Evidence-based Nursing Practice—getting started

1. Evidence-based Nursing Practice—getting started

2. Keystones of Evidence-based Practice • Integration of the best possible research/evidence with clinical expertise and with patient needs.

3. Why Evidence-based Practice? • Patients who receive care based on the best and latest evidence experience 28% better outcomes (Heater, Becker, & Olson, 1988) • Healthcare providers who use an EBP approach to delivering patient care experience higher levels of satisfaction (Dawes, 1996) • Without EBP, practice is rapidly outdated, often to the detriment of patients. It often takes as long as 17 years to translate research findings into practice (Balas &Boren, 2000)

4. Sources of Knowledge • Experience • Nursing School • Workplace Sources • Physician Sources • Intuitions • Literature—rated bottom 5 for frequency Estabrook CA. Will evidence-based nursing practice make practice perfect? CJ Nurs Res 1998; 30:15-36.

5. Lack of knowledge regarding EBP strategies Misperceptions or negative views about research and evidence based care Lack of time and resources to search for and appraise evidence Overwhelming patient loads Organizational constraints, such as administrative support or incentives Demands from patients for a certain type of treatment Peer pressure to continue with practices steeped in tradition Inadequate content and behavioral skills regarding EBP in educational programs Barriers to Evidence-based Practice Barsteiner & Prevost, 2002; Cronenwett, 2002; McKibbon, 1999; Melnyk, 2002; Menyk et. al., 2000; Silagy & Haines, 1998.

6. Facilitating Conditions • Organizational capacity for change that includes strong support and interest at all levels of leadership • Implementation infrastructure (adequate resources & time) • Characteristics of the healthcare team (a shared vision and mission) • Guideline characteristics (Importance of the guideline to clinicians, credibility of the guideline) (Solberg et al., 2000) • Mentorship in EBP (Melnyk & Fineout-Overholt, 2002)

7. The power of observation • “The most important practical lesson that can be given to nurses is to teach them what to observe-how to observe…but if you cannot get the habit of observation one way or other, you had better give up being a nurse…” Florence Nightingale

8. Observe patients and families for their responses to treatment and for cues that the current plan of care may not be effective. Question current practice and identifies issues amenable to change. PI data Nursing report cards Staff practice concerns New knowledge shared Policies and Procedures Question significance of the clinical issue. What are we observing?

9. Five Steps ofEvidence-based Practice • Ask the burning clinical question. • Collect the most relevant and best evidence. • Critically appraise the evidence. • Integrate all evidence with one’s clinical expertise, patient preferences, and values in making a practice decision or change • Evaluate the practice decision or change.

10. Model for Evidence Based Practice from Larabee and Rosswurm as published in Sigma Theta Tau

11. What’s the question? • Background vs. Foreground Information • Therapy • Etiology • Diagnosis • Prevention • Prognosis • Meaning

12. PICOT: asking the question • P= Population • I= Intervention • C= Compared to • O= Outcome • T= Timeframe

13. What are your resources? • Polices and Procedures • Leadership • Clinical Nurse Specialists/APN/Medical Staff • Clinical Instructors • Educators • Directors • Nursing Practice and PI Committees • Medical Library • Internet

14. Start with guidelines*! • Evidence Based Practice Centers • http://www.ahcpr.gov/clinic/epc/ • Cochrane Collaboration • http://www.cochrane.org • National Guideline Clearinghouse • http://www.guideline.gov/ • Agency for Healthcare Research and Quality • http://www.ahrq.gov • University of York Center for Reviews • http://www.york.ac.uk/inst/crd/crddatabases.htm • The Joanna Briggs Institute for Evidence-Based Nursing • http://www.joannabriggs.edu.au/about/home/php *List not complete

15. Burkholder Medical Library • Requests can be faxed to 381-4317, phoned to Ext. 12276 or e-mailed to library@slrmc.org. • Information to include in fax: Please complete a search for me—more pertinent information is better than less if in question

16. Literature Search Results • Search output--parts • Title • Who ,When, Where and What published • Peer reviewed • Qualitative vs. Quantitative

17. Quantitative Rating System for the Hierarchy of Evidence • Level I: Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs), or evidence-based clinical practice guidelines based on systematic reviews of RCTs • Level II: Evidence obtained from at least one well-designed RCT • Level III: Evidence obtained from well-designed controlled trials without randomization • Level IV: Evidence from well-designed case-control and cohort studies • Level V: Evidence from systematic reviews of descriptive and qualitative studies • Level VI: Evidence from a single descriptive or qualitative study • Level VII: Evidence from the opinion of authorities and/or reports of expert committees Melnyk & Fineout-Overholdt: Evidence-Based Practice in Nursing & Healthcare, 2005

18. Qualitative Rating System for the Hierarchy of Evidence • Level I: Evidence from systematic reviews of descriptive and qualitative studies • Level II: Evidence from a single descriptive or qualitative study • Level III: Evidence from the opinion of authorities and/or reports of expert committees • Level IV: Evidence-based clinical practice guidelines based on systematic reviews of RCTs • Level V: Evidence obtained from well-designed controlled trials without randomization and from well-designed case-control and cohort studies • Level VI: Systematic review or meta-analysis of all relevant RCTs • Level VII: Evidence obtained from at least one well-designed RCT Melnyk & Fineout-Overholdt: Evidence-Based Practice in Nursing & Healthcare, 2005

19. AACN Levels of Evidence • Level I: Manufacturer’s recommendation only • Level II: Theory based, no research data to support recommendations: Recommendations from expert consensus group may exist • Level III: Laboratory data, no clinical data to support recommendations • Level IV: Limited clinical studies to support recommendations • Level V: Clinical studies in more than one or two patient populations and situations to support recommendations • Level VI: Clinical studies in a variety of patient populations and situations to support recommendations.

20. Reading a research article • Purpose of study • Methodology • Analysis • Discussion of Results • Key findings • Significance for nursing • Implications for use • Bottom line: do you have confidence in the TRUTH value of the results?

21. Putting It All Together: Burning Clinical Question P= Population (Laboring Women) I= Intervention (Sterile Water Injections in lower back) C= Compared to (Epidural, Stadol, or non-pharmacological methods) O= Outcome (Sterile Water Injections will help relieve the lower back pain?) T= Timeframe (Start in Spring 2010)

22. Putting It All Together: Evidence and Appraisal of the Evidence National Guideline Clearinghouse Several articles from different resources Looked at the References for Sentinel Articles Tools for appraisal

23. Putting It All Together: Integration and Evaluation Part of a research study Staff to notify research personnel when patient requested the intervention Pain monitored after intervention Patient and nurse talked to after delivery about the intervention

24. Evidence in Practice • “Knowledge of the research process alone does not ensure translation of that knowledge into practice.” • Seymour et al. 2003

26. Lessons from the field… • Most successful transformation focuses on the needs of the patient. • Appropriate use of data is a key element in successful efforts to transform. • Outcomes are the most important measures to create transformation. • Most of the successful instances of transformation involved a local change champion. • Local input is important to customize approaches in order to obtain buy-in and create sustainable change. • Leadership/Infrastructure to hold people accountable. Agency for Healthcare Research and Quality, October 2004

27. Diffusion of Innovations • Innovators (2.5%) • Venturesome • Early Adapters (13.5%) • Respect • Early Majority (34%) • Deliberate • Late Majority (34%) • Skeptical • Laggards (16%) • Traditional

28. Mechanism of Diffusion • Knowledge – person becomes aware of an innovation and has some idea of how it functions, • Persuasion – person forms a favorable or unfavorable attitude toward the innovation, • Decision – person engages in activities that lead to a choice to adopt or reject the innovation, • Implementation – person puts an innovation into use, • Confirmation – person evaluates the results of an innovation-decision already made.

29. Diffusion of Innovation Process The four main elements are: • (1) innovation - an idea, practices, or objects that is perceived as new by an individual or other unit of adoption. • (2) communication channels - the means by which messages get from one individual to another. • (3) time - the three time factors are: • a) innovation-decision process, • b) relative time with which an innovation is adopted by an individual or group, • c) innovation's rate of adoption. • (4) social system - a set of interrelated units that are engaged in joint problem solving to accomplish a common goal.

30. Journal Clubs • Purpose: The purpose of the Nursing Journal Club is to foster excellence in nursing practice by promoting evidence-based practice • Goals: • Improve nursing knowledge of current research findings. • Foster the application of clinical research and best practice modules to nursing practice. • Provide a means by which to address clinical issues.

31. Journal Clubs • Format for Presentations • Introduce topic and presenter • Give brief synopsis • Discuss major findings of study • Discuss other relevant research that supports/does not support this study

32. Journal Clubs • Discuss implications of article in terms of impact on nursing practice • What is the relevance of this article to our practice? • Should we change our practice based on this information?

33. Staff nurses must “do” and “use” research…. • Staff nurses provide direct patient care and are the link between research and practice, • Staff nurses have the opportunity to identify clinical problems amenable to research, and • The number of nurses with research preparation at the doctoral level will always be small. • Dr. Janelle Krueger, “Promoting Nursing Research as a Staff Nursing Function” 1980.

34. Evidence Based Practice and Research at St. Luke’s • Nursing Research Fellowship • Johns Hopkins Evidence-Based Practice Model • www.ijhn.jhmi.edu

35. Why do we observe? • “In dwelling upon the vital importance of sound observation, it must never be lost sight of what observation for. It is not for the sake of piling up miscellaneous information or curious facts, but for the sake of saving life and increasing health and comfort.” Florence Nightingale

36. How will we know we’ve arrived? • Nurses will pause to ask “what does the data show” • Patients will have an individualized, evidence based care plan • Policies and Procedures will be evidenced-based • Nursing research will be conducted regularly • Nursing-Sensitive Quality Indicators:Our outcome and process measures will reflect nursing excellence

37. “The illiterate of the 21st century will notbe those who cannot read and write, but those who cannot learn, unlearn and relearn.” -Alvin Toffler Discussion