This document provides an overview of evidence-based practice (EBP) presented by Amritanshu Chanchal at Subharti Nursing College in Meerut. It defines EBP, discusses its components and key steps. The presentation covers asking questions using PICOT format, searching for evidence, critically appraising evidence, integrating evidence with clinical expertise and patient preferences, evaluating outcomes, and disseminating results. Models for EBP are also introduced, including the Iowa Model which outlines identifying triggers for change, determining organizational priority, and forming an interdisciplinary team to develop, evaluate and implement EBP changes.

1. PANNADHAI MAA
SUBHARTI NURSING
COLLEGE, MEERUT
Presentation on: Evidence Based Practice
Presented by: Amritanshu Chanchal
Msc nursing 1st year

2. General Objective
• After completion of this seminar the group will be able to understand about
Evidence Based Nursing Practice and will be able to apply in clinical setting.

3. Specific Objective
• To define Evidence Based Practice(EBP)
• To introduce EBP
• To enlist components of EBP
• To explain steps of EBP
• To enumerate models of EBP
• to understand barriers of EBP

4. Evidence based practice
• It is defined as use of current best evidence by clinicians when making
patient care decision, it entails finding the best evidence, critically evaluating
it, integrating it with clinical expertise and patient preference and applying
the results to the clinical practice.

5. • Evidence based practice is the conscious, explicit, and judicious use of
current best evidence in making decision about he individual patient. The
practice of evidence-base means integrating individual clinical expertise with
the best available clinical evidence from systematic research.
• It is a problem solving approach that integrates a systematic research for and
critical appraisal for the most relevant evidence to answer a burning clinical
question.

6. Evidence based nursing practice
Improved
patient
outcome
Patient value and
expectation
Individual clinical expertise
Best available clinical evidence

7. Components of evidence based practice
• During the 1980s, the term “evidence-based medicine” emerged to describe
the approach that used scientific evidence to determine the best practice.
Later, the term shifted to become “evidence-based practice as clinicians other
than physicians recognized the importance of scientific evidence in clinical
decision-making. Various definitions of evidence-based practice (EBP) have
emerged in the literature, but the most commonly used definition is, “the
conscientious, explicit, and judicious use of the current best evidence in
making decisions about the care of individual patients”(Sackett, Rosenberg,
Gray, Hayes, & Richardson, 1996).

8. • Subsequently, experts began to talk about evidence-based healthcare as a
process by which research evidence is used in making decisions about a
specific population or group of patients. Evidence-based practice and
evidence-based healthcare assume that evidence is used in the context of a
particular patient’s preferences and desires, the clinical situation, and the
expertise of the clinician.They also expect that healthcare professionals can
read, critique, and synthesize research findings and interpret existing
evidence-based clinical practice guidelines.

9. Key steps of evidence based practice
• Evidence based practice is a thoughtful integration of best available
evidence, coupled with clinical expertise. As such it enables health
practitioner of all varieties to address healthcare questions with an evaluative
and qualitative approach. EBP allows the practitioner to assess current and
past research, clinical guidelines and other information resources in order to
identify relevant literature while differentiating between high quality and low
quality findings.

10. Steps
• Step 1: Asking the burning clinical question in the format that will yield the
most relevant and best evidence.
• Step 2: Collecting the most relevant and best evidence to answer the clinical
question including research for systematic reviews.
• Step 3: Critically appraising the evidence that has been collected for its
validity, relevance and applicability.
• Step 4: Integrating the evidence with one’s clinical expertise, assessment of
patient’s condition and available health care resources along with the patient
preference and values to implement a clinical decision.
• Step 5: Evaluating the change resulting from implementing the evidence in
practice.

11. Steps of evidence based practice
Ask the right question
Assess the evidence
Apply the evidence Audit clinical practice
Appraise the evidence
Access the evidence

12. Steps of EBP
• Step 1: Ask clinical questions in PICOT format. Inquiries in this format
take into account patient population of interest (P), intervention or area of
interest (I), comparison intervention or group (C), outcome (O), and time
(T). The PICOT format provides an efficient framework for searching
electronic databases, one designed to retrieve only those articles relevant to
the clinical question.
• Step 2: Search for the best evidence. The search for evidence to inform
clinical practice is tremendously streamlined when questions are asked in
PICOT format. If the nurse in the rapid response scenario had simply typed
"What is the impact of having a rapid response team?" into the search field
of the database, the result would have been hundreds of abstracts, most of
them irrelevant. Using the PICOT format helps to identify key words or
phrases that, when entered successively and then combined, expedite the
location of relevant articles in massive research databases such as MEDLINE
or CINAHL.

13. • Step 3: Critically appraise the evidence. Once articles are selected for
review, they must be rapidly appraised to determine which are most relevant,
valid, reliable, and applicable to the clinical question. These studies are the
"keeper studies." One reason clinicians worry that they don't have time to
implement EBP is that many have been taught a laborious critiquing process,
including the use of numerous questions designed to reveal every element of
a study.
• Step 4: Integrate the evidence with clinical expertise and patient
preferences and values. Research evidence alone is not sufficient to justify
a change in practice. Clinical expertise, based on patient assessments,
laboratory data, and data from outcomes management programs, as well as
patients' preferences and values are important components of EBP. There is
no magic formula for how to weigh each of these elements; implementation
of EBP is highly influenced by institutional and clinical variables.

14. • Step 5: Evaluate the outcomes of the practice decisions or changes based
on evidence. After implementing EBP, it's important to monitor and evaluate
any changes in outcomes so that positive effects can be supported and
negative ones remedied. Just because an intervention was effective in a
rigorously controlled trial doesn't mean it will work exactly the same way in
the clinical setting. Monitoring the effect of an EBP change on health care
quality and outcomes can help clinicians spot flaws in implementation and
identify more precisely which patients are most likely to benefit. When
results differ from those reported in the research literature, monitoring can
help determine why.

15. • Step 6: Disseminate EBP results. Clinicians can achieve wonderful
outcomes for their patients through EBP, but they often fail to share
their experiences with colleagues and their own or other health care
organizations. This leads to needless duplication of effort, and
perpetuates clinical approaches that are not evidence based. Among
ways to disseminate successful initiatives are EBP rounds in your
institution, presentations at local, regional, and national conferences,
and reports in peer-reviewed journals, professional newsletters, and
publications for general audiences.
• When health care organizations adopt EBP as the standard for clinical
decision making, the steps outlined in this article naturally fall into
place. The next article in our series will feature a staff nurse on a
medical–surgical unit who approached her hospital's EBP mentor to
learn how to formulate a clinical question about rapid response teams
in PICOT format.

16. Posing the question using PICO
P The patient population or disease of interest e.g. age , gender,
identity , ethnicity and certain disorders e.g. hepatitis
I Intervention or range of intervention of interest e.g. exposure to
disease, risk behavior
C What you want to compare the intervention against e.g. no
disease, placebo or no intervention/therapy, absence of risk
factors
O Outcomes of interest e.g. risk of disease, accuracy of diagnosis,
rate of occurrence of adverse outcome death.

17. Models and theories for EBP
• Models that offer a framework for launching an EBP includes the following:
Advancing research and Clinical Practice through Close Collaboration
Model 2005
Centre for advanced nursing practice model 2000
Diffusion of innovation theory 1995
Evidence based multidisciplinary practice model 1999
Iowa model of research in practice 2001
John Hopkins nursing EBP model 2005
Ottowa model of research use 1998
Stelter model of research utilization 2001

18. IOWA Model
• Overview of Model The Iowa Model can help nurses and other healthcare
providers translate research findings into clinical practice while improving
outcomes for patients. The first step in the Iowa Model is to identify either a
problem-focused trigger or a knowledge-focused trigger where an EBP
change might be warranted. Problem focused triggers are those problems that
derive from risk management data, financial data, or the identification of a
clinical problem (e.g., patient falls). Knowledge focused triggers are those
that come forward when new research findings are presented or when new
practice guidelines are warranted. The next step in the Iowa Model is for the
nurse or team to determine whether the problem at hand is a priority for the
organization, department, or unit in which they work. Those problems that
may have higher volume or higher costs associated likely will have higher
priority from the organization. Organizational buy-in is crucial when
working on EBP issues, so knowing the prioritization of the problem is
important.

19. • Once the priority has been determined, the next step is to form a team
consisting of members that will help develop, evaluate, and implement the
EBP change. The composition of the team will be determined by the problem
at hand.
• Titler et al. (2001) pointed out that the team should include interested
interdisciplinary stakeholders. This step is important and should include team
players outside of those from nursing. Once a team has been formed, the next
step is to gather and critique pertinent research related to the desired practice
change. The most important portion of this step is to form a good question
(using the PICOT method ).

20. IOWAModel

21. Stetler Model
• The Stetler model of research utilization helps practitioners assess how
research findings and other relevant evidence can be applied in practice. This
model examines how to use evidence to create formal change within
organizations, as well how individual practitioners can use research on an
informal basis as part of critical thinking and reflective practice. The model
links research use, as a first step, with evidence-informed practice.The Stetler
model provides a way to think about the relationship between research use
and evidence-informed practice. These two concepts are not the same.
Integrating both concepts enhances the overall application of research.
• Research use, in light of available supplemental evidence to aid decision
making, provides the first step for research-related actions that result in
evidence-informed practice. Research use occurs in three forms (Stetler,
1994): Instrumental use refers to the concrete, direct application of
knowledge.

22. • Conceptual use occurs when using research changes the understanding or the
way one thinks about an issue. Symbolic use or political/strategic use
happens when information is used to justify or legitimate a policy or
decision, or otherwise influence the thinking and behaviour of others. These
different kinds of research use can occur together and can be influenced by
multiple factors at the individual level. The Stetler model of research use is
based on the notion that the user's internal characteristics, as well as external
environmental factors, influence use of knowledge.

23. Stetler Model

24. Barriers to using nursing research

25. Research related barrier
• One impediment is using research in practice is that for many nursing
problems, a solid base of valid and trustworthy study results has not been
developed. Single studies rarely provide an adequate basis for making
changes in nursing practice. Therefore another constraints to using research
evidence is dearth of published replication.

26. Nurse related barriers
• Many nurses have not received any formal instruction and they lack skill to
judge the merits of study.
• Nurses attitude towards research and their motivation to engage in EBP have
been identified a potential barrier. People are often resistant to change.
Change requires effort, retraining and restructuring of work habits. Thus,
there is likely to be some opposition to introducing innovation in practice
setting.

27. Organizational Barriers
• Many of the major impediments to using research in practice stem from the
organizations that train and employ nurses. Organization have failed to
motivate or reward nurses to seek ways to implement appropriate findings in
their practice. In several studies of barriers to EBP, one of the greatest
reported barriers was “insufficient time on the job to implement new ideas”.
Organizations may be reluctant to expand resources for EBP activities or for
changing organizational policy.

28. Barriers related to nursing profession
• There is shortage of appropriate role models- nurses who can be emulated for
their success in using or promoting the use of research in clinical practice.
The nurses feel that he/she didn’t have “enough authority to change patient
care procedures”.

29. Benefits to the field of nursing include:
• Prioritizing the needs of patients. Although evidence-based practice relies
on research, it also considers the desires of individual patients. Since one of
the main tenets of nursing is focusing on the patient’s needs, evidence-based
practice helps you continue to improve patient outcomes while weighing the
preferences and experiences of each patient.
• Better patient care decisions that also save nurses time. Evidence-based
practice can save time, as you can stop engaging in activities that have no
known benefit to patients. For example, nurses used to spend up to 20
minutes a day bathing each patient and changing their dressings, until
research revealed that some dressings are better left in place longer and that
daily baths don’t impact outcomes. (Of course, under some circumstances it
may be indicated to perform these practices daily or even more often; it
depends on each patient case.

30. • It keeps nursing practice current: For nurses to apply evidence-based
practice in the care they provide, they have to stay informed on any new
discoveries that have been made.
• Economic concerns: EBP is appealing because it can help determine high
quality cost-effectiveness intervention that actually work.
• Variation in practice: Variation in practice are becoming more evident and
evidence of harm and lack of benefits is increasing.
• Quality intervention: EBP promotes high quality and cost-effectiveness
intervention and treatment.
• Correct advice: Individualized intervention Evidence-Based practice
encourages, tailored, and individualized treatment of clients and emphasizes
care and outcome.

31. Summary
• Evidence-based practice is a conscientious, problem-solving approach to
clinical practice that incorporates the best evidence from well-designed
studies, patient values and preferences, and a clinician's expertise in making
decisions about a patient's care. Unfortunately, no standard formula exists for
how much these factors should be weighed in the clinical decision-making
process. However, there are a variety of rating systems and hierarchies of
evidence that grade the strength or quality of evidence generated from a
research study or report. Being knowledgeable about evidence-based practice
and levels of evidence is important to every clinician as clinicians need to be
confident about how much emphasis they should place on a study, report,
practice alert or clinical practice guideline when making decisions about a
patient's care.

32. Conclusion

33. Thank You