Evidence Based Practice Final

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EVIDENCE BASED

NURSING PRACTICE

Submitted to: Mrs. Sunita Sharma

Lecturer, N.I.N.EP.G.I.M.E.R, Chandigarh

Submitted By: Ms Prabhjot Kaur

M.Sc.(Nursing) 1st

Year

8/26/2009


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EVIDENCE BASED NURSING PRACTICE

NTRODUCTION

When there is a lack of research reported in literature to guide clinical

practice, it becomes necessary to design and conduct studies to generateevidence. There are many areas in clinical practice that do not have an

established evidence base (e.g. care for dying children, primary care

intervention to improve mental health outcomes in high risk individuals) as a result,

their is an urgent need to conduct studies so that health care providers can base

their treatment decisions on sound evidence from studies. Evidence based

practice is an approach that enables clinicians to provide the highest quality of

care in meeting the multifaceted needs of their patients and families.

When health care providers know find, critically appraise and use the bestevidence and patients are confident that their health care providers are using

evidence based bare optimal outcomes are achieved for all.

for example, If you are caring for a patient who sustained head injury

in a motor vehicle accident, would you want to know and use the most

effective, empirically supported treatment established from randomally

controlled triad to decrease his/her intracranial pressure.

If you are diagnosed with cancer today and when faced with thedecision about which type of chemotherapy to choose, would you want to know

the evidence regarding the risks and benefits of each chemotherapeutic

agents.

Without current best evidence, practice is rapidly outdated, often to the

detriment of patients. e.g. for years paediatric primary care providers adviced

parents to place their infants in a prone position while sleeping with the underlying

reasoning that this is the best position to prevent aspiration in event of vomiting.

With evidence indicating that the prone positioning increases the risk of Sudden

infant death Syndrome, the American Academy of Paediatrics released a clinical

practice guidelines recommending a supine position for infant sleep (AAP, 2000)

Research utilization emphasizes the transfer of specific research based knowledge

into practice.

I


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Research Utilization.

The term research utilization and evidence based practice are sometimes used

synonymously.

It is the process of transferring research knowledge into practice; thus facilitatingan innovative change in practice protocols. Research utilization is the use of

findings from a disciplined study or a set of studies in a practical application that is

unrelated to the original research.

Research utilization can be defined very broadly as the use of research findings in

any and all aspects of one's work as a registered nurse. While there are specific

kinds of research utilization, such as instrumental, conceptual, and persuasive

(Estabrooks, 1997), at its simplest it is the use of research.

Evidence-Based Nursing Practice

EBN is, this author believes, much broader than research utilization,

encompassing not only research findings, but other forms of practice knowledge

as well. Evidence based practice involves making clinical decision on the basis of

the best possible evidence.

It is defined as the use of current best evidence by clinicians when making

patient care decisions, it entails finding the best evidence , critically evaluating it,

integrating it with clinical expertise and patient preferences and applying the

results to the clinical practice.


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Evidence-based medicine is the conscientious, explicit, and judicious use of

current best evidence in making decisions about the care of individual patients.

The practice of evidence-based medicine means integrating individual clinical

expertise with the best available external clinical evidence from systematic

research. (Sackett et al., 1996, p. 71)

Evidence-based medicine de-emphasizes intuition, unsystematic clinical

experience, and pathophysiologic rationale as sufficient grounds for clinical

decision making and stresses the examination of evidence from clinical research.

Evidence-based medicine requires new skills of the physician literature searching

and the application of formal rules of evidence evaluating the clinical literature.

(Evidence-Based Working Group, 1992, p. 2420)

It is a problem solving approach to clinical practice that integrates-

A systematic search for and critical appraisal for the most relevant evidence to

answer a burning clinical question

Ones own clinical expertise

Patients preference and values


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Components of Evidence Based Practice

evidencebased clinical

decisionmaking

evidence fromresearch,/theor

ies/expertpanels

evidence fromassessment of

patients history& physical exam&availability of

health care

resources

clinicalexpertise

informationabout

patientpreferences

& values


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History of movement

The evidence based practice movement was founded by Dr. Archie

Cochrane, british epidemiologist, who struggled with the efficacy of health care

and challenged the public to pay for care that had been empirically supported as

effective (Eukin, 1992)

In 1972, Cochrane published a landmark book that criticized the medical

profession for not providing rigorous review of evidence so that policy makers and

organization could make decisions about health care. Cochrane was a strong

proponent of using evidence from randomized clinical trials because he believed

that this was the strongest evidence to base clinical practice decisions.He asserted

that reviews of research evidence across all speciality needs to be prepared

systematically through a rigorous process and they should be maintained to

consider the generation of new evidence(Cochrane Collaboraton,2001)

Cochrane noted that thousand of LBW premature infants died needlessly.

He emphasized that the results of several randomized clinical trials supporting the

effectiveness of corticosteroid therapy to halt premature labour in high risk woman

had never been analyzed and compiled in the form of systematic review. The data

from systematic review showed that corticosteroid therapy reduced the odds ofpremature infant death from 50% to 30%.

Dr. Archie Cochrane died in 1998. However, as a result of his influence and

care for updates of systematic reviews of randomized controlled trials, the

Cochrane centre was launched in Oxford England in 1992, and Cochrane

Collaboration was founded a year later.


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Key steps of Evidence based practice

Evidence-Based Practice (EBP) is a thoughtful integration of the best

available evidence, coupled with clinical expertise. As such it enables health

practitioners 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. The practice of Evidence-Based Practice includes five fundamental steps.

Step 1: Asking the burning clinical question in the format that will yield the most

relevant and best evidence (i.e. PICO Format)

Step 2: collecting the most relevant and best evidence to answer the clinical

question including searching for systematic reviews/ meta-analysis or clinical

practice guidelines

Step 3: Critically appraising the evidence that has been collected for its validity,

relevance and applicability.

Step 4: integrating the evidence with ones clinical expertise, assessment of

patients condition and available health care resources along with the patients

preferences and values to implement a clinical decision

Step 5: Evaluating the change resulting from implementing the evidence in

practice.


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Steps of evidence based practice

1. Asking a searchable, answerable question

The first step to accomplish this goal is to formulate the clinical issues ito asearchable answerable question. There are two type of questions- Background

questions and foreground questions.

Background questions are those that need to be answering as a foundation

of asking the searchable answerable foreground questions.

Sackett and collegues(2000) describe background questions as that ask for

general information about a clinical issue. It has two components: the starting

place of questions(e.g. what, where,why, how) and outcome of questions (clinical

diagnosis) e.g. How does drug Acetaminophen work to affect fever? The answerto this question can be found in a drug pharmacokinetic text.


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Foreground questions are those that can be answered from scientific

evidence about diagnosing, treating, and assisting patients with understanding

their prognosis. These questions form on specific knowledge e.g. which is more

effective in reducing fever in children Acitaminophen or Ibuprofen? Or which is

more effective in patients with ARDS Prone or supine positiong?

The first question is based on the knowledge of how acetaminophen works but can

be answered only by a study that compare the two listed medications.

The second question requires knowledge of how positioning changes

haemodynamics but the two types of positioning must be compared In specific

population of patients in order to answer it.

Posing the question using PICO

Patient population of interest

Intervention of interest

Comparison of interventions

Outcome of interest

P The patients population or disease of interest e.g. age, gender,

ethnicity, and certain disorders (e.g. Hepatitis)

I Intervention or range of intervention of interest e.g. exposure to

diseases, 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 Outcome of interest e.g. risk of disease, accuracy of diagnosis,rate of

occurance of adverse outcomes (death)

As for example, for patients of 65 years old (P) does the use of an influenza vaccine

(I) reduces the future risk of Pneumonia (O) compared with patients who have not

received the vaccine (C).


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2. Assembling and evaluating the evidence

Once a clinical practice question has been selected, the next step is

to search and assemble research evidence on the topic. In doing a literaturereview as a background for a new study, the central goal is to discover where the

gap are and how best to advance knowledge. cochrane reviews are an important

resource. They have been found to be more rigorous than published in journals

(jaded etal,1998). Another critical resource available for integrative review is the

agency for health care research and quality (AHRQ).

Research based evidence sites are CINAHL and Medline databases,

Cochrane library(www.cochrane.org), American college of physician pier, National

Guideline Clearinghouse (www.guideline.gov), Turning research into practice(www.tripdatabase.com) Professional association Guidelines /Standards of care,

expert opinion/clinical expertise (clinical articles, web search)

3. Critically Appraising the Article

In determining the implementation potential of an innovation in a particular

setting, several issues should be considered, particularly the transferability of the

innovation, the feasibility of implementing it and its cost benefit ratio.

If the implementation assessment suggest that there might be problems in

testing the innovation in that particular practice setting, then the team can either

identify a new problem and begin the process anew or consider adopting the plan

to improve the implementation potential (e.g seeking external resources if cost

were the inhibiting factors)

4. Integrating the evidence with ones clinical expertise

if the implementation criteria are met the team can design and plot the

innovation. Based on the IOWA model the following activities can be involved:

o developing an evaluation plan (identifying outcomes to be achieved,

determining how many clients to involve in the pilot, deciding when

and how often to take measurements)
http://www.cochrane.org/http://www.cochrane.org/http://www.cochrane.org/http://www.guideline.gov/http://www.guideline.gov/http://www.guideline.gov/http://www.tripdatabase.com/http://www.tripdatabase.com/http://www.tripdatabase.com/http://www.tripdatabase.com/http://www.guideline.gov/http://www.cochrane.org/


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o collecting baseline data relating to those outcomes to develop a

counterfactual against which outcomomes would be assessed.

o Developing a written EBP guideline based on the synthesis of the

evidence, preferably a guideline that is clear and user friendly and that

uses such devices as flow charts and decision treeso Training the relavant staff in the use of the new guideline and if

necessary marketing the innovation to user so that it is given a fair

test.

o Trying the guideline out on one or more units or with the sample of

clients.

5. Evaluating the change

The last step in EBP is evaluation of the pilot project in terms of both

process (e.g how the innovation received, to what extent were the guidelines

actually followed, what implementation problems were encountered?) and

outcomes ( in terms of client outcomes and cost effectiveness)

A variety of research designs can be used in the evaluation ,of course ,with the

most rigorous being an experimental design. In most cases however, a less formal

evaluation will be more ractical, comparing collected out comes data or hospital

records before and after the innovation and gathering information about patient

and staff satisfaction. Qualitative and mixed method research designs can also

contribute to evaluating an innovation. Valuable information on the feasibility and

participant burdens can be obtained.

Evaluation data should be gathered over a sufficiently long period to allow

for a true test of a mature innovation the end result of this process is a decision

about whether to adopt the innovation , to modify it for on going use or to revert it

to prior practices.


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Models for evidence based Nursing practice

The models offer guidelines for designing and implementing a utilization

project in a practice setting. The two models stelter model and Iowa modelincorporate evidence practice processes rarther than research utilization alone.

THE STELTER MODEL

The stelter model was designed with the assumption that Research Utilization

could be undertaken not only by organizations but by individual clinicians and

managers. It was a model designed to promote and facilititate critical thinking

about the application of research findings in practice. The current model presentedgraphically involves five sequential phases:

1. Preparation

In this phase, the nurse defines the underlying purpose and outcomes of

the project, search, sort and select sources of research evidence. She consider

external factors that can influence potential application and internal factors that

can diminish objectivity and affirm the priority of perceived problem.

2. Validation

This phase involves a utilization of focused critique of each source of

evidence, focusing in particular on whether it is sufficiently sound for potential

application in practice.

3. Comparative evaluation and decisionmaking

This phase involves a synthesis of findings and application of criteria, that

taken together are used to determine the desirability and feasibility of applyingfindings from validated source to nursing practice. The end result of the

comparative evaluation is to make a decision about using the study findings.


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4. Translation/Application

This phase involves activities to conform how the findings will be used(e.g

formally or informally) and spell out the operational details of the application andimplement them.

5. Evaluation

In the final phase, the application is evaluated. Informal use of the

innovation versus formal use would lead to different evaluative strategies.


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IOWA Model

Efforts to use research evidence to improve nursing practice are often

addressed by group of nurses interested in the same practice issues. This model,

like the stelter model, was revised recently and renamed the Iowa Model of

evidence Based Practice to promote quality of care.

The current version of Iowa Model acknowledges that formal RU/EB Project

begins with a trigger an impetus to explore possible changes to practice. The start

point can be either knowledge focused trigger that emerges from awareness of

innovative research findings.

The model outlines a series of activities with three clinical decision points.

I. Deciding whether the problem is a sufficient priority for the

organization exploring possible changes; if yes, a team is formed to

proceed with the project: if No, a new trigger would be sought.

II. Deciding whether there is sufficient Research base; if Yes, the

innovation is piloted in the practice setting. If No, the team would

either search for other sources of evidence or conduct its own

research.III. Deciding whether the change is appropriate for adoption in practice; if

Yes, a change would be instituted and monitored. If No; the team

would continue to evaluate quality of care and search for new

knowledge.

The point of entry to this model were problem and knowledge focused triggers.

Problem focused triggers encompassed frequently encountered clinical problems,

risk management and quality improvement data and total quality management

programs/ in contrast, Knowledge focused triggers include new information that

resulted from such sources as the Agency for Health care policy and Research,

speciality organizations and research publications.

When a trigger was identified the next step included assembling, critiquing,

and evaluating the applicability of relevant research literature.


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After the research base was evaluated and critiqued, a decision was made

regarding whether or not a change in practice was warranted. If, however, a

sufficient and appropriate research base was found that supported modification of

current practice, changes were initiated that were congruent with those suggested

by the research results. If research base had insufficiencies, further research wasconducted, experts were consulted and application of scientific principles were

considered.

To translate research findings into practice several steps were necessary:

1. Expected outcomes of the change and baseline or current status were

documented.

2. Nursing/ multidisciplinary interventions were designed

3. Practice changes were implemented on a pilot unit.

4. Process and outcomes were evaluated; and5. The interventions were modified as necessary

The next critical decision point involved determination of whether practice

changes should be made for all patient populations affected by the research

based interventions. Considerations included cost of implementations,

overall impact on quality of care, staff competency and support of

administration.

This model used a process of planned change . staff need to be

empowered with ownership of the change, as well as, with the knowledge

and resources necessary to make this change.

This model supported the monitoring of patient outcomes by unit staff

members for atleast two consecutive quarters after implementation. These

activities assisted in maintaining the practice change and facilitating

feedback to the staff. Outcome measurements are also focused on the

effects of change on the staff and fiscal parameters. Without thorough

monitoring of all these areas an accurate refklection of the cost/benefit

relationship could not be realized.


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Barriers to using Research in Nursing

Research Related Barriers

One impediment to using Resarch 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 constraint to using research evidence is the

dearth of published replications.

TIP : Some tips for researchers interested in promoting the use of research

findings in clinical practice are as follows:

Collaborate with clinicians. Practicing nurses will be more willing to use

research findings if researchers addresses clinical questions.

Do high quality research. The quality of nursing studies has improved

dramatically in the past two decades, but progress remains to be made to

ensure valid and transferable findings.

Replicate use of research results can rarely be justified based on a single

study, so researchers must replicate studies and publish the results.

Communicate clearly A general aim should be to write research reports that

are user-friendly with a minimum of research jargon.

Present findings amenable to meta-analysis integrative reviews of research

findings are essential to EBP, and such reviews are increasingly using

statistical methods of integration.

Suggest clinical implications if an implications section with suggestion for

clinical practice became a standard feature of research reports, then theburden of using research evidence would be lighter for nurse clinicians.

Disseminate aggressively and broadly if researcher fails to communicate the

results of a study to other nurses it is obvious that the results will never be

used by practicing nurses. The researcher should report their results in

journals especially nursing research journals, take steps to disseminate

study findings at conferences, workshops attended by nurse clinicians.


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Nurse related Barriers

Many Nurses have not received any formal instruction in research and they

lack skill to judge the merits of a study.

Nurses attitude toward 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 innovations in practice setting.

TIP: Every nurse can play a role in using research evidence. Here are some

strategies:

Read widely and critically. Professionally accountable nurses should read

journals relating to their speciality, including research reports in them.

Attend professional conference.Conference attending give opportunities to

meet researchers and to explore practice implications.

Learn to expect evidence that a procedure is effective. Nurses need to

develop expectations that the decisions they make in their clinical practice

are based on sound rationales.

Become involved in a journal club.Many organizations that employ nurses

sponsor journal clubs that meet to review research articles that have

potential relevance to practice.

Pursue and participate in EBP projects. Nurses who are involved in research

related activities develop more positive attitudes toward research and better

research skills.


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Organizatonal Barriers

Many of the major impediments to using research in practice stem from the

organizations that train and employ nurses. Organizations have failed to motivate

or reward nurses to seek ways to implement appropriate findings in their practice.

In several studies of barrirers to RU , one of the greatest reported Barrier was

insufficient time on the job to implement new ideas. Organizations may be

reluctant to expand resources for RU, EBP activities or for changing organizational

policy.

TIP: To promote the use of research evidence, administrators can adopt the

following strategies:

Foster a climate of intellectual curiosity.Open communication is important in

persuading staff nurses that their experiences and problem are important

and that the administration is willing to consider innovative solutions.

Offer emotional or moral support. Administrators need to make their support

visible by informing staff by establishing EBP committees, by helping to

develop journal clubs and by serving as role models for staff nurses.

Offer financial or research support for utilization.

Reward efforts for using research. RU should not be the primary criterion

for evaluating nurses performance but its inclusion is an important criteria to

affect their behavior.

Seek opportunities for institutional RU/EBP projects. Organizational efforts

and commitment are essential for the type of projects.


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Barriers relating to Nursing Profession

There is a shortage of appropriate role models- nurses who can be

emulated for their success in using or promoting the use of research in clinicalpractice. The nurses feel that he or she didnt have enough authority to change

patient care procedures

TIP:Educators could help to promote the use of research evidence through the

following strategies:

Incorporate research findings into curriculum. Research findings should be

integrated throughout the curriculum and when possible, the efficacy of

specific procedures should be documented by referring to relevant studies.

Encouraging research and research use.Either by acting as role models to

students or by demonstrating positive attitudes towards research and its use

in nursing.

Place demands on researchers. Faculty review of research proposals

should demand that researchers demonstrate the proposed studies potential

for clinical use; they can also demand that the researchers include a specific

plan for dissemination or utilization


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References

1. Polit Denise F, Beck Cheryl Tatano. Nursing Research principles and

Methods: Utilizing Research: Putting Research Evidence Into NursingPractice . 7thedition. Lippincott Williams and Wilkins 2008 :673-99.

2. Melnyk Bernadette Mazurek, Fineout Overhot Allen. Evidence Based

Practice In Nursing and Health Care. 1st edition. Lippincott Williams

and Wilkins 2005 : 4,5,23-9

3. Katheleen S. Oman, Christine Duran, Regina Fink.Evidence based

Policy and Procedures: An Algorithm for Success. The Journal Of

Nursing Administration 2008; 38(1): 47-51

4. Diane S. Pravikoff, Susan T Pierce, Annelle Tanner. Evidence Based

Practice readiness study supported by academy nursing informatics

expert panel. Nursing Outlook 2003; 53(1): 49-50

5. Constance l Milton. Evidence Based Practice: Ethical Ouestions for

Nursing. Nursing Science Quarterly 2007; 20(2): 123-26

6. Makhija Neelam. Applicaton and Utilization of Research in Practice:

Evidence Based Practice. Nursing Nightingale Times 2007:18-20

7. Marianne Matzo. Evidence for Excellence. American Journal Of

Nursing 2008; 108(8):73-74

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