What is Evidence-Based Practice?

Evidence-Based Practice from a Nursing Perspective

Cynthia Padula, PhD, RN

Nurse Researcher, The Miriam Hospital

Masters Program Director, Rhode Island College

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Objectives

Describe evidence based practice from a nursing perspectiveIdentify challenges to using evidence based practice in nursingCompare and contrast evidence based nursing and medicineRecognize the impact of the Magnet movement on evidence based nursing practiceIdentify resources relevant to nursing

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Definition

Process by which nurses make clinical decisions using best available evidence, clinical expertise, & patient preferences in the context of available resources (DiCenso, 1998)

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Evidence Based Practice

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What is Evidence-Based Nursing Practice

Builds on process of research use, but more encompassingMore specific than term best practicesDoes not foster rigid adherence to standardized guidelinesRecognizes the role of clinical expertiseEB nursing practice is a state of mind!

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Why Evidence-Based Practice in Nursing

Fueled by accrediting bodies, professional organizations, third party payersPotential to improve quality, reduce variations in careFocus on practices that result in best possible outcomes at possibly lower costProvides a way to keep pace with advances

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Why Evidence-Based Practice in Nursing

Potential to narrow the research-practice gap:

adoption of research findings into practice can

take as long as 17 years (Balas & Boren)

Impacted by perception that published research is not relevant to practice Provides a means to answer problematic clinical practice issuesPotential to improve individual bedside practice; supports/improves clinical decision-making skillsBedside nurse as conduit!!

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Traditional Basis for Nursing
Practice (Stetler)

Rituals, unverified rulesAnecdotes, isolated experiencesCustoms, opinions, unit cultures Physicians authority

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Bases for Practice in
Nursing (Stetler, 1998)

Philosophical/conceptual basis: mission; values; professional practice models; conceptual frameworks; professional codesRegulatory basis: state practice act; JCAHO; regulatory agenciesTraditional basis*Evidence-based practice

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Alternative Approach

Clinical expertise as necessary but not sufficient to provide best possible careEmphasis is on systematic, reproducible, unbiased evidenceFocus on evidence authority *in combination with clinical expertise

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Core Competencies

Ask: why are we doing this..

what is the evidence?

Think critically! Think out of the box!

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Core Competencies (cont.)

Prioritize and clearly articulate answerable

clinical questions with a focus on outcomes

Appreciate role of quality improvement activitiesEvaluate practice outcomes*Work effectively with others

1.bin

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Search for evidence

Evaluate the evidence

Core Competencies (cont.)

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Core Competencies (cont.)

Read and understand research

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Levels of Evidence Hierarchy
(Stetler et al.)*

Level I: Meta-analysis of multiple RCTs (gold standard)Level II: Individual RCTsLevel III: Quasi-experimentalLevel IV: Non-experimental; qualitativeLevel V: Program evaluation; QI; RU; case reportsLevel VI: Opinion of respected authorities

*modified slightly by Padula

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Levels of Evidence Pyramid

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Evidence Based Practice Process

Identify a practice issueFormulate an answerable questionSearch for best evidenceCritically evaluate the evidence and clinical relevanceMake recommendationsApply to clinical practiceEvaluate impact/effectiveness/ outcomes

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EBP in Nursing

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Readiness of US Nurses for EBP (Pravikoff et al., 2005)

Purpose: to examine nurses perceptions of their skills in obtaining evidence and their access to tools with which to do so.Sample: stratified random sample of 3,000 RNs across the US; 1,097 respondedMeasurement: 93 item measure; content validity established; varying response format

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Sample Characteristics
(Pravikoff et al.)

91% female79% between >40 years of ageEducational preparation:

Diploma 17%

AD 34%

BSN 39%

MS 9%

Employment: 60% in hospitals

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Subscale: Information Need/Seeking

How often do you need information to support nursing role?

61%: once or twice a week

How do you find the information needed?

67% always or freq sought a colleague

58% didnt use research reports at all

82% had never used a hospital library

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Subscale: Resource Availability and Use

83%: at least somewhat successful when searching the Internet19% somewhat confident in ability to search CINAHL; 76% never search CINAHL36% somewhat confident in ability to search MEDLINE83% rarely or never sought librarian assistance; 82% didnt use hospital library

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Resource Use/Availability (cont.)

77% had never received instruction re: electronic resources36% reported had access to electronic databases; 29% did not know if access was available26% had access to electronic databases on nursing units49% had access to the Internet on units

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Subscale: Individual Barriers
(other than time)

Lack of value for research in practiceLack of understanding of electronic databasesDifficulty accessing materialsLack of computer skillsDifficulty understanding articlesLack of: access to computer; library access; search skills; research knowledge; critiquing skills

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Differing Challenges:
Nursing Medicine

Varying entry levels

Rapid indoctrination

Off unit access difficult

Clinical reality more subjective/human response

Most quasi or below; qualitative

MD degree

Internship/residency

Easier access off unit

Focus on objective reality/ treatment effectiveness research

More RCTs

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Using the Magnet Influence

Administered by the American Nurses Credentialing Center

http://nursingworld.org.ancc

Magnet designation recognized and rewards nursing excellenceForces of Magnetism (14) identified via a landmark study (McClure & Hindshaw)

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Selected Forces

Professional models of care

-must designate a nursing theory

Quality of care

-support of research/evidence based practice

Quality improvement

-nurse driven, evidence based quality initiatives

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Selected Forces (cont.)

Professional development

-training, mentoring

Interdisciplinary relationships

-opportunities for collaboration; consultation

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Collaboration is Key

Library can serve as archive for nursing publications/Magnet applications (Rourke)Committee participationHeightened visibilityFacilitation is keyWrite library services and librarians into grants

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Take the Magnet Journey!!

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Resources

Evidence Based Nursing JournalOnline Journal of Knowledge Synthesis for Nursing, Sigma Theta Tau

http://www.nursingsociety.org

US Preventive Services Task Force

http://www.ahrq.gov/clinic/uspsfact.htm

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Selected Lifespan Resources

Direct links to PubMed and OvidMicromedex> 3000 journalsDXplainMD consult

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References

Baras, E., & Boren, S. (2000). Managing clinical knowledge for healthcare improvement (pp. 65-70). Germany: Schattauer Publishing. Dee, C., & Stanley, e. (2005). Nurses information needs: nurses and hospital librarians perspective. J Hosp Librar, 5(2), 1-13. Hallyburton, A., & St. John, B. (2009). Partnering with your library to strengthen nursing research. J Nsg Educ, 49(3), 164-167.McClure, M., & Hinshaw, A. (2002). Magnet hospital revisited. Washington DC: ANA. Pravikoff, D., Tanner, A., & Pierce, S. (2005). Readiness of US nurses for evidence-based practice. AJN, 105(9), 40-51.

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References (cont.)

Rourke, D. (2007). The hospital library as a Magnet ForceMed Ref Svcs Quar, 26(3), 47-54.

Sherwill-Navarro, P., & Roth, K. (2007). Magnet hospital/magnetic

libraries. J Hosp Librar, 7(3), 21-31Stetler C. et al. (1998). Evidence-based practice and the role of nursing leadership. JONA, 28(7/8), 45-53.Stetler, C. et al. (1998). Utilization-focused integrative reviews. Appl Nurs Res, 11(4).

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