Discuss evidence based practice
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Please discuss how you can link evidence based nursing practice and patient centered care based on patient preferences?
NRG 5005 Evidence-based Practice for Advanced Practice Nurses
Pulling It All Together
Evidence-Based Practice
How do you know that your practice
is a “best practice” (that it is safe
and efficient) and that you get the
best outcomes possible?”
Evidence-based Clinical Decision Making
What works best, for whom,
and under what circumstances?
Research utilization is using knowledge gained from a research study.
Evidence-based practice is a synthesis of evidence from multiple studies
Barriers to Research Utilization
Typical source of information: colleague
58% had never used research articles to support clinical practice
18% had never used a library
Pravikoff, D.S., Tanner, A.B., & Pierce, S.T. (2005). Readiness of US nurses for evidence-based practice. American Journal of Nursing, 105(9), 40-51.
Barriers to Research Utilization
Perceived value of research
Resistant to change
Lack of time and resources
Communication gap between researchers and clinicians
Organizational culture
Inability to evaluate research
Sources of Evidence
Sources of information informing practice currently:
Tradition
Authority
Trial and error
Personal experience
Intuition
Borrowed evidence
Scientific research
Why are vital signs taken routinely every four hours on patients who are clinically stable?
Result of trial and error:
Settling on one approach that is more often than not effective
Personal experiences:
Frequently based on tradition, authority, and trial and error
What is Evidence-based Practice?
Evidence-based Practice
“The conscientious, explicit, and judicious use of theory-derived, research-based, information in making decisions about care delivery… in consideration of individual [patient] needs and preferences.”
Ingersoll, G.L. (2000). Evidence-based nursing: What it is and what it isn’t. Nursing Outlook, 48, 151-152.
Evidence-based Clinical Decision Making
Uses evidence from:
Research
Clinical judgment (the ability to think about, understand, and use research evidence; the ability to assess a patient’s condition through history, examination, and lab reports)
Opinion leaders
Expert panels
Clinical expertise (evidence from outcomes management, quality improvement projects)
Patient preferences and values
Evidence-based Practice
The examination and application of research findings or other reliable evidence
Use of critical thinking skills to review research publications and other sources of information
Assessment of patient needs, culture, and preferences
Use of clinical decision-making skills to apply evidence to patient care
History
Dr. Archie Cochrane (British epidemiologist) in 1971:
individuals should pay only for health care based on scientific evidence
Rigorous, systematic research should inform practice and policy development
Cochrane Center established (http://www.cochrane.org/)
History
During this time, nursing involved in applying research findings to practice (research utilization).
By 2000, realization that practice should not be changed from one study, and clinical judgment involved as well as patient preferences.
Using EBP as an
Advanced Practice Nurse
Assessing patients
Deciding when to change practice
Evaluating patient outcomes
Using EBP as an Advanced Practice Nurse
Use rates to assess patient needs
Compare the prevalence of disease with larger populations (state, national) to detect issues within the community
Use rates to determine causes of disease within the community and to target interventions to those who need them the most
Assessing Patients
Your patient population has Lyme’s disease at a rate of 0.06 per 1,000. If the county’s rate is 0.003 per 1,000 and the state’s rate is 0.059 per 1,000, does your patient population have a problem with Lyme’s disease?
Assessing Patients
Your patient population has respiratory disease at a rate of 0.067 per 1,000. Is this a concern if the county rate is 0.080 per 1,000 and the state rate is 0.053 per 1,000?
Assessing Patients
Your patient population has diabetes mellitus at a rate of 0.04 per 10,000 people. Are you concerned, given that the state rate is 0.06 and the national rate is 0.05?
Assessing Patients
Use the evidence pyramid to determine strength of evidence
Analyze existing evidence for credibility
Analyze relevance for your group of patients
Analyze the strength of the collective group of studies
Determine next steps
Evidence is not strong enough to support change in practice
Evidence shows promise but more research needed
Evidence is strong enough to support change in practice
Deciding When to Change Practice
You want to develop a protocol using a new hypothermia blanket for patients pre and post surgery. You search the literature and find 4 studies that support the use of the new hypothermia blanket to increase patient satisfaction, reduce nausea and vomiting, and reducing the pain medication required after in the recovery room. Two of the studies are correlational studies, one is a descriptive study, and one is a quasi-experimental study conducted on 40 patients. The quasi-experimental study was conducted by the manufacturer of the hypothermia blanket. How strong is the evidence of the outcomes of using the new blanket?
Deciding When to Change Practice
Is the evidence credible?
Is the evidence relevant?
How strong is the evidence?
Determine next steps
Is the evidence strong enough to support change in practice?
Does the evidence show promise but more research is needed?
Deciding When to Change Practice
Measuring Patient Outcomes
The success of evidence-based changes must be measured in patient outcomes
Evaluating Patient Outcomes
Patient Outcomes are the focus of evidence-based practice!
Patient Outcomes
Measure how well current policies and practices are working
Focus on groups of patients, not individual patients
Indicate need for change
Indicate feasibility of policies and practices
Patient Outcomes
Medical outcomes measures
Quality of care
Patient-centered care
Other outcome measures
Efficiency of processes
Environmental changes
Professional expertise
Patient Outcomes Include…
Are quantifiable and community-focused or organization-focused
Used to evaluate changes in clinical practice and establish new policies or guidelines
Examples: health status, disability, iatrogenic effects of treatment, health behaviors, & economic impact of therapy and illness management
Medical Outcomes
Measures the effectiveness of symptoms management
Examples: pain, fatigue, nausea & vomiting, sleep disturbances, appetite changes, depression
Quality of Care
Measures how well the patient is viewed as an equal partner in health care.
Examples: adequate communication with patients, unhurried interactions, participation in decision-making, education regarding illness, consideration of culture and beliefs, respect, empathy patience, and caring attitude.
Patient-centered Care
Measures how well care is delivered efficiently and effectively
Examples: appropriate timing of interventions, effective discharge planning, efficient use of hospital beds
Efficiency of Processes
Measures the degree to which there is a culture of EBP throughout the organization
Examples: evaluation of policy, policy adherence, resource availability, supplies and materials necessary for EBP
Environmental Changes
Measures the ability of providers to meet accepted standards of care essential for best practice.
Examples: knowledge and competence with EBP, ability to measure patient outcomes, commitment to guide practice based on most up-to-date evidence and patient outcomes
Professional Expertise
Changing Practice Based on
Empirical Research
General Process of Changing Practice based on Empirical Research
Select a topic
Problem focused
Knowledge focused
Evidence retrieval
Types of reviews
Appraisal of strength and level of evidence
Synthesis of research
Decide whether to change practice
Selection of Topic
Problem-focused:
recurring clinical problems
discrepancies in procedures
quality improvement
Knowledge-focused:
new information
new equipment, drugs or treatments
Sources of Evidence
Preferred sources of evidence:
Primary sources
Peer reviewed sources
Journals (not magazines)
Integrated reviews
Meta-analyses
Systematic reviews
Popular vs Scholarly Sources
Does the Study Provide Good Evidence?
Five Step Approach
Ask (Identify the research question. Determine if the question is well constructed to elicit a response or solution.)
Acquire (Search the literature for pre-appraised evidence or research. Secure that best evidence that is available.)
Appraise (Conduct a critical appraisal of the literature and studies. Evaluate for validity and determine the applicability in practice.)
Apply (Institute recommendations and findings and apply them to nursing practice.) (Evaluate the application of the findings, outcomes, and relevance to nursing practice.)
Judging Credible Sources
Is it absolutely clear which company or organization is responsible for the information on the site?
Is there a link to a page describing what the company or organization does and the people who are involved (an “About Us” page)?
Is there a valid way of making sure the company or organization is legit – meaning, is this a real place that has real contact information (email only is not enough)?
Judging Credible Sources
Can I easily figure out who wrote the information?
Are all factual claims clearly substantiated, that is, are there cited (linked) sources?
Are there any glaring grammatical and spelling errors? This could indicate that the content is not credible.
How long ago was the page updated? Is there a date stamp on the article somewhere? You’ll need this especially if you’re using MLA-style citation.
Can you verify the expertise of the author? Are the writer’s qualifications clearly stated somewhere on the site?
Judging Credible Sources
Is there an overwhelming bias in the information? Does the writing seem fair and balanced? Or is the writing overly slanted towards a particular point of view?
Is the URL appropriate to the content? You should be able to figure out from the site address who the site belongs to, since most organizations and businesses put their name in the URL. This is a good way to determine quickly if the site is legit for your purposes; for example, if you’re researching mad cow disease you probably don’t want to get information from the Beef Farmers of America.
Are the ads clearly separated from the content?
Which of the following are credible web sites?
Wikipedia
New York Times online
Newsweek
Society of Thoracic Surgeons
ObamaCare 101
Americans for Tax Reform
RN Journal
Sources of Evidence
Electronic indices
Used to be called index, now called databases
Examples: Cumulative Index to Nursing and Allied Health Literature (CINAHL)
OVID (physician)
Pub Med (US National Library of Medicine)
Ebsco
Silverplatter
Elsevier
Thomson Gale
EBN Online (
http://ebn.bmj.com)
Cochrane Collaboration and Library (http://www.cochrane
Sources of Evidence
Electronic indices (cont.):
TRIP database (Centre for Evidence-based Medicine)
Virginia Henderson International Nursing Library (STTI)
Evidence-based Practice (AHRQ)
National Guidelines Clearinghouse (
http://www.guideline.gov)
National Institute of Nursing Research (NINH)
EMBASE (pharmaceutical and biomedical)
Clinical Trials.gov (
http://clinicaltrials.gov/ct/gui)
American Factfinder (
http://factfinder.census.gov/home/saff/main.html?_lang=eng)
PsycINFO (http://www.apa.org/psyinfo/)
Sources of Evidence
Electronic indices (cont.):
ERIC (Educational Resources Information Center) (http//www.eric.ed.gov)
Sociological Abstracts (http:www.csa.com/factsheets/socioabs-set-c.php)
Social Services Abstracts
http://www.sca.com/factsheets/ssa-set-c.php
ABI/Inform (business database)
http://proquest.com/products_pq/descriptions/abi_inform.shtml
UMI Dissertation Publishing (http:www.il.proquest.com/products_umi/dissertations)
Google Scholar (http://scholar.google.com/)
Sources of Evidence
Grey literature
Unpublished reports
Unpublished conference papers
Grant proposals
Exercise
Electronic Sources
Synthesis of Evidence
Scientific merit of studies
Subjects studied
Relevance of study to research question
Strength of evidence
Design
Weaknesses
Significance of results
Levels of Evidence
RCT
Cohort
Case Control
Correlational
Non-experimental Studies
Case Series
Descriptive
Case Reports
Expert Opinion
Make a Decision of Whether
to Change Practice
Relevance of evidence for practice
Consistency of findings across studies and/or guidelines
Representativeness of the sample to your patient population
Consistency among research evidence and non-research evidence
Feasibility for use in practice
Risk/benefit ratio for the patient
Exercise: Judging Strength of Evidence
National Guidelines Clearinghouse
Models Used for Building an Evidence-based Culture in Organizations
Building Evidence-based Practice
Evidence-based practice shouldn’t
happen in isolation.
Steps of Evidence-based Practice
Cultivate a spirit of inquiry (clinicians must be comfortable with and excited about asking questions about patient care and institutional or unit-based practices)
Steps of Evidence-based Practice
2. Ask clinical questions in PICOT format
P = patient population
I = Intervention or Issue of interest
C = Comparison intervention or group
O = Outcome
T = Time frame
Steps of Evidence-based Practice
Example of PICOT question:
In teenagers (the patient population), how does cognitive-behavioral skills building (the experimental intervention) compared to yoga (comparison intervention) affect anxiety (the outcome) after 6 weeks of treatment (time frame)?
Steps of Evidence-based Practice
3. Search for best evidence (conduct a systematic, integrated review)
Steps of Evidence-based Practice
4. Critical appraisal of evidence
Are the results of the study valid? (Are the results as close to the truth as possible?)
What are the results? (Did the intervention work? How large was the treatment effect? Would replication of the study yield similar results?)
Will the results help me in caring for my patients? (Are the subjects in the studies similar to my patients? Are the benefits greater than the risks? It the treatment feasible? Does the patient desire the treatment?)
Steps of Evidence-based Practice
If the answer to # 4 is yes,
5. Integrate the evidence with clinical expertise and patient preferences to make the best clinical decision.
Steps of Evidence-based Practice
If the answer to # 4 is no,
5. Generate internal evidence through an EBP implementation or outcomes management project or a research study
Steps of Evidence-based Practice
6. Evaluate the outcomes of the practice change based on evidence (Measure patient outcomes or health care quality to determine if this clinical decision was effective.)
Steps of Evidence-based Practice
7. Disseminate the outcomes of the evidence-based practice change. (locally, regionally, nationally)
Barriers to Evidence-based Practice
Staff lack EBP knowledge and skills
Lack of belief that EBP will result in better outcomes than traditional care
Amount of information published
Lack of time to appraise evidence
Overwhelming patient loads
Barriers to Evidence-based Practice
6. Lack of administrative support
7. Peer pressure to “not make waves”
8. Resistance to change
9. Lack of autonomy over practice
10. Lack of consequences for not implementing EBP
Leading Organization-wide Change
Implementing Evidence in Clinical Settings
Develop a vision for change.
Start with small steps. Select a nursing intervention, conduct an intensive literature review, and build awareness among the nursing staff. Stress the need for a change in practice.
Implementing Evidence in Clinical Settings
2. Promote engagement in EBP
Engage key stakeholders. Assess current attitudes toward the practice in question. Have discussions about the issue. Determine who the decision makers are. Enlist staff with expertise in EBP. Gain administrative support for EBP initiative. Assess and eliminate barriers.
Implementing Evidence in Clinical Settings
3. Integrate evidence-based practice
Establish formal integration teams. Build excitement. Disseminate evidence. Show link between proposed change and patient outcomes. Develop clinical tools that are available to staff and easy to use. Pilot test the change, implementing complex change in stages. Establish goals and timelines. Celebrate success.
Implementing Evidence in Clinical Settings
4. Link evidence-based practice to clinical outcomes. Measure outcomes through:
outcome measures (healthcare results that can be measured such as health status, death, health behaviors, economic impact, disability)
Quality care improvement (quantify how interventions impact the quality of lives)
Patient-centered quality care (the patient is an equal partner in their own care)
Efficiency of processes (efficient utilization of resources)
Environmental changes (creation of a culture that promotes EBP)
Professional expertise (creates an expectation of professional competence)
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