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Evidence-Based Nursing Practice

Paolo D. Vega, RN Critical Care Services Manager


Chong Hua Hospital January 22, 2014

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.

What is Evidence-Based 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)

The EBM Triad

Process of Evidence-Based Nursing Practice

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)

Process of Evidence-Based Nursing Practice is also the Nursing Process


Evidence-based Nursing

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.

Assessment Diagnosis Planning Intervention Evaluation

We just have to emphasize the EVIDENCE!!!

Is Evidence-Based Nursing Practice the same as Nursing Research?

What makes good evidence?


Good

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

Searching for Evidence Pyramid: Basic


Systematic Reviews, MetaAnalyses

ex. Cochrane

Evidence Summaries, Evidence Guidelines

ex. DynaMed, Nursing Reference Center, NGC ex. MEDLINE/PubMed, CINAHL ex.Textbooks, UptoDate

Randomized Controlled Trials (RCTs), Cohort Studies, Qualitative Studies


Background Information, Expert Opinion

Pyramid of Evidence

Where do you look for evidence?

Wikipedia?

Search for the Best Evidence to answer the Question

MEDLINE or PubMed CINAHL/CINAHL Plus

www.pubmed.gov

Cumulative Index to Nursing and Allied Health Literature www.cinahl.com

E-Journals Clinical Practice Guidelines


Clearinghouse www.guideline.gov

National Guideline

Nursing Reference Center

www.ebscohost.com/pointOfCare/evidence-based-information

Advanced Google or Google Scholar

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

Why Evidence Based Practice?


Knowledge explosion + Nursing shortage

Mandate

Timely research evidence translation into best practice.


(Melnyk & Fineout-Overholt, 2005; Salmon, 2007)

Why Evidence Based Practice?

Traditional practice
Knowledge gained in school Pathophysiological rationale Intuition Experiences (past & usual practice) Workplace colleagues

17-year lag between research findings and practice application


(Melnyk & Fineout-Overholt, 2005; Salmon, 2007)

Why Evidence Based Practice?


Results in better patient outcomes Failure to use evidence results in lower quality, less effective, more expensive care
(Berwick DM, 2003)

EBP can lead to:

Increased practitioner satisfaction Decreased burnout and turnover Third party reimbursement
(Melnyk & Fineout-Overholt, 2005; Salmon, 2007)

Why do nurses need to do EBP?

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

Barriers to Nurses using EBP

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.

Why Evidence Based Practice?

Evidence continually evolves

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

(Gray, et al., 2002)

Evidence Gaps

>Primary Research
(Salmon, 2007)

What is Evidence Based Practice?

Conscientious use of best evidence in clinical decision making:


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)

History of EBP Movement

Dr. Archie Cochrane, British epidemiologist

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

History of EBP Movement

2000 IOM report, To Err is Human

Preventable medical errors were 8th leading cause of death in US

2002 IOM report, Crossing the Quality


Chasm

Major lag between medical science and technology advancements and healthcare delivery
(Salmon, 2007)

5 (7) Steps for EBN Practice


1. Convert your information into an answerable question (PICO) Population; Intervention; Comparison; Outcome 2. Search the literature for the best available evidence 3. Critically appraise the evidence for validity and usefulness 4. Apply the findings to your clinical practice along with clinical expertise and patients perspective to plan care 5. Evaluate the outcomes of your practice decisions or changes based on evidence.
Melnyk & Fineout-Overholt, 2005

2 Additional Steps for EBP=7 Steps

Step 0: Cultivate a spirit of inquiry Step 6: Disseminate EBP results

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.

Levels and Grades of Evidence

REPROLINE, Johns Hopkins University www.reproline.jhu.edu

Additional Point of Care EvidenceBased Resources for Nursing:


[have some level of evidence-based information]

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

Cochrane Database of Systematic Reviews


Gold standard for high quality systematic reviews Includes full-text reviews and protocols Cochrane Abstracts available in CINAHL and MEDLINE/PubMed

So, you want to use Google? Not a problem!!!


Google www.google.com Largest search engine: over 25 billion pages Relevance ranking based on link analysis Google Advanced Search www.google.com/advanced_search?hl=en Google Scholar www.scholar.google.com

But use Google Scholar!!! www.scholar.google.com

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

Criteria for Evaluating Web Sites


www.healthlinks.washington.edu/howto/navigating/criteria.pdf

Authority Accuracy

Objectivity
Currency Coverage Design

Questions???
Lets hear from

Prof. Sharon Hewner, PhD, RN


Asst. Professor of Nursing State University of New York at Buffalo School of Nursing on her discussion on HOW EVIDENCE-BASED PRACTICE, QUALITY and NURSING RESEARCH form the bench-stool of Nursing practice.

Hungry for more???


We invite you to the 1st Evidence-based Research Workshop here in Cebu..
WHEN: April 25-26, 2014 (2-day Workshop) WHERE: Chong Hua Hospital, AB Conf. Room SPEAKER: Ms. Lee Banguilan, RN, MAN Head, Nursing Research Dept. Philippine Heart Center, QC PRICE: Php 1,200 (inclusive of kit, ID and lunch) FREE for Chong Hua Hospital employees

Thank

you!!!!

1. Ask the burning question using PICO

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

Intervention focused clinical question:

In teenagers (patient population), how effective is Depo-Provera (intervention) in the prevention of pregnancy (outcome)?

Non-intervention focused question:

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)

2. Collect most relevant and best evidence


1. 2. 3.

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)

2. Collect most relevant and best evidence

Evidence Based Clinical Practice Guideline

Based on scientific literature Explicitly documents process used to develop statement Grades strength of evidence used

(www.chestnet.org/education/guidelines/currentGuidelines.php; cited in Melnyk & Fineout-Overholt, 2005)

2. Collect most relevant and best evidence

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

Precise; minimizes error & bias


(Salmon, 2007)

2. Collect most relevant and best evidence

Meta-analysis:

Integrates results of similar descriptive or qualatitative studies

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)

2. Collect most relevant and best evidence

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)

2. Collect most relevant and best evidence

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)

2. Collect most relevant and best evidence

Qualitative Research:

Collects data through observations and interviews Generates ideas and hypotheses through inductive

Descriptive Studies:

Can be quantitative or qualitative Describe what is going on

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

Pre-appraised literature is golden


(Salmon, 2007)

3. Critically Appraise Evidence RCT

Rapid Screening

Random allocation of interventions? Blindness to interventions by


Researchers? Participants? Involved health care professionals?

(Melnyk & Fineout-Overholt; 2005)

3. Critically Appraise Evidence Systematic Review

Rapid Appraisal

Relevant papers identified? Method of assessing quality of papers? Method of summarizing results?

(Melnyk & Fineout-Overholt; 2005)

3. Critically Appraise Evidence Qualitative Research

Lincoln & Gubas Evaluative Criteria:

Trustworthiness
Credibility (internal validity) Transferability (external validity) Dependability (reliability) Confirmability (objectivity)

(Melnyk & Fineout-Overholt; 2005)

4.Integrate Evidence/Patient Preferences/Values/Clinical Experience

Evidence assists but does not replace sound clinical reasoning.

Evidence Analogy Experience Meaning Theory


Salmon, 2007)

4.Integrate Evidence/Patient Preferences/Values/Clinical Experience

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)

5. Implement & Evaluate Impact

Track outcomes

Include patients evaluations Requires informatics for imputing & tracking


Patient Treatment Outcome

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