Evidence Based Evidence Based Practice In NursingPractice In Nursing

Dr. Abdul-Monim BatihaDr. Abdul-Monim BatihaAssistant ProfessorAssistant ProfessorCritical Care NursingCritical Care Nursing

Philadelphia university Philadelphia university

Today’s health care system has become

increasingly more costly and complex.

Consequently, in this market-driven delivery

system, there is a greater emphasis on

outcomes, cost-effectiveness, and consumer

satisfaction.

These pressures operate in an

environment of rapid information

exchange, technological advancements,

and an increasing nursing workload

Nurses are challenged to maintain clinical

competence, to demonstrate how their

care positively affects patient outcomes, &

to participate actively in clinical decision-

making & practice improvements

Nurses are now mandated to demonstrate

cost-effectiveness and efficiency with the use

of time and resources, while continuing to

demonstrate their value added impact on

outcomes. These mandates provide a strong

rationale for adopting an evidence-based

model of practice

What Is Evidence- Based Nursing?What Is Evidence- Based Nursing?

Evidence – Based Nursing (EBN)Evidence – Based Nursing (EBN)

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

Clinical expertise Ability to use our clinical skills &

experience to rapidly identify each patient's unique health state &diagnosis, their individual risks & benefits of potential interventions, & their personal values & expectations

Patient valuesPatient values & preference& preference

Unique preferences, concerns &

expectations each patient brings to a clinical

encounter & which must be integrated into

clinical decisions if they are to serve the

patient

Goals of EBN are to apply valid & reliable

nursing research to clinical practice

"Research utilization" & to bring the most

current knowledge to clinicians. This is

particularly important due to the knowledge

explosion in nursing and health care

Steps to Evidence-Based Critical Steps to Evidence-Based Critical Care Nursing PracticeCare Nursing Practice

Accept the fact that health care is evolving, with the consequent need to base nursing care on evidence, rather than on tradition or previous education

Identify a need for change in practice by examining less-than-favorable patient outcomes; causes of patient, family/significant other, or staff dissatisfaction; or situations in which compelling new evidence exists in an aspect of care

Frame a clinical question and search the literature

for evidence regarding the topic

Once current research data and evidence have

been collected, evaluate the evidence for

scientific merit, quality, and applicability

Synthesize to determine the strength of the evidence

to support a change in practice

Conduct a comparison between current practice

recommendations and current research

If there is sufficient evidence to suggest a change

in practice and the change in practice is practical in

respect to costs, staff skill, and resources required,

application of the evidence into practice can occur

Implicit in the implementation of evidence are the issues

associated with change, including fear of change & the

need for information, staff training, leadership, & ongoing

evaluation of the change

Continue to evaluate the evidence through an ongoing and systematic review to promote state of- the-science nursing care

Converting information needs Converting information needs into clear questionsinto clear questions

Art to Phrasing Questions Art to Phrasing Questions

An art to phrasing questions in such a way as

to elicit a meaningful answer, there are three

key reasons for focusing questions:

Facilitating the search for relevant evidence. The more explicit the question, the easier it is to run searches on electronic databases such as those contained within the Library shelves, CINAHL (Cumulative Index of Allied Health and Nursing Literature, or MEDLINE

A non-focused question is more likely to yield larger numbers of non-relevant studies than a focused question, and valuable search time will be wasted trying to sift through the long list

of retrieved references for relevant studies

Sorting best evidence from weaker, less valid evidence

Deciding whether the evidence is applicable to our patients

The PICO (population, intervention, comparison

intervention, out come) framework, devised by Saekett et al

(1997), is a useful method for making questions more

focused. The question is built in four (or three) parts

PICO Frame PICO Frame Population or Problem, it may be necessary to specify

age, gender, disease type, disease severity or co-morbidity. This will depend on whether the results of a very broad, inclusive population could be applied to your specific patient group

Define who or what the question is about

PICO FramePICO Frame Intervention: Define which intervention, test or

exposure you are interested in. An intervention is a planned course of action. An exposure is something that happens such as a fall, anxiety. The intervention (or test or exposure) may need to be described in some detail to ensure clarity

Describe what it is you are considering doing or what it is that has

happened to the patient

PICO FramePICO Frame

Comparison intervention: Define the alternate intervention

Describe the alternative that can be compared with the intervention Outcomes:

Define the important outcomes, beneficial or harmful

Define what you are hoping to achieve or avoid

PICO FramePICO Frame

Outcomes: very general outcomes may be difficult to measure, and details of how outcomes can be objectively measured may need to be specified

Searching LiteratureSearching Literature

Basic search principlesBasic search principles

Analyzing the question

Generating a word list

Linking word lists( Boolean logic: AND,

OR, NOT)

Boolean OperatorBoolean Operator

Boolean OperatorBoolean Operator

Boolean OperatorBoolean Operator

Types Of Evidence UsedTypes Of Evidence Used

Health Care Indexes Research Retrospective or Concurrent Chart Review Quality Improvement & Risk Data &

Benchmarking International, National, & Local Standards Infection Control Data Pathophysiology Cost-effectiveness Analysis Patient Preferences Clinical Expertise

Health care indexesHealth care indexes

Two of the most common indexes used by nurses

are MEDLINE, produced by the National Library of

Medicine (NLM)

CINAHL (Cumulative Index for Nursing & Allied

Health Literature) produced by the C1NAHL

corporation. Both of these are available in print &

computerized forms

The International Nursing Index, Hospital

Literature Index, Psych Index, and Social Sciences

Index are other common used indexes that would

reference articles and books pertinent to nursing

practice

Many libraries subscribe to computerized

databases such as Ebsco and Proquest, which

provide citations, abstracts, and some whole

articles

The Cochrane library Collaboration prepares

maintains and disseminates systematic reviews of

health care interventions focusing primarily on

systematic reviews of controlled trials of

therapeutic interventions (the gold standard for

experimental research design)

ResearchResearch

Most experts consider the well-designed double-blind

experiment (often referred to as the randomized control trial)

the best type of evidence

Another type of evidence is found in research studies that have

fewer controls. Some of these types of studies are included in

the discussion of reading research. The Centers for Disease

Control and Prevention identify these types of research

evidence as the most important in demising their guidelines for

disease and injury prevention and control

Retrospective or concurrent chart Retrospective or concurrent chart reviews, Quality improvement and reviews, Quality improvement and

risk datarisk data Aggregating data across an institution or several institutions

provides an opportunity to assess how well current practices are working

Determining patient outcomes for large groups provides a firm foundation of data that, although not part of a research study, can guide practice

Individual health care institutions and health plans are compiling information for statistical analysis & making decisions about health care based on these statistical measures

International, national, and local International, national, and local standards standards

Bring together the opinions & expertise of many health care providers

The standards are based on the collective experience & goals of individuals who are intimately involved with health care practice

Individuals who have worked with many patients, seen the results of multiple trials, & identified at first hand the complexity of the care have a special insight into effective practice. Because of this involvement & knowledge, the standards provide guidance and support for practice

Infection control dataInfection control data Because infection remains a major complicating factor in

health care, infection control data assume major

importance as guide for practice

The incidence of infection is of critical importance to both

the patient and the entire system in terms of its impact on

overall health outcomes

Practices that decrease the potential for infection have high

priority

Modern understanding of Modern understanding of pathophysiology pathophysiology

Modern understanding of pathophysiology at even

the cellular level has changed thinking about many

health care practices

Information regarding cost-Information regarding cost-effectiveness analysis effectiveness analysis

Helps an institution weigh possible benefits

against costs

It compares how much improvement a certain

practice makes versus how much that practice

costs

Patient preferencesPatient preferences

the importance of self-care in managing health

and illness, practices to which patients will adhere

and ones that make their lives simpler are more

likely to be incorporated

Failure to take into consideration patient

preferences may make the best-designed therapy

ineffective

Opinions of clinical expertsOpinions of clinical experts

Remain an important aspect of evidence.

Individuals who have worked with many patients,

seen the results of multiple trials, and identified at

first hand the complexity of the care have a special

insight into effective practice

Systematic Analysis of Information Systematic Analysis of Information &Evidence&Evidence

Not all published research evidence can be used for making

decisions about patient care

Deficiencies in research design can make an intervention

look better than it really is

The location and subjects of a particular research study may

affect the results in a unique way

Assess the quality, importance and applicability of any

research evidence that is being consulted to answer a specific

clinical question critical appraisalcritical appraisal

Critical AppraisalCritical Appraisal

The purpose of the critical appraisal for evidence-based practice is to decide whether the quality of a research study is good enough for the results it provides to be used to answer a question posed by a health care practitioner or patient

Critical appraisal can be broken down into three distinct but related parts:

Is the quality of the study good enough to

use the results?

Are the findings applicable in my setting?

What do the results mean for my patients?

QuestionQuestion about the effectiveness

of a therapy or intervention

Question about whether a

particular diagnostic test or

method of assessment works

Question about finding out the

likely pattern and/or outcome

of a particular health problem/

disease

DesignComparative / prospective,

ideally randomized, controlled trial.

Cross-sectional/ comparative study

(longitudinal) cohort or case control study

SampleRandom allocation to

intervention or control group. Baseline group comparability

Appropriate spectrum of subjects

Defined, representative sample.

Assembled at a common (usually | early} point

MeasuresIntervention clearly described.

Appropriate outcome measuresNew test compared against a

reference standardAppropriate end points

ResearcherClinician/assessor/ patient

masked (blinded) as to which group the patient has been

allocated to

Clinician/assessor masked (blinded) as to the results of

the reference standard

No dependent relationship between subject &

investigator

Data collection

All entrants adequately accounted for at the end of the

study

All entrants given both new and reference standard test

Follow-up of adequate duration & completeness

Data analysisAnalysis carried out on an

intention to treat basisReliability reported Effect of time confounders

explored

Criteria & questions for use in assessing the quality of research studies

Matching study design to questions

Type of question Example question Research design

The effectiveness of a therapy or intervention

Does a nurse-led discharge package for children admitted

with acute asthma reduce readmission rates?

Comparative/prospective randomized controlled trial

Finding out the likely pattern and/ or outcome of a particular health problem or disease (i.e.

prognosis)

Are women oral contraceptive users who smoke at greater risk of

myocardial infarction (Ml

Cohort study: participants exposed to an agent (contraceptive pill) are followed forward in time to see if

they develop an outcome (Ml)Case-control study: participants

with the condition (Ml) are matched with controls (no Ml),

study looks back in time to identify exposure to an agent

(contraceptive pill)

Whether a particular diagnostic test or method of assessment

works

In primary care, does asking patients about feeling

depressed and loss of interest accurately identify those who

are clinically depressed?

Cross-sectional study where the 'new' test (or method of

assessment) is compared with a reference standard test

Factors to consider when assessing Factors to consider when assessing the quality of a studythe quality of a study

Randomization

The group to which the patient has been allocated must be concealed from the clinician/researcher until the patient has been accepted into the trial

Demographic and health status details for the two groups are of interest

It is helpful if the intervention is described in sufficient detail to allow clinicians to reproduce it in their own setting

Keeping patients, clinicians and researchers blinded as

to whether a patient is in the treatment or control group

is a useful way of minimizing bias

People drop out of studies for all sorts of reasons: death,

relocation to another geographical area, treatment found

to be too unpleasant, etc. It is important that the

researcher tries to identify whether the reasons relate to

the outcomes of interest

Factors to consider when assessing Factors to consider when assessing applicabilityapplicability

The characteristics of the participants in the study

Is it feasible to introduce the intervention or test

described in the study?

When thinking of the costs and benefits of the

intervention or test, think beyond purely financial

terms

Questions for assessing & screening Questions for assessing & screening applicabilityapplicability

Is it clear what the study about?

Is the same sample adequately considered?

Are my patients / context sufficiently different that results will not apply?

Is the action indicated, or the intervention available, or the change possible in my setting?

Do the benefits of any change for my patients / context outweigh the like costs?

Are the patient’s values and preferences satisfied by change? Are my colleagues and mine?

Questions that must be included in Questions that must be included in

deliberations for evaluating informationdeliberations for evaluating information

Is the source identified? Is the source reliable? Is the source biased? How timely is the information relative to the need? How does the information fit with the purpose for

which it will be used? How does the setting that originated the information

compare with your setting?

Evaluation the studies results Evaluation the studies results using the Meta analysis testusing the Meta analysis test

Meta Analysis TestMeta Analysis Test

Like all quantitative studies, systematic reviews often include a statistical analysis

A meta-analysis combines the results of several studies that address a set of related research hypotheses, in an attempt to overcome the problem of reduced statistical power in studies with small sample sizes; analyzing the results from a group of studies can allow more accurate estimation of effects

Meta-analysis is a collection of systematic techniques for resolving apparent contradictions in research findings

Meta-analysis translates results from different studies to a common

Metric and statistically explore relations between study characteristics and findings

Modern meta-analysis does more than just combine the effect sizes of a set of studies. It tests if the studies outcomes show more variation than the variation that is expected because of sampling different research participants

Steps in performing meta-analysis Steps in performing meta-analysis

Meta-analysis should be viewed as an observational study of the evidence. The steps involved are similar to any other research undertaking: Formulation of the problem to be addressed Collection and analysis of the data Reporting of the results

Researchers should write in advance a detailed research protocol that clearly states the objectives, the hypotheses to be tested, the subgroups of interest, and the proposed methods and criteria for identifying and selecting relevant studies and extracting & analyzing information

As with criteria for including and excluding patients in clinical studies, eligibility criteria have to be defined for the data to be included

Criteria relate to the quality of trials and to the combinability of treatments, patients, outcomes, and lengths of follow up

Quality and design features of a study can influence the results. Ideally, researchers should consider including only controlled trials with proper randomization

The strategy for identifying the relevant studies should be

clearly delineated. In particular, it has to be decided

whether the search will be extended to include unpublished

studies, as their results may systematically differ from

published trials

A standardized record form is needed for data collection. It

is useful if two independent observers extract the data, to

avoid errors. At this stage the quality of the studies may be

rated, with one of several specially designed scales

Blinding observers to the names of the authors and their institutions, the names of the journals, sources of funding, and acknowledgments leads to more consistent scores

This entails photocopying papers, removing the title page, and concealing journal identifications and other characteristics with a black marker, or scanning the text of papers into a computer and preparing standardized formats

Levels of evidenceLevels of evidence

1++ High-quality meta-analyses, systematic reviews of randomized controlled trials (RCTs) or RCTs with a very low risk of bias

I+ Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias

1 Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias

2++ High-quality systematic reviews of case control or cohort studies. High-quality case control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal

Levels of evidenceLevels of evidence

2+

Well-conducted case control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal

2

Case control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal

3 Non-analytic studies, e.g. case reports, case series

4 Expert opinion

The process of changing practiceThe process of changing practice

Evidence- based guidelinesEvidence- based guidelines

Clinical guidelines are systemically developed statement to assist practitioner decisions about appropriate health care for specific clinical circumstances

Prioritizing topic areas for Prioritizing topic areas for guideline developmentguideline development

Situations where there is evidence of excessive morbidity, disability or mortality

Conditions for which available treatment offers the potential for improvement in any of the above

Those where there is evidence of wide variation in practice

Conditions that are resource intensive either because they are high cost or high volume

Situations involving cross-boundary issues, e.g., interprofessional working or the need for joint working between primary and secondary care

How are guidelines developed?How are guidelines developed? Selection of guideline topic Composition of the guideline development group Defining the scope of the guideline Systematic literature review Formation of recommendations Consultation and peer review Presentation and dissemination Local implementation Audit and review

skills are required in guideline skills are required in guideline development groupdevelopment group

Clinical expertise Other specialist expertise (e.g. Health

economics, research methods) Practical understanding of the problems

faced in the delivery of care Critical appraisal skills

Characteristics of effective Characteristics of effective guidelinesguidelines

Attribute Validity Cost-effectiveness Reproducibility Reliability Representative development Clinical applicability Clinical flexibility Clarity Scheduled review

Benefits of clinical guidelinesBenefits of clinical guidelines Ensure safe practice Improve consistency of care in different parts of the

country/settings patients receive correct treatment Build parity of knowledge amongst staff Bring the expert opinion to everyday clinical care Allow for individual patient variation - non-application is

not disallowed, it simply has to be justified Provide more information for patients about what they

should expect from the health care system Distill the vast array of knowledge relating to individual

clinical conditions into a manageable guide for busy clinicians

disbenefits of clinical guidelinesdisbenefits of clinical guidelines

Stifle individual clinical judgment

De-skill professionals by reducing their capacity to think for themselves

Limit quality of care by restricting care/treatment options

Introduce practice which could be ineffective or dangerous

Encourage the illusion that there is clear-cut direction to be taken in every clinical situation

Be very resource-intensive in relation to their development and implementation

Introducing guidelines into practice Introducing guidelines into practice

Dissemination

Implementation

Diagnosing the challenges to Diagnosing the challenges to changing practice changing practice

Identifying all the groups involved in, affected by, or influencing the proposed change (s) in practice

Assessing the characteristics of the proposed change that might influence its adoption

Assessing the preparedness of the health professionals to change and other potentially relevant internal factors within the target group

Identifying the potential external barriers to change

Identifying the likely enabling factors, including resources and skills

Methods exists for gaining Methods exists for gaining a purchase a purchase

Surveying key groups of stakeholders (such as senior staff, managers, and patient representatives

Adapting ward meetings or clinical supervision sessions so that potential problems can be identified, recorded and fed into the strategic planning process

Establishing a focus group of professionals, managers and, where appropriate, patient representatives, to identify pertinent barriers and drivers

Isolating some of the barriers to research uptake in clinical practice

Common complexities associated with nursing and research use

Professional culture Clinical information Environment Individual decision – maker Knowledge and educational attainment

Valuing research

Valuing change

Forces working for and against an evidence-based Forces working for and against an evidence-based organizational cultureorganizational culture

Planning for and managing Planning for and managing resistance and changeresistance and change

Social marketing modeSocial marketing modeThe model has six stages: Research the group(s) you wish to target and identify the

resources you have available to help you achieve the change

Select the 'raw materials' for the change you want to introduce

Develop and pilot the materials used to facilitate the change

Implement the change Evaluation Feedback

Precede—proceed modePrecede—proceed mode Its name is derived from the fact that it specifies the steps

that should precede any change and the ways in which

organizations should proceed with the change

The first stage of the precede-proceed model is concerned

with specifying the problem to be addressed and isolating

those factors which contribute to the presence of the

problem

This stage recognizes that problems will have

different priorities for different organizational

stakeholders & so it is important to try to reach

some form of consensus regarding the factors

which predispose & contribute to the problem, the

importance of these factors and their susceptibility

to change

Commonly, this takes the form of a ranking or rating approach. Common factors include:

Predisposing: the perceptions, attitudes, motivations

and beliefs of stakeholders involved with the change

Enabling: resources such as skills, knowledge (& funds)

Reinforcing: rewards or incentives - even if only in the

form of positive feedback

Strategic approaches for bridging Strategic approaches for bridging the gap between the research and the gap between the research and

practicepractice

GeneralGeneral

Continuing education

Clinical guidelines

Other broad approaches

Specific interventions classified according to Specific interventions classified according to

the degree of effect on clinical practicethe degree of effect on clinical practice

Educational outreach / detailing

Reminder

Multifaceted interventions

Mixed effectsMixed effects

Audit and feedback

Local opinion leaders

Local consensus approaches

Little or no effectLittle or no effect

Strategies to Overcome ChallengesStrategies to Overcome Challenges

Lack of knowledge or skill Identify resources

Staff development plans

Supervision and mentoring

Collaborative training and technical assistance

Developing shared vision and commitment

Strategies to Overcome ChallengesStrategies to Overcome Challenges Beliefs and Attitudes

Articulate existing beliefs and attitudes Hold frequent meetings to discuss change Utilize motivational strategies to move staff

ambivalence toward positive change Ensure a clear understanding of terms Enlist a neutral facilitator Affect beliefs through information Provide opportunities to speak with people who have

done it Provide incentives and recognition

Strategies to Overcome ChallengesStrategies to Overcome Challenges

Lack of Adequate Resources Resource sharing with other providers

Cross-site training and technical assistance

Community-wide collaboration

Strategies to Overcome ChallengesStrategies to Overcome Challenges

Lack of collaboration Implement a collaborative planning model Use stakeholder teams to make decisions Partner with other agencies implementing the

same intervention Develop a community-wide system of care where

the evidence-based practice is essential to producing desired outcomes