Evidencebased Practice Tools for Nurses

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Evidence-based Practice Tools for Nurses

• Woods Hole 2008
• Suzanne Bakken, RN, DNSc
• Columbia University

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Objectives

• Discuss issues and challenges associated with
  application of evidence into nursing practice
• Differentiate among stand alone,
  context-specific, and integrated EBP tools
• Describe at least two approaches for integrating
  EBP tools into practice

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What is Evidence-based Practice?

• Traditional conceptualizations
• Research utilization
• http//www.cebm.net/levels_of_evidence.asp
• Clinical trials-based
• Clinical practice guidelines
• Application of domain knowledge to patient care
• Evidence as a continuum

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What Data Do We Need for Evidence-Based Practice?

• Information about the patient
• Domain information and knowledge (the evidence)
  from systematic inquiry and other sources

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Informatics Supports

• Building the evidence
• Retrieving the evidence
• Analyzing the evidence
• Applying the evidence

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Strategic Action Framework (2004)

• Inform clinical practice
• Incentivize EHR adoption
• Reduce risk of EHR investment
• Promote EHR diffusion in rural and underserved
  areas
• Interconnect clinicians
• Foster regional collaborations
• Develop national health information network
• Coordinate federal health information systems
• Personalize care
• Encourage use of personal health records
• Enhance informed consumer choice
• Promote use of telehealth systems
• Improve population health
• Unify public health surveillance architectures
• Streamline quality and health status monitoring
• Accelerate research and dissemination of evidence

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Types of EBP Tools

• Stand alone
• Context-specific access
• Integrated

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Types of EBP Tools

• Stand alone
• Bibliographic
• Synthesized
• Context-specific access
• Integrated

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Synthesized

• CINAHL Plus
• Evidenced-based Care Sheets
• http//www.york.ac.uk/healthsciences/centres/evide
  nce/cebn.htm
• http//www.joannabriggs.edu.au/pubs/best_practice.
  php

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Clinical Decision Support Systems

• A clinical decision support system is any
  computer program designed to help health care
  professionals make clinical decisions
  (Shortliffe, 1987).

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Focus of M5710

• Application of evidence and prevention of errors
  (commission and omission) through
• Diagnostic decision support (expert) systems
• Other decision aids
• Decision analysis
• Computer-based provider order entry
• Practice guidelines

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Descriptive Studies of Clinical Reasoning/
Medical Problem Solving

• Simulated case studies - written, computer-based,
  actors
• Verbal protocol analysis - telling more than we
  know?
• Think aloud
• Stimulated recall
• Observational studies
• Paradigm cases - phenomenology

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Hypothetico-deductive Approach to Diagnostic
Reasoning

• Generate alternative hypotheses
• Gather data
• Use data to test hypotheses
• Select a course of action

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Novice to Expert

• Novice rules-based
• Advanced beginner
• Competent
• Proficient
• Expert pattern recognition

(Benner, 1986)
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Issues and Challenges with Stand Alone Tools

• Pravikoff et al. study

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Types of EBP Tools

• Stand alone
• Context-specific access
• Integrated

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Types of EBP Tools

• Stand alone
• Context-specific access
• Integrated
• Rules
• Documentation/Nursing Orders/Plans of Care

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WebCIS Instrument Currie et al.
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Results Page
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Safety Measures Documentation
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Assessment Trends
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Safety Measures Trends
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PDA Decision Support for Advanced Practice Nurses

• Settings hospital, ambulatory care, community
• Support evidence-based nursing practice including
  guideline-based care (RCT funded by NINR 1R01
  NR008903)
• Rules and documentation-based approach
• Facilitate documentation of practice
• Enable benchmarking by students and faculty
• Enhance informatics competencies

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PDA User Interface

• Approach
• Tailored to student rotation or specialty (e.g.,
  Pediatrics, Medical/Surgical, Gerontology Nurse
  Practitioner)
• Types of data
• Patient demographics
• Student information
• Clinical data (e.g., medical diagnoses, nursing
  diagnoses, nursing interventions, plan)
• Other applications
• Micromedex
• Medrules

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Extending MODS-APN with Infobuttons and
Information Prescriptions

• Improving Use of CIS in the Underserved Through
  Mobile Access and Decision Support (R21 CA126325)
  
• Smoking cessation model Ask, Advise, Assess,
  Assist, and Arrange
• Reminder to screen/screening questions Ask
• Guideline-based documentation template - Advise,
  Assess, Assist, and Arrange
• Context-specific access to Cancer Information
  Service Resources
• Information prescriptions
• Hypothesis Approach will increase use of CIS by
  nurses in APN training and patients

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Commercial Integrated Products

• http//www.zynx.com/solutions/care/care_overview.a
  spx

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Conclusions

• EBP tools for nurses exist
• Challenges exist related to their integration
  into practice
• Vital that nurses have the informatics
  competencies to fully utilize tools to advance
  patient care through evidence-based practice
• Nursing expertise pivotal in developing
  information systems that enable evidence-based
  practice