Ebp Lab Sum 09 A (2)
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    Ebp Lab Sum 09 A (2) Ebp Lab Sum 09 A (2) Presentation Transcript

    • Evidence-Based Nursing Practice Clinical Lab Nursing V Summer 2009 Judith Van Sant, PhD, RN, CNE
    • Objectives  Describe evidence-based practice (EBP)  Discuss the five steps of EBP  Ask at least one clinical question to be researched  Search, collect, and evaluate level of evidence on a clinical question  Disseminate search findings to lab participants
    • What is Evidence-Based Practice?  Definition: “…a systematic approach to problem solving for health care providers” (Pravikoff, Tanner, & Pierce, 2005).  Integrated components:  clinical expertise (best practice)  external evidence from systematic research  patient preferences (Sackett, et al., 1996)
    • Process of Evidence-Based 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)
    • Sources for Evidence-Based Practice  Guidelines and Best Practices  Data base of evidence-based clinical practice guidelines  Best practice information sheets  Systematic Literature Reviews  Research method which produces a synthesis of the literature on a specific question and a discussion of concomitant implications  Cochrane Data-base of Systematic Reviews  Other Resources  Abstracted information and commentary on research studies from various international journals
    • Why Evidence Based Practice?  Knowledge explosion +  Nursing shortage Mandate  Timely research evidence translation into best practice. (Melnyk & Fineout-Overholt, 2005; Salmon, 2007)
    • Why Evidence Based Practice?  Traditional practice  Knowledge gained in school  Pathophysiological rationale  Intuition  Experiences (past & usual practice)  Workplace colleagues 17-year lag between research findings and practice application (Melnyk & Fineout-Overholt, 2005; Salmon, 2007)
    • Why Evidence Based Practice?  EBP can lead to:  Increased practitioner satisfaction  Decreased “burnout” and turnover  Third party reimbursement (Melnyk & Fineout-Overholt, 2005; Salmon, 2007)
    • Why Evidence Based Practice?  Evidence continually evolves Evidence-based practice Opinion-based Melnyk & Fineout-Overholt, 2005; Salmon, 2007
    • WARNING!!!!!  “EBP does not replace clinical reasoning or judgment.”  20% medical practice Supported by <20% nursing practice solid evidence (Gray, et al., 2002) Evidence Gaps >Primary Research (Salmon, 2007)
    • What is Evidence Based Practice?  Conscientious use of best evidence in clinical decision making:  Systematic search for best evidence  Critical appraisal of most relevant evidence to answer clinical question  Clinical context or circumstances  One’s own clinical experience  Patient preferences and values EBP is more than research utilization (Melnyk & Fineout-Overholt, 2005; Salmond,2007)
    • 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 case – several RCTs supporting effectiveness of corticosteroid therapy to halt premature labor in high risk women had not been systematically analyzed  1,000’s of low-birth-weight premature infants continued to die needlessly  Review data showed therapy decreased death from 30% to50% Melnyk & Fineout-Overholt, 2005
    • History of EBP Movement  2000 IOM report, To Err is Human  Preventable medical errors were 8th leading cause of death in US  2002 IOM report, Crossing the Quality Chasm  Major lag between medical science and technology advancements and healthcare delivery Salmon, 2007
    • Steps in EBP 1. Ask the “burning” question (PICO). 2. Collect the most relevant & best evidence. 3. Critically appraise evidence 4. Integrate all evidence with one’s clinical expertise/patient preferences/values. 5. Evaluate the practice decision or change. Melnyk & Fineout-Overholt, 2005
    • 1. Ask the “burning” question using PICO  P: Patient, population, or problem being addressed  I: Intervention or dimension of interest  C: Comparison intervention  O: Outcome  Format helps focus the question by determining the important concepts  Not necessary to follow above order (Melnyk & Fineout-Overholt, 2005; Salmon, 2007)
    • PICO Examples  Intervention focused clinical question:  “In teenagers (patient population), how effective is Depo-Provera (intervention) in the prevention of pregnancy (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 months after the infants birth versus those who do not have breast related complications (comparison)? (Salmon, 2007)
    • 2. Collect most relevant and best evidence 1. Systematic review/meta-analysis of all RCTs or evidence-based clinical practice guidelines 2. At least one well-designed RCT 3. Well-designed controlled trials without randomization 4. Well designed case-control and cohort studies 5. Systematic review of descriptive and qualitative studies 6. Single descriptive or qualitative study 7. Opinion of authorities and/or reports of expert committees (Melnyk & Fineout-Overholt; 2005)
    • 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)
    • 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 Precise; minimizes error & bias (Salmon, 2007)
    • 2. Collect most relevant and best evidence  Meta-analysis:  Integrates results of similar descriptive or qualatitative 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)
    • 2. Collect most relevant and best evidence  RCT:  “Gold Standard” for intervention studies  Most reliable  Treatment randomization eliminates large amount of bias  Cohort Study:  Observational longitudinal study with 2 patient groups  One group receives treatment  Groups measured over time for development of outcomes (Salmon, 2007)
    • 2. Collect most relevant and best evidence  Case-control studies:  Compares patients who have a specific condition to people who do not  Uses medical records and/or patient recall  Less reliable than RCTs and cohort studies  showing a statistical relationship does not necessarily mean clinical causal relationship (Salmon, 2007)
    • 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)
    • Search Strategy 1. Determine appropriate data base for question 2. Determine type of study design that would best answer question 3. Enter a subject heading (e.g., MeSH in PubMed) and/or textword search guided by the PICO components 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 to studies gathered by the search Pre-appraised literature is golden (Salmon, 2007)
    • 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. 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. Critically Appraise Evidence Qualitative Research  Lincoln & Guba’s Evaluative Criteria:  Trustworthiness  Credibility (internal validity)  Transferability (external validity)  Dependability (reliability)  Confirmability (objectivity) (Melnyk & Fineout-Overholt; 2005)
    • 4.Integrate Evidence/Patient Preferences/ Values/Clinical Experience  Evidence assists but does not replace sound clinical reasoning.  Evidence  Analogy  Experience  Meaning  Theory Salmon, 2007)
    • 4.Integrate Evidence/Patient Preferences/Values/Clinical Experience  Is evidence useful for this particular patient?  Cost effective?  Patient values and preferences?  Clinician expertise? Best clinical decision making is integrative and collaborative! Salmon, 2007)
    • 5. Implement & Evaluate Impact  Track outcomes  Include patients’ evaluations  Requires informatics for imputing & tracking  Patient  Treatment  Outcome