Professional Documents
Culture Documents
Objectives
Describe evidence-based practice (EBP) Identify levels of evidence using the EBP pyramid Learn where to find the best evidence Understand why evidence-based practice is important and should be integrated in scholarly work Learn the importance of EBP, QI and NR in the Nursing Practice.
"Evidence-based nursing (EBN) means using the best available evidence from research, along with patient preferences and clinical experience, when making nursing decisions.
(Cullum N. Users' guides to the nursing literature: an introduction. Evid Based Nurs 2000 Jul;3(3):71-2. doi:10.1136/ebn.3.3.71)
Integrated components: clinical expertise (best practice) external evidence from systematic research patient preferences
(Sackett, et al., 1996)
Assess and define problem. Formulate specific question. Locate and evaluate appropriate evidence. Integrate evidence into planning and implementing interventions. Evaluate process and results.
(Sackett, et al., 1996)
Nursing Process
Assess and define problem. Formulate specific question. Locate and evaluate appropriate evidence. Integrate evidence into planning and implementing interventions. Evaluate process and results.
Shoddy
Based on scientific research Randomized Control Trials Systematic review Meta-analysis Clinical guidelines
Opinion Consensus Because its been done this way for 100 years
Chocolate decadence
ex. Cochrane
ex. DynaMed, Nursing Reference Center, NGC ex. MEDLINE/PubMed, CINAHL ex.Textbooks, UptoDate
Pyramid of Evidence
Wikipedia?
www.pubmed.gov
National Guideline
www.ebscohost.com/pointOfCare/evidence-based-information
CINAHL vs MEDLINE
CINAHL Coverage: 1982+ Indexes 1700 journals Focuses on nursing and allied health literature CINAHL Thesaurus with more nursing terms Has peer-reviewed limit Includes cited references at end of many refs
MEDLINE Coverage: late 1940s+ Indexes 5000 journals Focuses on biomedical literature Uses MeSH as its controlled vocabulary No peer-reviewed limit No cited references
Mandate
Traditional practice
Knowledge gained in school Pathophysiological rationale Intuition Experiences (past & usual practice) Workplace colleagues
Results in better patient outcomes Failure to use evidence results in lower quality, less effective, more expensive care
(Berwick DM, 2003)
Increased practitioner satisfaction Decreased burnout and turnover Third party reimbursement
(Melnyk & Fineout-Overholt, 2005; Salmon, 2007)
Keeps practice current and relevant Increases confidence in decision making Experience greater autonomy in practice Increases level of job satisfaction
Berwick DM. Disseminating innovations in health care. JAMA 2003 Apr 16;289(15):1969-75
Lack of TIME Lack of value of research in practice Lack of understanding of electronic databases to find evidence Lack of computer skills Lack of EBP mentors at point of care Difficulty understanding research articles
Pravikoff DS, Tanner AB, Pierce ST. Readiness of U.S. nurses for evidence-based practice. Amer J Nurs 2005 Sep;105(9): 40-52.
Evidence-based practice
Opinion-based
Melnyk & Fineout-Overholt, 2005; Salmon, 2007
WARNING!!!!!
EBP does not replace clinical reasoning or judgment. 20% medical practice <20% nursing practice
Supported by solid evidence
Evidence Gaps
>Primary Research
(Salmon, 2007)
Systematic search for best evidence Critical appraisal of most relevant evidence to answer clinical question Clinical context or circumstances Ones own clinical experience Patient preferences and values EBP is more than research utilization
(Melnyk & Fineout-Overholt, 2005; Salmond,2007)
In 1972 criticized medical profession for lack of systematic review of available evidence to direct clinical decision making
Landmark case several RCTs supporting effectiveness of corticosteroid therapy to halt premature labor in high risk women had not been systematically analyzed
1,000s of low-birth-weight premature infants continued to die needlessly Review data showed therapy decreased death from 30% to 50%
Melnyk & Fineout-Overholt, 2005
Major lag between medical science and technology advancements and healthcare delivery
(Salmon, 2007)
Melnyk BM, Fineout-Overholt E, Stillwell SB, Williamson KM. Evidence-based practice: step by step: the seven steps of evidence-based practice. Am J Nurs 2010 Jan;110(1):51-3. PMID: 20032669.
Clini-eguide Nursing Advisor www.clineguide.com/nursing-standards-careplan.aspx Lippincotts Nursing Procedures & Skills www.healthstream.com/Lippincott/ Mosbys Nursing Consult www.nursingconsult.com Mosbys Nursing Skills mosbysnursingskills.com UptoDate www.uptodate.com
Gold standard for high quality systematic reviews Includes full-text reviews and protocols Cochrane Abstracts available in CINAHL and MEDLINE/PubMed
Searches for scholarly literature, including peerreviewed papers, theses, books, abstracts and technical reports Finds articles from academic publishers, professional societies, universities, etc. as well as scholarly articles on the web "Cited by" link identifies # that have cited the original Access to full text only available with subscription Caution: Not a reliable sole source for searching scholarly literature
Authority Accuracy
Objectivity
Currency Coverage Design
Questions???
Lets hear from
Thank
you!!!!
P: Patient, population, or problem being addressed I: Intervention or dimension of interest C: Comparison intervention O: Outcome
Format helps focus the question by determining the important concepts Not necessary to follow above order
(Melnyk & Fineout-Overholt, 2005; Salmon, 2007)
PICO Examples
In teenagers (patient population), how effective is Depo-Provera (intervention) in the prevention of pregnancy (outcome)?
What is the duration of breast feeding (outcome) in new mothers (population) who have breast-relatedcomplications (area of interest) in the first 3 months after the infants birth versus those who do not have breast related complications (comparison)?
(Salmon, 2007)
4.
5. 6. 7.
Systematic review/meta-analysis of all RCTs or evidence-based clinical practice guidelines At least one well-designed RCT Well-designed controlled trials without randomization Well designed case-control and cohort studies Systematic review of descriptive and qualitative studies Single descriptive or qualitative study Opinion of authorities and/or reports of expert committees
(Melnyk & Fineout-Overholt; 2005)
Based on scientific literature Explicitly documents process used to develop statement Grades strength of evidence used
Systematic Review:
Rigorous systematic review of primary studies Preplanned comprehensive search strategy Relevant articles
appraised data synthesized results interpreted summary of best available evidence provided
Meta-analysis:
Meta-synthesis:
Statistical method Integrates results of several independent studies addressing a set or related research hypotheses Objective appraisal Precise estimate of treatment effect
(Salmon, 2007)
RCT:
Gold Standard for intervention studies Most reliable Treatment randomization eliminates large amount of bias
Cohort Study:
Observational longitudinal study with 2 patient groups One group receives treatment Groups measured over time for development of outcomes
(Salmon, 2007)
Case-control studies:
Compares patients who have a specific condition to people who do not Uses medical records and/or patient recall Less reliable than RCTs and cohort studies
showing a statistical relationship does not necessarily mean clinical causal relationship
(Salmon, 2007)
Qualitative Research:
Collects data through observations and interviews Generates ideas and hypotheses through inductive
Descriptive Studies:
Expert Opinion
(Salmon, 2007)
Search Strategy
1. 2. 3.
4. 5.
6.
Determine appropriate data base for question Determine type of study design that would best answer question Enter a subject heading (e.g., MeSH in PubMed) and/or textword search guided by the PICO components of the question Combine searches to find relevant evidence Further restrict combined searches for study design, methods, indicators of clinical meaningfulness, English, human Apply pre-established inclusion & exclusion criteria to studies gathered by the search
Rapid Screening
Rapid Appraisal
Relevant papers identified? Method of assessing quality of papers? Method of summarizing results?
Trustworthiness
Credibility (internal validity) Transferability (external validity) Dependability (reliability) Confirmability (objectivity)
Is evidence useful for this particular patient? Cost effective? Patient values and preferences? Clinician expertise?
Best clinical decision making is integrative and collaborative!
Salmon, 2007)
Track outcomes