Chapter 13_mcgee

Practicing Evidence-Based Decision Making

Chapter 13

Copyright © 2014, 2009 by Mosby, Inc., an imprint of Elsevier Inc.

What Is Evidence-Based Practice? Evidence-based practice (EBP)

Integration of the best available evidence, combined with clinical expertise, enabling health practitioners of all varieties to address health care questions with an evaluative and qualitative approach

Reflects clinical expertise that is integrated with the best scientific evidence, patient values and preferences, and clinical circumstances

Copyright © 2014, 2009 by Mosby, Inc., an imprint of Elsevier Inc. 2

Defining Evidence-Based Practice Overall aim of EBP

To standardize practice by maximizing good practice, reducing costs, and improving quality of care

To integrate the best available research and clinical expertise in the context of patient characteristics, culture, and patient preferences and values

To use a problem-solving approach to nursing practice, involving conscientious use of current best evidence in making decisions about patient care


Defining Evidence-Based Practice (Cont'd)

Definitions Integration of individual clinical expertise with

the best available external clinical evidence from systematic research

Process by which nurses make clinical decisions using the best available research evidence, their clinical expertise, and patient preferences


Defining Attributes of Evidence-Based Practice

Three unique key features Is problem solving in its approach, which takes

into account the clinical experience of the nurse Clinical experience: nurse’s ability to use clinical

skills and past experience Combines researched evidence with

knowledge and theory Allows for patient values to be expressed and

incorporated in treatment regimens


Putting Evidence-Based Practice to Work

Five fundamental steps Step 1: Construct a relevant, answerable

question from an identified clinical concern. Step 2: Search the literature for the best

external evidence that addresses the clinical concern.

Step 3: Critically appraise the evidence for validity and applicability.

Step 4: Apply the evidence to your clinical concern.

Step 5: Evaluate your performance.


Getting Started Step 1: Construct a relevant, answerable

question from an identified clinical concern. Background questions

Seek general knowledge about a disease or condition. Foreground questions

Ask for specific knowledge for clinical decisions/actions. PICO

P: Patient or problem I: Intervention C: Comparison O: Outcome

Example: In children with acute otitis media, should watchful waiting be considered instead of treatment with antibiotics?


Getting Started (Cont'd) Step 1: Construct a relevant, answerable

question from an identified clinical concern. Clinical question categories

Will influence the type of search strategies and resources to be used

Types Diagnosis Therapy Harm or etiology Prognosis Prevention Qualitative


Getting Started (Cont'd) Step 2: Search the literature for the best

external evidence. Track down the evidence.

Evidence-based medicine review from Ovid Medline: largest biomedical research literature

database for general information HealthStar: focuses on health sciences, technology,

administration, and clinical and nonclinical research The Cochrane Library: helps make informed health care

decisions National Guideline Clearinghouse: provides evidence-

based clinical guidelines Agency for Healthcare Research and Quality (AHRQ):

provides evidence guidelines and technology assessments on various clinical topics


Getting Started (Cont'd) Step 3: Critically appraise the evidence.

Evaluating the strength of a study Studies are assigned a level of evidence based

on quality, validity, and applicability. Level 1 evidence represents the most valid

reports addressing patient-oriented outcomes. A level 1 ranking also indicates that specific quality

criteria were met based on the study type.



Evaluating the strength of a study Level 2 evidence addresses patient-oriented

outcomes and uses some method of scientific investigation. Level 2 evidence implies an association rather than

reliable evidence. Level 3 evidence represents reports that are not

based on scientific analysis of patient-oriented outcomes.



Evaluating the strength of a study Strongest level: systematic review or meta-

analysis of randomized controlled trials and evidence-based practice guidelines

Weakest level: opinion from authorities and/or reports of expert committees

Critically appraising the evidence means to examine its validity, beginning with the overview. Requires knowledge of the research design and

statistics Involves looking at the reference list of the study



Evaluating the strength of a study Special tools to help evaluate study Three basic questions to ask

Is it worth looking at the results of this study; can I trust the results (reliability)?

What are the results? Are the results relevant for the patient?



Evaluating the strength of a study Questions to ask when performing a systemic

critical appraisal Was the review question clearly stated? Is it likely that relevant studies were missed? Were the criteria used to select articles for inclusion

appropriate? Were the included studies sufficiently valid for the

type of question asked? Were the results similar from study to study? What are the results?


Getting Started (Cont'd) Step 4: Apply the evidence.

The role of the RN is a critical link in bringing research-based changes into clinical practice.

Step 5: Evaluate performance. Knowledge that has its foundation in scientific

study will assist the RN in making optimal clinical judgments as well as formulating a sound plan of care.


Getting Started Question 1A nurse is using the PICO criteria to write a research question. In the research question “In patients with congestive heart failure, will ACE inhibitors compared with beta blockers improve ejection fraction?” which section is the comparison?

1. ACE inhibitors2. Improve ejection fraction 3. Beta blockers4. Patients with congestive heart failure


answer ANSWER AND RATIONALE: 3. Beta blockers.

PICO is an acronym used to describe a format of the four elements required to formulate a good clinical question (P, patient or problem; I, intervention; C, comparison; O, outcomes). In this question the beta blockers are the comparison with ACE inhibitors.

1. ACE inhibitors comprise the intervention. 2. Improve ejection fraction is the outcome. 4. Patients with congestive heart failure are the

patient and problem.


Limitations of Evidence-Based Practice

The evidence Accessibility

The end user (nurse) may have inadequate access to clinical researched evidence and guidelines.

Large volume of research to sift through The research language Complex data retrieval systems

The individual Resistant to change


Limitations of Evidence-Based Practice (Cont'd)

The health care system Systemic barriers such as policies, procedures,

and financial accountability Physician idiosyncrasy vs. disciplined inquiry Cost-benefit issues Bureaucratic structures


Limitations of Evidence-Based Practice (Cont'd)

Nursing Split between education and service

(lack of time) Lack of consensus about nursing

responsibilities Lack of communication among nurses and

researchers Lack of skills in locating, reading, and

appraising nursing research data Lack of organizational support


Apparent Gaps in Research Utilization

Not all nurses must conceive of and conduct new research.

However, all nurses need the ability and the empowerment to institute change appropriately based on research findings.

RNs must base specific interventions and all aspects of the nursing process on scientific research.


Apparent Gaps in Research Utilization (Cont'd)

Barriers Lack of knowledge of the availability of

research applicable to nursing practice Lack of educational preparedness to

understand research Lack of time; nurses are pressed for time Lack of authority to institute changes based

on research No forum for research-based practice change

proposals No clear method of launching a trial study


Apparent Gaps in Research Utilization (Cont'd)

Research, both simple and necessary Simplest research for the RN

Quality assurance (QA) or performance improvement (PI) studies Use data to determine whether patient outcome

criteria are being met, charting is complete, or procedures are being done per protocol.

The result of these studies is to assist the staff in achieving consistently excellent quality care.


Components and Process in a Research Study

Concepts Basic research is refining concepts. An abstract idea is taken from an observed

behavior or characteristic to make it usable or applicable.

Research attempts to define a concept in terms of common behaviors.


Components and Process in a Research Study (Cont'd)

Variables Concept, idea, or attribute that is captured and defined

within a research study So named because varies from subject to subject Researcher attempts to control variables, statistically

account for them, or explain them in relation to what is being studied. Active variable: researcher manipulates an active variable

in an attempt to determine whether this will have the desired effect on the outcome

Attribute variable: researcher has no control over an attribute variable



Variables Independent variable: variable that influences a

presumed effect Dependent variable: variable that is influenced Purpose of the research study: to determine the

apparent relationship between the independent variable and the dependent variable

Defining variables Must define variables in a research study Operational definition: specifies the operations

associated with collecting the data on that variable or how the researcher will measure the variable



Literature search To determine whether prior research has been done Can also identify past research related to study Can assist in defining the variables, formulating a

hypothesis, establishing tools that may be needed to collect data, and clarifying the problem

May define the theory or identify additional variables that may need to be considered or controlled

Also suggests areas that are not as well supported by research

Serves to support the findings


Components and Process in a Research Study Question 2

A nurse is testing two types of wound care for patients of all ages, genders, and diagnoses. The wound care would be randomly used on different patients, one group receiving one type and another group receiving the second type. What is the active variable in this study?

1. Gender2. Diagnoses 3. Age4. Wound care Copyright © 2014, 2009 by Mosby, Inc.,

an imprint of Elsevier Inc. 28

Research Process Making predictions

Hypothesis: written prediction made by the researcher with regard to the variables Directs the research by setting limits to the

study because the researcher will try to prove or disprove the prediction

Example: Menopausal women who include 40 mg of isolated soy protein in their daily diets report fewer hot flashes and more uninterrupted sleep than those whose diet contains no isolated soy protein.

Empirical data: objective evidenceCopyright © 2014, 2009 by Mosby, Inc.,


Research Process (Cont'd) Defining the research study

Research design Experimental design: controls the independent

variables and randomly assigns the subjects to study groups

Quasi-experimental design: researcher does not attempt to randomize the subjects but does attempt to show a relationship between the dependent and independent variables

Defining the population Population chosen is one that will potentially

benefit from the study resultsCopyright © 2014, 2009 by Mosby, Inc.,


Research Process (Cont'd) Selecting a sample

Sample selection Choosing a representational model of the entire

population on which data can be easily or realistically collected

Sample size: number of study participants


Research Process (Cont'd) Making a data collection plan

Quantitative study Asks the question who, what, why, where, when,

or how; describes the relationship among variables

Qualitative study Attempts to clarify underlying assumptions that

are vague or unclear by asking what the perceptions, beliefs, or tenets are within a particular setting

May conduct a pilot study before implementing the actual study


Research Process (Cont'd) Checking reliability and validity

Criteria used to test whether instruments, tools, machines, and research designs will give accurate results.

Reliability measures the device or technique, or the instrument, used to collect data by asking how trustworthy it is at gathering the intended data.

Validity measures the degree to which an instrument is measuring what it is supposed to measure.


Research Process (Cont'd) Collecting data

Methods must be approved before implementing.

Patient consent is needed. Consider legal and ethical issues.

Interpreting the results This requires providing information on how the

data were analyzed, what limitations were identified, and how the results support the hypothesis.

Formal statistical analysis is used.Copyright © 2014, 2009 by Mosby, Inc.,


Research Process (Cont'd) Communicating the results

This is the final step. Research summaries may be submitted for

publication. This includes a section that demonstrates how

the research will apply to nursing.


Research Utilization Validating research results

Critically read and evaluate to determine whether the research has applications to practice

Applying research to practice Direct research utilization

Actually changes a practice habit or includes a new intervention in practice

Indirect research utilization Enhances knowledge base

Persuasive research utilization Advocates for a practice changeCopyright © 2014, 2009 by Mosby, Inc.,


Research Utilization (Cont'd)

Identifying areas for research Objective evidence from clinical observations

gathered from patient care experiences can spur research questions.

Staff RNs may take part in the study through data gathering or testing new procedures or products.

Encouraging all nurses to bring research into their daily practice will ultimately help improve patient care.


Date post:	14-Apr-2017
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