Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Chapter 5Evidence-Based Practice
2Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.A Case for Evidence A response to societal forces A p...
3Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Evidence-Based Decision Making
4Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Steps to Evidence-Based Practice(EBP) Six steps provid...
5Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Steps to Evidence-Based Practice(EBP) (cont’d)4. Integr...
6Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.PICOT Developing a PICOT question: P = Patient popula...
7Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Gathering Evidence The more focused a PICOT question i...
8Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Hierarchy of Evidence
9Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Reviewing Studies Evidence-based articles include the ...
10Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Analysis of Evidence After critiquing all articles fo...
11Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Integration of Evidence When you decide to apply evid...
12Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Nursing Research A way to identify new knowledge, imp...
13Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Case Study Shana and Eric are nurseswho work in the s...
14Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Case Study (cont’d) Shana notes that the incidence of...
15Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Outcomes ManagementResearch Designed to assess and do...
16Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Quick Quiz!1. Which of the following is the first step...
17Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Scientific Method The foundation of research The mos...
18Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Nursing and the Scientific Approach Nursing research ...
19Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Research Process An orderly series of steps that allo...
20Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Human Research Terminology Institutional Review Board...
21Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Case Study (cont’d) Shana and Eric volunteer as part ...
22Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Quality and PerformanceImprovement Every health care ...
23Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
24Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Quick Quiz!2. Every health care organization gathers d...
25Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Example: QI Program Plan—Review available data to und...
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  • This model for evidence-based clinical decision making shows how using your clinical expertise and considering patients’ values and preferences ensures that you will apply the evidence in practice both safely and appropriately.[Figure is on p. 51 of text.]
  • •Box 5-1 (on text p. 52) reviews the parts of development of a clinical “PICOT” question. These elements direct the nurse to:Identify patients by age, gender, ethnicity, and disease or health problem Which intervention is worthwhile to use in practice (e.g., a treatment, diagnostic test, prognostic factor)? What is the usual standard of care or the intervention used now in practice? What result do you wish to achieve or observe as a result of an intervention (e.g., change in patient behavior, physical finding, patient perception)? How much time is needed for an intervention to achieve an outcome (e.g., the amount of time needed to change quality of life or patient behavior)?
  • After critiquing all articles for a PICOT question, synthesize or combine the findings to consider the scientific rigor of the evidence and whether it has application in practice.
  • The hierarchy of available evidence offers a guide to the types of literature or information that offer the best scientific evidence.This diagram of the hierarchy of evidence shows that stronger evidence is farther up the triangle. For instance, a well-designed randomized controlled trial (RCT) carries more weight than the opinion of even experts.A randomized controlled trial is the highest level of experimental research.[Discuss each level.][Figure is on p. 54 of text.]
  • When you read an article, do not put it down and walk away because of the statistics and technical language. Know the elements of an article and use a careful approach when reviewing each one.•An abstract is a brief summary of the article that quickly tells you if it is research or clinically based. An abstract summarizes the purpose of the article. •The introduction contains more information about the purpose of the article. •A good author offers a detailed background of the level of science or clinical information that is available on the topic. •The “middle section” or narrative of an article differs according to the type of evidence-based article it is: clinical or research. •Aclinical articledescribes a clinical topic, often including a description of a patient population, the nature of a certain disease or health alteration, how patients are affected, and appropriate nursing therapies. •A research article contains several subsections within the narrative, including the following: A purpose statement explains the focus or intent of a study and includes hypotheses—predictions made about the relationship or difference between studies—and questions or variables—concepts, characteristics, or traits that vary within or among subjects. • The methods or design explains how a research study was organized and conducted to answer the research question or test the hypothesis. • Clinical and research articles have a summary section. In a clinical article, the author explains the clinical implications for the topic presented. In a research article, the author details the results of the study and explains whether a hypothesis is supported or how a research question is answered. • Clinical implications: A research article includes a section that explains whether findings from the study have clinical implications. [Ask the class to write the parts of a clinical study, then to write the parts of a research study. Review the components of each.]
  • Critiquing evidence involves evaluating it, which includes determining the value, feasibility, and usefulness of evidence for making a practice change (ONS, no date). When critiquing evidence, first evaluate the scientific merit and clinical applicability of the findings of each study. Then using a group of studies and expert opinion, determine what findings have a strong enough basis for use in practice. After critiquing the evidence, you will be able to answer the following questions: Do the articles together offer evidence to explain or answer my PICOT question? Do the articles show support for the reliability and validity of the evidence? Can I use the evidence in practice?
  • Evidence is integrated in a variety of ways through teaching tools, clinical practice guidelines, policies and procedures, and new assessment or documentation tools. Depending on the amount of change needed to apply evidence in practice, it becomes necessary to involve a number of staff members from a given nursing unit.After the change is implemented, ask yourself, “How does the intervention work? How effective was the clinical decision for my patient or practice setting?”When evaluating an EBP change, determine whether the change was effective, if modifications in the change are needed, or if the change needs to be discontinued.When a practice change occurs on a nursing unit level, the first group to discuss the outcomes of the change is often the clinical staff on that unit. Clinicians enjoy and appreciate seeing the results of a practice change.In addition, the practice change will more likely be sustainable and remain in place when staff are able to see the benefits of an EBP change.
  • What are some of the advantages and disadvantages of belonging to such a committee? [Discuss.]
  • How would the incidence of such infections come to a nurse’s attention? How would awareness of a trend of increased incidence come to a nurse’s attention?What are some other possible causes of SR-BSIs from central venous catheters? [Discuss.]
  • Answer: B
  • Before conducting any study with human subjects, the researcher obtains approvals from the agency’s human subjects committee or institutional review board. An IRB includes scientists and laypersons who review all studies conducted at the institution to ensure that ethical principles, including the rights of human subjects, are followed.Confidentiality guarantees that any information a subject provides will not be reported in any manner that identifies the subject and will not be accessible to people outside the research team.
  • [Ask the class: What clinical question would you develop to address such a problem?Discuss.] [Ask the class: What outcomes would you use to measure implementation of changes suggested by the study? Discuss.]
  • The relationship among research, evidence-based practice, and quality improvement is overlapping and reinforcing. [Figure is on text p. 60.]See Table 5-3 [on text p. 61] to review the similarities and differences of these three methods.When implementing a research project, EBP and QI can inform opportunities for research. Rapid-cycle improvements measured through QI often identify gaps in evidence. Similarly, EBP literature reviews often identify gaps in scientific evidence. Thus the two processes help to identify topics for research.
  • Answer: D
  • A thorough analysis of QI data leads clinicians to understand work processes and the need to change practice. One type of QI Program, the PDSA cycle or approach, is described here.
  • Chapter 5

    1. 1. Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Chapter 5Evidence-Based Practice
    2. 2. 2Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.A Case for Evidence A response to societal forces A problem-solving approach to practice Challenge to obtain: The very best information The most current information Information at the right time, when you need it forpatient care
    3. 3. 3Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Evidence-Based Decision Making
    4. 4. 4Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Steps to Evidence-Based Practice(EBP) Six steps provide a systematic approach torational clinical decision making:1. Ask the clinical question.2. Collect the best evidence.3. Critique the evidence.(cont’d)
    5. 5. 5Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Steps to Evidence-Based Practice(EBP) (cont’d)4. Integrate the evidence.5. Evaluate the practice decision or change.6. Share the outcomes of EBP changes with others.
    6. 6. 6Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.PICOT Developing a PICOT question: P = Patient population of interest I = Intervention of interest C = Comparison of interest O = Outcome T = Time
    7. 7. 7Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Gathering Evidence The more focused a PICOT question is, theeasier it will become to search for evidence in thescientific literature. Expert clinicians are a rich source of evidencebecause they use it frequently to build their ownpractice and to solve clinical problems. The critique or evaluation of evidence includesdetermining the value, feasibility, and usefulnessof evidence in making a practice change.
    8. 8. 8Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Hierarchy of Evidence
    9. 9. 9Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Reviewing Studies Evidence-based articles include the following: Abstract Introduction Literature review or background Narrative (clinical or research)• Purpose• Methods or design Results and/or conclusion• Clinical implications
    10. 10. 10Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Analysis of Evidence After critiquing all articles for a PICOTquestion, Synthesize or combine the findings Consider the scientific rigor of the evidence and Whether it has application in practice
    11. 11. 11Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Integration of Evidence When you decide to apply evidence,consider: The setting Whether support is provided from staff andavailable resources Evaluate the change. Share the information.
    12. 12. 12Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Nursing Research A way to identify new knowledge, improveprofessional education and practice, and useresources effectively The International Council of Nurses (ICN)supports the need for nursing research as ameans of improving the health and welfare ofpeople.
    13. 13. 13Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Case Study Shana and Eric are nurseswho work in the surgicalintensive care unit (ICU).They belong to their unitpractice committee, whichmeets monthly to discusspractice issues. They havereceived a copy of themonthly report on qualityindicators.
    14. 14. 14Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Case Study (cont’d) Shana notes that the incidence of catheter-related bloodstream infections (SR-BSIs) hassteadily increased during the last 3 months. Patients with central venous catheters, usedto deliver fluids and medications overextended periods of time, are becominginfected, but why? Is there a problem with the type of dressingplaced over the catheter or the way the site iscleansed before insertion?
    15. 15. 15Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Outcomes ManagementResearch Designed to assess and document theeffectiveness of health care services andinterventions A response of the health care industry todemands from policy makers, insurers, andthe public Outcomes must be observable ormeasurable.
    16. 16. 16Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Quick Quiz!1. Which of the following is the first step of theresearch process?A. Analyze data.B. Identify problem.C. Conduct study.D. Use the findings.
    17. 17. 17Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Scientific Method The foundation of research The most reliable and objective means ofacquiring and conducting research andgaining knowledge. A step-by-step process to ensure that findingsfrom a study are valid, reliable, andgeneralizable to a similar group of subjects
    18. 18. 18Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Nursing and the Scientific Approach Nursing research provides a way for nursingquestions and problems to be studied inbroader context. Quantitative Qualitative Quantitative types: historical, exploratory,evaluation, descriptive, experimental,correlational
    19. 19. 19Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Research Process An orderly series of steps that allows aresearcher to find the answer to a question Consists of five steps: Identify problem. Design study. Conduct study. Analyze data. Use the findings.
    20. 20. 20Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Human Research Terminology Institutional Review Board (IRB) Informed consent means Participants receive full and complete information They can understand the information They have free choice to participate They understand how their confidentiality will bekept Confidentiality
    21. 21. 21Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Case Study (cont’d) Shana and Eric volunteer as part of theircommittee responsibilities to implement anEBP project. Their first step will be to develop a clinicalquestion and then search the scientificliterature. Their aim is to determine what evidence isavailable so that they can make an informeddecision about the best approaches forreducing CR-BSIs among their patients.
    22. 22. 22Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Quality and PerformanceImprovement Every health care organization gathers dataon health outcome measures as a way togauge the quality of care. Quality improvement Performance improvement A thorough analysis of QI data leadsclinicians to understand work processes andthe need to change practice.
    23. 23. 23Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
    24. 24. 24Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Quick Quiz!2. Every health care organization gathers dataon health outcomes. Examples of dataincludeA. Discharges.B. Medications administered.C. Healthy births.D. Infection rates.
    25. 25. 25Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.Example: QI Program Plan—Review available data to understandexisting practice conditions or problems toidentify the need for change. Do—Select an intervention on the basis of thedata reviewed and implement the change. Study—Study (evaluate) the results of thechange. Act—If the process change is successful withpositive outcomes, act on these practices byincorporating them into daily unit performance.

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