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    Nur3052 ch4 Nur3052 ch4 Presentation Transcript

    • Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 4: Critically Appraising Knowledge for Clinical Decision Making
    • Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins The Need for Critical Appraisal • It is vital to discern biased evidence from unbiased, reliable from unreliable • Practice that is based on flawed evidence cannot be considered EBP
    • Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Knowledge Sources • In the past, practice was based largely on tradition, logic, and expertise • Research Utilization (RU) movement began to change this − RU emphasized the use of single studies, however • The process for generating practice-based evidence (e.g., quality improvement data) has improved
    • Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Weighing the Evidence • Practitioners take into account the validity and reliability of the specific evidence • Reliance on inexplicit or inferior knowledge sources (tradition; trial and error) is rapidly becoming unacceptable
    • Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Knowledge Sources for EBP 1. Valid research evidence − The primary basis of clinical decisions 2. Clinical expertise − To best use research by filling in gaps and combining it with practice-based evidence to tailor clinical actions for individual patients’ contexts 3. Patient choices and concerns − For determining the acceptability of evidence-based care to the individual patient • The main criterion is certainty
    • Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Question • Which of the following sources of knowledge would a nurse prioritize when determining the turning schedule for an immobilized patient? a. The traditional practice on the unit b. The nurse’s knowledge of skin breakdown c. The preferences of the patient and the patient’s family d. A clinical practice guideline for preventing skin breakdown
    • Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer • d. A clinical practice guideline for preventing skin breakdown • Rationale: EBP encompasses patient preferences and the clinical expertise of individual practitioners, but the primary source of knowledge is research evidence. Clinical practice guidelines synthesize this evidence in order to guide practice.
    • Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Rating the Strength of Evidence • Not necessarily synonymous with “hierarchy of evidence” − High-level study design does not necessarily mean high quality • Grading the strength of a body of evidence addresses three domains – quality, quantity, and consistency
    • Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Rating the Strength of a Body of Evidence • Quality: the extent to which a study’s design, conduct, and analysis has minimized selection, measurement, and confounding biases (internal validity) • Quantity: the number of studies that have evaluated the question, overall sample size across all studies, magnitude of the treatment effect, strength from causality assessment, such as relative risk or odds ratio • Consistency: whether investigations with both similar and different study designs report similar findings (requires numerous studies)
    • Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins What is Meant by “Evidence” • Research evidence • Clinical knowledge gained via the individual practitioner’s experience • Patients’ and practitioners’ preferences • Basic principles from logic and theory
    • Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Question • Tell whether the following statement is true or false. • A post-operative patient’s statement that Dilaudid (hydromorphone) has been ineffective in treating her pain can be considered a form of evidence.
    • Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer • True • Rationale: Patient preferences and experiences are an important consideration and are a form of evidence. While the patient’s preference does not likely constitute the “final word” on treatment choices, it must be weighed carefully and integrated into the nurse’ choice of intervention.
    • Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Internal Evidence • Evidence that is generated by outcomes management, quality improvement, or EBP implementation projects • Aimed at improving outcomes at the site where improvement efforts are conducted • Quality Indicator Systems: − AHRQ National Healthcare Quality Report − National Quality Forum (NQF) − National Database of Nursing Quality Indicators® (NDNQI®)
    • Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Question • Tell whether the following statement is true or false. • Internal evidence is characterized by findings that are applicable and generalizable to multiple practice settings.
    • Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer • False • Rationale: Unlike external evidence, the generation of internal evidence is intended to improve clinical practice and patient outcomes within the local setting that it is conducted.
    • Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Combining Internal and External Evidence • The PDSA Cycle 1. Plan: Plan the change and observation 2. Do: Try out the change on a small scale 3. Study: Analyze the data and determine what was learned 4. Act: Refine the change based on what was learned and repeat the testing