Evidence Based Nursing: A Seminar in Literature, Clinical Practice and Patient Education

1. Evidence Based Nursing:A Seminar in Literature, Clinical Practice and Patient Education Darra Ballance Lindsay Blake Kevin Bradford

2. Three Elements of Evidence-Based Practice Clinician Experience + Patient Preferences + Scientific Findings = Evidence-Based Practice

3. How is Evidence Based Nursing different from Medicine? Nursing = Care Medicine = Cure

4. What Is Evidence-Based Practice? • Evidence-based medicine (EBM) has been defined as “… a conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients."(1) • EBP has also been described as “…an approach that enables clinicians to provide the highest quality of care in meeting the multifaceted needs of their patients and families."(2) 1. David Sackett, et al. "Evidence Based Medicine: What It Is and What It Isn't," BMJ 312, no. 7023 (1996) 2. Melnyk, Bernadette & Fineout-Overholt, Ellen. Evidence-Based Practice in Nursing and Healthcare. Philadelphia, Lippincott Williams & Wilkins (2005)

5. What EBP Is Not • NOT “Cookbook” medicine • NOT a tool for administrators and insurers • NOT restricted to randomized trials and systematic reviews • NOT opposed to patient-centered care • NOT just for physicians or those doing research

6. Why use Evidence-Based Practice? • Assistance in making informed decisions • Higher levels of patient satisfaction • Encourages individualized treatment of patients resulting in better outcomes • Keeping current on best treatments • Promotes innovation and practice change • Respects professional judgment

7. 5 Steps of Evidence-Based Practice 1. Posing a Clinical Question 2. Finding Relevant Evidence 3. Appraising the Evidence 4. Combining the Evidence with Nursing Experience and Patient Preferences 5. Evaluating the Outcomes

8. Moving from the Clinical Problem to the answerable question • Observe your daily interactions, note any questions that arise. • Could you investigate this question? • Is there a better method than what you are using that you have seen or heard about? Melnyk, Bernadette & Fineout-Overholt, Ellen. Evidence-Based Practice in Nursing and Healthcare. Philadelphia, Lippincott Williams & Wilkins (2005)

9. Posing a Clinical Question: the PICO Model P = Patient / Population / Problem I = Intervention / Area of interest C = Comparison intervention / Status O = Measurable outcome of interest

10. Does group intervention for parents and children achieve greater weight loss in obese children than routine care? Http://ebn.bmj.com/cgi/reprint/11/2/43 P – obesity, children, families or parents I – Group or Family intervention Includes diet. Physical activity, behavior change C – Routine Care or Individual intervention O – greater weight loss

11. Posing a Clinical QuestionWhat kind of Question is it? 1. Therapy 2. Diagnosis 3. Prognosis 4. Etiology 5. Prevention 6. Meaning 7. Quality Improvement

12. Clinical Question to Study Design

13. Level I Level II Level III Level IV Level V Level VI Level VII Systematic review, meta-analysis , or evidence based guideline At least one well-designed Randomized Controlled Trial A well-designed controlled trial without randomization Non experimental studies, such as case-control and cohort studies Systematic reviews of descriptive or qualitative studies A single descriptive or qualitative study Opinion of authorities and/or reports of expert committees Levels of Evidence Best Evidence Other Evidence LoBiondo-Woo, G. P., RN, FAAN and Judith Haber, PhD, APRN, BC, FAAN. (2006). Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice (6th ed.). St. Louis, Mo.: Mosby Elsevier.

14. Types of Literature/Research • Systematic/Integrative Research Review • Meta-analysis • Research • Review • Clinical Trial • Controlled Trial • Randomized controlled clinical trials

15. Types of Literature/Research • Case Control Studies • Cohort Studies • Qualitative Studies • Descriptive Studies • Case Reports • Case Series • Expert Opinion

16. Acquiring the evidence - Policies MCGHI Policy Manual • http://hi.mcg.edu/Hospital/pcs/policy.htm

17. Acquiring the evidence – Protocols/Guidelines Mosby’s - http://app32.webinservice.com/MosbySkills/skillsMain.asp

18. Acquiring the evidence – Guidelines & Standards • Protocols/Guidelines • National Guidelines Clearinghouse - http://www.guideline.gov/ • Centers for Disease Control - http://www.cdc.gov/ • Critical Pathways • http://www.utmb.edu/cpg/ • Standards of Care • AACN – http://www.aacn.org/aacn/practice.nsf/vwdoc/scp • LSU Health Sciences Center – http://www.medcom.lsuhsc-s.edu/cfdocs/policies/Std_of_Care.cfm

19. Acquiring the evidence - databases CINAHL Plus with Full Text - the world's most comprehensive source of full text for nursing & allied health journals. With full text coverage dating back to 1937, CINAHL Plus with Full Text is the definitive research tool for all areas of nursing. MEDLINE - Contains over 12 million citations to research articles, case reports, letters, editorials, and animal studies published in biomedical journals. Search Filters for: Therapy, Diagnosis, Prognosis, Etiology, Qualitative Studies.

20. Acquiring the evidence - etc • Other databases • Evidence-based reviews • ACP Journal Club • Cochrane databases - http://www.cochrane.org/ • Joanna Briggs Institute - http://www.joannabriggs.edu.au/about/home.php • In-Print • Evidence-Based Nursing - http://ebn.bmj.com/contents-by-date.0.dtl • Worldviews on Evidence-Based Nursing - http://www3.interscience.wiley.com/journal/121371704/grouphome/home.html

21. Combining the Evidence: Patient-Centered Perspective • Are the results of this study appropriate for my patients? • Do my patients meet the criteria for inclusion and exclusion? • Do the treatment benefits outweigh the potential harm and/or costs?

22. Study Design Good Quantitative Evidence • Background/Literature review • Study Design • Control/comparison group • Randomization & Blinding • Population (size, traits) & time frame • Follow-up (>80%) • Results of study • Well defined outcome criteria • Applicable to patients

23. Study DesignGood Qualitative Evidence • Purpose & problem clearly stated • Data Collection Procedures • Method & time frame specified • Organization & analysis of data • Study Participants • Selection process & number of participants • Nature of setting(s) utilized • Results of study • Impact on clinical practice • Suggestions for future research

24. Why use Statistics? Results - Statistics

25. Types of Statistics - Descriptive • Frequency Distribution Percentage Distribution

26. Descriptive Statistics Measures of central Tendency 57, 51, 49, 43, 37, 36, 35, 31, 26, 26 Mean 39.1 Mode 26 Median 36 & 37

27. Descriptive Statistics Measures of Dispersion 57, 51, 49, 43, 37, 36, 35, 31, 26, 26 Range 31 Standard Deviation Normal Distribution Graphs courtesy of wikipedia

28. Types of Statistics - Inferential • P or Probability Value • Paired t-test • Independent t-test • ANOVA • Chi-Squared • Mann-Whitney U test • Spearman Rho Make friends with a statistician !

29. Evaluating the Outcomes How did the implementation proceed? Were staff receptive? Were there areas that could have been smoother? Ones that went well? Did the process improve outcomes?

30. Three Elements of Evidence-Based Practice Clinician Experience + Patient Preferences + Scientific Findings = Evidence-Based Practice