Strategies for Achieving Evidence Based Practice

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Strategies for Achieving Evidence Based Practice

• Nicky Cullum
• Centre for Evidence Based Nursing, University of
  York

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Aims

• To introduce you to key principles and processes
  of evidence based nursing including strategies
  and resources to promote evidence based care

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Clinical Scenario

• You are a senior nurse on an acute admissions
  ward where lumbar punctures are regularly
  undertaken for diagnostic purposes. Standard
  practice has long been to lie people flat to
  reduce the likelihood of headache but the Unit
  Manager asks if this period of bed rest can be
  reduced or abolished as this bed-blocking is
  giving her a headache

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How long do you think someone should lie flat
after lumbar puncture?
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REFLECT ON PRACTICE IDENTIFY AREAS OF
UNCERTAINTY
AUDIT
PHRASE ANSWERABLE QUESTIONS
IMPLEMENTATION WHERE APPROPRIATE
SEARCH FOR RESEARCH EVIDENCE
CRITICAL APPRAISAL OF THE RESEARCH
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Patient Preferences
Evidence from research
Evidence based decision
Professional expertise
Available resources
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Clinical Decisions (Doctors)

• Achieving a diagnosis
• Estimating a prognosis
• Choosing to intervene
• Choosing an intervention
• Determining Harm

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What kinds of clinical uncertainty do nurses face?

• Interventions
• Therapy
• Prevention
• Targeting
• Timing
• Diagnosis
• Communicating risks and benefits
• Referral
• Service Delivery/Organisation
• One choice every 10 minutes in acute care

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Question formation - PICO

• Population (who are the relevant people?)
• Interventions or exposures (diagnostic tests,
  foods, drugs, environmental hazards etc)
• Control or Alternative intervention/exposure
• Outcome (what are the person-level consequences
  we are interested in?)

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Population

• Who are the relevant people?

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Intervention
What are they exposed to?
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Alternative or control intervention
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Outcome (what are the person-level consequences
we are interested in?)
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Focusing Answerable Questions
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Focusing Answerable Questions
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Focusing Answerable Questions
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Focusing Answerable Questions
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Focusing Answerable Questions
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REFLECT ON PRACTICE IDENTIFY AREAS OF
UNCERTAINTY
AUDIT
PHRASE ANSWERABLE QUESTIONS
IMPLEMENTATION WHERE APPROPRIATE
SEARCH FOR RESEARCH EVIDENCE
CRITICAL APPRAISAL OF THE RESEARCH
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Fundamental Principle of Evidence Based anything

• The weight given to research evidence for any
  decision depends on internal validity and
  relevance (external validity) of research
• Match the type of question with the best research
  design
• Certain research designs likely to yield more
  valid (more likely true) results for particular
  types of questions (minimise bias)

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Matching questions to designs
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Randomised controlled trial
OUTCOME
Experimental intervention
NO OUTCOME
Eligible patients
OUTCOME
Control intervention
Direction of data collection exposure ? outcome
NO OUTCOME
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The total body of research is distilled down to a
conclusion based on the best available, reliable
and relevant research
Poor quality and/or irrelevant research
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Systematic reviews

• Reviews that look, in a systematic way, at all
  the available research on a topic
• Systematic reviews have a clear method - like
  original research
• Critically appraise each piece of research they
  include
• Reliable information for practice

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www.nelh.nhs.uk/cochrane.asp
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Examples of Systematic Reviews from the Cochrane
Library

• Beds, mattresses and cushions for preventing
  pressure ulcers
• Non-nutritive sucking for pre-term infants
• Absorbent products for containing urinary and/or
  faecal incontinence
  in adults
• Caregiver support for women during childbirth
• Communicating with children and adolescents about
  their cancer

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REFLECT ON PRACTICE IDENTIFY AREAS OF
UNCERTAINTY
AUDIT
PHRASE ANSWERABLE QUESTIONS
IMPLEMENTATION WHERE APPROPRIATE
SEARCH FOR RESEARCH EVIDENCE
CRITICAL APPRAISAL OF THE RESEARCH
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Only approximately 10 of articles in the most
prestigious internal medicine journals can be
regarded as valid and ready for application
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Critical Appraisal

• Important for practitioners to be able to sort
  the good research from the bad quickly
• A number of checklists available different ones
  for different research designs
• See Evidence Based Nursing Users Guides
• CASP website http//www.phru.org.uk/casp/appraisa
  .htm

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Features of Clinically Useful Information

• Trustworthy (pre-appraised)
• Concise
• Easy to understand
• Easy to access
• Clear implications for practice

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Sources of Pre-Appraised Research

• Clinical Evidence

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www.nelh.nhs.uk/clinical_evidence.asp
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Sources of Pre-Appraised Research

• Clinical Evidence
• Evidence Based journals
• Evidence Based Nursing, Medicine, Mental Health
  etc

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Evidence Based journals

• Aim to select, from international literature,
  best quality research and reviews relevant to
  medicine, nursing etc
• Summarises each article in value-added
  abstracts
• Commentary from clinical expert

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Sources of Pre-Appraised Research

• Clinical Evidence
• Evidence Based journals
• Evidence Based Nursing, Medicine, Mental Health
  etc
• Systematic reviews
• Cochrane Library (via NeLH)
• Cochrane Database of Systematic Reviews
• DARE - Database of Abstracts of Reviews of
  Effectiveness

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Hayness Typology of Research Information (4S)
Systems
synopses
Synopses
Syntheses (reviews)
syntheses
Studies
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REFLECT ON PRACTICE IDENTIFY AREAS OF
UNCERTAINTY
AUDIT
PHRASE ANSWERABLE QUESTIONS
IMPLEMENTATION WHERE APPROPRIATE
SEARCH FOR RESEARCH EVIDENCE
CRITICAL APPRAISAL OF THE RESEARCH
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Evidence Based Implementation

• Growing body of evidence regarding successful
  implementation strategies
• Multifaceted interventions better than single
  interventions eg. audit and feedback, plus
  reminders, plus opinion leaders

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Back to Lumbar Puncture
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Where do you start?

• Work with nurse colleagues to identify common
  clinical uncertainties
• Frame these as answerable, searchable questions
• Search for answers following the synopsis,
  synthesis, study approach