Everything you always wanted to know about EBN but were afraid to ask…

1. Everything you always wanted to know about EBN but were afraid to ask… Carl Thompson and Nicky Cullum Centre for Evidence Based Nursing, University of York

2. Aims • To introduce you to key principles and processes of evidence based nursing including strategies and resouces to promote evidence based care

3. Clinical Scenario You are a senior nurse on an acute admissions ward where lumbar punctures are regularly undertaken for diagnostic purposes. Standard practice has long been to lie people flat to reduce the likelihood of headache but the Unit Manager asks if this period of bedrest can be reduced or abolished as this bed-blocking is giving her a headache…

4. Please write on the pink paper how long you think someone should lie flat after lumbar puncture (please make it clear whether your answer is in minutes or hours)

5. Where do we go for help with decisions when we are not sure how to proceed?

6. Good Idea or Bad Idea? • A weekly exercise programme for nursing staff in the workplace • Bicycle safety education programmes for children • Driver education for teenagers • Pint glasses made of toughened glass for use in pubs • Lying babies prone to prevent choking

7. Good Idea or Bad Idea?? • Weekly exercise programme for nursing staff had no effect on fitness and health, merely interfered with ability to plan work • Bicycle safety education programme for children increased risk of injury overall, doubling risk in boys

8. Teenage driver education associated with a modest but potentially important increase in teenagers involved in traffic crashes • Use of toughened pint glasses in bars increased injury rate by 60% because the glass shattered more easily • Lying babies prone for sleep intuitively makes sense (reduction of risk of inhaling vomit or choking), but increases risk of sudden infant death syndrome

9. We may inadvertently widen health inequalities … • Bike Ed cycle safety programme was more harmful in younger children, those from families with lower parental education levels, those in families without other cyclists • Sesame Street benefited all children but gap between fast and slow learners increased

10. Patient Preferences Evidence from research Evidence based decision Professional expertise Available resources

11. REFLECT ON PRACTICE; IDENTIFY AREAS OF UNCERTAINTY AUDIT PHRASE ANSWERABLE QUESTIONS IMPLEMENTATION WHERE APPROPRIATE SEARCH FOR RESEARCH EVIDENCE CRITICAL APPRAISAL OF THE RESEARCH

12. Nursing Uncertainty • Diagnosis • Selecting interventions • targeting • timing • Organising Care • Communication (including communication of risks and benefits) • The patient experience • Prognosis • Health Needs Assessment

13. Question formation - PICO • Population (who are the relevant people?) • Interventions or exposures (diagnostic tests, foods, drugs, environmental hazards etc) • Control or Alternative intervention/exposure • Outcome (what are the person-level consequences we are interested in?)

14. Population Who are the relevant people?

15. Intervention What are they exposed to?

16. Alternative or control intervention

17. Outcome (what are the person-level consequences we are interested in?)

18. Focusing Answerable Questions

19. Scenarios • Focus these uncertainties into answerable questions

20. Falls Prevention • You are working in a PCT and a GP rings to say she is developing a practice protocol on preventing falls in older people. She asks you what should go into the protocol.

21. Focusing Answerable Questions

22. Exercise on Prescription • You are working in a PCT and your Chief Executive decides that local practices should run an exercise on prescription scheme – how would you respond?

23. Focusing Answerable Questions

24. Mammography A 40 year old friend with no symptoms or family history, has registered with a new GP who suggested that she have her first mammogram. Your friend asks you your opinion as to whether this is worthwhile?

25. Focusing Answerable Questions

26. REFLECT ON PRACTICE; IDENTIFY AREAS OF UNCERTAINTY AUDIT PHRASE ANSWERABLE QUESTIONS IMPLEMENTATION WHERE APPROPRIATE SEARCH FOR RESEARCH EVIDENCE CRITICAL APPRAISAL OF THE RESEARCH

27. Fundamental Principle of Evidence Based anything… • The weight given to research evidence for any decision depends on internal validity and relevance (external validity) of research • Match the type of question with the best research design • Certain research designs likely to yield more valid (more likely true) results for particular types of questions (minimise bias)

28. Matching questions to designs

29. Why are randomised controlled trials the best design for answering questions of effectiveness? • Only when the treatment under evaluation is the only systematic difference between the groups in a trial can we confidently attribute a difference in outcomes to the treatment

30. Randomised controlled trial OUTCOME Experimental intervention NO OUTCOME Eligible patients OUTCOME Control intervention Direction of data collection: exposure  outcome NO OUTCOME

31. The total body of research is distilled down to a conclusion based on the best available, reliable and relevant research Poor quality and/or irrelevant research

32. Systematic reviews • Reviews that look, in a systematic way, at all the available research on a topic • Systematic reviews have a clear method - like original research • Critically appraise each piece of research they include • Reliable information for practice

34. Examples of Systematic Reviews from the Cochrane Library • Beds, mattresses and cushions for preventing pressure ulcers • Non-nutritive sucking for pre-term infants • Absorbent products for containing urinary and/or faecal incontinence in adults • Caregiver support for women during childbirth • Communiciating with children and adolescents about their cancer

35. REFLECT ON PRACTICE; IDENTIFY AREAS OF UNCERTAINTY AUDIT PHRASE ANSWERABLE QUESTIONS IMPLEMENTATION WHERE APPROPRIATE SEARCH FOR RESEARCH EVIDENCE CRITICAL APPRAISAL OF THE RESEARCH

36. Take Home Message Where most research belongs

37. Only approximately 10% of articles in the most prestigious internal medicine journals can be regarded as “valid” and ready for application

38. Critical Appraisal • Important for practitioners to be able to sort the good research from the bad quickly • A number of checklists available; different ones for different research designs • See Evidence Based Nursing Users’ Guides • CASP website http://www.phru.org.uk/~casp/appraisa.htm

39. Features of Clinically Useful Information • Trustworthy (pre-appraised) • Concise • Easy to understand • Easy to access • Clear implications for practice

40. Sources of Pre-Appraised Research • Clinical Evidence • Evidence Based journals • Evidence Based Nursing, Medicine, Mental Health etc • Systematic reviews • Cochrane Library (via NeLH) • Cochrane Database of Systematic Reviews • DARE - Database of Abstracts of Reviews of Effectiveness

43. Evidence Based journals • Aim to select, from international literature, best quality research and reviews relevant to medicine, nursing etc • Summarises each article in “value-added” abstracts • Commentary from clinical expert

44. Sources of Clinically Useful Information • SYSTEMS – decision support – brings research directly into clinical decision making • SYNOPSES – eg. Clinical Evidence, evidence based journals, DARE database, précis and appraisal element • SYNTHESES – systematic reviews of all relevant primary research (Cochrane Library) (primary research pre-appraised_ • STUDIES – MEDLINE, Cinahl, etc.

45. Haynes’s Typology of Research Information (4S) Systems synopses Synopses Syntheses (reviews) syntheses Studies

47. Focusing Answerable Questions