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Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 2
Evidence-Based Nursing Practice: Fundamentals
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Research Utilization Versus Evidence-Based Practice
• Research utilization (RU)
– The use of study findings in a practical application unrelated to the original research
• Evidence-based practice (EBP)
– Basing clinical decisions on best possible evidence, typically high-quality research
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Types of Research Utilization
• Instrumental (direct) utilization
• Conceptual (indirect) utilization
• Persuasive utilization
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
History of RU in Nursing Practice• Studies identified knowledge–practice gaps
(e.g., Ketefian, 1975).
• RU projects sought to address the gap (1970s and 1980s):
– e.g., the Conduct and Utilization of Research in Nursing (CURN) project
• RU efforts began to be superceded by call for EBP, 1990s
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Key proponents of the EBP• Archie Cochrane
– Efforts led to development of Cochrane Center in Oxford and the Cochrane Collaboration
– Proposed an evidence hierarchy for weighing evidence
• David Sackett
– EBP pioneer at McMaster Medical School
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Staff nurses are proposing to their facility’s administration a change in a nursing protocol for skin care, based on research findings. This is an example of which type of research utilization?
a. Instrumental
b. Conceptual
c. Direct
d. Persuasive
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
c. Persuasive
– Persuasive utilization involves the use of findings to persuade others (typically those in decision-making positions) to make changes in policies or practices relevant to nursing care.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Evidence Hierarchies
• Involve ranking evidence sources according to the strength of evidence they provide
• Typically, hierarchies rank evidence relating to the effectiveness of health care interventions.
• Evidence hierarchies are not meaningful for certain types of questions (e.g., about meaning and process).
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Example of an Evidence Hierarchy• Levels of evidence (from strongest to weakest):
– I. Systematic reviews of RCTs
– II. Individual RCTs
– III. Systematic reviews of non-RCTs (correlational)
– IV. Individual correlational studies
– V. Systematic reviews of descriptive studies
– VI. Individual descriptive studies
– VII. Opinions of respected authorities and expert committees
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Barriers to RU and EBP in Nursing
• Research-related barriers
– e.g., scarcity of published replications
• Nurse-related barriers
– e.g., inadequate skills in locating and appraising evidence
• Organizational barriers
– e.g., lack of financial support and staff release time for EBP
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Is the following statement True or False?
• The strongest level of evidence is obtained from individual correlational studies.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
• False
– The strongest level of evidence is obtained from systematic reviews of randomized clinical trials (RCTs).
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Key Resources for RU/EBP• Systematic reviews that integrate evidence
about a topic in a rigorous, systematic way
• Traditional narrative reviews are being replaced by:
– Meta-analyses that integrate findings across quantitative studies statistically
– Meta-syntheses that integrate and amplify findings across qualitative studies
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Key Resources for RU/EBP (cont.)• Other preappraised evidence, e.g.,
– Clinical practice guidelines
– Synopses of studies in EBP journals
– Critically appraised topics (CATs)
• Models and theories for EBP or RU
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Models for Evidence-Based Nursing Practice
• Dozens of models exist
• Three widely-referenced models:
– The Stetler Model of research utilization to promote evidence-based practice
– The IOWA Model of evidence-based practice to promote quality care
– Rogers’ Diffusion of Innovations Theory
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
EBP in Individual Nursing Practice
• Nurses are called upon to make decisions or give advice daily.
• Many clinical scenarios provide opportunity for EBP, e.g.,
– Is there a reliable assessment tool for early detection of foot complications in patients with end-stage renal disease?
– Are there ways to reduce anxieties of children undergoing allergy scratch tests?
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Is the following statement True or False?
• Meta-analyses use statistics to integrate findings across quantitative studies.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
• True
– Statistics are involved with meta-analyses to integrate findings across quantitative studies. Meta-syntheses integrate and amplify findings across qualitative studies.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Steps in Individual EBP Efforts
1. Ask questions that are answerable with research evidence.
2. Search for and assemble evidence.
3. Appraise and synthesize evidence.
4. Integrate evidence with other sources.
5. Assess effectiveness of decision or advice.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Asking Well-Worded Clinical Questions
• Components for quantitative evidence
– Population
– Intervention (exposure, issue)
– Comparison*
– Outcome
– Time*
*Not always specified
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Asking Well-Worded Clinical Questions (cont.)
• Components for qualitative evidence
– Population
– Situation (conditions, experiences, circumstances of interest)
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Templates for Clinical Questions
• Templates can greatly facilitate wording of questions, e.g., an intervention question:
In _____ (population), what is the effect of ________ (intervention), in comparison to _______ (comparison), on __________(outcome)?
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
QuestionWhich of the following would be the first step
when personally investigating evidence for a specific nursing care problem?
a. Search for possible evidence.
b. Ask answerable clinical questions.
c. Assess effectiveness of decision.
d. Assemble available evidence.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
b. Ask answerable questions.
– The first step in individual EBP efforts is to ask questions that are answerable with research evidence. Searching for, assembling, appraising, and synthesizing would occur next in that order. Assessing effectiveness is the last step.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Appraising the Evidence: Key Questions
• What is the quality of the evidence?
• What is the magnitude of effects?
• How precise are estimates of effects?
• Is there evidence of side effects?
• What are the costs?
• Is there relevance to my clinical situation?
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
EBP in an Organizational Context
• Select a topic or problem
– Knowledge-focused triggers
Begins with an innovation or research finding (e.g., might emerge in a journal club)
– Problem-focused triggers
Begins with a perplexing or troubling clinical situation
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
EBP in an Organizational Context (cont.)
• Assemble and evaluate evidence
– Evidence-based clinical practice guidelines invaluable, if available
– Guidelines must be appraised (e.g., using AGREE instrument)
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
EBP in an Organizational Context (cont.)
• Assess implementation potential
– Transferability
– Feasibility
– Cost–benefit ratio
• Develop evidence-based protocols
• Implement and evaluate the innovation
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Question
Is the following statement True or False?
• Clinical practice guidelines put evidence into a usable form.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Answer
• True
– Clinical practice guidelines give specific recommendations for evidence-based decision-making, putting evidence into a usable form for implementation.
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Strategies for Nurses to Play a Role in RU/EBP
• Read widely and critically.
• Attend professional conferences.
• Learn to expect evidence that a procedure is effective.
• Become involved in a journal club.
• Pursue and participate in RU/EBP projects.