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1Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Chapter 13
Building an Evidence-Based Nursing Practice
2Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Evidence-Based Practice
Conscientious integration of best research evidence with clinical expertise and patient values and needs in delivery of quality cost-effective health care
Has a broader focus than research use Goal is implementation of quality cost-
effective care to promote positive outcomes
3Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Barriers to EBP
Practical Conceptual May create a “cookbook” approach to care
4Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Benefits to EBP
Improved patient outcomes for patients, providers, and agencies
Leads to best treatment (Gold Standard) plan An integral part of the Magnet Status process
5Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Evidence-Based Sources
Systematic reviews Meta-analyses Integrative reviews Metasummaries Metasyntheses
6Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Developing Evidence-Based Practice for Nursing
Findings from a study are different from research evidence.
Research evidence is a synthesis of quality, relevant studies to form a body of empirical knowledge for selected area of practice.
7Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Synthesis of Research Findings
Knowledge comes from quantitative, qualitative, and outcomes research.
Content clustering: integration of findings from scientifically sound research to determine what is currently known or not known Accomplished through:
• Integrative reviews• Systematic reviews• Meta-analyses, metasummaries, metasyntheses
8Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Integrative Reviews
Identifies, analyzes, and synthesizes results from independent quantitative and qualitative studies to determine current knowledge
Includes multiple types of research designs and literature types
A complicated review, but gives breadth and depth to conclusions
Annual Review of Nursing Research publishes integrative reviews.
9Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Qualitative Research Contributions to Integrative Reviews
Identifies and refines questions and outcomes
Identifies types of participants and interventions
Augments and provides data for research synthesis
Highlights inadequacies in methods Explains findings and interpretation of
findings Helps make recommendations
10Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Systematic Reviews of Research
A narrowly focused synthesis of research findings from quantitative studies
Looks at studies of similar methodology Has same standards of clarity, rigor, and
replication as primary research studies
11Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Steps in Systematic Reviews
Formulate purpose and identify scope. Develop specific questions or hypotheses. Establish criteria for inclusion/exclusion of
studies. Conduct extensive literature search of all
sources.(Melnyk & Fineout-Overholt, 2005; Whittemore, 2005)
12Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Steps in Systematic Reviews (cont’d)
Develop questionnaire and contact authors to gather data.
Critique studies for scientific merit and data analysis.
Analyze and interpret data. Report the review.
(Melnyk & Fineout-Overholt, 2005; Whittemore, 2005)
13Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Meta-analyses of the Research Literature
Statistically pools results from previous studies into single quantitative analysis
Allows for application of scientific criteria For example, sample size, level of significance,
variables
14Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Results of Meta-analysis
A large, diverse sample that is more representative of target population
Determination of overall significance of probability of pooled data
Indication of the efficacy of the intervention from the average effect size determined from several quality studies
Strength of relationship between variables
15Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Metasummaries in Qualitative Research
Definition: a synthesis of multiple primary qualitative studies to produce a narrative about a selected phenomenon
Expands our knowledge base
16Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Metasynthesis of Qualitative Research
Synthesizes qualitative research with a critical analysis of primary studies and synthesis of findings into a new theory
17Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Best Evidence for Use in Practice
The strength of the evidence is on a continuum from high-quality results to lower-quality results.
Evidence-based guidelines are essential in developing evidence-based practice for nursing.
18Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Continuum of Strength of Research Evidence
19Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Strength of Evidence
Strongest evidence1. Meta-analysis2. Integrative reviews3. Experimental studies
Weakest evidence1. Descriptive surveys2. Qualitative studies3. Correlational studies4. Quasi-experimental
studies
20Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Stetler Model of Research Utilization
Phase I: Preparation Phase II: Validation Phase III: Comparative Evaluation/Decision
Making Phase IV: Translation/Application Phase V: Evaluation
21Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Iowa Model of Evidence-Based Practice
Provides direction for development of evidence-based practice in an agency
Looks at triggers for change, such as: Risk management data Financial data Organizational standards Philosophy of care
22Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Iowa Model of Evidence-Based Practice (cont’d)
23Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Application of the Iowa Model
What are effective strategies for implementation?
What are outcomes from using the research findings?
Do the data support the change? Is the proposed change an agency priority?
24Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Scientific Merit Critique
According to the Iowa model, research should be examined for:1. Conceptualization and internal consistency of the
study2. Methodological rigor of the design, sample
methods, data, and analysis3. Generalizability of the findings4. Number of replications
25Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Determining Agency Compatibility with the Change in Practice
Who needs to approve the change in the agency?
What steps are needed to get the change approved in the institution?
Do physicians support the change? Do nurses support the change? Who are the leaders and will they support the
change?
26Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Instituting the Change in Practice
Will the implementation take a long time? What support is needed to make the change? Are there barriers to instituting change in the
agency?
27Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Utilization Barriers
Administration barriers Research not valued Limited change in agency or change not based on
research Limited resources to make research-based
change
28Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Utilization Barriers (cont’d)
Clinician barriers Do not read research reports Lack education about research process Do not believe research findings Do not know how to implement findings
29Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Monitoring Outcomes
After the change is effected, the outcomes must be monitored for effectiveness.
Change should be documented regarding improved quality of care, decreased costs, saved nursing time, and improved access to care.
Feedback is needed.
30Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
The Cochran Collaboration
P – Population or participant of interest I – Intervention needed for practice C – Comparison of interventions to determine
best practice O – Outcomes needed for practice
31Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Development of Evidence-Based Guidelines
AHRQ helps with guidelines through development of an expert panel.
The group designates the scope of the guidelines.
They synthesize the findings to develop recommendations for practice.
Guidelines developed are presented at meetings and published.
32Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Examples of AHRQ Practice Guidelines
Pain management Decubiti prediction/prevention Cataract treatment in adults Depression treatment Screening, diagnosis, management of sickle
cell disease in newborns and infants Otitis media treatment in children Availability of cardiac rehabilitation services
33Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Access to Evidence-Based Guidelines
Agency for Healthcare Research and Quality (AHRQ)
National Guideline Clearinghouse (NGC) Academic Center for Evidence-Based
Nursing American College of Physicians American Academy of Pediatrics
34Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Implementing a Model of Evidence-Based Practice
Identify practice problem. Search for best research evidence. Determine quality of guideline by assessing:
Authors Significance of problem Strength of evidence Link to national standards Cost-effectiveness of guideline
35Copyright © 2011 by Saunders, an imprint of Elsevier Inc.
Translational Research
An evolving concept defined by the NIH as the translation of basic scientific discoveries into practical application
Encouraged by nursing and medicine to increase the implementation of evidence-based interventions in practice and determine if these interventions are effective