What is Evidence-Based Practice?

1. What is Evidence-Based Practice? Evidence-Based Practice from a Nursing Perspective Cynthia Padula, PhD, RN Nurse Researcher, The Miriam Hospital Master’s Program Director, Rhode Island College

2. Objectives • Describe evidence based practice from a nursing perspective • Identify challenges to using evidence based practice in nursing • Compare and contrast evidence based nursing and medicine • Recognize the impact of the Magnet movement on evidence based nursing practice • Identify resources relevant to nursing

3. Definition “Process by which nurses make clinical decisions using best available evidence, clinical expertise, & patient preferences in the context of available resources” (DiCenso, 1998)

4. Evidence Based Practice

5. What is Evidence-Based Nursing Practice • Builds on process of research use, but more encompassing • More specific than term ‘best practices’ • Does not foster rigid adherence to standardized guidelines • Recognizes the role of clinical expertise • EB nursing practice is a state of mind!

6. Why Evidence-Based Practice in Nursing • Fueled by accrediting bodies, professional organizations, third party payers • Potential to improve quality, reduce variations in care • Focus on practices that result in best possible outcomes at possibly lower cost • Provides a way to keep pace with advances

7. Why Evidence-Based Practice in Nursing • Potential to narrow the ‘research-practice gap’: adoption of research findings into practice can take as long as 17 years (Balas & Boren) • Impacted by perception that published research is not • relevant to practice • Provides a means to answer problematic clinical • practice issues • Potential to improve individual bedside practice; • supports/improves clinical decision-making skills • Bedside nurse as conduit!!

8. Traditional Basis for Nursing Practice (Stetler) • Rituals, unverified rules • Anecdotes, isolated experiences • Customs, opinions, unit cultures • Physicians’ authority

9. Bases for Practice in Nursing (Stetler, 1998) • Philosophical/conceptual basis: mission; values; professional practice models; conceptual frameworks; professional codes • Regulatory basis: state practice act; JCAHO; regulatory agencies • Traditional basis • *Evidence-based practice

10. Alternative Approach • Clinical expertise as necessary but not sufficient to provide best possible care • Emphasis is on systematic, reproducible, unbiased evidence • Focus on evidence authority *in combinationwith clinical expertise

11. Core Competencies • Ask: why are we doing this.. what is the evidence? • Think critically! • Think out of the box!

12. Core Competencies (cont.) • Prioritize and clearly articulate answerable clinical questions with a focus on outcomes • Appreciate role of quality improvement activities • Evaluate practice outcomes • *Work effectively with others

13. Core Competencies (cont.) • Search for evidence • Evaluate the evidence

14. Core Competencies (cont.) • Read and understand research

15. Levels of Evidence Hierarchy(Stetler et al.)* • Level I: Meta-analysis of multiple RCTs • (‘gold standard’) • Level II: Individual RCTs • Level III: Quasi-experimental • Level IV: Non-experimental; qualitative • Level V: Program evaluation; QI; RU; case reports • Level VI: Opinion of respected authorities *modified slightly by Padula

16. Levels of Evidence Pyramid

17. Evidence Based Practice Process • Identify a practice issue • Formulate an answerable question • Search for best evidence • Critically evaluate the evidence and clinical relevance • Make recommendations • Apply to clinical practice • Evaluate impact/effectiveness/ outcomes

18. EBP in Nursing

19. Readiness of US Nurses for EBP (Pravikoff et al., 2005) • Purpose: to examine nurses’ perceptions of their skills in obtaining evidence and their access to tools with which to do so. • Sample: stratified random sample of 3,000 RNs across the US; 1,097 responded • Measurement: 93 item measure; content validity established; varying response format

20. Sample Characteristics (Pravikoff et al.) • 91% female • 79% between >40 years of age • Educational preparation: Diploma 17% AD 34% BSN 39% MS 9% • Employment: 60% in hospitals

21. Subscale: Information Need/Seeking • How often do you need • information to support nursing role? 61%: once or twice a week • How do you find the information • needed? 67% always or freq sought a colleague 58% didn’t use research reports at all 82% had never used a hospital library

22. Subscale: Resource Availability and Use • 83%: at least somewhat successful when searching the Internet • 19% somewhat confident in ability to search CINAHL; 76% never search CINAHL • 36% somewhat confident in ability to search MEDLINE • 83% rarely or never sought librarian assistance; 82% didn’t use hospital library

23. Resource Use/Availability (cont.) • 77% had never received instruction re: electronic resources • 36% reported had access to electronic databases; 29% did not know if access was available • 26% had access to electronic databases on nursing units • 49% had access to the Internet on units

24. Subscale: Individual Barriers (other than time) • Lack of value for research in practice • Lack of understanding of electronic databases • Difficulty accessing materials • Lack of computer skills • Difficulty understanding articles • Lack of: access to computer; library access; search skills; research knowledge; critiquing skills

25. Varying entry levels Rapid indoctrination Off unit access difficult Clinical reality more ‘subjective’/’human response’ Most quasi or below; qualitative MD degree Internship/residency Easier access off unit Focus on ‘objective’ reality/ treatment effectiveness research More RCTs Differing Challenges:Nursing Medicine

26. Using the Magnet Influence • Administered by the American • Nurses Credentialing Center http://nursingworld.org.ancc • Magnet designation recognized • and rewards nursing excellence • Forces of Magnetism (14) identified via a landmark study (McClure & Hindshaw)

28. Selected Forces • Professional models of care -must designate a nursing theory • Quality of care -support of research/evidence based practice • Quality improvement -nurse driven, evidence based quality initiatives

29. Selected Forces (cont.) • Professional development -training, mentoring • Interdisciplinary relationships -opportunities for collaboration; consultation

30. Collaboration is Key • Library can serve as archive for nursing publications/Magnet applications (Rourke) • Committee participation • Heightened visibility • Facilitation is key • Write library services and • librarians into grants

31. Take the Magnet Journey!!

32. Resources • Evidence Based Nursing Journal • Online Journal of Knowledge Synthesis for Nursing, Sigma Theta Tau http://www.nursingsociety.org • US Preventive Services Task Force http://www.ahrq.gov/clinic/uspsfact.htm

33. Selected Lifespan Resources • Direct links to PubMed and Ovid • Micromedex • > 3000 journals • DXplain • MD consult

34. References • Baras, E., & Boren, S. (2000). Managing clinical knowledge for • healthcare improvement (pp. 65-70). Germany: Schattauer • Publishing. • Dee, C., & Stanley, e. (2005). Nurses’ information needs: nurses’ and • hospital librarians’ perspective. J Hosp Librar, 5(2), 1-13. • Hallyburton, A., & St. John, B. (2009). Partnering with your library to • strengthen nursing research. J Nsg Educ, 49(3), 164-167. • McClure, M., & Hinshaw, A. (2002). Magnet hospital revisited. • Washington DC: ANA. • Pravikoff, D., Tanner, A., & Pierce, S. (2005). Readiness of US nurses • for evidence-based practice. AJN, 105(9), 40-51.

35. References (cont.) • Rourke, D. (2007). The hospital library as a “Magnet Force”…Med Ref • Svcs Quar, 26(3), 47-54. Sherwill-Navarro, P., & Roth, K. (2007). Magnet hospital/magnetic • libraries. J Hosp Librar, 7(3), 21-31 • Stetler C. et al. (1998). Evidence-based practice and the role of nursing • leadership. JONA, 28(7/8), 45-53. • Stetler, C. et al. (1998). Utilization-focused integrative reviews. Appl • Nurs Res, 11(4).