Evidence Based Practice: Core Concepts


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At the end of this presentation you will be able to:
Define evidence-based practice
Describe process & outline steps of EBP
Understand PICO elements & search strategy
Identify resources to support EBP
The focus of this presentation is nursing practice, although it is still of value to physicians and other health care professionals.

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  • Bostrom and Suter found that only 21% of 1200 practising nurses had implemented a new research finding in the previous six months.3
  • Foster that ‘spirit of inquiry’ in your institution
  • 1) In mechanically ventilated patients (P), how does a weaning protocol (I) compared with no weaning protocol (C) affect ventilator days (O) during ICU length of stay (T)? 2) In hospitalized adults (P), how does hourly rounding (I) compared with no rounding (C) affect fall rates (O)?
  • T – timeframe could be ‘during there stay in your unit/ ward’
  • Search stategy – use your PICOT question to guide the search
  • Different levels of evidence - types of research suit different types of questions
  • Information pyramidPrognosis questions ~ cohort studies are goodPrevention questions ~ RCT, Case studies and Cohort studiesEtiology/ harm – risk questions ~ can use all types of research studies
  • Use our PICO question about falls
  • The first link is an excellent 10 part video series from Yale U
  • One way to foster and support EBP in your institution – blog
  • Evidence Based Practice: Core Concepts

    1. 1. Evidence-BasedPractice:Core ConceptsAdapted from PPT by Caroline E. Brown, UCSD& “Evidence-Based Practice: Step-by-Step”AJN series by Melnyk & Stillwell (CE)March 2011
    2. 2. ObjectivesAt the end of this presentation you will be able to: Define evidence-based practice Describe process & outline steps of EBP Understand PICO elements & search strategy Identify resources to support EBP
    3. 3. Why do you do what you doeach day?????What information do you baseyour nursing care on?” The goal of EBP is to change practice – tolocate the best evidence and put it intopractice.” RN.com EBP CE
    4. 4. The sources of information that shapeclinical practice… Colleagues Textbooks The internet Educational events Pharmaceutical or other Industry Reading the Journal articles What you learned in school
    5. 5. Bases for nursing carePravikoff et al., A 2005 survey of 760 RN‟s in theUS, working in clinical practice, found that: 67% get information for practice from other nurses 58% do not use research reports to support theirpractice 82% never used a hospital library 54% were not familiar with term EBP 67% never searched CINAHL 72% hadn‟t evaluated research reports
    6. 6. “Most nurses practice accordingto what they learned in nursingschool, their experience, andwhat colleagues share in theclinical setting.”Estabrooks, 1998; 2003 &Pravikoff 2005
    7. 7. Common DriversHow Patient Care is Practiced… Ritual…accepted practices versusresearch proven practices…The “that’s theway we’ve always done it” syndrome. Tradition…the way I learned how to do it. Personal opinion… without assessmentof underlying assumptions. Arrogance…I have to be right syndrome. Lack of concern… for patients values‟.
    8. 8. The Need for EBP “EBP is essential to transform healthcareby providing proven effective treatments.At present there is a gap between theoryand practice that results in diminishedpatient care, inefficient practice, and anexcessive time lag between the discoveryof knowledge and its incorporation intoclinical practice.” (Salmond 2007) p.460 „Knowledge translation‟ ~ 17 years
    9. 9. The Need for EBP “An extensive body of research knowledgeexists now that needs to be incorporated intopractice.” (Drenning 2006) Practices supported by research improveoutcomes Knowledge explosion makes it impossible to“keep up” EBP provides means to• Standardize best practices• Improve adherence to best practices• Makes relevant data available at the bedside whenneeded
    10. 10. Why does EBP Matter?“Research shows that EBP leads to higherquality care, improved patient outcomes,reduced costs, and greater nursesatisfaction than traditional approaches tocare.” (Melnyk, 2010)
    11. 11. EBP has demonstrated that… 28% better patient outcomes if patientsreceive care based on the best and latestevidence from well-designed studiescompared to traditional practice (Heater 1988) “Patients should receive care based onthe best available scientific knowledge” IOM, Crossing the Quality Chasm: A New Health System for21st Century, 2001
    12. 12. Why Does Evidence-BasedPractice Matter to You?“Higher level of satisfaction amonghealthcare providers who use evidence-based approach in delivering patient carethan those who deliver care steeped intradition.” Dawes, M. (1996)
    13. 13. Status of EBP Abundance of knowledge exists waiting to be putinto practice (@17 years lag time) Growing expectation that EBP is part ofeveryday clinical practice IOM wants 90% compliance by 2020 only 10~15 % of clinicians currently take aconsistent EBP approach to care One study that surveyed 1200 practicing nursesfound that only 21% had implemented a newresearch finding in the previous six months.
    14. 14. What are the topbarrier‟s to EBP ?
    15. 15. Barriers to EBP in Nurses The nurse does not have enough time to read research,or implement new ideas Overwhelming patient loads The nurse is unaware of the research, or doesn‟tperceive it as informing practice The nurse does not have authority to change practice The amount of research is overwhelming Inadequate resources and lack of administrative support Lack of EBP mentors to work with providers
    16. 16. Other Deficits Among Nurses Inadequate EBP knowledge and skills EBP only recently included in nursing education never learned how to search an electronic database not able to differentiate between research reports andother types of literature lack the ability to critically evaluate research reports orassess the quality still lack comfort, skills, time, access to appropriatematerials to engage in EBP
    17. 17. Factors that Facilitate EBP EBP knowledge and skills Belief in the value of EBP & the ability toimplement it A culture that supports EBP and providesthe necessary tools to sustain evidence-based care EBP mentors
    18. 18. Transition Towards EBPThe movements that have been involved intransitioning health care delivery awayfrom ritual practice include: Quality Assurance/ Process Improvement Knowledge Translation movement Evidence-based practice Research and it‟s utilization Evidence-based Consumer/Patient Choice
    19. 19. Evidence-Based Practice isDefined as…“ a problem-solving approach to the delivery ofhealth care that integrates the best evidencefrom studies and patient care data with clinicalexpertise and patient preferences and values.”“an approach to providing care that integratesnursing experience and intuition with valid andcurrent clinical research to achieve bestoutcomes.” (p.460)
    20. 20. ClinicalExpertiseResearchEvidencePatientPreferences
    21. 21. (Melnyk & Fineout-Overholt, Stillwell 2010)EBP: Seven StepsStep Zero: Cultivate a spirit of enquiry1. Ask the burning clinical question in PICOT format2. Search & collect the most relevant and best evidence3. Critically appraise the evidence4. Integrate all evidence with one‟s clinical expertise,patient preferences, and values in making a practicedecision or change5. Evaluate the outcomes of the practice decisions orchanges based on evidence6. Disseminate EBP results.
    22. 22. The process of doing EBP issimilar to the nursing process Assess Ask Acquire & Appraise Apply Analyze Advance & Adopt Assess Diagnosis Plan Implement Evaluate
    23. 23. AskingAppraisingApplyingAnalyzingAssessingAcquiringAdvancing&AdoptingThe Process of Doing Evidence-Based PracticeCatalystAdapted by the SanDiego Consortium forNursing Excellence
    24. 24. The Catalyst and Assessing
    25. 25. The Catalyst… Inquiring clinicians set the process of EBPin motion. Inquiring clinicians possesscuriosity and inquisitiveness, they questionthe status quo!!! The catalyst may come from manysources. Some examples are new research, ineffectivesystems for providing care, new technologies,and questioning ritual practices.
    26. 26. Becoming an Inquiring Nurse Startswith… Understanding Why…By Asking Questions!!! Why are you giving care this way? Why do you do what you do each day? Is there evidence to support the currentpractice? Is there a better way?
    27. 27. Step Zero: A Spirit of InquiryStrategies for Building aSpirit of Inquiry:Think about these clinicalquestions when caring foryour patients… Ask why? .. why am Idoing what I am doingwith my patients? Where can I find the bestevidence to answer myclinical questions?(Melnyk, 2010) Who can assist me toenhance my EBPknowledge and skills? Who can be my mentor? Which of my practices arecurrently EB and whichdon‟t have supportingevidence? When is the best time toquestion my currentclinical practices and withwhom?
    28. 28. Strategies to Promote EBP Integrate into philosophy and mission Administrative commitment Integrate throughout organization Create an environment that promotescritical thinking, autonomous decisionmaking, empowerment Introduce staff to EBP Provide tools and access
    29. 29. Assessing… Leads the inquiring provider to gatherinformation about why a practice is donethe way it is. Assessing involves gathering evidencefrom colleagues, policies, and datasources to understand the history of thepractice and to confirm that a problemexists with the practice.
    30. 30. Assessing confirms the relevance Once you know more about whysomething is done a certain way you canmake a determination of the relevance andimportance of the problem for theparticular unit and the organization.
    31. 31. Step One:Asking the Right Question Facilitates literature searches Guides your plan Narrows your focus Searchable Answerable
    32. 32. The Evidence-Based Practice Process1. Asking a clinical question (PICOT)2. Searching for the best evidence3. Critically appraising the evidence4. Integrating evidence into practice5. Evaluating the results6. Disseminating the evidence
    33. 33. Comparison of Background &Foreground Questions Background question:A broad, basic-knowledgequestion commonlyanswered in textbooks.May begin with what / when.1) What is the best method toprevent pressure ulcers?2) What is sepsis?3) When do the effects offurosemide peak? Foreground question:A specific question that,when answered, providesevidence for clinicaldecision making.Includes PICOTelements:(1) population (P),(2) intervention /issue ofinterest (I)(3) comparison intervention orissue of interest (C),(4) outcome (O)(5) and sometimes time (T).
    34. 34. Why is the PICOT questionso important? The PICOT format provides a consistent,systematic way to identify the componentsof a clinical issue. Structuring a clinical question with PICOThelps to clarify the components which willguide the search for evidence. A well-built PICOT question increases thelikelihood of finding the best evidencequickly and efficiently.
    35. 35. PICOT Format Foreground questions ask for specificknowledge to inform clinical decisions oractions.PICOT Format: Problem/Population Intervention Comparison Intervention Outcome Timeframe (optional)
    36. 36. The Basic PICO Question: In or among your patient or population,does your intervention, (versus yourcomparison), result in or affect youroutcome?
    37. 37. Asking A Question with PICOP:PopulationDescribeasspecificallyas possibleI:InterventionDescribe theinterventionof interest,this may be atreatment,risk factor,perceptionC:ComparisonUse acomparison ifit fits to do so,this may be aalternative, aplacebo,usual careO:OutcomeWhat is theclinicaloutcome ~add thetimeframe ifimportant(T)
    38. 38. Asking the Clinical Questions In mechanically ventilated patients (P),how does a weaning protocol (I) comparedwith no weaning protocol (C) affectventilator days (O) during ICU length ofstay (T)? In hospitalized adults (P), how does hourlyrounding (I) compared with no rounding(C) affect fall rates (O)?
    39. 39. P:PopulationI:InterventionC:ComparisonO:OutcomeExample In postcardiacsurgerypatientsdoidentificationprotocolsas comparedto usual carereduce risk ofskin tears?Example In patientsundergoingdiagnosticproceduresdoes listeningto taped musicas comparedto live musicreduceanxiety andincreasepatientsatisfaction?Example In acute careunitsdoes nursewalkingroundsas comparedto taped reportincreasepatientsatisfactionand missedtreatments?,
    40. 40. Exercise: Scenario Scenario - You are interested in reducingthe number of elderly patients that fallduring their hospital stay and the severityof injury. Currently the rate of falls ishigher in your unit than in other units in thehospital and the national benchmark.There are a variety of interventionscurrently being used in the hospital andyou want to know where to start on yourunit to address this problem.
    41. 41. What is your PICO Question? Question Population – in elderly hospitalizedpatients does Intervention – fall assessment Comparison – usual care Outcome – prevent or reduce thenumber and severity of falls
    42. 42. Exercise: Scenario Scenario - You are interested in knowingthe best approaches to teaching acutecare nurses how to teach patients aboutdiabetic self-care.
    43. 43. What is your PICO Question? Question Population – In acute care nurses does Intervention – a self-learning module Comparison – compared to a interactiveclass session Outcome – provide the knowledge andskills required to teach patients diabeticself-care management?
    44. 44. BERNARD BECKERMEDICAL LIBRARYWashington UniversitySchool of MedicineStep 2:Search for the Best Evidence Developed PICOT question Identify keywords and terms from PICO Identify standardized subject headings Combine subject headings and keywordsto narrow or broaden your search Evaluate your search results Revise the search in light of your results
    45. 45. Collecting the evidence…
    46. 46.  Answering the background question. Anumber of textbooks, handbooks anddatabases may be consulted to effectivelyanswer background questions. Answering the foreground question. Thehighest level of research evidenceavailable to answer the question.The evidence you search for should bedriven by your PICO question…
    47. 47. Levels of Evidence…but it was in a nursingjournal – so doesn‟t thatmean it is good???
    48. 48. Types of Questions Diagnosis Therapy (treatment) Prognosis Etiology / harm Prevention Cost-effective Quality of life
    49. 49. Levels of Evidence:Treatment (Therapy) QuestionsSystematic reviews or meta-analysis or clinical guidelinesOne well-designed RCTWell-designed research without randomizationWell-designed case-control or cohort studiesSingle descriptive or qualitative studyExpert opinion, expert committee
    50. 50. “Not everything that counts canbe counted, and not everythingthat can be counted counts.”~ Albert Einstein
    51. 51. Levels of Evidence:Experiential (Quality of Life)QuestionsSystematic Reviews of Qualitative and Descriptive ResearchSingle Qualitative ResearchExpert Opinion, Expert CommitteesEvidence from Quantitative Research
    52. 52. Where to find Evidence /EBP Guidelines? The Cochrane Library National Clearinghouse Guidelines Registered Nurse Association of Ontario www.rnao.org Clinical Decision Support Tools: JAMA Evidence, BMJ Best Evidence, Clinical Evidence, etc. www.nursingsociety.org Worldviews on Evidence Based Practice (Journal) Schools and Universities Pubmed EBSCO host ~ Medline, CINAHL, Nursing ReferenceCenter, DynaMed, etc. Check links on the ARL Nursing & Clinical Toolkits
    53. 53. Strategy for Finding Evidence Start with a meta-search engine Trip database or Sum Search(links on ARL Nursing Toolkit) First look for systematic reviews, meta-analysis and clinical guidelines, Cochrane Next search major databases, EBSCO PubMed, CINAHL, Medline, PsychINFO Next search regulatory agencies,professional organizations (list p.464)
    54. 54.  Scenario - You are interested in reducing thenumber of elderly patient that fall during theirhospital stay and the severity of injury. Question Population – in elderly hospitalized patientsdoes Intervention – fall assessment Comparison – usual care Outcome – prevent falls or reduce thenumber and severity ?
    55. 55. Step 3: Critically Appraisethe Evidence Purpose of critical appraisal is todetermine value of evidence for practice. Rapid critical appraisal of a study‟s worthasks 3 questions…
    56. 56. Rapid Critical AppraisalAttempt to answer three questions: Are the results of the study or systematicreview valid?(Validity of the evidence) What are the results and are they reliable /important?(Reliability of the evidence) Are the findings clinically relevant to mypatients?(Applicability of the evidence to your population)
    57. 57. Step 4:Integrate the evidence with clinicalexpertise and patient preferencesand values.“Research evidence alone is not sufficientto justify a change in practice.”(Melnyk, 2010)
    58. 58. Can you draw conclusions basedon your literature base? Have you completed an exhaustive search? Do themes emerge from your literature base/research summary ? What levels of evidence are contained with inthe articles found? What conclusion can you make? A body of reliable evidence Inconclusive evidence No evidence
    59. 59. Is there asufficientliterature base?yes noDesign PracticeChangeBest Practiceswith other typesof evidenceConduct research
    60. 60. Balancing the literature…ClinicalExpertiseHealth careresourcesClinicalcontextEvidencePatientPreferencesEvidenceBasedDecision
    61. 61. Moving Forward Applying theEvidence to your Practice Develop recommendations for practice. Integrate the evidence recommendations,with collaboration with patients, into a planof care. Complete human subject protectionrequirements.
    62. 62. Making the project a reality1. Define project plan2. Define the protocol (what you are changing)3. Specify outcome measures4. Determine method for data collection1. Develop a system for managing data collected2. Plan to maintain integrity of data collection5. Implement process6. Draw conclusion about success: adoptchange – reject change – modify change
    63. 63. AnalyzingThis step involvesanswering the questions: Did you do what you setout to ? Were there anyunintendedconsequences of thechange in practice?Step 5:Evaluate theoutcomes ofthe practicedecisions orchanges basedon evidence.
    64. 64. Analyzing… Evaluating outcome in health careproviders‟ own setting. Important to consider bias andconfounding influences. Patient evaluations of experiences as wellas nurses‟ evaluation must be considered. Interdisciplinary collaboration is essential.
    65. 65. Step 6: Disseminate EBP ResultsAdvancing This step involvessharing what yourexperience was withothers. It involvesdisseminating theoutcomes of yourproject and thelessons you learnedthough the process.Adopting This step involvesplanning for broaderadoption of thepractice beyond yourpatient, unit, serviceor division. Not allprojects will proceed thisfar.
    66. 66. EB Nursing Practice Tutorials http://cwml-tutorials.blogspot.com/search/label/Evidence-Based%20Practice http://hsl.lib.umn.edu/biomed/help/evidence-based-practice#toc20146 http://www.libraries.psu.edu/psul/tutorials/ebpt.html http://nursingandhealth.asu.edu/node/6393 http://ktclearinghouse.ca/cebm/syllabi/nursing http://www.hsl.unc.edu/services/tutorials/ebm/welcome.htm
    67. 67. ResourcesFor your reference
    68. 68. Sources of Evidence:EBP SourcesThe TRIP Database started in 1997 as a small search engine witha focus on medical articles consideredevidence-based. aim is to allow health professionals to easilyfind the highest-quality material available onthe web. http://www.tripdatabase.com
    69. 69. Another Google for EBPSum Search is a search engine that searches other EBPdatabases as a “one-stop-shop model” http://sumsearch.uthscsa.edu
    70. 70. Cochrane CollaborationThis international organization supportsinformed health care decision-making bypreparing, maintaining, and makingavailable systematic reviews of the effectsof health care interventions. www.cochrane.org (main website- paid) http://cochrane.bireme.br/portal/php/index.php?lang=en (free access in Caribbean via PAHO)
    71. 71. National Institute for Health and ClinicalExcellenceThe National Institute for Health and ClinicalExcellence (NICE) is an independent UK organization responsible forproviding national guidance on the promotion of goodhealth and the prevention and treatment of ill health. NICE produces guidance in three areas of health:• public health• health technologies• clinical practicehttp://www.nice.org.uk/
    72. 72. Sources of Evidence: The Registered Nurses Association ofOntario (RNAO):Nursing Best Practice Guidelines Program(NBPG) http://www.rnao.org/Page.asp?PageID=861&SiteNodeID=133 Some Topics: IV line care, crisis intervention,constipation, continence, pain, wounds, strokeassessment, breastfeeding…
    73. 73. Sources of Evidence: What is Bandolier? The first issue of Bandolier, an independentjournal about evidence-based healthcare,written by Oxford scientists, 1994. It has appeared monthly ever since and hasbecome the premier source of evidencebased healthcare information in the UK andworldwide for both healthcare professionalsand consumers http://www.medicine.ox.ac.uk/bandolier/
    74. 74. Nursing Research:Show me the evidence! http://evidencebasednursing.blogspot.com/ The Saint Joseph Hospital (Orange, California)Nursing Research Blog communicates nursingresearch activities at SJO to staff. Posts includeannouncements of Nursing Grand Rounds,Nursing Journal Clubs, Nursing EBN classes,ongoing nursing research and relevant medicallibrary announcements and news. Provides an open discussion forum for nursesand librarians interested in evidence-basednursing.