Eb Pn Lecture

8/12/2019 Eb Pn Lecture

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Evidence-Based Nursing

PracticePaolo D. Vega, RN

Critical Care Services Manager

Chong Hua HospitalJanuary 22, 2014


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Objectives

Describe evidence-based practice (EBP)

Identify levels of evidence using the EBPpyramid

Learn where to find the best evidence

Understand why evidence-based practice isimportant and should be integrated in scholarly

work Learn the importance of EBP, QI and NR in the

Nursing Practice.


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What is Evidence-Based Nursing

Practice?

"Evidence-based nursing (EBN) means using the bestavailable evidence from research, along with patientpreferences and clinical experience, when makingnursing decisions.

(Cullum N. Users' guides to the nursing literature: an introduction. Evid Based Nurs 2000Jul;3(3):71-2. doi:10.1136/ebn.3.3.71)

Integrated components:

clinical expertise (best practice) external evidence from systematic research

patient preferences(Sackett, et al., 1996)


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The EBM Triad


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Process of Evidence-Based

Nursing Practice

Assess and define problem.

Formulate specific question.

Locate and evaluate appropriate evidence.

Integrate evidence into planning and

implementing interventions.

Evaluate process and results.

(Sackett, et al., 1996)


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Process of Evidence-Based Nursing

Practice is also the Nursing Process

Evidence-based Nursing

Assess and define problem.

Formulate specific question. Locate and evaluate

appropriate evidence.

Integrate evidence intoplanning and implementing

interventions. Evaluate process and results.

Nursing Process

Assessment

Diagnosis Planning

Intervention

Evaluation

We just have to emphasize the EVIDENCE!!!


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Is Evidence-Based

Nursing Practice the same

as Nursing Research?


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What makes good evidence?

Good

Based on scientific

research Randomized Control

Trials

Systematic review

Meta-analysis

Clinical guidelines

Shoddy

Opinion

Consensus

Because its been donethis way for 100 years


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Chocolate decadence


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Searching for Evidence Pyramid: Basic

Systematic

Reviews,

Meta-

Analyses

Evidence Summaries,

Evidence Guidelines

Randomized Controlled Trials (RCTs),

Cohort Studies, Qualitative Studies

Background Information, Expert Opinion

ex. Cochrane

ex. DynaMed, Nursing

Reference Center, NGC

ex.

MEDLINE/PubMed,

CINAHL

ex.Textbooks,

UptoDate


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Pyramid of Evidence


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Where do you look for

evidence?

Wikipedia?


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Search for the Best Evidence to

answer the Question MEDLINE or PubMed www.pubmed.gov

CINAHL/CINAHL Plus Cumulative Index to Nursing andAllied Health Literature www.cinahl.com

E-Journals

Clinical Practice Guidelines National GuidelineClearinghouse www.guideline.gov

Nursing Reference Centerwww.ebscohost.com/pointOfCare/evidence-based-information

Advanced Google or Google Scholar
http://www.pubmed.gov/http://www.cinahl.com/http://www.guideline.gov/http://www.ebscohost.com/pointOfCare/evidence-based-informationhttp://www.ebscohost.com/pointOfCare/evidence-based-informationhttp://www.ebscohost.com/pointOfCare/evidence-based-informationhttp://www.ebscohost.com/pointOfCare/evidence-based-informationhttp://www.ebscohost.com/pointOfCare/evidence-based-informationhttp://www.ebscohost.com/pointOfCare/evidence-based-informationhttp://www.guideline.gov/http://www.cinahl.com/http://www.pubmed.gov/


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CINAHL vs MEDLINE

CINAHL

Coverage: 1982+

Indexes 1700 journals

Focuses on nursing andallied health literature

CINAHL Thesaurus withmore nursing terms

Has peer-reviewed limit

Includes cited referencesat end of many refs

MEDLINE

Coverage: late 1940s+

Indexes 5000 journals

Focuses on biomedicalliterature

Uses MeSH as itscontrolled vocabulary

No peer-reviewed limit

No cited references


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Why Evidence Based Practice?

Knowledge explosion+

Nursing shortage

Timely research evidence translation intobest practice.

(Melnyk & Fineout-Overholt, 2005; Salmon, 2007)

Mandate


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Traditional practice Knowledge gained in school

Pathophysiological rationale

Intuition

Experiences (past & usual practice)

Workplace colleagues


17-year lag between research findings andpractice application


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Results in better patient outcomes Failure to use evidence results in lower

quality, less effective, more expensive

care(Berwick DM, 2003)

EBP can lead to:

Increased practitioner satisfaction Decreased burnout and turnover

Third party reimbursement



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Why do nurses need to do EBP?

Keeps practice current and relevant

Increases confidence in decision making

Experience greater autonomy in practice Increases level of job satisfaction

Berwick DM. Disseminating innovations in health care. JAMA 2003 Apr16;289(15):1969-75


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Barriers to Nurses using EBP

Lack of TIME

Lack of value of research in practice

Lack of understanding of electronicdatabases to find evidence

Lack of computer skills

Lack of EBP mentors at point of care Difficulty understanding research articles

Pravikoff DS, Tanner AB, Pierce ST. Readiness of U.S. nurses for

evidence-based practice. Amer J Nurs 2005 Sep;105(9): 40-52.


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Evidence continually evolves

Evidence-based practice

Opinion-based

Melnyk & Fineout-Overholt, 2005; Salmon, 2007


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WARNING!!!!!

EBP does not replace clinical reasoning orjudgment.

20% medical practice

Primary Research

(Salmon, 2007)


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What is Evidence Based Practice?

Conscientious use of best evidence inclinical decision making:

Systematic search for best evidence

Critical appraisal of most relevant evidence toanswer clinical question

Clinical context or circumstances

Ones own clinical experience Patient preferences and values

(Melnyk & Fineout-Overholt, 2005; Salmond,2007)

EBP is more than research utilization


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History of EBP Movement

Dr. Archie Cochrane, British epidemiologist In 1972 criticized medical profession for lack

of systematic review of available evidence to

direct clinical decision making Landmark caseseveral RCTs supporting

effectiveness of corticosteroid therapy to haltpremature labor in high risk women had not beensystematically analyzed 1,000s of low-birth-weight premature infants continued

to die needlessly

Review data showed therapy decreased death from 30%to 50%

Melnyk & Fineout-Overholt, 2005


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History of EBP Movement

2000 IOM report, To Err is Human

Preventable medical errors were 8thleadingcause of death in US

2002 IOM report, Crossing the QualityChasm

Major lag between medical science andtechnology advancements and healthcaredelivery

(Salmon, 2007)


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5 (7) Steps for EBN Practice

1. Convert your information into an answerablequestion (PICO) Population; Intervention; Comparison; Outcome

2. Search the literature for the best available evidence

3. Critically appraise the evidence for validity andusefulness

4. Apply the findings to your clinical practice alongwith clinical expertise and patients perspective to plan

care5. Evaluate the outcomes of your practice decisions orchanges based on evidence.

Melnyk & Fineout-Overholt, 2005


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2 Additional Steps for EBP=7 Steps

Step 0: Cultivate a spirit of inquiry

Step 6: Disseminate EBP results

Melnyk BM, Fineout-Overholt E, Stillwell SB, Williamson KM. Evidence-basedpractice: step by step: the seven steps of evidence-based practice. Am J Nurs2010 Jan;110(1):51-3. PMID: 20032669.


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Levels and Grades of Evidence

REPROLINE, Johns Hopkins University www.reproline.jhu.edu


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Additional Point of Care Evidence-

Based Resources for Nursing:[have some level of evidence-based information]

Clini-eguide Nursing Advisorwww.clineguide.com/nursing-standards-care-plan.aspx

Lippincotts Nursing Procedures & Skillswww.healthstream.com/Lippincott/

Mosbys Nursing Consultwww.nursingconsult.com

Mosbys Nursing Skills mosbysnursingskills.com

UptoDate www.uptodate.com
http://www.clineguide.com/nursing-standards-care-plan.aspxhttp://www.clineguide.com/nursing-standards-care-plan.aspxhttp://www.healthstream.com/Lippincott/http://www.nursingconsult.com/http://www.uptodate.com/http://www.uptodate.com/http://www.nursingconsult.com/http://www.healthstream.com/Lippincott/http://www.clineguide.com/nursing-standards-care-plan.aspxhttp://www.clineguide.com/nursing-standards-care-plan.aspxhttp://www.clineguide.com/nursing-standards-care-plan.aspxhttp://www.clineguide.com/nursing-standards-care-plan.aspxhttp://www.clineguide.com/nursing-standards-care-plan.aspxhttp://www.clineguide.com/nursing-standards-care-plan.aspxhttp://www.clineguide.com/nursing-standards-care-plan.aspx


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Cochrane Database of

Systematic ReviewsGold standard for high quality systematic

reviews

Includes full-text reviews and protocols

Cochrane Abstracts available in CINAHLand MEDLINE/PubMed


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So, you want to use Google?

Not a problem!!! Google www.google.com

Largest search engine: over 25 billionpages

Relevance ranking based on link analysis

Google Advanced Search

www.google.com/advanced_search?hl=en Google Scholar

www.scholar.google.com
http://www.google.com/http://www.google.com/advanced_search?hl=enhttp://www.scholar.google.com/http://www.scholar.google.com/http://www.google.com/advanced_search?hl=enhttp://www.google.com/


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But use Google Scholar!!!

www.scholar.google.com Searches for scholarly literature, including peer-

reviewed papers, theses, books, abstracts andtechnical reports

Finds articles from academic publishers, professionalsocieties, universities, etc. as well as scholarlyarticles on the web

"Cited by" link identifies # that have cited the

original Access to full text only available with subscription

Caution: Not a reliable sole source for searchingscholarly literature
http://www.scholar.google.com/http://www.scholar.google.com/


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Criteria for Evaluating Web Siteswww.healthlinks.washington.edu/howto/navigating/criteria.pdf

Authority

Accuracy

Objectivity

Currency

Coverage

Design
http://www.healthlinks.washington.edu/howto/navigating/criteria.pdfhttp://www.healthlinks.washington.edu/howto/navigating/criteria.pdf


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Questions???

Lets hear from

Prof. Sharon Hewner, PhD, RNAsst. Professor of Nursing

State University of New York at Buffalo

School of Nursing

on her discussion on HOW

EVIDENCE-BASED PRACTICE, QUALITY and NURSINGRESEARCH form the bench-stool of Nursing practice.


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Hungry for more???

We invite you to the 1stEvidence-basedResearch Workshop here in Cebu..

WHEN: April 25-26, 2014 (2-day Workshop)

WHERE: Chong Hua Hospital, AB Conf. Room

SPEAKER: Ms. Lee Banguilan, RN, MAN

Head, Nursing Research Dept.Philippine Heart Center, QC

PRICE: Php 1,200 (inclusive of kit, ID and lunch)

FREE for Chong Hua Hospital employees


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Thank you!!!!


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1. Ask the burning question using

PICO

P: Patient, population, or problem beingaddressed

I: Intervention or dimension of interest

C: Comparison intervention O: Outcome

Format helps focus the question bydetermining the important concepts

Not necessary to follow above order



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PICO Examples

Intervention focused clinical question: In teenagers (patient population), how effective is

Depo-Provera (intervention) in the prevention ofpregnancy (outcome)?

Non-intervention focused question: What is the duration of breast feeding (outcome) in

new mothers (population) who have breast-related-

complications (area of interest) in the first 3 monthsafter the infants birth versus those who do not havebreast related complications (comparison)?

(Salmon, 2007)


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2. Collect most relevant and

best evidence1. Systematic review/meta-analysis of all RCTs or

evidence-based clinical practice guidelines2. At least one well-designed RCT3. Well-designed controlled trials without

randomization4. Well designed case-control and cohort studies5. Systematic review of descriptive and qualitative

studies6. Single descriptive or qualitative study7. Opinion of authorities and/or reports of expert

committees

(Melnyk & Fineout-Overholt; 2005)


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best evidence

Evidence Based Clinical Practice Guideline

Based on scientific literature

Explicitly documents process used to develop

statement

Grades strength of evidence used

(www.chestnet.org/education/guidelines/currentGuidelines.php; cited in Melnyk

& Fineout-Overholt, 2005)
http://www.chestnet.org/education/guidelines/currentGuidelines.phphttp://www.chestnet.org/education/guidelines/currentGuidelines.php


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best evidence

Systematic Review:

Rigorous systematic review of primary studies

Preplanned comprehensive search strategy

Relevant articles

appraised

data synthesized

results interpreted summary of best available evidence provided

(Salmon, 2007)

Precise; minimizes error & bias


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best evidence

Meta-analysis:

Integrates results of similar descriptive orqualatitative studies

Meta-synthesis:

Statistical method

Integrates results of several independent studies

addressing a set or related research hypotheses Objective appraisal

Precise estimate of treatment effect

(Salmon, 2007)

C


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best evidence

RCT: Gold Standard for intervention studies

Most reliable

Treatment randomization eliminates large amount ofbias

Cohort Study:

Observational longitudinal study with 2 patient groups One group receives treatment

Groups measured over time for development ofoutcomes

(Salmon, 2007)

2 C ll l d


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best evidence

Case-control studies:

Compares patients who have a specificcondition to people who do not

Uses medical records and/or patient recall

Less reliable than RCTs and cohort studies

showing a statistical relationship does notnecessarily mean clinical causal relationship

(Salmon, 2007)

2 C ll t t l t d


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best evidence

Qualitative Research: Collects data through observations and interviews

Generates ideas and hypotheses through inductive

Descriptive Studies:

Can be quantitative or qualitative

Describe what is going on

Expert Opinion

(Salmon, 2007)

S h St t


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Search Strategy

1. Determine appropriate data base for question

2. Determine type of study design that would bestanswer question

3. Enter a subject heading (e.g., MeSH in PubMed)and/or textword search guided by the PICOcomponents of the question

4. Combine searches to find relevant evidence

5. Further restrict combined searches for study design,methods, indicators of clinical meaningfulness, English,human

6. Apply pre-established inclusion & exclusion criteria tostudies gathered by the search

(Salmon, 2007)

Pre-appraised literature is golden

3 C iti ll A i E id


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3. Critically Appraise Evidence

RCT

Rapid Screening

Random allocation of interventions?

Blindness to interventions by

Researchers?

Participants?

Involved health care professionals?


3 C iti ll A i E id


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Systematic Review

Rapid Appraisal

Relevant papers identified?

Method of assessing quality of papers?

Method of summarizing results?


3 C iti ll A i E id


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Qualitative Research

Lincoln & Gubas Evaluative Criteria:

Trustworthiness

Credibility (internal validity)

Transferability (external validity) Dependability (reliability)

Confirmability (objectivity)



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4.Integrate Evidence/Patient

Preferences/Values/Clinical Experience

Evidence assists but does not replacesound clinical reasoning.

EvidenceAnalogy

Experience

Meaning Theory

Salmon, 2007)

4 I t t E id /P ti t


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4.Integrate Evidence/Patient

Preferences/Values/Clinical Experience

Is evidence useful for this particularpatient?

Cost effective? Patient values and preferences?

Clinician expertise?

Best clinical decision makingis

integrative and collaborative!

Salmon, 2007)


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5. Implement & Evaluate Impact

Track outcomes

Include patients evaluations

Requires informatics for imputing & tracking

Patient

Treatment

Outcome

Documents

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