Evidence-Based Practice and the Future of Nursing


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Evidence-Based Practice and the Future of Nursing

  1. 1. Evidence-Based Practice and the Future of Nursing Suzanne Prevost, RN, PhD Associate Dean for Practice University of Kentucky College of Nursing President-Elect – Sigma Theta Tau International Brought to you by
  2. 2. The Evolution of Evidence-Based Practice Brought to you by
  3. 3. What is - Evidence? Anything that provides material or information on which a conclusion or proof may be based; used to arrive at the truth, used to prove or disprove the point at issue. (Webster) Brought to you by
  4. 4. Evidence-Based Practice • Evidence-Based Practice – Conscientious, explicit and judicious use of current best evidence with clinical expertise, and patient values to make decisions about the care of patients. (Sackett, 2000) • Evidence-based nursing practice is the process of shared decision-making between practitioner, patient and significant others, based on research evidence, the patient’s experiences and preferences, clinical expertise, and other robust sources of information. (STTI , 2007) Brought to you by
  5. 5. • EBP is both a process and a product… requiring that the evidence which is produced – is also applied to practice. (D. Rutledge, 2002) Brought to you by
  6. 6. Evolution of EBP • 1991 – Evidence-based medicine -first described in the American College of Physicians Journal Club. • 1992 – the Evidence-based Medicine Working Group described it as a “paradigm shift” in JAMA – Clinical observations and experience, principles of pathophysiology, knowledge gained from authoritative figures, and common sense -- are no longer a sufficient guide for clinical practice, decision-making, or the development of practice guidelines Brought to you by
  7. 7. Evolution of EBP • Early 1990’s – US Prev. Services TF – began developing EB Guidelines for Screening and Prevention • 1992 – AHCPR (now AHRQ) – started publishing systematic reviews and consensus statements in the form of Clinical Practice Guidelines, starting with the guideline for Acute Pain, 19 guidelines were produced from ’92-’96 • 1993 - the first annual Cochrane Colloquia was held at the New York Academy of Sciences • 1993 – Online Journal of Knowledge Synthesis for Nursing Brought to you by
  8. 8. Evolution of EBP 1997 – Jan 2011 – 198 Evidence Reports published by the EBP centers – May, 2005 – Episiotomy Use – “…no health benefits from episiotomy… routine use is harmful …” Brought to you by
  9. 9. Recent Evidence Reports 193. Alzheimer's Disease and Cognitive Decline 192. Lactose Intolerance and Health 190. Enhancing Use and Quality of Colorectal Cancer Screening 189. Exercise-induced Bronchoconstriction and Asthma 188. Impact of Consumer Health Informatics Applications 187. Treatment of Overactive Bladder in Women 185. Management of Ductal Carcinoma in Situ (DCIS) 184. Treatment of Common Hip Fractures 151. Nurse Staffing and Quality of Patient Care 140. Tobacco Use: Prevention, Cessation, and Control This is just one example of literature syntheses that are available to support EBP. Brought to you by
  10. 10. Nurse Staffing and Quality of Patient Care • Objectives: To assess how nurse to patient ratios and nurse work hours were associated with patient outcomes in acute care hospitals • Results: Higher RN staffing was associated with less mortality, failure to rescue, cardiac arrest, hospital acquired pneumonia, and other adverse events. Limited evidence suggests that the higher proportion of RNs with BSN degrees was associated with lower mortality and failure to rescue. More overtime hours were associated with an increase in hospital related mortality, nosocomial infections, shock, and bloodstream infections. Brought to you by
  11. 11. Evolution of EBP • 1998 – Evidence-Based Nursing journal debuted • 1999 – The UK Department of Health stipulated that, to enhance the quality of care, nursing, midwifery, and health visiting practice must be evidence-based • 2002 - JCAHO begins requiring monitoring of evidence- based core measures • 2004 – WorldViews on Evidence-Based Nursing • 2004 – AACN began publishing “Practice Alerts” Brought to you by
  12. 12. Evolving Interest in Evidence-Based Practice 0 0 1 0 0 5 25 35 47 51 67 83 139 530 0 100 200 300 400 500 600 '91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 2011 – Medline search > 38,000 Brought to you by
  13. 13. Within one decade, the concept of evidence-based practice has evolved and been embraced by nurses in nearly every clinical specialty, across a variety of roles and positions, and in locations around the globe. EBP – means many things to many people Brought to you by
  14. 14. Factors Contributing to Emphasis on Evidence-Based Nursing Practice • Scientific knowledge expansion – Knowledge expands exponentially q 2 yrs – 12 yrs. from now – 128 x as much knowledge • Knowledge availability -- The Internet • Highly educated nurses in clinical settings – APNs – focusing on evidence-based clinical problem-solving – Clinical Nurse Researchers – DNP Movement Brought to you by
  15. 15. Factors Contributing to Emphasis on Evidence-Based Nursing Practice • Aggressive pursuit of cost-effectiveness • Focus on quality of care, Risk & error reduction • Highly educated consumers • JCAHO/Accreditation expectations • Increased attention to institutional image – Magnet hospital movement Brought to you by
  16. 16. • Most nurses agree that EBP is important… but how do we make it happen? Brought to you by
  17. 17. What is the 1st step toward EBP for the practicing nurse? • Asking good clinical questions • Nurses must be empowered to ask critical questions in the spirit of looking for opportunities to improve nursing care and patient outcomes • Risk-taking environment Brought to you by
  18. 18. Nursing vs. Medical Questions • Often more exploratory • Less frequently focused on intervention selection • Less evidence to support many nursing interventions • Most nursing interventions have less capacity for harm • Many nursing challenges often go beyond individual clinical interventions (e.g. nurse staffing, education, recruitment) Brought to you by
  19. 19. Clinical Nursing Questions • In postoperative patients, does prn or ATC analgesic administration yield better pain relief? • Among critically ill patients, is controlled or open visitation more effective in reducing patient anxiety? Brought to you by
  20. 20. Questions for APNs • In acute care hospitals, is the CNS more effective by focusing on a specific patient population or a specific unit? • What else? Brought to you by
  21. 21. What kind of questions might the Nurse Manager ask? • On medical-surgical units, do 12 hour or 8 hour shifts result in more medication errors? Brought to you by
  22. 22. Key Questions to Ask When Considering EBP • Why have we always done “it” this way? • Do we have evidence-based rationale? • Or, is this practice merely based on tradition? • Is there a better (more effective, faster, safer, less expensive, more comfortable) method? • What approach does the patient (or the target group) prefer? • What do experts in this specialty recommend? Brought to you by
  23. 23. Key Questions to Ask When Considering EBP • What methods are used by leading/benchmark, organizations? • Do the findings of recent research suggest an alternative method? • Are organizational barriers inhibiting the application of best practices in this situation? • Is there a review of the research on this topic? • Are there nationally recognized standards of care, practice guidelines, or protocols that apply? Brought to you by
  24. 24. Steps in the EBP Process • Developing a well-built question • Finding evidence-based resources to answer the question • Evaluating the strength and applicability of the evidence • Applying the evidence to practice • Evaluating the effects Brought to you by
  25. 25. • Once we agree upon the question that poses an opportunity for improvement, then we must find the evidence • Where should we look? • Are all forms of evidence equivalent in quality? Brought to you by
  26. 26. Strength of Evidence • Level I - meta-analysis of multiple studies • Level II - experimental studies, RCTs • Level III - quasiexperimental studies • Level IV - nonexperiemental studies • Level V - case reports, clinical examples AHCPR/AHRQ • At what level is most nursing evidence? Brought to you by
  27. 27. AACN Levels of Evidence (Armola, et al. , C C Nurse, 2009) • Level A • Level B • Level C • Level D • Level E • Level M • Meta-analysis or metasynthesis of multiple controlled studies, supporting a specific action • Controlled, randomized, or nonrandomized studies, supporting a specific action • Qualitative, descriptive or correlational studies or systematic reviews with consistent results • Peer-reviewed prof. organ. standards with studies to support them • Theory-based evidence from expert opinion or case studies • Manufacturer’s recommendations only Brought to you by
  28. 28. What constitutes the “Evidence” in Evidence-Based Practice? “Evidence-based practice has been defined as the use of the best clinical evidence from systematic research (referring to meta-analysis, integrated reviews, & RCTs – as the gold standard). …Others (often nurses) believe that experimental studies, observational studies, and correlational studies are also suitable evidence.” C. Goode, Applied Nursing Research, 2000 Brought to you by
  29. 29. University of Colorado Multidisciplinary Evidence-Based Practice Model • Emphasizes that all types of research can be evaluated for their contribution • Recognizes the use of 9 non-research sources of evidence: – Pathophysiology, Retrospective or Concurrent Chart Review, Quality Improvement or Risk Data, International and Local Standards, Infection Control Data, Clinical Expertise, Benchmarking Data, Cost- Effectiveness Analysis, and Patient Preferences Brought to you by
  30. 30. A major dilemma for the practicing nurse: Finding the time, access, and research expertise that are needed to search and analyze the evidence to find answers to their clinical questions. For those of you who are already pursuing EBP, which of these issues pose the greatest challenges for you? Brought to you by
  31. 31. Finding the Evidence • Don’t reinvent the wheel • If other experts have reviewed the evidence on your topic … start there Brought to you by
  32. 32. Preprocessed Evidence (A. DiCenso, 2009) Brought to you by
  33. 33. Resources to Support Evidence-Based Practice • Government agencies • Cochrane Collaboration • Professional Organizations • Benchmark Institutions Brought to you by
  34. 34. AHRQ – Agency for Healthcare Research and Quality Brought to you by
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  37. 37. Cochrane Collaboration • “an international, independent, not-for-profit organization of over 27,000 contributors from more than 100 countries, dedicated to making up-to-date, accurate information about the effects of health care readily available worldwide. • Contributors produce systematic assessments of healthcare interventions, known as Cochrane Reviews, which are published online in The Cochrane Library. • Rely heavily on RCTs • Primarily focused on effectiveness of interventions, more medical and pharmaceutical than nursing Brought to you by
  38. 38. Cochrane Collaboration http://www.cochrane.org Brought to you by
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  40. 40. Substitution of Drs by Nurses in Primary Care Objectives: to evaluate the impact on patient outcomes, processes of care, and costs. Outcomes included: morbidity; mortality; satisfaction; compliance; and preference. Studies were included if nurses were compared to doctors providing a similar primary health care service. Doctors included: general practitioners, family physicians, pediatricians, internists or geriatricians. Nurses included: nurse practitioners, clinical nurse specialists, or advanced practice nurses. Results: 4253 articles were screened, 25 articles met our inclusion criteria. No appreciable differences were found between doctors and nurses in health outcomes, processes of care, or cost; but patient satisfaction was higher with nurse-led care.Brought to you by
  41. 41. Professional Nursing Organizations Supporting Evidence-Based Practice • AACN • AWHONN • AORN • ONS • Sigma Theta Tau Brought to you by
  42. 42. Am. Assoc. of Critical Care Nurses Succinct dynamic directives…supported by evidence to ensure excellence in practice and a safe and humane work environment. • Venous Thromboembolism Prevention • Oral Care in the Critically Ill • Noninvasive BP Monitoring • Verification of Feeding Tube Placement • Ventilator Associated Pneumonia • Dysrthymia Monitoring • Published since 2005 • Available free on AACN website • Include ppt presentations and audit tools Brought to you by
  43. 43. Oncology Nursing Society • EBP Resource Center • http://onsopcontent.ons.org/toolkits/evidence/ • Also provides topical toolkits, on specific topics, plus: • How To Find The Evidence • How To Critique Evidence • How To Develop An Evidence Based Presentation • Evidence Based Practice Education Guidelines • Evidence on Clinical Topics • How to Change Practice • Levels of Evidence Table Brought to you by
  44. 44. Sigma Theta Tau EBP Initiatives • Strategic Plan • Online Resources – NKI http://www.nursingknowledge.org > 200 resources for EBP – some free, some for purchase • New Award for EBP (formerly Clin Scholarship) • Conferences – International EBP and Research Congress – July, 2010 – Orlando – July, 2011 – Cancun – July, 2012 – Australia Brought to you by
  45. 45. Journals Supporting EBP – Evidence-Based Nursing – Online Journal of Clinical Innovations – WorldViews on Evidence-Based Nursing – The Online Journal of Knowledge Synthesis for Nursing – (archived, no longer being published) – Reflections on Nursing Leadership (Vol 28, 2) Brought to you by
  46. 46. Local vs. Global Evidence • Institutional/Local > National/International – CPI Data/Research Results – Standards & Protocols/Practice Guidelines – Expert Advice – Patient/Family Preferences Brought to you by
  47. 47. Values and Preferences EBN - integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families and communities … Yasmin Amarsi, RNL, 2002: “The crux is to ensure that EBN attends to what is important to nursing and that caring is not sacrificed on the altar of scientific evidence.” Brought to you by
  48. 48. Amy’s Blog • I consulted a well-regarded oncologist in New York. After the tests she regretfully informed me that my disease was not curable. She recommended an evidence-based course of medications aimed at slowing the progression. Before I committed, I wanted a second opinion. I secured an appointment with the pre-eminent researcher/ clinician in inflammatory breast cancer. … • The building was beautiful, the staff attentive. …I had no doubt that the care would be top-notch. • Everything changed when I sat down with the physician. He never asked about my goals for care. He recommended an aggressive approach of chemotherapy, radiation, mastectomy, and more aggressive chemotherapy. My doctor in New York had said this was the standard, evidence-based protocol for patients in Stage III B…But since I am in Stage IV (with mets) she said I wouldn’t get the benefit of this aggressive, curative approach. Brought to you by
  49. 49. • “All of my patients use this protocol,” he said. • I was shocked. “Does this mean I could get better?” I asked. • “No, this is not a cure.” he answered. “But if you respond to the treatment, you might live longer, although there are no guarantees.” • My goals are to maximize my quality of life so I can live, work, and enjoy my family … Would I undergo a year or more of grueling, debilitating treatment only to live with spinal fractures if the cancer progressed? … Would I get the possibility of quantity and no quality? • I pressed him. “Why do the mastectomy? If the cancer has already spread to my spine. You can’t remove it.” • His brow furrowed. “Well, you don’t want to look at the cancer, do you?” He made it sound like cosmetic surgery. • Right now, I feel fine. I can work. I am pain free. Did I want to trade that for a slim chance of a little extra time (no guarantees, of course)? Brought to you by
  50. 50. • “But what about the side effects of radiation?” I asked. “I’ve heard they are terrible.” • He frowned and seemed annoyed by my questions. “My patients don’t complain to me about it,” he replied. • Inwardly, I shook my head. Of course his patients never complained to him. Most of them were probably unaware that less aggressive treatments were viable options. To me, there were real drawbacks. Undergo aggressive therapy that might buy me a longer life…at what cost? I might never recover my health for the limited period of time I have. • This doctor, top in his field, was reflecting the bias of our medical system towards focusing (evidence-based) survival. He was focused only on quantity and forgot about quality. Brought to you by
  51. 51. • The patient’s goals and desires, hopes and fears, were not part of the equation. He was practicing one-size-fits-all (cookbook?) medicine that was not going to be right for me, even though scientific studies showed it was statistically more likely to lengthen life. • Based on a perverse set of metrics, this oncologist was offering technically the “best” care America had to offer. • Yet this good care was not best for me. It wouldn’t give me health. Instead, it might take away what health I had. It doesn’t matter if care is cutting-edge, technologically advanced, (and evidence-based); if it doesn’t take the patient’s goals into account, it may not be worth doing. Brought to you by
  52. 52. • I returned to my original New York oncologist. • I was determined not only to choose treatment that would maximize the healthy time I had remaining, but also to use that time to call on our health care institutions and professionals to make a real commitment to listening to their patients. Brought to you by
  53. 53. Moving Toward our Destiny Evidence-based practice is every nurses’ responsibility What can you do to make this goal a reality? Brought to you by
  54. 54. Educator’s Role – EB Education for EB Practice – Base educational content on evidence – Seek the most current forms of evidence, e.g. journals & online sources vs. texts – Encourage students to question and challenge – Teach research content in a manner that is interesting and useful Brought to you by
  55. 55. Manager/Administrator’s Role – Encourage inquisitive minds – Promote risk-taking and flexibility in the clinical environment – Incorporate EBP activities into performance evals – Provide time & resources – unit internet access – Provide support personnel – Empower staff to make EB practice changes – Acknowledge and reward EB improvements Brought to you by
  56. 56. Researcher’s Role – Remain clinically in touch – Conduct clinically useful studies – Support clinicians in accessing and synthesizing the evidence – Collaborate with clinicians and patients – Disseminate findings that are understandable and accessible – Emphasize clinical implications Brought to you by
  57. 57. Nurse Clinician’s Role – “Worry and Wonder” – Be the Inquiring Mind – Question clinical traditions – Stay abreast of the literature - guidelines – Find your niche – and become the expert – Collaborate with APNs & researchers – Be an advocate for evidence-based changes – LISTEN to your PATIENTS – to guard patient & family preferences Brought to you by
  58. 58. Join us: STTI Research & EBP Congress July 11-14, 2011 Brought to you by
  59. 59. 59 THE 2010 IOM REPORT ON THE FUTURE OF NURSING Brought to you by
  60. 60. Center to Champion Nursing in America http://championnursing.org • Center to Champion Nursing in America is an initiative of AARP, the AARP Foundation and the Robert Wood Johnson Foundation. The Center, a consumer-driven, national force for change, works to increase the nation’s capacity to educate and retain nurses who are prepared and empowered to positively impact health care access, quality, and costs. Brought to you by
  61. 61. Nursing has an unprecedented opportunity to have one voice on behalf of patient care… • 18 member committee – Donna E. Shalala (Chair), President, University of Miami – Linda Burns Bolton (Vice Chair), Vice President and Chief Nursing Officer, Cedars-Sinai Health • Evidence based • IOM part of National Academy of Sciences – Private, nonprofit, society of distinguished scholars engaged in scientific research, dedicated to the furtherance of science and technology and to their use for the general welfare 61 Brought to you by
  62. 62. Interprofessional Team-Based Competencies • IPEC Expert Panel Presentation • HRSA, Macy Foundation, Robert Wood Johnson Foundation, and ABIM Foundation • Amy Blue, PhD • Jane Kirschling, DNS, RN, FAAN • Madeline Schmitt, PhD, RN, FAAN-Chair • Thomas Viggiano, MD, MEd 62 Brought to you by
  63. 63. “Work in Interprofessional Teams” Core Competencies Utilize Informatics Employ Evidence- Based Practice Provide Patient- Centered Care Apply Quality Improvement IOM 5 core competencies, adapted to IPEC Expert Panel Work 63 Brought to you by
  64. 64. Institute of Medicine October 2010 Report: The Future of Nursing Leading Change, Advancing Health 1. Remove scope-of-practice barriers 2. Expand opportunities for nurses to lead and diffuse collaborative improvement efforts 3. Implement nurse residency programs 4. Increase the proportion of nurses with a baccalaureate degree to 80% in 2020 5. Double the number of nurses with a doctorate by 2020 6. Ensure that nurses engage in lifelong learning 7. Prepare and enable nurses to lead change to advance health 8. Build an infrastructure for the collection and analysis of interprofessional health care workforce data Brought to you by
  65. 65. 65 IOM Key Message RECOMMENDATION NO. 1 Brought to you by
  66. 66. The many faces of advanced practice registered nurses in 2011 High quality, safe, affordable health care provided by teams of health care professionals Brought to you by
  67. 67. Health care reform • Survey published in JAMA 2008, only 2% fourth- year medical students plan to work in general internal medicine (primary care) after graduation, despite need for 40% increase in number of primary care physicians in the U.S. by 2020 • Association of American Medical Colleges predicts shortage of 35,000-44,000 primary care physicians by 2025 • Expanded opportunities for APRNs 67 Brought to you by
  68. 68. Hospital care… • Evolution of opportunities for advanced practice registered nurses – Change in residency hours – 24 x 7 coverage – Evolving recognition of specialty needs 68 Brought to you by
  69. 69. 69 Brought to you by
  70. 70. National barriersNational barriers • National nursing organizations are working to  Improve APRN reimbursement, Medicare reimburses NPs and CNSs at 85% of physician rate  Amend rules that prohibit APRNs from ordering such things as home health and hospice services or diabetic shoes Brought to you by
  71. 71. Recent national advancesRecent national advances Medicare now – Allows NPs to serve as the attending for a hospice patient – Allows Governors of states to opt out of supervision rule for CRNAs – 16 states have opted out – Reimburses CNMs at 100% Brought to you by
  72. 72. ““Messaging”Messaging” Barriers to practice reduce access to care Main issue is access to care and this should define our focus Brought to you by
  73. 73. 73 IOM Key Message RECOMMENDATION NO. 3 New graduates and nurses in transition Brought to you by
  74. 74. The Problem – Transition to Practice: Promoting Public Safety • 35 to 60% new nurses leave position in first year of practice, estimated replacement cost $46,000 to $64,000 per nurse • 10% typical hospital’s nursing staff comprised of new graduates • New nurses experience increased stress 3-6 months after hire, increased stress levels are risk factors for patient safety and practice errors Brought to you by
  75. 75. • NCSBN – transition programs reduce 1st year turnover from 35-60% to 6-13%, results in positive return on investment from 67 to 885% Brought to you by
  76. 76. University Healthsystem Consortium (UHC) and American Assoc. of Colleges of Nursing  A one year education and support program to assist new BSN graduates employed as staff nurses on clinical units to transition to professional nursing practice  Now 54 sites nationwide in 25 states › Over 12,000 BSNs have been enrolled nationwide  National research component to determine the best practice for integrating new BSN nurses into the workforce Brought to you by
  77. 77. What is the Residency Research Showing?  Retention nationally 94.4% for new grad first year vs. about 73% without residency  Surveys completed initially, 6 months, and 12 months; scores improve in new graduate’s ability to › organize and prioritize › communicate and be leaders at bedside › decreased stress over the year (less so at Kentucky) Brought to you by
  78. 78. 78 IOM Key Message RECOMMENDATION NO. 4 Brought to you by
  79. 79. Rationale (Institute of Medicine, 2011, p. 169-170)  “Several studies support significant association between educational level of RN and outcomes for patients in acute care settings, including mortality” 79 Brought to you by
  80. 80. Enrollments increasing in both DNP and PhD programs (1997-2009) 80 AACN 2009: over 9,500 applicants turned away master’s and doctoral programs Brought to you by
  81. 81. 81 IOM Key Message RECOMMENDATION NO. 6 Brought to you by
  82. 82. Faculty partner with health care organizations • Develop and prioritize competencies so curricula updated regularly across all programs – go beyond task-based proficiencies to higher- level competencies • demonstrate mastery over care management knowledge domains • provide foundation decision-making skills under variety clinical situations across care settings 82 Brought to you by
  83. 83. Academic administrators • Require all faculty – participate continuing professional development – Perform cutting-edge competence in practice, teaching, and research 83 Brought to you by
  84. 84. Health care organizations and schools of nursing • Foster culture of lifelong learning • Provide resources for interprofessional continuing competency programs • If offer continuing competency programs, regularly evaluate for flexibility, accessibility, and impact on clinical outcomes 84 Brought to you by
  85. 85. 85 Institute of Medicine October 2010 Report: The Future of Nursing Leading Change, Advancing Health 2. Expand opportunities for nurses to lead and diffuse collaborative improvement efforts 7. Prepare and enable nurses to lead change to advance health 8. Build an infrastructure for the collection and analysis of interprofessional health care workforce data Brought to you by
  86. 86. 86 …IN CONCLUSION  We must commit to take action on recommendations from IOM report  Affirm that this is about access to access to patient-centered care and health care reform  Essential that nurses mobilize  Not just to support nursing, but more importantly – to support the public Brought to you by
  87. 87. This platform has been started by Parveen Kumar Chadha with the vision that nobody should suffer the way he has suffered because of lack and improper healthcare facilities in India. We need lots of funds manpower etc. to make this vision a reality please contact us. Join us as a member for a noble cause. Brought to you by
  88. 88. Our views have increased the mark of the 10,000  Thank you viewers  Looking forward for franchise, collaboration, partners. Brought to you by
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