Introduction To Evidence Introduction To Evidence Based NursingBased Nursing

By Dr. Hanan Said Ali

ObjectivesObjectivesDefine evidence – informed nursingIdentify the main imperative for

evidence – informed nursing.List the requirement of evidence –

informed nursing .Identify how does it relate to clinical

effectiveness and evidence – based practice

Discuss how to Implement evidence – informed practice.

Determine the Strengths of evidence.

What is evidence – informed What is evidence – informed nursingnursingWe use the term ( evidence –

informed nursing ) in preference to evidence – based nursing in order to recognizes that nurses are critical practitioners.

The nurse made a decision for actions which can be justified from knowledge base.

The main imperative for evidence – The main imperative for evidence – informed nursinginformed nursing

Proper use of evidence supports nurses in accounting for what they do.

Providing clinically effective patient care and being able to justify the procedures used , the care plan devised or the services provided by reference to authoritative evidence.

The main imperative for evidence – The main imperative for evidence – informed nursinginformed nursing

Making of decision about the care of individual patients and families, on the basis of the best available evidence

Integration of professional judgement and research evidence about effectiveness of interventions.

What it requires is that all What it requires is that all nurses havenurses have

An understanding of the importance of practice being based on the most appropriate evidence on effectiveness.

Access to and the ability to use research findings.

The ability to evaluate research.The ability to implement research

finding in their own practice.

Evidence – informed nursing Evidence – informed nursing requiresrequires

The formulation of answerable questions that arise from practice- Reflection,

The searching of the literature or other relevant evidence sources – Information,

The evaluation of the evidence for validity , generalisability, and transferability - appraisal

Evidence – informed nursing Evidence – informed nursing requires Cont.requires Cont.

The use of the best available evidence alongside clinical expertise and patient preferences in planning care - implementation,

The evaluation by practitioners of their own professional practice – evaluation.

The evidence – informed The evidence – informed nursing cyclenursing cycle

How does it relate to clinical How does it relate to clinical effectiveness and evidence – based effectiveness and evidence – based

practicepracticeThey refer , at least in part , to using

research to inform practice and to ensure efficient and effective practice.

It refers to clinical effectiveness as : applying the best available knowledge , derived from research , clinical expertise and patient preferences, to achieve the optimum processes and outcomes of care for patients.

How does it relate to clinical How does it relate to clinical effectiveness and evidence – based effectiveness and evidence – based

practicepracticeIt is doing the right thing in the right

way for the right patient at the right time.

There is a dissonance between the core beliefs of nursing and clinical effectiveness.

Nurses are committed to providing holistic care as opposed to care based on the biomedical model.

How does it relate to clinical How does it relate to clinical effectiveness and evidence – based effectiveness and evidence – based

practicepracticeNurses are committed to treat

patients as whole people and work with them rather on them.

Furthermore, effectiveness is only one element of the decision – making process –in deciding on the therapeutic intervention others include safety, acceptability , cost – effectiveness and appropriateness.

Example:Example: If he was diagnosed with cancer today and was faced with the decision about which type of chemotherapy to choose, would he want to know the evidence regarding the risks and benefits of each therapeutic agent as generated from prior clinical trials with other similar cancer clients?

Implementing evidence – informed Implementing evidence – informed

pracpractice tice To achieve evidence – informed nursing

a nurse needs to have:The research awareness skills and the

knowledge and competence to interpret research material and to use it to inform their clinical decision- making.

A managerial and organisational culture that facilitate the implementation of research into clinical practice.

To implement evidence- To implement evidence- informed practice the nurse informed practice the nurse needs:needs:

1. Clinical expertise1. Clinical expertise

Nurses are professionally accountable for the effectiveness of the care they provide and imposes on them a duty to monitor and improve their knowledge and competence

1. Clinical expertise Cont.1. Clinical expertise Cont.

The nurses have began to recognise the importance of evidence- informed practice and the need to have the skills to assess the research literature and implement findings in their own day – to –day practice.

2. Knowledge of research 2. Knowledge of research evidenceevidence

There is increased emphasis on using the latest and highest- quality evidence to inform clinical practice and service delivery to improve health outcomes for individuals and the population as a whole.

2. Knowledge of research 2. Knowledge of research evidence Cont.evidence Cont.

Evidence –informed nursing is a systematic approach to providing nursing care that requires critical appraisal skills. While research evidence is at the centre of it, it does not require all nurses to be researcher

3. An understanding of 3. An understanding of patient preference and patient preference and

choicechoicePatients and their families place

their trust in nurses.

The nurse needs to assess the patient’s knowledge and understanding of their condition and involve them in the decision – making process regarding their care.

3. An understanding of 3. An understanding of patient preference and patient preference and

choice Cont.choice Cont.

The nurse needs to be able to access and critically appraise the evidence in relation to the care needs of each patient and communicate this information in a style most appropriate to the individual patient.

4. Access to adequate 4. Access to adequate resourcesresources

For nursing to be evidence- informed, research needs to be accessible to nurses who understand the need to base their practice on research and who have the critical appraisal skills necessary to evaluate it. ,time to access it and skills to implement it.

Strengths of evidenceStrengths of evidenceEvidence is categorized according

to the overall research studies design in preventing bias from influencing the research finding.

What needs to be emphasised here is the value of the research in answering the proposed question.

The Five Strengths of The Five Strengths of EvidenceEvidence

Class

Strength of evidence

I Strong evidence from at least one systematic review of multiple well- designed randomised controlled trials

II Strong evidence from at least one properly designed randomised controlled trial of appropriate size.

III Evidence from well- designed trials without randomisation , single group pre- post, cohort, time series or matched case – control studies.

The Five Strengths of The Five Strengths of Evidence Cont.Evidence Cont.

Class Strength of evidence

IV Evidence from well- designed non –experimental studies from more than one centre or research group.

V Opinions of respected authorities based on clinical evidence, descriptive studies or reports of expert committees.

Best EvidenceBest Evidence

Define the best research evidence?Is define as:

Clinically relevant research, often from the basic sciences of medicine, but especially from patient centered

clinical research.

Without current best evidence , practice is rapidly outdated

Best Evidence Best Evidence Example:Example:For years , pediatrics primary care

providers advised parents to place their infant in prone position while sleeping, this is beast position to prevent aspiration of vomiting. With evidence indicating that prone positioning increase risk of sudden infant death syndrome, the American academic of pediatrics released the clinical practice guideline recommending a supine position for infant sleep.

Common Terminology in Common Terminology in EBNEBN

Patient value• The unique preferences, concerns and expectations each client brings to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patient.

Common Terminology in EBN Common Terminology in EBN Cont.Cont.

Systematic review A summary of the medical literature

that uses explicit methods to perform a comprehensive literature search and critical appraisal of individual studies and that uses appropriate statistical techniques to combine these valid studies.

Cochrane collaborationA worldwide association of groups who

create and maintain systematic reviews of the literature for specific topic areas.

Common Terminology in EBN Common Terminology in EBN Cont.Cont.

Case-control study A study which involves identifying patients

who have the outcome of interest (cases) and patients without the same outcome (controls), and looking back to see if they had the exposure of interest.

Cohort Study Involves identification of two groups

(cohorts) of patients, one which received the exposure of interest, and one which did not, and following these cohorts forward for the outcome of interest

Common Terminology in EBN Common Terminology in EBN Cont.Cont.Cross-sectional study The observation of a defined population

at a single point in time or time interval. Exposure and outcome are determined simultaneously.

Meta-analysis A systematic review that uses

quantitative methods to synthesize and summarize the results.

Common Terminology in EBN Common Terminology in EBN Cont.Cont.Randomization (or random allocation) Method analogous to tossing a coin to assign patients to treatment groups (the experimental treatment is assigned if the coin lands “heads” and a conventional, “control” or “placebo” treatment is given if the coin lands “tails”).

Randomized control clinical trial (RCT) Participants are randomly allocated into an experimental group or a control group and followed over time for the variables/outcomes of interest

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