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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/8/12/2019 Eb Pn Lecture
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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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Why Evidence Based Practice?
Traditional practice Knowledge gained in school
Pathophysiological rationale
Intuition
Experiences (past & usual practice)
Workplace colleagues
(Melnyk & Fineout-Overholt, 2005; Salmon, 2007)
17-year lag between research findings andpractice application
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Why Evidence Based Practice?
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
(Melnyk & Fineout-Overholt, 2005; Salmon, 2007)
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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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Why Evidence Based Practice?
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.aspx8/12/2019 Eb Pn Lecture
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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/8/12/2019 Eb Pn Lecture
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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
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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.pdf8/12/2019 Eb Pn Lecture
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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
(Melnyk & Fineout-Overholt, 2005; Salmon, 2007)
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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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2. Collect most relevant and
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)
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2. Collect most relevant and
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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2. Collect most relevant and
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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2. Collect most relevant and
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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2. Collect most relevant and
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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2. Collect most relevant and
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?
(Melnyk & Fineout-Overholt; 2005)
3 C iti ll A i E id
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3. Critically Appraise Evidence
Systematic Review
Rapid Appraisal
Relevant papers identified?
Method of assessing quality of papers?
Method of summarizing results?
(Melnyk & Fineout-Overholt; 2005)
3 C iti ll A i E id
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3. Critically Appraise Evidence
Qualitative Research
Lincoln & Gubas Evaluative Criteria:
Trustworthiness
Credibility (internal validity)
Transferability (external validity) Dependability (reliability)
Confirmability (objectivity)
(Melnyk & Fineout-Overholt; 2005)
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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