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Chapter 13

Building an Evidence-Based Nursing Practice

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Evidence-Based Practice

Conscientious integration of best research evidence with clinical expertise and patient values and needs in delivery of quality cost-effective health care

Has a broader focus than research use Goal is implementation of quality cost-

effective care to promote positive outcomes

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Barriers to EBP

Practical Conceptual May create a “cookbook” approach to care

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Benefits to EBP

Improved patient outcomes for patients, providers, and agencies

Leads to best treatment (Gold Standard) plan An integral part of the Magnet Status process

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Evidence-Based Sources

Systematic reviews Meta-analyses Integrative reviews Metasummaries Metasyntheses

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Developing Evidence-Based Practice for Nursing

Findings from a study are different from research evidence.

Research evidence is a synthesis of quality, relevant studies to form a body of empirical knowledge for selected area of practice.

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Synthesis of Research Findings

Knowledge comes from quantitative, qualitative, and outcomes research.

Content clustering: integration of findings from scientifically sound research to determine what is currently known or not known Accomplished through:

• Integrative reviews• Systematic reviews• Meta-analyses, metasummaries, metasyntheses

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Integrative Reviews

Identifies, analyzes, and synthesizes results from independent quantitative and qualitative studies to determine current knowledge

Includes multiple types of research designs and literature types

A complicated review, but gives breadth and depth to conclusions

Annual Review of Nursing Research publishes integrative reviews.

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Qualitative Research Contributions to Integrative Reviews

Identifies and refines questions and outcomes

Identifies types of participants and interventions

Augments and provides data for research synthesis

Highlights inadequacies in methods Explains findings and interpretation of

findings Helps make recommendations

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Systematic Reviews of Research

A narrowly focused synthesis of research findings from quantitative studies

Looks at studies of similar methodology Has same standards of clarity, rigor, and

replication as primary research studies

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Steps in Systematic Reviews

Formulate purpose and identify scope. Develop specific questions or hypotheses. Establish criteria for inclusion/exclusion of

studies. Conduct extensive literature search of all

sources.(Melnyk & Fineout-Overholt, 2005; Whittemore, 2005)

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Steps in Systematic Reviews (cont’d)

Develop questionnaire and contact authors to gather data.

Critique studies for scientific merit and data analysis.

Analyze and interpret data. Report the review.

(Melnyk & Fineout-Overholt, 2005; Whittemore, 2005)

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Meta-analyses of the Research Literature

Statistically pools results from previous studies into single quantitative analysis

Allows for application of scientific criteria For example, sample size, level of significance,

variables

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Results of Meta-analysis

A large, diverse sample that is more representative of target population

Determination of overall significance of probability of pooled data

Indication of the efficacy of the intervention from the average effect size determined from several quality studies

Strength of relationship between variables

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Metasummaries in Qualitative Research

Definition: a synthesis of multiple primary qualitative studies to produce a narrative about a selected phenomenon

Expands our knowledge base

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Metasynthesis of Qualitative Research

Synthesizes qualitative research with a critical analysis of primary studies and synthesis of findings into a new theory

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Best Evidence for Use in Practice

The strength of the evidence is on a continuum from high-quality results to lower-quality results.

Evidence-based guidelines are essential in developing evidence-based practice for nursing.

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Continuum of Strength of Research Evidence

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Strength of Evidence

Strongest evidence1. Meta-analysis2. Integrative reviews3. Experimental studies

Weakest evidence1. Descriptive surveys2. Qualitative studies3. Correlational studies4. Quasi-experimental

studies

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Stetler Model of Research Utilization

Phase I: Preparation Phase II: Validation Phase III: Comparative Evaluation/Decision

Making Phase IV: Translation/Application Phase V: Evaluation

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Iowa Model of Evidence-Based Practice

Provides direction for development of evidence-based practice in an agency

Looks at triggers for change, such as: Risk management data Financial data Organizational standards Philosophy of care

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Iowa Model of Evidence-Based Practice (cont’d)

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Application of the Iowa Model

What are effective strategies for implementation?

What are outcomes from using the research findings?

Do the data support the change? Is the proposed change an agency priority?

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Scientific Merit Critique

According to the Iowa model, research should be examined for:1. Conceptualization and internal consistency of the

study2. Methodological rigor of the design, sample

methods, data, and analysis3. Generalizability of the findings4. Number of replications

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Determining Agency Compatibility with the Change in Practice

Who needs to approve the change in the agency?

What steps are needed to get the change approved in the institution?

Do physicians support the change? Do nurses support the change? Who are the leaders and will they support the

change?

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Instituting the Change in Practice

Will the implementation take a long time? What support is needed to make the change? Are there barriers to instituting change in the

agency?

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Utilization Barriers

Administration barriers Research not valued Limited change in agency or change not based on

research Limited resources to make research-based

change

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Utilization Barriers (cont’d)

Clinician barriers Do not read research reports Lack education about research process Do not believe research findings Do not know how to implement findings

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Monitoring Outcomes

After the change is effected, the outcomes must be monitored for effectiveness.

Change should be documented regarding improved quality of care, decreased costs, saved nursing time, and improved access to care.

Feedback is needed.

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The Cochran Collaboration

P – Population or participant of interest I – Intervention needed for practice C – Comparison of interventions to determine

best practice O – Outcomes needed for practice

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Development of Evidence-Based Guidelines

AHRQ helps with guidelines through development of an expert panel.

The group designates the scope of the guidelines.

They synthesize the findings to develop recommendations for practice.

Guidelines developed are presented at meetings and published.

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Examples of AHRQ Practice Guidelines

Pain management Decubiti prediction/prevention Cataract treatment in adults Depression treatment Screening, diagnosis, management of sickle

cell disease in newborns and infants Otitis media treatment in children Availability of cardiac rehabilitation services

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Access to Evidence-Based Guidelines

Agency for Healthcare Research and Quality (AHRQ)

National Guideline Clearinghouse (NGC) Academic Center for Evidence-Based

Nursing American College of Physicians American Academy of Pediatrics

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Implementing a Model of Evidence-Based Practice

Identify practice problem. Search for best research evidence. Determine quality of guideline by assessing:

Authors Significance of problem Strength of evidence Link to national standards Cost-effectiveness of guideline

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Translational Research

An evolving concept defined by the NIH as the translation of basic scientific discoveries into practical application

Encouraged by nursing and medicine to increase the implementation of evidence-based interventions in practice and determine if these interventions are effective