Advocacy Through Evidence-Based Practice

1. Sally Decker, PhD, RN, CNE Saginaw Valley State University Advocacy Through Evidence-Based Practice

2. Objectives: • Explain Evidence-Based Practice as a form of patient advocacy • Explore how Evidence-Based practice can be used to advocate for the nursing profession

3. “advocatus” in Latin is one who is summoned to give evidence • Thinking of evidence broadly, nurses are “summoned” to use the best evidence in the care of the individual and the care of groups of individuals and the care of the nursing profession.

4. Models of Advocacy – Fowler, 1989; Baldwin 2003 • Guardian of Patients’ rights (legal) • Preservation of Patient values • Champion of social justice in the provision of health care (social advocacy – use of best practice for groups) • Conservator of Patients’ best interests (respect for persons- use of best practice for individuals)

5. “The good of the one versus the good of the many”

6. Definitions of Evidence-Based Practice • EBP is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research." (Sackett D, 1996) • EBP is the integration of clinical expertise, patient values, and the best research evidence into the decision making process for patient care. Clinical expertise refers to the clinician's cumulated experience, education and clinical skills. The patient brings to the encounter his or her own personal and unique concerns, expectations, and values. The best evidence is usually found in clinically relevant research that has been conducted using sound methodology. (Sackett D, 2002)

7. Evidence from the many but applied to the one • definitions of EBP suggest practice based on the best available evidence that also incorporates patient values and preferences and clinician judgment and expertise Sackett, et al. (2000); Cronenwett et al. (2009)

8. Evidence is collected from groups of individuals • Advocacy has been thought of as protecting legal and moral “rights” of individuals but individuals also have the “right” to the best possible care and advocacy can be for groups and not just individuals. • Evidence is generated from groups and therefore the use in a specific case can’t be assumed.

9. Advocate for the one or for the many- is there a difference? • Saitz (2010) writing in the Annals of Internal Medicine, questioned if the candidate performance measures for screening for unhealthy substance use in hospitals was advocacy or evidence-based practice – suggesting they were two different things.

10. Hospital vs outpatient • So evidence collected in one setting and for one purpose may not be the evidence needed in another setting and for another purpose

11. Steps in EBP: • Develop the question: P= population I = intervention C=comparison O=outcome t = time (Fineout-Overholt, et al.) • Search for best evidence • Critically analyze and synthesize • Develop recommendations • Evaluate the outcome of EBP changes

12. RCTs create the highest evidence in terms of generalizability and reproducability – but are not the only evidence for use in clinical practice Polit and Beck 2008

13. Where is the evidence – Systematic Reviews and Evidence websites • Agency for Healthcare Research and Quality www.ahrq.gov/clinic/epcix.htm • Cochrane Library www.cochrane.org • Joanna Briggs Institute for Evidence-Based Nursing and Midwifery www.joannabriggs.edu.au • National Guideline Clearinghouse www.guidelines.gov • CINAHL/Medline

14. Nightingale: Advocate for individuals, groups, and for the nursing profession Use of social statistics in the care of individuals and group – policy change

15. Evidence-based advocacy for nurses • Kendall-Gallagher, Aiken, Sloane, & Cimiotti (2011). Nurse specialty certification, inpatient mortality and failure to rescue. • Mchugh et al. (2011). Impact of nurse staffing on safety-net hospitals. • Flynn, Liang, Dickson, & Aiken (2010) Effects of nursing practice environments on quality outcomes in nursing homes. • AHRQ. Hospital Nurse Staffing and Quality of Care

16. Advocacy by nurses for groups of individuals Tapping the potential for research-based advocacy King (2011) – • Policy-relevant research and evidence-informed policy in public health and now policy-directed advocacy –especially in obesity, environmental factors, food labeling. • Global issues such as tobacco use have been addressed by WHO with expert synthesis of research

17. Other examples of use of evidence as advocacy in the literature • Mmatli (2009). Translating disability-related research into evidence-based advocacy • Anderson (2011). Behavioral research in pediatric diabetes: Putting the evidence to work for advocacy and education • Vaartio, Leino-Kilpi, Suominen & Puukka (2009). Nursing advocacy in procedural pain care

18. Remember- an advocate uses the best evidence (from the many) and applies it to the individual (the one) using clinical expertise and patient uniqueness • Rosenberg & Allard (2008) Women and statin use: A women’s health advocacy perspective. • Ford-Gilboe, Wuest, Varcoe & Mettirr-Gray (2006). Developing an evidence-based health advocacy intervention for women who have left an abusive partner.