Introduction to Evidence-Based (Informed) Practice (EBP)

1. Introduction to Evidence-Based (Informed) Practice (EBP) Ms. Laura Banfield, Health Sciences Library Dr. Michelle Butt, School of Nursing Fall 2009

2. Learning Objectives • Define evidence-based (informed) practice and the steps in the process • Distinguish background and foreground questions and identify resources to answer them • Differentiate among different research approaches and designs • Use PICO to formulate a clinical question • Understand the steps needed to plan and carry out a search of the literature for the best external evidence

3. “The integration of best research evidence with clinical expertise and patient values to facilitate clinical decision making” (Sackett et al., 2000) Evidence-Based Practice (EBP)

4. Clinical Decisions Patient preferences and actions Clinical state, setting, and circumstances Clinical Expertise Clinical Expertise Health care resources  Research evidence DiCenso, Cullum & Ciliska [as adapted from Haynes, Devereaux & Guyatt (2002)] Introduction to EBP

5. Evidence-Based Practice (EBP) • “The best available evidence is used alongside clinical expertise and the patient’s perspective to plan care” (Flemming, 1998, p.36) • Evaluation of performance (or outcome) occurs via peer assessment, an audit, or through a process of self-reflection (Flemming, 1998) Flemming, K. (1998). Asking answerable questions. Evidence-Based Nursing, 1(2), 36-7.

6. Steps of EBP* • Construct a relevant, answerable question from a clinical case. • Search the literature to retrieve the best evidence. • 3. Critically appraise the literature (evidence) for validity and applicability. • 4. Apply the evidence to your clinical practice. • 5. Evaluate the outcome or performance. *From:Flemming, K. (1998). Asking answerable questions. Evidence-Based Nursing, 1(2), 36-7.

7. Asking Clinical Questions Two Types of Clinical Questions: 1. Background 2. Foreground

8. Background & Foreground Questions • Background questions are: • general in nature • address gaps in background knowledge • examples include: pathophysiology, or risk • factors of a disease; an overview of a nursing • theory • Foregroundquestions are: • focused on the particular patient scenario, and • ask for specific knowledge to manage the patient

9. Background & Foreground Questions • Background questions • Need to be answered first • Can be answered by books or general Websites • Foreground questions • Need to be very focused • Can be answered by searching journal databases

10. Background & Foreground Questions • Examples of Background questions: • What is the mechanism of action of insulin? • How do you conduct a neurological assessment? • Examples of Foreground questions: • Is exercise more effective than a low-fat diet in reducing blood pressure in hypertensive patients? • Is there a relationship between cell phone use in adults and the incidence of brain tumors?

11. Two Major Research ‘Categories:’Quantitative Research & Qualitative Research

12. Two Major Research ‘Categories’ Quantitative Researchis an “objective, systematic process to describe and test relationships and, examine cause and effect interactions among variables” (Burns & Grove, 1993, p. 777) Qualitative Researchis a systematic, subjective approach used to describe life experiences and give them meaning” (Burns & Grove, 1993, p. 777)

13. Quantitative Research** • Goal is the discovery of relationships, or causation (cause & effect). • Based on scientific method (hypothesis formation and testing) • Many quantitative designs compare two or more groups • Often involves an element of control • Objectivity (related to measurement) • Collection of data (numerical) and analysis via statistics **Burns & Groove, 1993; Roberts & Burke, 1989

14. Studies focus primarily on one of the following: Therapy/Treatment/Intervention; Prevention and Control – Effectiveness Etiology/Causation/Harm Prognosis – Outcome Diagnosis and Screening/Assessment Economics Quantitative Research Studies

15. Quantitative Research Designs*** Quantitative research designs (studies) include: • Randomized Controlled Trials (RCTs) • Cohort Study (Cohort Analytic) • Case-Control Study • Cross-Sectional Study (survey) • Case Report or Study ***Greenhalgh, 1997

16. Steps in Searching for Research Literature – Quantitative Research • What aspect of care are you interested in? • Etiology/causation? • Therapy/treatment/prevention? • Diagnosis? • Prognosis? • Quality of care? • What are you doing? (Intervention) • Who are you doing it to? (Patient population) • What do you want/not want to happen? (Outcome)

17. Steps in Searching for Research Literature – Quantitative Research • Ask a focused question using PICO* * This is what you will do for your evidence-based resources report (assignment)

18. Framing the Question • P opulation / Situation • I ntervention / Exposure • C ounter intervention • O utcome

19. Question - Therapy Is water as effective as alcohol in preventing umbilical cord infections in newborn infants?

20. P opulation: I ntervention: Counter intervention: O utcome: newborn infants water alcohol umbilical infections Question - Therapy

21. Question – Causation (Etiology) or Harm Do vending machines in high schools increase the risk of obesity?

22. P opulation: E xposure: Counter exposure: O utcome: High school students Soft drinks in vending machines No soft drinks Obesity Question – Causation or Harm

23. Qualitative Research • Aim is to discover meaningor gain understanding of a phenomena • Investigates a phenomena in-depth Roberts & Burke (1989)

24. How people feel or experience a certain situation or circumstance Sampling of a small group of people Data collected via in-depth unstructured interviews, observation, focus groups, diaries Analysis of findings in narrative format Qualitative Research

25. Qualitative Research Examples of qualitative research designs include: • Phenomenology • Examine the ‘lived experience” of individuals experiencing a phenomena • Grounded Theory • Goal is to understand a social-psychological process and develop a theory • Ethnography • Study of a group or culture within their own setting

26. Framing the QUALITATIVE Question • P opulation • S ituation

27. Question How do caregivers feel about placing a spouse with Alzheimer’s Disease in a nursing home?

28. P opulation: S ituation: caregivers placing a spouse with Alzheimer’s Disease in a nursing home Question

29. Steps in Searching for Research Literature • Ask a focused question using PICO (for quantitative studies) • Determine what are the best sources for this question, e.g. which journal database – CINAHL, Medline

30. Identify the terminology used in the chosen resource (thesaurus): Nursing & Allied Health (CINAHL) subject headings MeSH (Medical Subject Headings) Map your question to the thesaurus Steps in Searching for Research Literature

33. Hands-on Workshops for Searching Will be Offered When? • one hour during tutorial on: • Thursday, October 1st OR • Friday, October 2nd Where? • eClassroom – upper level, Health Sciences Library