
identify each patients unique health state and diagnosis, their
individual risks and benefits of potential interventions, and their
personal values and expectations (Sackett et al 2000)
Intuitive practice:
A way in which we know and behave about the situation that is not
based on conscious reasoning or rational thought process
(Parahoo 1997)
Builds on repeated practice situations, it is context specific and it
enables the integration of complex pieces of a data to derive a
decision that is difficult to articulate through linear rules
(Greenhalgh 2000)
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5. Implement best evidence in
clinical practice
Where to start?
Identifying appropriate topics to address
" Consider local and national views on the topic
" Attitudes to using research evidence
Choosing a project manger
Diagnosing the situation
The organizational environment, stakeholders and
practitioner opinion leaders, grassroots workers, Users views,
the way we do things round here, SWOT analysis
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5. Implement cont
How to implement the changes?
Developing a dissemination and implementation
strategy
General/ specific approaches to manage change
Educational approach, epidemiological stances,
marketing of a product, information or strategies,
behavioural changes, social interactionism,
organizational approach, resources and management
issues, realistic goals and time frames, reviewing.
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6. Evaluation
Evaluating the progress and effects of the
changes?
Maintaining close contact with the progress and effects
Formal evaluation and dissemination
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How Do I Participate in an Evidence-
Based Practice?
! Ask an authority or expert in the field
! Consult a textbook
! Look for an article in a nursing journal
! Look for an article in a scholarly journal
! Ask a nursing peer
! Use simple trial and error
! Use your intuition, judgment, or reasoning skills
to solve the particular problem
Godshall, Maryann 2010
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