Introduction•Paradigm shift from expert or opinionbased practice to Evidence-basedpractice.•Has potential to increase patients’involvement in clinical decisionmaking.To improve health outcomes.
INTRODUCTION T he concept of EBP emer ged out of the Evidence-Based Medicine (EBM) movement, which is rooted in the wor k of A.L. Cochrane. In the 1970s, Cochrane stronglyencouraged his colleagues to use evidence from random controlled trials to deter mine the ef fectiveness and ef ficiency of medical inter ventions (T he Cochrane Collaboration, 2002).
Evidence-based practice(EBP) Is the acknowledgement of uncertainty followed by the seeking, appraising and implementation of new knowledge. It enables us to accept the difference, possibly more effective, methods of care than those currently employed.
Evidence-based nursing"Evidence-based nursing (EBN)means using the best availableevidence from research, along withpatient preferences and clinicalexperience, when making nursingdecisions."
Evidence Based Nursing Evidence Based Nursing is the process by which nurses make clinical decisions using the best available research evidence, their clinical expertise and patient preferences. Three areas of research competence are: interpreting and using research, evaluating practice, and conducting
Model for clinicaldecisions Patients preferences ResearchResources evidence Clinical Expertise
T he EBP- processEvidence-Based Practice is a five- step process: Identify a knowledge need and for mulate an answerable clinical question Locate the best available evidence Critically evaluate the evidence Inte grate the evidence with patient’s unique biology ,preferences and values Evaluate the outcome
Steps in EBN•Select a topic•Collect appropriate and accurate data to generateevidence for nursing practice.•Analyze data from clinical practice.•Design interventions based on evidence.•Predict and analyze outcomes.•Examine patterns of behavior and outcomes.•Identify gaps in evidence for practice.•Evaluate project to determine and implement bestpractices
Various Models-EBNP•The IOWA Model of nursing utilization•Rogers diffusion of innovation-model•Stetler model for research utilization•Disciplined clinical inquiry model
Various Models-EBNP cont’d•Conduct and utilization of Researchin Nursing (CURN) model•Translational research model
The IOWA Model•Is a research utilization model and modifiedto include more emphasis on EBP .•The model is renamed, The IOWA Model ofevidence-based practice to promote qualitycare.•Problem focused triggers & knowledgefocused triggers
The IOWA Model-cont’d•Assess, pilot the change in practice•Continue to evaluate quality of careand the new knowledge•Institute the change in practice•Monitor and analyze structure,process &outcome
Rogers diffusion ofinnovation-modelMajor concepts are :•innovation•Communication•Time•Social system
Stetler model for researchutilizationI Phase- preparationII Phase-validationIII Phase – comparativeevaluation/decision makingIV Phase-translate or apply theresearch in theV Phase –evaluate the out come asof the change in practice
Evidence-based practiceThe quality of the evidence is based on: Is this the best available evidence? Best sources included peer reviewed journals & reports no more than 3-5 years old. Will the recommendations work for my practice to solve the client’s problems? Do the recommendations fit well with the preferences & values of the clients the nurse commonly works with?
Disciplined clinical inquirymodelPhase I Phase 3Needsassessment Current Phase 4 state PC KD& Phase 2 EBNP CA EBPC RE Desired DCI state Principles Tools & process Phase 5 Outcomes& impact Evaluation
Nursing practices are examined for: • Feasibility which relates to the practicality of implementing the action. •Appropriateness refers to whether it is acceptable & justifiable with in ethical guidelines. •Meaningfulness provides the rationale for the practice being adopted. •Effectiveness relates to how much evidence supports the practice & what evidence provides divergent view points
Benefits of using evidencebase for clinical practice: A sound foundation for practice Enhanced self-confidence, autonomy, critical thinking skills and professional self-concept Cost-effective patient care Increased job satisfaction &quality of care
BENEFITS cont’d.. Improved patient outcomes A stimulus for collaborative practice, retention & recruitment An improved image of nursing An ever –increasing scientific nursing knowledge base
What Data Do We Need forEvidence-Based Practice?•Information about the patient•Domain information and knowledge(“the evidence”) from systematicinquiry and other sources
Informatics Supports•Building the evidence•Retrieving the evidence•Analyzing the evidence•Applying the evidence
A successful EBP programrequires:(a) consistent long-term vision and support from senior leadership;(b) resources such as trained personnel, finances, and time; and(c) structured approach to create an environment that facilitates the process.
Criticisms of the evidence –based approach•Health professionals are already doing it•Evidence –based health care is ‘’cookbook’’ health care•Evidence –based practice relies on RCT&Meta -analyses•There is no evidence•Theory is more important than evidence inguiding practice
Challenges to EBP•Resistant to changes in nursingpractice.•Ability to critically appraise researchfindings.•Time, workload pressures, andcompeting priorities.•Lack of continuing educationprograms.•Fear of "stepping on ones toes"•Poor administrative support .
Challenges to EBP-cont’d•Relevant research based evidencebases are not comprehensive( there is gap in the practice)•The relevant evidence bases arenot static•Life long-learning is generallyaccepted as an important priority inthe 21 st century
Challenges to EBP-cont’d•The piece of research conducteddoes not mean that the finding sshould be transferred directly in tothe clinical setting•Demands from patients for a certaintype of treatment
Challenges to EBP-cont’d•Peer pressure to continue withpractices that are stepped intradition•Inadequate content and behavioralskills regarding EBP in educationalprograms•Lack of commitment and computerskills
Facilitating conditions toenhance EBP•Support and encouragement fromadministration•Time to critically appraise studies andimportant findings•Clearly written research reports•Adequate resources and time•Characteristics of health care team(sharedvision & mission)•Guideline characteristics
Strategies that guide our workinclude:•Providing superior educationalopportunities•Enhancing health-related quality of lifethrough development, acquisition, andapplication of knowledge•Generating and using empirical data todevelop informed nursing policies andpractice
Strategies that guide ourwork-cont’d•Developing a dynamic nursing culturethat is embraced and respected, bothinternally and externally•Fostering excellence in practice andcontinuity of care•Synchronizing best practices throughoutto quality outcomes
EBP-CMC•Reduction in IM injection•Chlorhexidine Hand rub in ICU to preventinfection•Preparation of patient education materialsto enhance increase patient outcomes•Most patient friendly strategies to improveQuality of care•Strategies to minimize patient fall, pressuresore care•Independent nursing practice( nurseeducators in the specialty areas)
EBP –C MC, cont’d•Open and closed endo tracheal suctioning•Use of coconut oil instead of powder toreduce pressure sore•Use of vegetable oil instead of glycerineto prevent glossitis•Use of NRS to assess pain management• use of Postoperative check list
EBP –CMC, cont’d•use of lactulose enema instead of bowelwash for hepatic encephalopathy•Use of dry/empty humidifier to preventinfections•Use of mild sedation instead ofmechanical restraints in the ICU•Use of tap water to clean RTA wounds inEmergency unit•Kangaroo care for neonates•No skin preparation and soap and waterenema for woman in labour
Best evidence to guideclinical practice: Exercise improves glycemic control and reduces plasma triglycerides and visceral adipose tissue in type- 2 diabetes; evidence obtained from -14 RCT, Meta-analysis(JEBN- 2007). A low protein diet delays ESRD in chronic kidney disease.
Best evidence to guideclinical practice-cont’d… Peri operative education coordinated at one facility identified the occurrence of deep vein thrombosis as a significant problem. Nurse conducted a literature review ,created an evidence –based practice change. Life style education programmes lower glucose concentrations & reduce the incidence of type 2 diabetes
Best Evidence cont’d..McCormack investigated existingevidence-based literature toanswer the clinical question Howeffective is the use of wrist splintsas a single first-line therapy forthe relief of symptoms in adultsCarpel Tunnel Syndrome-suggestthe Wrist splints as a first-linetherapy.
Best evidence-cont’d•Allowing wounds to be uncoveredand wet in the first 48 hours afterminor skin excision did not differ fromstandard dry management for woundinfection.•Meta-analysis of (28 RCTs) exercisetraining decreased long term cardiacmortality, MI recurrence & majorcardiac risk factors( BP, total serumcholesterol, weight ).
Best evidence contd…. RCTs (19 studies) to evaluate the effectiveness of nurse delivered smoking cessation intervention for adults, had >2 groups & had > 6 months of follow-up. At longest follow up, pts’ who received advice from a nurse were more likely to stop smoking than received usual care.
Best evidence cont’d.. RCT to compare the effectiveness and cost-effectiveness of aggressive versus symptomatic therapy in established rheumatoid arthritis(2005). The finding reported that there was no significant difference between the groups for any of the clinical outcome measures.
Best evidence cont’d… Research makes a difference in practice. A meta-analysis designed to determine the contribution of research-based practice to patient outcomes. Heater & Colleagues reported that patients who receive research based nursing care make “sizable gains” compared to those receiving routine nursing care.
Best Evidence cont’d.. Interventions involving family care givers to improve outcomes of hospitalized elders; the finding of studies suggest that family member involvement has benefits for both the elder and the family members.
Summary•Evidence based nursing started in the1800s with Florence Nightingale.•EBN is a problem solving approach toclinical decision making.•EBN integrates providers clinicalexpertise with the best external clinicalevidence.
Summary-cont’dEBN is the process of integrating • Clinical knowledge • Judgement • Proficiency skills • with the best available clinical evidence, such as nursing practice in to patient care (TRIP &GRIP).
Conclusion•A commitment to the continuedpreparation of nurses as scientist is vitalto achieve excellence in nursing practice•we can continue to shape the future ofnursing and healthcare...through theplanning, implementation anddissemination of quality research studies.
REFERENCES: • Ellis, J. R & Hartley C. L (2005). Managing and Coordinating nursing care (4thed.). PhiladelphiaLippincott Williams & Wilkins Company. • Heidenthal, P.K (2004).Essentials of Nursing Leadership &Management. USA, Delmar learning. • Journal of Evidence Based Nursing, January, 2007. • Kathuric, O. (2003).Evidence Based Nursing practice. The Nursing Journal of India. No.11.p251-252 • Rose, M., Best, D & Higgs, J (2005). Transforming practice through Clinical Education, Professional Supervision & Mentoring. Philadelphia, Elsevier Company. • Vanwicken, W. Cantrell, W. (2006). Implementing a research utilization plan for prevention of deep vein thrombosis.AORNJ,83(6) 1353-62
References contd.. Melnyk,B. & Fineout-Overholt, E.(2005).Evidence-based Practice in Nursing & Health care. Philadelphia. Lippincott Williams & Wilkins Company.Web sites: www.ebn.bmj.com/cgi/ www.cebm.utoronto.ca/syllabi/nur/ www.ahrq.gov/qual/ www.himiss.org/content/ www.tripdatabase.com