400 likes | 411 Views
Explore evidence-based practice in midwifery, identify key research questions, and improve outcomes for women and infants. Learn about the EBP process, critical appraisal of evidence, and practical applications.
E N D
Onderzoek ontmoet praktijkEvidence meets practice Helen Spiby Mother and Infant Research Unit University of York, UK 11th December 2007
Where evidence meets experience PLAN • Overview EBP process • Identifying research questions from midwifery practice • Early Labour Support & Assessment trial • Suggest ways to increase midwives’ involvement in evidence based practice
Evidence Based Practice in Midwifery Why? • Best possible care & outcomes • Ethical imperative • Reduce variations in practice • Efficient use of finite resources • Professional accountability • Women & families as partners
Alternatives to Evidence Based Practice • Opinion-based practice • Custom • Interventions implemented/ practice changes without a strong evidence base
Procedures : evidence of harm/mixed effects/no clear evidence/evidence applied inappropriately • Supplementation with formula for breastfed babies • Routine rupturing of membranes • Not suturing second degree tears • Placing babies prone to sleep
Overview of the EBP process • Identifying questions from practice • Locating the evidence • Critically appraising the evidence • Utilisation in practice • Evaluation & reflection
Identifying questions from practice Formulating the question: PICO • Population • Intervention/exposure • Comparison • Outcome
Identifying questions from practice: PICO • Population - description of a similar group of women/babies
Identifying questions from practice: PICO • Intervention • treatment • therapeutic intervention • screening • diet
Identifying questions from practice: PICO • Comparison • alternative option • control/current treatment
Identifying questions from practice: PICO • Outcome • clinical : wellbeing enhanced • organisational • economic
Relating questions to research methods • Effectiveness of treatment: systematic reviews/ randomised controlled trials • Effect of environmental factors on health: cohort & case control studies • Women’s experiences : qualitative (interviews) & quantitative (questionnaire surveys)
Locating the evidence:Evidence Based Healthcare: Resources • Pre-synthesized information • E.g. systematic reviews, evidence summaries; higher quality clinical guidelines (NICE); Practice Standards (KNOV) • Cochrane Reviews • Individual studies
Critical appraisal • Was an appropriate research method used to answer that question? • Is the research described comprehensively? • Was the context relevant? Resource: CASP www.phru.nhs.uk
Critical appraisal • Is there a clear focus to the research question? • Appropriate allocation between groups? • How were outcomes measured? • What is the risk of bias? • How are results presented? • Valid conclusions?
Identifying questions from practice:some examples • Are there midwifery practices that prevent perineal trauma ? • What are women’s experiences of labouring in water ? • Should women in early labour receive midwifery care at home ?
Practices: impacts unknown & evidence required • When should support start once women are in labour? • What information do women need in early labour? • What is the appropriate schedule for vaginal examinations in early labour?
Asking questions about effectiveness • Impacts at individual level • Improvements in physical/ emotional wellbeing • Consequences/ side-effects • Uptake/ acceptability
Identifying & measuring outcomes • Clearly defined & interpreted consistently • Valid & reliable methods of measurement • Risk of bias minimised
The Early Labour Support and Assessment trial (ELSA) Funded by: NIHR Service Delivery & Organisation of Care programme Conducted by: a midwifery-led multi-disciplinary research team
Background (1) • Arriving at hospital early- more intervention during labour; higher rate of instrumental & operative births • 10-33% women admitted to a delivery suite are not in labour • 97% births in UK in hospital • Caesarean Section rate 22%: national concern • 40%-50% first babies born by CS/ instrumental birth in Yorkshire in 2001
Background (2) • Critical appraisal of existing research: • Methodologically prone to bias • Settings unrepresentative of current UK maternity care • Home visits not tested as a single intervention
Aim & Research design To determine the effect of offering home visits by a midwife to nulliparous women in early labour Using A multi-centre randomised controlled trial with cost-effectiveness analysis
Intervention Offer of a home visit by a community midwife (08.00-21.00) Advice & support, assessment of wellbeing & progress Control Group Standard care - telephone contact with labour & delivery suite; advice to attend for assessment
Outcomes Primary: • Caesarean section in labour & instrumental vaginal birth Secondary: • Impacts on labour: length, pain relief, procedures • Maternal & neonatal complications • Breastfeeding • Women’s emotional wellbeing & experiences of care • Health professionals’ views & experiences • Economic analysis
Timetable & progress • Recruitment August 2004 – July 2006 • 3500 participants; 11 clinical sites in England • Analysis in progress; Final report March 2008 • Active dissemination to all stakeholders • Conference September 2008
Workshops • Please divide into 4 groups • Work in small groups • Identify a writer, work through the task; hand notes to facilitator
Workshops • Identify an issue from practice that you encounter nearly every day with your students & develop a research question- Using the PICO framework • Which type of research would answer that question?
Challenges to EBP in midwifery • Access to & quantity of evidence • Providing women with evidence • Changing professional practice
Changing professional practice Consistently effective: • Educational outreach visits • Manual/computerised reminders • Multifaceted interventions • Interactive educational meetings Haines A. (2001) Getting research into practice. 2nd ed. London: BMJ
Changing professional practice Mixed effects: • Audit & feedback • Local opinion leaders • Local consensus processes • Patient-mediated interventions
Evaluation & reflection • Evaluation - early, under-resourced, methodologically weak • Reflection- individual & system-based approaches
Evidence based practice in midwifery: making it happen • Throughout midwifery –policy, education, practice; avoid divisions • Education & skills • Building capacity • Infra-structure support
Core skills & attitudes for EBP in midwifery • Formulating questions about practice • Ability to locate evidence • Skills in critical appraisal • Ability to collaborate & lead research • Implementation knowledge
Evidence based practice in midwifery: making it happen Build capacity by creating opportunities • Secondments- clinical midwives joinresearch teams ; mentorship • Joint appointments – shared fundingbetween academic & practice settings • Academic midwifery practices • How do we involve midwifery students?
Evidence based practice in midwifery: making it happen Build capacity by creating opportunities • Career pathways • Academic development funding streams • What opportunities are there for you ?
Opportunities- in the Early Labour trial • Midwifery Research Fellow –PhD • Local Midwifery Co-ordinators – 10 midwives, part –time, working in practice • Midwives : investigators, all Trial Committees & working groups • 2 Midwives seconded into MIRU working on the trial
Evidence based practice in midwifery: making it happen Infrastructure support • Identify existing systems that could foster EBP e.g. Journal clubs ; academic assessments • Information specialists • Link activity to policy, professional & public health priorities • Develop skills in acquiring funding • National & international collaborations
Evidence based practice in midwifery: making it happen • Identify support systems • Engage stakeholders • Set achievable goals, celebrate early success • Evaluate & disseminate all experiences