Evidence Based Practice In Nursing

1. Evidence Based Practice In Nursing Dr. Abdul-MonimBatiha Assistant Professor Critical Care Nursing Philadelphia university

2. Today’s health care system has become increasingly more costly and complex. Consequently, in this market-driven delivery system, there is a greater emphasis on outcomes, cost-effectiveness, and consumer satisfaction.

3. These pressures operate in an environment of rapid information exchange, technological advancements, and an increasing nursing workload • Nurses are challenged to maintain clinical competence, to demonstrate how their care positively affects patient outcomes, & to participate actively in clinical decision-making & practice improvements

4. Nurses are now mandated to demonstrate cost-effectiveness and efficiency with the use of time and resources, while continuing to demonstrate their value added impact on outcomes. These mandates provide a strong rationale for adopting an evidence-based model of practice

5. What Is Evidence- Based Nursing?

6. Evidence – Based Nursing (EBN) • Process by which nurses make clinical decisions using the best available research evidence, their clinical expertise & patient preferences" Clinical expertise • Ability to use our clinical skills & experience to rapidly identify each patient's unique health state &diagnosis, their individual risks & benefits of potential interventions, & their personal values & expectations

7. Patient values& preference • Unique preferences, concerns & expectations each patient brings to a clinical encounter & which must be integrated into clinical decisions if they are to serve the patient

8. Goals of EBN are to apply valid & reliable nursing research to clinical practice "Research utilization" & to bring the most current knowledge to clinicians. This is particularly important due to the knowledge explosion in nursing and health care

9. Steps to Evidence-Based Critical Care Nursing Practice • Accept the fact that health care is evolving, with the consequent need to base nursing care on evidence, rather than on tradition or previous education • Identify a need for change in practice by examining less-than-favorable patient outcomes; causes of patient, family/significant other, or staff dissatisfaction; or situations in which compelling new evidence exists in an aspect of care

10. Frame a clinical question and search the literature for evidence regarding the topic • Once current research data and evidence have been collected, evaluate the evidence for scientific merit, quality, and applicability

11. Synthesize to determine the strength of the evidence to support a change in practice • Conduct a comparison between current practice recommendations and current research

12. If there is sufficient evidence to suggest a change in practice and the change in practice is practical in respect to costs, staff skill, and resources required, application of the evidence into practice can occur Implicit in the implementation of evidence are the issues associated with change, including fear of change & the need for information, staff training, leadership, & ongoing evaluation of the change

13. Continue to evaluate the evidence through an ongoing and systematic review to promote state of- the-science nursing care

14. Converting information needs into clear questions

15. Art to Phrasing Questions • An art to phrasing questions in such a way as to elicit a meaningful answer, there are three key reasons for focusing questions:

16. Facilitating the search for relevant evidence. The more explicit the question, the easier it is to run searches on electronic databases such as those contained within the Library shelves, CINAHL (Cumulative Index of Allied Health and Nursing Literature, or MEDLINE A non-focused question is more likely to yield larger numbers of non-relevant studies than a focused question, and valuable search time will be wasted trying to sift through the long list of retrieved references for relevant studies

17. Sorting best evidence from weaker, less valid evidence • Deciding whether the evidence is applicable to our patients • The PICO (population, intervention, comparison intervention, out­come) framework, devised by Saekett et al (1997), is a useful method for making questions more focused. The question is built in four (or three) parts

18. PICO Frame • Populationor Problem, it may be necessary to specify age, gender, disease type, disease severity or co-morbidity. This will depend on whether the results of a very broad, inclusive population could be applied to your specific patient group Define who or what the question is about

19. PICO Frame • Intervention: Define which intervention, test or exposure you are interested in. An intervention is a planned course of action. An exposure is something that happens such as a fall, anxiety. The intervention (or test or exposure) may need to be described in some detail to ensure clarity Describe what it is you are considering doing or what it is that has happened to the patient

20. PICO Frame • Comparison intervention: Define the alternate intervention Describe the alternative that can be compared with the intervention Outcomes: Define the important outcomes, beneficial or harmful Define what you are hoping to achieve or avoid

21. PICO Frame • Outcomes: very general outcomes may be difficult to measure, and details of how outcomes can be objectively measured may need to be specified

22. Searching Literature

23. Basic search principles • Analyzing the question • Generating a word list • Linking word lists( Boolean logic: AND, OR, NOT)

24. Boolean Operator

25. Boolean Operator

26. Boolean Operator

27. Types Of Evidence Used

28. Health Care Indexes • Research • Retrospective or Concurrent Chart Review • Quality Improvement & Risk Data & Benchmarking • International, National, & Local Standards • Infection Control Data • Pathophysiology • Cost-effectiveness Analysis • Patient Preferences • Clinical Expertise

29. Health care indexes • Two of the most common indexes used by nurses are MEDLINE, produced by the National Library of Medicine (NLM) • CINAHL (Cumulative Index for Nursing & Allied Health Literature) produced by the C1NAHL corporation. Both of these are available in print & computerized forms

30. The International Nursing Index, Hospital Literature Index, Psych Index, and Social Sciences Index are other common used indexes that would reference articles and books pertinent to nursing practice • Many libraries subscribe to computerized databases such as Ebscoand Proquest, which provide citations, abstracts, and some whole articles

31. The Cochrane library Collaboration prepares maintains and disseminates systematic reviews of health care interventions focusing primarily on systematic reviews of controlled trials of therapeutic interventions (the gold standard for experimental research design)

32. Research • Most experts consider the well-designed double-blind experiment (often referred to as the randomized control trial) the best type of evidence • Another type of evidence is found in research studies that have fewer controls. Some of these types of studies are included in the discussion of reading research. The Centers for Disease Control and Prevention identify these types of research evidence as the most important in demising their guidelines for disease and injury prevention and control

33. Retrospective or concurrent chart reviews, Quality improvement and risk data • Aggregating data across an institution or several institutions provides an opportunity to assess how well current practices are working • Determining patient outcomes for large groups provides a firm foundation of data that, although not part of a research study, can guide practice • Individual health care institutions and health plans are compiling information for statistical analysis & making decisions about health care based on these statistical measures

34. International, national, and local standards • Bring together the opinions & expertise of many health care providers • The standards are based on the collective experience & goals of individuals who are intimately involved with health care practice • Individuals who have worked with many patients, seen the results of multiple trials, & identified at first hand the complexity of the care have a special insight into effective practice. Because of this involvement & knowledge, the standards provide guidance and support for practice

35. Infection control data • Because infection remains a major complicating factor in health care, infection control data assume major importance as guide for practice • The incidence of infection is of critical importance to both the patient and the entire system in terms of its impact on overall health outcomes • Practices that decrease the potential for infection have high priority

36. Modern understanding of pathophysiology • Modern understanding of pathophysiology at even the cellular level has changed thinking about many health care practices

37. Information regarding cost-effectiveness analysis • Helps an institution weigh possible benefits against costs • It compares how much improvement a certain practice makes versus how much that practice costs

38. Patient preferences • the importance of self-care in managing health and illness, practices to which patients will adhere and ones that make their lives simpler are more likely to be incorporated • Failure to take into consideration patient preferences may make the best-designed therapy ineffective

39. Opinions of clinical experts • Remain an important aspect of evidence. Individuals who have worked with many patients, seen the results of multiple trials, and identified at first hand the complexity of the care have a special insight into effective practice

40. Systematic Analysis of Information &Evidence

41. Not all published research evidence can be used for making decisions about patient care • Deficiencies in research design can make an intervention look better than it really is • The location and subjects of a particular research study may affect the results in a unique way • Assess the quality, importance and applicability of any research evidence that is being consulted to answer a specific clinical question critical appraisal

42. Critical Appraisal • The purpose of the critical appraisal for evidence-based practice is to decide whether the quality of a research study is good enough for the results it provides to be used to answer a question posed by a health care practitioner or patient • Critical appraisal can be broken down into three distinct but related parts:

43. Is the quality of the study good enough to use theresults? • Are the findings applicable in my setting? • What do the results mean for my patients?

44. Criteria & questions for use in assessing the quality of research studies

45. Matching study design to questions

46. Factors to consider when assessing the quality of a study • Randomization • The group to which the patient has been allocated must be concealed from the clinician/researcher until the patient has been accepted into the trial • Demographic and health status details for the two groups are of interest • It is helpful if the intervention is described in sufficient detail to allow clinicians to reproduce it in their own setting

47. Keeping patients, clinicians and researchers blinded as to whether a patient is in the treatment or control group is a useful way of minimizing bias • People drop out of studies for all sorts of reasons: death, relocation to another geographical area, treatment found to be too unpleasant, etc. It is important that the researcher tries to identify whether the reasons relate to the outcomes of interest

48. Factors to consider when assessing applicability • The characteristics of the participants in the study • Is it feasible to introduce the intervention or test described in the study? • When thinking of the costs and benefits of the intervention or test, think beyond purely financial terms

49. Questions for assessing & screening applicability • Is it clear what the study about? • Is the same sample adequately considered? • Are my patients / context sufficiently different that results will not apply? • Is the action indicated, or the intervention available, or the change possible in my setting? • Do the benefits of any change for my patients / context outweigh the like costs? • Are the patient’s values and preferences satisfied by change? Are my colleagues and mine?

50. Questions that must be included in deliberations for evaluating information • Is the source identified? • Is the source reliable? • Is the source biased? • How timely is the information relative to the need? • How does the information fit with the purpose for which it will be used? • How does the setting that originated the information compare with your setting?