Evidence-Based Practice

1
Evidence-Based Practice

• An Independent Study Short Course for
  Medical-Surgical Nurses

2

• This module was developed by the Clinical
  Practice Committee of the Academy of
  Medical-Surgical Nurses,
• in accordance with
• the 2006-2010 strategic plan.

3
Why is evidence-based practice important and why
now?

• Changing patient demographics require new
  approaches to care.
• The evidence base for practice is rapidly
  expanding and growing in complexity for nursing
  and other disciplines.

4
Why is evidence-based practice important and why
now?

• How to search, evaluate, and apply evidence in
  practice is unknown by many or inconsistently
  used.
• There continues to be a mismatch between what we
  know to be quality care and the quality of care
  that is delivered.

5
Why is evidence-based practice important and why
now?

• Quality problems occur even in the hands of
  dedicated, conscientious professionals.
• The burden of harm from the underuse, misuse, and
  overuse
• of care is staggering.

6
Why is evidence-based practice important and why
now?

• The 2003 report by the Institute of Medicine
  (Health Professions Education A Bridge to
  Quality) recommends that all health care
  professionals possess certain skills and
  competencies in order to enhance patient care
  quality and safety.
• All health professionals should be educated to
  deliver patient-centered care as members of an
  interdisciplinary team, emphasizing
  evidence-based practice, quality improvement
  approaches, and informatics.
• (Institute of Medicine, 2003)

7
Purpose of Module

• To provide an overview of evidence-based practice
  (EBP), one of the five competencies that all
  health care professionals should possess
  (Institute of Medicine, 2003).
• Where and how to find the best possible sources
  of evidence for your practice.
• How to formulate clear clinical questions.
• How to search for relevant answers to the
  questions.
• Determine when and how to integrate these new
  findings into practice.

8
Objectives

• At the end of this module, you will be able to
• Recognize evidence-based practice (EBP) as one of
  five core competencies all health professionals
  should possess regardless of their title or
  discipline (Institute of Medicine, 2003) for
  crossing the quality chasm.
• Define EBP.

9
Objectives

• Identify two characteristics differentiating
  research utilization and EBP in nursing.
• List three components of EBP.
• Provide two examples of how EBP benefits the
  nurse.
• Provide two examples of how EBP benefits the
  patient.

10
Objectives

• Describe the 5 steps of the EBP process.
• Write a researchable clinical question.
• Identify resources for developing relevant
  answers to the question.
• Use clinical judgment and the 5-step process for
  determining when and how to integrate findings
  into practice.

11
Evidence-Based Practice

• is
• Knowing that what we do is the best practice.

12
How do we know in nursing?

• Tradition
• Authority
• Borrowing
• Trial and error
• Personal experience
• Role modeling and mentorship
• Intuition and reasoning
• Nursing research

13
Nursing Research

• Diligent, systematic inquiry to validate and
  refine existing knowledge and generate new
  knowledge that directly and indirectly influences
  nursing practice. (Burns Grove, 2004)

14
Types of Nursing Research

• Describe
• Identify and understand phenomena, issues
• Explain
• Clarify relationships
• Predict
• Estimate the probability of outcome
• Control
• Manipulate the situation to get desired outcomes

15

• Much of what is known from research has not been
  applied in practice.
• This is known as

Research-Practice Gap
16
Research-Practice Gap

• During the 1980s and 1990s, nursing emphasized
  bridging this research-practice gap through the
  development of research utilization (RU)
  projects.

17
Research-Practice Gap

• Steps of the process included
• Dissemination of knowledge.
• Synthesis of findings.
• Critique of studies.
• Application of findings.
• Development of research-based practice guidelines
  (i.e., Agency for Health Care Policy and
  Research/AHCPR practice guidelines Conduct and
  Utilization of Research in Nursing/CURN practice
  protocols).

18
Research-Practice Gap

• Even though guidelines and knowledge have been
  disseminated, the overall effect on clinical
  practice and patient outcomes is unclear.

19
Research-Practice Gap

• The problems of importance to medical-surgical
  nursing (skin breakdown, pain, bowel function,
  treatment adherence, nausea) and related
  interventions are largely not collected in
  medical record databases.
• Nursing research studies are predominately
  descriptive or qualitative in design, rather than
  what is considered more rigorous and
  quantitative.

20
EBP is

• Needed to help bridge the research-practice gap
  by
• Strengthening the evidence base so that we know
  what works and what doesnt work in providing
  patients with the best outcomes.
• Standardizing evidence across fields to reach the
  best outcome for the patient.
• Housing evidence in online databases providing
  reviews of the evidence base.
• Translating and consolidating state of the
  science into clinical recommendations.
• (Stevens, 2004)

21
EBP is

• Conscientious, explicit, and judicious use of
  theory-driven, research-based information in
  making decisions about care delivery to
  individuals or a group of patients, and in
  consideration of individual needs and preferences
  (Ingersoll, 2000).

22
EBP is

• Integration of best research evidence, clinical
  expertise, and patient values in making decisions
  about the care of individual patients (Institute
  of Medicine, 2001).

23
Key Components of EBP

• Decisions about care are based on
• A. Research evidence.
• B. Clinical expertise, judicious use.
• C. Patient values and circumstances.
• (Institute of Medicine, 2003)

24
A. Research Evidence

• Randomized controlled trials
• Laboratory experiments
• Clinical trials
• Epidemiological research
• Outcomes research
• Qualitative research
• Expert practice knowledge, inductive reasoning

25
B. Clinical Expertise

• Knowledge gained from practice over time
• Inductive reasoning

26
C. Patient Values, Circumstances

• Unique preferences
• Concerns
• Expectations
• Financial resources
• Social supports

27
Benefits for Med-Surg Nurses

• Fewer Errors Reduced likelihood of making type
  1 and type 2 errors in practice
• Type 1 Acceptance of a practice that is
  incorrect. Example Administration of a wrong
  dose, using the wrong procedure, teaching
  patients using the wrong information.
• Type 2 Rejection of a practice that is correct.
  Example Failing to screen patients for fall or
  pressure ulcer risks failing to wash hands
  before and after patient contact failing to
  provide patients with smoking cessation
  information.
• (Aherns, 2005)

28
Benefits for Med-Surg Nurses

• Greater professional satisfaction from working
  as part of a team and experiencing effective
  practice.

29
Benefits for Med-Surg Nurses

• Better Care
• Less variation in care among caregivers where
  knowledge for improvement is already available.
• More predictable health outcomes.
• Less waste and inefficiency yielding fewer delays
  in diagnosis and treatment and fewer
  complications.

30
EBP Process

• There are 5 steps in judging the evidence and
  determining the circumstances and patient values
  for guiding application.

31
EBP Process
The EBP Process Steps are

• Assess practice (formulate question)
• What isnt working?
• What do you want to know about?
• Decide (evidence review)
• What resources are available and are they any
  good?
• What has worked in other places?
• How can you change your practice?
• Plan (develop a plan based on findings)
• Make a plan to change care based on relevant,
  applicable information.
• Let others help.
• Intervene (take action to review process or
  change)
• Implement revised caregiving protocol in
  clinical unit.
• Evaluate (care improved or modify and again
  intervene)
• How well is that working for you?

32
References

• Aherns, T. (2005). Evidence-based practice
  Priorities and implementation strategies. AACN
  Clinical Issues. 16(1), 36-42.
• Burns, N. Grove, S. K. (2004) The Practice of
  Nursing Research Conduct, Critique
  Utilization, 2-3.
• Fineout-Overholt, E., Melnyk, B.M., Schultz, A.
  (2005). Transforming health care from the inside
  out Advancing evidence-based practice in the
  21st century. Journal of Professional Nursing,
  21(6), 335-344.
• French, B. (2005). Evaluating research for use in
  practice what criteria do specialist nurses use?
  Journal of Advanced Nursing, 50(3), 235-43
• Ingersoll, G. I. (2000). Evidence-based Nursing
  What it is and what it isnt, Nursing Outlook,
  48, 151-152
• Institute of Medicine,(US) Committee on Quality
  Healthcare in America (2001). Crossing the
  quality chasm A new health system for the 21st
  Century, The National Academies Press, 145-163
• Institute of Medicine, (US)Greiner, A. Knebel,
  E., (Eds.) (2003) Health Professions Education A
  bridge to quality, The National Academies Press,
  45-74
• Ledbetter, C. A, Stevens, K.R. (2000). Basics
  of Evidence-Base Practice, Seminars in
  Perioperative Nursing 9 (3) 91-97
• National Patient Safety Goals. (2006). The Joint
  Commission (formerly JCAHO)
• Stevens, K. R. (2004). ACE Star Model of EBP
  Knowledge Transformation. Academic Center for
  Evidence-based Practice. The University of Texas
  Health Science Center at San Antonio.
  www.acestar.uthscsa.edu

33
Additional Readings

• Cullen, L., Greiner, J., Greiner, J., Bombei, C.,
  Comried, L. (2005). Excellence in
  evidence-based practice Organizational and unit
  exemplars. Critical Care Nursing Clinics of
  North America, 17, 127-142.
• Greiner, A., Knebel, E., (Eds.). (2003). Health
  professions education A bridge to quality.
  Washington, DC The National Academies Press.
• Stevens, K.R., Staley, J.M. (2006). The
  Quality Chasm reports, evidence-based practice,
  and nursings response to improve healthcare.
  Nursing Outlook, 54(2), 94-101.
• Titler, M., Kleiber, C., Steelman, V., Goode, C.,
  Rakel, B., Barry-Wlker, J., et. al. (1994).
  Infusing research into practice to promote
  quality care. Nursing Research, 43, 307-313.
• Titler, M., Kleiber, C., Steelman, V., Rakel, B.,
  Budreau, G., Everett, L., et. al. (2001). The
  Iowa Model of evidence-based practice to promote
  quality care. Critical Care Nursing Clinics of
  North America, 13(4), 497-509.