How Tos of Evidencebased Practice for RNs

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How Tos of Evidence-basedPractice for RNs

• Pat Quigley, PhD, ARNP, CRRN
• Deputy Director,
• VISN 8 Patient Safety Center of Inquiry
• James A. Haley Veterans Hospital
• Tampa, FL

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Objectives

• Compare at least 2 strategies to find evidence to
  guide practice.
• Examine levels of practice and research
  expectations
• Evaluate strategies for implementation of
  evidence-based practice

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Integration of Complementary Perspectives
Innovation Diffusion
Knowledge Transfer
Knowledge
Outcome

• Evidence-based Practice

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Three Perspectives

• Evidence-based Practice (Sackett)
• the conscientious use of current best evidence
  in making decisions about the care of individual
  patients or the delivery of health services.
• Innovation Diffusion (Rogers)
• The process of communicating new ideas through
  certain channels over time among members of a
  social system
• Knowledge Transfer (Dixon)
• Sharing of common knowledge, that is the
  knowledge that employees learn from doing the
  organizations tasks.

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When to Use...

• Evidence-based Knowledge
• Practice Transfer
• Scientific evidence Common knowledge
• Knowledge is clinical Knowledge may be clinical
• Clinical practice Knowledge is tacit (or
  guidelines explicit)
• Health care perspective Organizational learning
  orientation

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VISN 8 Patient Safety Center

• Commitment to clinical practice and practical
  knowledge (for elderly persons and persons with
  disabilities)
• Falls and fall-related injury prevention
• Restraint-free environments
• Pain management
• Pressure ulcer prevention
• Safe patient handling and movement
• Safe transitions between care settings
• End of life care

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Strategies to Find Evidence

• Critique of the Literature
• Determine the Evidence of Research Findings
• Use of Expert Consensus and Panels

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Evolution of Evidence-Based Practice (EBP)

• Concept from medicine
• Wide variations in practice clinical focus
• Recommendation from Institute of Medicine
  Crossing the Quality Chasm
• Resources for EBP
• Cochrane Collaboration
• Agency for Healthcare Research and Quality
  http//www.ahrq.gov/
• Centre for Evidence-Based Nursing
  http//www.evidencebasednursing.com/

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Evidence

• What is it?

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Definitions

• Evidence-Based Practice Evidence-based
  practice is the integration of best research
  evidence with clinical expertise and patient
  value. (Sackett, 2000)
• Evidence-Based Nursing (EBN) The process by
  which nurses make clinical decisions using the
  best available research evidence, the clinical
  expertise and patient preferences.
• (University of Minnesota Evidence-Based Health
  Care Project, 2002)

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Evidence-Based Medicine

• the conscientious, explicit and judicious use
  of current best evidence in making decisions
  about the care of individual patients. This
  practice means integrating individual clinical
  experience with the best available external
  clinical evidence from systematic research.
  (Sackett, 1996)

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Critical Factors for EBN

• Sufficient research on a specific topic
• Skill in accessing and critically analyzing
  research
• Nurses area of practice must allow her/him to
  implement changes based on the evidence
• (University of Minnesota Evidence-Based Health
  Care Project, 2002)

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Resources Cochrane Collaboration

• An international endeavor that prepares,
  maintains and promotes the accessibility of
  systematic reviews of the effects of health care
  interventions.
• Collaborative Review Groups
• Cochrane Centers
• Methods Working Groups
• The Cochrane Consumer Network
• The Cochrane Collaboration Steering Group
• http//www.cochrane.org/cochrane/general.htm

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Resources Cochrane Library

• Cochrane Database of Systematic Reviews
• The Database of Abstracts of Reviews of
  Effectiveness
• The Cochrane Controlled Trials Register
• The Cochrane Review Methodology Database

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Issues in Getting the Evidence Straight

• What counts as evidence?
• How to judge the quality of a review?
• How to reconcile conflicting recommendations from
  different groups?
• How to evaluate quality of guidelines?

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Components of EBP

• COMPONENTS PRODUCTS
• Systematic reviews Practice guidelines
• Meta-analysis Pathways of care
• Clinical trials Clinical algorithms
• Economic analysis Performance measures
• Decision analysis Process-based
• Outcomes-based

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Resources for EBP

• Agency for Health Care Policy Research
• http//www.ahrq.gov/
• Clinical practice guidelines
• Evidence-based practice centers
• Clearinghouse http//www.guideline.gov/index.asp
• Evidence reports

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Resources

• Centre for Evidence-Based Nursing (Subscription
  only)
• http//www.evidencebasednursing.com/
• ACP Journal Club http//www.acponline.org/journals
  /acpjc/jcmenu.htm
• Centre for Evidence-Based Medicine
• POEMS (J. of Fam Pract) http//www.medicalinforet
  riever.com/poems/poemsearch.cfm

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Strength of Evidence

• Grading the Evidence and Making Recommendations.
  The proposed schematic was used for judging
  quality ratings and recommendations, derived from
  American Geriatrics Society (AGS) i and
  previously used by the Registered Nurses
  Association of Ontario (RNAO).ii
• Level I Evidence from at least one properly
  randomized controlled trial.
• Level II Evidence from at least one
  well-designed clinical trial without
  randomization, from cohort or case-controlled
  analytic studies, from multiple time-series
  studies, or from dramatic results in uncontrolled
  experiments.
• Level III Evidence from respected authorities,
  based on clinical experience, descriptive
  studies, or reports of expert committees. This
  level includes qualitative studies, case reports,
  consensus statements, and panel guidelines. iii
• i AGS Panel on Persistent Pain in Older
  Persons. (2002). The management of persistent
  pain in older persons. Journal of the American
  Geriatrics Society, 50(6 suppl), S205-224.
• ii Registered Nurses Association of Ontario
  (RNAO). (2002). Assessment and management of
  pain. Toronto (ON) Registered Nurses Association
  of Ontario.
• iii AGS Panel on Persistent Pain in Older
  Persons. (2002). The management of persistent
  pain in older persons. Journal of the American
  Geriatrics Society, 50(6 suppl), S205-224.

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Making Recommendations

• Recommendations schema based on strength of
  evidence
• A Good evidence to support the use of a
  recommendation clinicians should do this all
  the time.
• B Moderate evidence to support the use of a
  recommendation clinicians should do this most
  of the time.
• C Poor evidence either to support or to reject
  the use of a recommendation clinicians may or
  may not follow the recommendation.
• D Moderate evidence against the use of
  recommendation clinicians should not do this.
• E Good evidence against the use of a
  recommendation, which is therefore
  contraindicated.i
• i AGS Panel on Persistent Pain in Older
  Persons. (2002). The management of persistent
  pain in older persons. Journal of the American
  Geriatrics Society, 50(6 suppl), S205-224.

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Steps in Application of Evidence

• 1. Select clinical questions
• 2. Getting the evidence straight
• Search literature/databases for information
• Evaluate validity and usefulness of evidence
• 3. Implement findings in clinical practice
• Developing clinical policy at right place/ time
• Applying the policy at right place/time

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Why Nurses Do Not Use (or think they do not use)
Research in Practice

• Research findings do not address their problems
• Nurses do not know about research findings or how
  to use them
• Nurses do not understand or believe published
  findings
• Nurses are not allowed to use them
• Nurse lack the time and right resources
• (Hunt, 1997, 1981)

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Experience

• What level of practice are you?

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Novice to Expert

• Novice Stimulus-response thinking rule
  governed behavior
• Advanced Beginner Begins to identify recurring
  meaningful situational aspects, applies to new
  situations
• Competent Aware of all aspects of situation
  plans are conscious, abstract, analytic
  contemplation
• Proficient Performance guided by maxims deep
  understanding web of perspectives of situation
  perception
• Expert Intuitive grasp of each situation- zeros
  in on the accurate region of the problem
• (Benner, 1984 Benner, Tanner, Chelsea, 1997)

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ANA Standards of Professional Performance

• Basis for VA Qualification Standards
• Appointment
• Position statements
• Performance appraisal
• 9 Dimensions of practice

• Practice
• Quality of care
• Performance
• Education/career development
• Collegiality
• Ethics
• Collaboration
• Research
• Resource Utilization

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Research Performance Expectation Novice Stage

• Research Dimension Assists in identifying
  problem areas in nursing practice
• Focus Questioning practice follows the rules,
  what was taught in nursing school
• Interpretation
• Questions traditions
• Asks why
• Observes incongruent practice and learning of
  formal education program

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Research Performance Novice Stage

• Behaviors/Examples
• Why do you change heparin lock IV sites every
  72 hours? Where did that number come from?
• We learned we must raise all 4 side rails if
  patients are confused to prevent falling from
  bed. Why did you take side rails off your beds?

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Research Performance Expectation Advanced
Beginner Stage

• Research Dimension Demonstrates an awareness of
  research application to practice
• Focus Use of guidelines
• Interpretation
• Understands linkage of research and clinical
  guidelines
• Uses nationally published guidelines

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Research Performance Advanced Beginner Stage

• Behaviors/Examples
• Uses ACLS algorithms on individual patients
  demonstrating critical thinking skills
• AHRQ guidelines for pressure ulcers family
  requests donut pressure relieving device
• knows request does not follow national guidelines
• educates family in current practice/rationale for
  alternatives

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Research Performance ExpectationAdvanced
Beginner -Competent Stage

• Research Dimension Uses a body of research to
  validate and/or change own professional practice
• Focus Validation of own practice using research
• Interpretation
• Knows the rationale for and changes personal
  practice
• Reads and shares current literature in the
  clinical specialty

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Research Performance Advanced
Beginner-Competent Stage

• Behaviors/Examples
• Changes own practice given evidence on restraint
  use explains rationale
• Uses decision algorithms to determine what type
  of equipment is appropriate to move a patient
  safely
• Identifies unit level problem Why are we
  observing a high percentage of post-op CABG
  patients developing atrial fibrillation on
  post-op day 2-4?
• Participates in unit level product trials

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Transfer to and from Bed to Chair, Chair to
Toilet, Chair to Chair, or Car to Chair
Can patient bear weight?
Caregiver assistance not needed stand by for
safety as needed
Fully
Is the Patient Cooperative?
Partially
Stand and pivot technique using a Gait/transfer
belt (1 caregiver) or- Powered standing assist
lift (1 caregiver)
Yes
No
Is the Patient Cooperative?
No
Use full body sling lift and 2 caregivers
No

• - For seated transfer aid, must have chair with
  
• arms that recess or are removable.
• For full body sling lift, select a lift that
  was specifically
• designed to access a patient from the car
  (if the car is
• the starting or ending destination).
• - If partial weight bearing, transfer toward
• stronger side.
• - Toileting slings are available for toileting.
• - Bathing mesh slings are available for
  bathing.
• Source The Patient Safety Center of Inquiry
  (Tampa, FL), Veterans Health Administration
  Department of Defense, October 2001.

Yes
Does the Patient have upper extremity strength?
No
Yes
Seated transfer aid may use gait/transfer Belt
until the Patient is proficient in completing
transfer independently
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Research Performance ExpectationCompetent Stage

• Research Dimension Uses a body of research to
  validate and/or change work group practice
• Focus Research appropriate for patient
  population work group practice
• Interpretation
• Identifies clinical issues/questions
• Conducts literature and/or research review
• Incorporates and uses knowledge to validate or
  change practice

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Research PerformanceCompetent Stage

• Behaviors/Examples
• Fall analysis on a cardiovascular unit after
  restraint reduction
• Lack of nursing-sensitive patient satisfaction
  measures in ambulatory care settings
  participation in instrument validation research
• Decreased ability to meet patient education needs
  with increased workloads new patient education
  tool developed after journal club participation
• Protocol development for rehabilitation of
  vent-dependent SCI patients

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Research Performance ExpectationProficient Stage

• Research Dimension Collaborates with others in
  research activities to improve care
• Focus Outcomes at the program/service level
• Interpretation
• Practice validation and/or improvement
• Application of research findings to practice or
  conducting research
• Collaboration with colleagues
• Reporting outcomes and results

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Research Performance Proficient Stage

• Behaviors/Examples
• Partnership Effective management of Class III
  IV CHF patients
• Long distance management of Class III IV CHF
  patients telemedicine technology
• Aggregate RCA on falls
• Institute/lead journal clubs in clinical areas

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Research Performance ExpectationProficient-Exper
t Stage

• Research Dimension Collaborates with staff,
  other disciplines, faculty and peers in
  developing, conducting and evaluating research
  activities.
• Focus Collaboration beyond the organization and
  discipline Conducting funded research
• Interpretation
• Developing or evaluating a program of research/
  research utilization activities
• Program development
• Research focused
• Large population groups or integrated programs

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Research Performance Proficient-Expert Stage

• Behaviors/Examples
• Development of a program of pain management
  research use of pain resource nurses to improve
  cancer pain outcomes
• Chronic disease self-management pilot program
  funded research at multiple sites
• Falls research program assessment of high risk
  pt populations synthesis of evidence research
  proposals development of fall assessment tools,
  clinics, pathways evaluation of outcomes

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Research Performance ExpectationExpert Stage

• Research Dimension Promotes an environment that
  supports the conduct and utilization of research
  in practice and a spirit of inquiry
• Focus Organization-wide regional and national
  involvement (administrative) or interdisciplinary
  research teams (researcher)
• Interpretation
• Nurse executives Research is demonstrated and
  promoted in clinical, educational and
  administrative practice areas
• Nurse researchers Funded program of nursing
  research

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Research Performance Expert Stage

• Nurse Executive and Researcher Examples
• Research function is formalized within structure
• Mechanisms established to assure clinical
  practice is supported by evidence
• Develops reward/recognition mechanisms for staff
  participation in research
• Establishes a program of research conducts
  funded research assists staff with
  implementation or conduct of research shares
  knowledge formally partners with other experts

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Review Research, Clinical and Laboratory
Information
Is evidence strong enough to warrant practice
change?
Yes
Implement evidence- based practice
No
Does evidence support clinical trials?
Technology Transfer
Clinical trial to test interventions
Yes
Equipment design or redesign with evaluation
Yes
No
Is equipment ready for Market?
Epidemiological study to identify modifiable risk
factors for adverse events or descriptive studies
to understand process and outcomes
Equipment design or redesign
OR
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Magnet Nursing ResearchThink Tank 12/03

• Research is needed to document clinical outcomes
  and administrative evidence. Have research done
  external to ANCC.
• Expand scope to address organizational dynamics
  of research business practices by forming
  relationships with school and business entities.

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Future Oriented Research

• What is the role of health system and
  credentialing in the total curriculum?
• What is the role of health systems and
  credentialing research in curricula?
• Develop methods for studying credentialing and
  their outcomes.

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Journal Clubs

• Role in Practice

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Research Committee Roles

• Purpose and Functions
• Link to Nursing Philosophy and Mission
• Strategic Planning
• Review of Proposals
• Nursing
• Medical
• Interdisciplinary

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Building Research Capacity

• Research Committee
• Funded Researchers
• Fellowships
• Grants
• Collaborations

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VISN 8 Patient Safety Center

• Three Centers for Research
• VHA HSRD REAP - outcomes
• VHA RRD REAP technology
• AHRQ DCERPS - transitions
• One Center for Translation of research into
  practice
• VISN 8 Patient Safety Center of Inquiry

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Your Thoughts?!

• Lets Share!

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References

• AGS Panel on Persistent Pain in Older Persons.
  (2002). The management of persistent pain in
  older persons. Journal of the American Geriatrics
  Society, 50(6 suppl), S205-224.
• Registered Nurses Association of Ontario (RNAO).
  (2002). Assessment and management of pain.
  Toronto (ON) Registered Nurses Association of
  Ontario.
• AGS Panel on Persistent Pain in Older Persons.
  (2002). The management of persistent pain in
  older persons. Journal of the American Geriatrics
  Society, 50(6 suppl), S205-224.
• AGS Panel on Persistent Pain in Older Persons.
  (2002). The management of persistent pain in
  older persons. Journal of the American Geriatrics
  Society, 50(6 suppl), S205-224.