Evidance Based Nursing Practice

8/13/2019 Evidance Based Nursing Practice

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e f i n i t i o n s

! Evidence-based practice can be thought of as requiring"the integration of the best research evidence with our

clinical expertise and our patient's unique values and

circumstances." (Straus, et al., 2005)

! "Fortunately, evidence-based practice (EBP) is anapproach that enables clinicians to provide highest

quality of care in meeting the multifaceted needs of their

patients and families." (Melnyk & Fineout-Overholt, 2005)


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Definitions

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Goals of E P

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Why the rapid spread of

evidence-based practice?

Some of major reasons cited by Sackett et al (1997)

for the spread of the EBP movement have been :

" the lack of research-based information to supportclinical decision making

" the lack research-based guidelines and protocols to usein clinical practice

" the overwhelming volume and variability of new journalinformation

" the inadequacy of traditional sources of information (e.g.textbooks out of date)


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What are the benefits ofevidence based practice?1. To patients/consumers

Patient typically accept recommended carefrom health professionals with the unspokenassumption that the practitioner know what

works


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What are the benefits ofevidence based practice?2. To nurses! EBP allows a more structured and streamlined way of

keeping abreast of relevant new developments withoutbecoming over-whelmed by information overload

! EBP also allows nurse to communicate effectively withtheir patients and with the healthcare team about the

rationales for decision making and care plans! An EBP nurse is a confident professional, feeling

assured that they are providing care that is supported byfacts rather than habits, and can take legalaccountability for their practice


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What are the benefits of

evidence-based practice?

3. To the healthcare organization! EBP philosophy allow healthcare organization to position themselves

in the market as quality institution.! An EBP-compliant institution should be less likely to attract

litigation, or to successfully defend the care delivered.

! EBP allows the scrutinizing of practice for effectiveness.! This process often results in practice changes that allow significant

cost savings, or alternatively justify necessary additionalexpenditure

! This is attractive to organizations frequently struggling to meetassigned budgetary limits, or lobbying government for additionalfunds


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W hat are the benefits ofevidence-based practice?FG H7 05+ %7


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1.Ask or identify the important clinical question2. Collect the best and more pertinent evidence3. Critically analyze and rate the evidence4. Integrate the evidence into clinical decisions5. Implement best evidence in clinical practice6. Evaluation


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1. Ask or identify the important

clinical question

! HOW?? PICO! Patient

!Age, sex, ethnicity, etc.! Condition, diseases, general health status

! Intervention! Education, diagnostics, treatment plan, self-care, etc.

! Comparison Intervention! Placebo, etc.

! Outcome! Expected and actual effects on patient


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PICO

! The nurses want to know:What is the best way of obtaining a urine specimen

culture, from a child?

Population: Children suspected of having UTI (Urinary

tract infection), who are not yet toilet training

Intervention: Bag-catch urine specimen, clean-catch urine

specimen

Comparison: Suprapubic aspiration

Outcome: Culture contamination


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PICO

The revised question:

In children suspected having of UTI, who are not yet toilet

training, what is the risk of culture contamination when

urine is obtained by bag-catch or clean catch, as

compared with urine obtained by suprapubic aspirationdirectly from the bladder?

! Not all questions are of a clinical nature! Intervention can be interpreted very broadly


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! Do nurse led tobacco cessation interventionsresult in decreased smoking rates after hospitaladmission for coronary heart disease?

! What are the factors, identified by mothers wholive in the deprived inner city areas, that

influences them to breastfeed or to bottle-feed

using infant milk formula


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2. Collect the best and more

pertinent evidence

Where is the evidence located?

! CINAHL (Cumulative Index to Nursing and the Allied Health Literature)! Medline www.ncbi.nlm.nih.gov/PubMed/.! Proquest

http://www.proquest.com/pqdweb

username: 0NQTKKWNKM& Password:brawijaya

! Ovidhttp://gateway.ovid.com/

ID & Password : hsll199

! EBSCOhttp://search.epnet.com/

user : cathedral & password : dc

NEW: http://search.ebscohost.com

Id: n5000145, passwords


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3. Critically analyze and rate the

evidence

! Critical Appraisal of the evidence! Grading of the evidence


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Grading of research studies that measure theeffect of an intervention treatment or therapyLevel ofevidence

Study designs

I Evidence obtained from a systematicreview or meta-analysis of all relevantrandomized controlled trials

II Evidence obtained from at least oneproperly designed randomized controlledtrial

III-1 Evidence obtained from well-designedpseudo-randomized controlled trials

Source : NHMRC 1999


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Grading of research studies that measure theeffect of an intervention treatment or therapyLevel ofevidence

Study designs

III-2 Evidence obtained from comparative

studies with concurrent controls andallocation not randomized (Cohort studies,case-control studies or interrupted time-

series with control group)

III-3 Evidence obtained from comparativestudies with historical control, two or more

single-arm studies, or interrupted time-series without a parallel control group

Source : NHMRC 1999


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Levels of evidence of effectivenessLevel Evidence of effectiveness

1 Systematic review (with homogeneity) of experimentalstudies, or one or more large experimental studies withnarrow confidence interval

2 Quasi-experimental studies (e.g without randomization)

3a Cohort studies (with control group)

3b Case-controlled

3c Observational studies without control groups

4 Expert opinion without explicit critical appraisal, orbased on physiology, bench research or consensus

Source:The Joanna Briggs Institute.Available at www.joannabriggs.edu.au/pubs/approach.php.


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TRIP = turning research into practice

Simultaneously searches evidence-based sources of systematic reviews, practice

guidelines, and critically-appraised topics and articles

QUALITY OF EVIDENCE


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4. Integrate the evidence into

clinical decisions

Key points:

Research evidence is, on its own, insufficient to ensurethe robust clinical decisions necessary for clinically

effective health care

Good clinical decisions require the sophisticatedapplication of research findings in the context ofclinical expertise, patient preferences and values, andthe individual decisions

The availability of resources influences how researchevidence is interpreted and applied


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4. Integrate cont

The seven rights of the clinical effectiveness

(Royal College of Nursing, 1996)

1.

Right thing for the2. Right patient from the3. Right person at the4. Right time in the5.

Right way to achieve the

6. Right outcome at the7. Right cost


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4. Integrate cont

Influences on clinical decision making

Decisionmaking

Clinicalexpertise

Intuition

Research

AvailableResources

Media

Experts

Values andbelief

Consensus


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4. Integrate cont

Clinical expertise:The ability to use our clinical skills and past experience to rapidly

identify each patients unique health state and diagnosis, theirindividual risks and benefits of potential interventions, and theirpersonal values and expectations (Sackett et al 2000)

Intuitive practice:

A way in which we know and behave about the situation that is notbased on conscious reasoning or rational thought process(Parahoo 1997)

Builds on repeated practice situations, it is context specific and it

enables the integration of complex pieces of a data to derive adecision that is difficult to articulate through linear rules(Greenhalgh 2000)


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5. Implement best evidence in

clinical practice

Where to start?

Identifying appropriate topics to address" Consider local and national views on the topic" Attitudes to using research evidence

Choosing a project manger Diagnosing the situation

The organizational environment, stakeholders andpractitioner opinion leaders, grassroots workers, Users views,the way we do things round here, SWOT analysis


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5. Implement cont

How to implement the changes?

Developing a dissemination and implementationstrategy

General/ specific approaches to manage changeEducational approach, epidemiological stances,marketing of a product, information or strategies,behavioural changes, social interactionism,organizational approach, resources and management

issues, realistic goals and time frames, reviewing.


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6. Evaluation

Evaluating the progress and effects of thechanges?

Maintaining close contact with the progress and effects Formal evaluation and dissemination


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How Do I Participate in an Evidence-

Based Practice?

!Ask an authority or expert in the field! Consult a textbook!

Look for an article in a nursing journal! Look for an article in a scholarly journal!Ask a nursing peer! Use simple trial and error! Use your intuition, judgment, or reasoning skills

to solve the particular problem

Godshall, Maryann 2010


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Evidance Based Nursing Practice