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Introduction and Overview
of Evidence Based Practice
Dr Helen Noble Queens University Belfast,
Lecturer, Health Services Research.
Associate Editor, Evidence Based Nursing
School of Nursing & Midwifery
Biography
Discuss Evidence Based Practice (EBP)
Examples of EBP
Evidence Based Renal Care - The ‘PACKS’ study
Importance to Nursing
Barriers to EBP
AIMS OF PRESENTATION
Senior Clinical Nurse Specialist - 2005
Established Renal Supportive and Palliative care Service
No evidence base
PhD Opting not to Dialyse: A Practitioner Research Study to
Explore Patient Experience
Symptoms
Impact on carers
Trajectories of dying
Added to theoretical knowledge of death and dying
……..City University
CAREER CHANGE
The conscious use of current best evidence in making decisions about patient care ( S a c ket t e t a l 2 0 0 0 Ev id en ce -Ba sed
M ed ic in e : H ow to P r a c t i c e a n d Tea c h E B M ) .
Definitions of EBP have broadened in scope. Now defined as
“a l ifelong problem-solving approach to clinical care that integrates:
A systematic search for and critical appraisal of the most relevant and best research to answer clinical questions
One’s own clinical expertise (the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice)
Patients preferences and values (Melnyk BM, Fineout-Overholt E 2005) Transforming
healthcare from the inside out: advancing evidence based practice in the 21 st century. Journal of Professional Nursing; 21: 6, 335-344)
WHAT IS EVIDENCE BASED PRACTICE
TRIAD OF EVIDENCE BASED PRACTICE
Best Available
Evidence
Patient values &
Expectations
Individual
Clinical
Expertise
EBP
Integrates best available external clinical evidence from systematic research ……with
Individual clinical expertise …..while
Taking into account patient preferences/values …to achieve
Improved patient outcomes
EBP
LEVELS OF EVIDENCE
I Evidence - Systematic reviews, meta-analysis
RCTs, EB clinical practice guidelines based on RCTs
I I Evidence - One well designed RCT
I I I Evidence - CTs without randomization
IV Evidence - Well-designed case control or cohort
studies
V Evidence - Systematic reviews of descriptive or
qualitative studies
VI Evidence - Single descriptive or qualitative study
VII Evidence – Opinions of authorities, reports of
experts
One of the simplest but most power ful tools of research.
People are al located at random to receive one of several cl inical interventions.
Used to examine the ef fect of interventions on par ticular outcomes such as death or the recurrence of disease.
Some consider randomized control led tr ials to be the best of al l research designs, or “the most power ful tool in modern cl inical research”.
N y s t r o m L , R u t q v i s t L E , W a l l S , e t a l . B r e a s t c a n c e r s c r e e n i n g w i t h m a m m o g r a p h y : o v e r v i e w o f S w e d i s h r a n d o m i s e d t r i a l s . L a n c e t 1 9 9 3 ; 3 4 1 : 9 7 3 – 9 7 8
KEY:
the act of randomizing patients to receive or not receive the intervention ensures that, on average, al l other possible causes are equal between the two groups.
C o c h r a n e L i b r a r y W e b s i t e . A v a i l a b l e a t :
w w w . u pd a t e - s o f t w a r e . c o m / a b s t r a c t s / a b 0 0 1 8 7 7 . h t m
RCTS
External evidence
Systematic reviews
Randomised controlled trials
Clinical practice guidelines
Internal evidence
Health care professionals expertise
Quality improvement projects
Patient evidence
Preferences – what does the patient want when given different options
Values – quality of life
FORMS OF EVIDENCE
ASSESS the patient
1. Start with the patient -- a clinical problem or question arises from the care of the patient
ASK the question
2. Construct a well built clinical question derived from the case
ACQUIRE the evidence
3. Select the appropriate resource(s) and conduct a search
APPRAISE the evidence
4. Appraise that evidence for its validity (closeness to the truth) and applicability (usefulness in clinical practice)
APPLY: talk with the patient
5. Return to the patient -- integrate that evidence with clinical expertise, patient preferences and apply it to practice
Self-evaluation
6. Evaluate your performance with this patient
STEPS IN THE EBP PROCESS
Environments constantly changing and evolving
Nursing has evolved from a series of dictated tasks to a holistic care approach = requires evidence and guidelines.
Guidelines support nurses to promote an individualised approach to holistic care, moving away from ritualistic practice.
Globally recognised that evidence based practice is the key to delivering the highest quality healthcare and ensuring best patient outcomes at the lowest costs .
An evidence based approach to providing health care versus the implementation of clinical care that is steeped in tradition or based on outdated policies, results in improved health, safety and cost outcomes, including a decrease in patient deaths
WHY DO NURSES NEED TO DELIVER
EVIDENCE BASED PRACTICE
SO MANY QUESTIONS . . .
Evidence-Based Practice (EBP): What is the best approach for managing neuropathic pain in the terminally ill patient?
What research has been done that could provide clinical practice guidelines?
Quality Improvement (QI): Are we doing the right things to appropriately manage patients’ neuropathic pain?
How do we know? How are we measuring patient outcomes?
Research (R): What is it like to live with neuropathic pain? Does drug “A” work better than drug “B?”
What’s been studied? Where are the gaps?
4.2 Responsibility, Accountability and Autonomy
Accountability
…. being able …. to justify their (nurses) decisions in the context of legislation, professional standards and guidelines, evidence-based practice and professional and ethical conduct.
SCOPE OF NURSING AND MIDWIFERY
PRACTICE FRAMEWORK
Chemotherapy -induced nausea and vomiting (CINV)
Common
Severe symptoms experienced by patients undergoing cancer treatment
Identification of risk factors for CINV
Structured, nurse-led telephone follow -up
Evidence-based methods to support patients undergoing cancer treatment.
The authors successfully implemented a structured, nurse -led CINV intervention to improve assessment, follow -up, and support patients undergoing chemotherapy
Underhill et al (2015) Clinical Journal of Oncology Nursing 19(1); 38 -40
A NURSE-LED EVIDENCE BASED PRACTICE PROJECT
MONITORING & IMPROVING MANAGEMENT OF
CHEMOTHERAPY-INDUCED NAU
EXAMPLE OF EVIDENCE BASED PRACTICE
https://www.youtube.com/w
atch?v=Q7ODSQrjB88
PALLIATIVE CARE IN CHRONIC KIDNEY DISEASE
(PACKS)
QUALIT Y OF LIFE, DECISION-MAKING, COSTS AND
THE IMPACT ON CARERS IN PEOPLE MANAGED
WITHOUT DIALYSIS: A STUDY PROTOCOL
http://bmcnephrol.biomedcentral.com/articles/10.1186/s12882-015-0084-7
AIM OF STUDY
Measure and describe
QOL,
Satisfaction with decision-making,
Costs,
Cognition, frailty and performance in patients with advanced chronic
kidney disease managed without dialysis.
Impact on Carers
10 UK sites
QUALITATIVE ARM
Understanding of the decision making process that precedes referral to CKM
Qualitative interviews with staff – Drs and nurses
Transcribed data
Line by line coding
Early themes
Fractured decision making – changing mind
Adequate support and input – staff opinion
Staff know what's best for patients
Paternalistic approach
Publication and sharing of knowledge
Prepare for new study
Inform practice based guidelines
POTENTIAL PROBLEMS AFFECTING NURSES
DELIVERING EVIDENCE BASED CARE
Lack of time
Poor access to facilities and information
Lack of educational skills in critiquing research
Lack of experience and little confidence in using computers
The quality of the resources that nurses access remains contentious
Evidence based practice is a natural, expected part of the
nursing role
Not an easy process and takes planning and interdisciplinary
collaboration
Improves patient care and outcomes
Requires evidence developed into guidelines:
Individualised care
Holistic care
Rigorous and robust
Stops ritualistic care – ‘how it’s always been done’
SUMMARY