KINGDOM OF SAUDI ARABIAKING SAUD UNIVERSITYCOLLEGE OF NURSING

Prepared by : Fatimah A. GhulmanSupervised by : Dr. Fatma M. Baddar

EBN

P

Evidence - based decision making and practice

Nursing Evidence Based Practice (NEBP )

Making the Vision a Reality

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Outlines:

• Introduction• The evidence-based practice trend• What evidence-based practice?• Where to find evidence to guide practice• Assessing the quality of studies• Critical appraisal• Hierarchy of evidence• Decision analysis• Using evidence for practice• Models of evidence-based practice• Barriers to evidence-based practice

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Introduction…Introduction…

Nursing has a strong tradition of focusing on various ways of knowing; to provide excellent care.

Carper (1978) identified four fundamental patterns of knowing in nursing: empiric, ethics,

personal, and aesthetic patterns.

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Introduction…Introduction…

Within the nursing profession, it is expected that new information in the form of research findings will be incorporated constantly and knowledgeably into nursing practice.

The staff nurse is a critical link in bringing research-based changes into clinical practice.

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Introduction…Introduction…

• Depending on the environment, a health care organization may or may not have the resources to ensure critical, succinct, reasonable evaluation and application of research findings as they relate to the point-of-care delivery.

• Health care organizations are beginning to create mechanisms to facilitate the process of information translation from the literature to practice.

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What we mean by:

Process " promotes the collection, interpretation, and integration of valid, important and applicable patient-reported, clinician - observed, and research - derived evidence.

EBP

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Introduction…Introduction…

It is the wave of the future.

A way to keep current with new developments.

Incorporating evidence into practice is necessary to deliver scientifically sound patient care.

In addition, understanding the importance of evidence is crucial for meeting the excellence requirements of Magnet designation.

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Evidence-based nursing practice (EBNP)Evidence-based nursing practice (EBNP)

TERMINOLOGYTERMINOLOGY

• Evidence-Based Practice (EBP)

• Evidence-Based Health Care (EBHC)

• Evidence-Based Nursing (EBN)

• Evidence-Based Medicine (EBM)

Sackett’s definition refers to all of these; EBP and EBHC are more

universally used.

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EBPEBP is not about conducting research it is about using RESEARCHRESEARCH …

Research Utilization vsvs Evidence - Based Practice

• Research utilization ( RU )

The use of study findings in a practical application unrelated to the original research

• Evidence-based practice ( EBP )

Basing clinical decisions on best possible evidence - especially high quality research

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What do we mean by What do we mean by “evidence-based practice?”“evidence-based practice?”

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Evidence-based practiceEvidence-based practice ? ?

“ Evidence-based practice is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences ” IOM, 2001 & Sackett, 2000

Or

Evidence based health care is the integration of individual clinical expertise with the best available external clinical evidence and the values and expectations of the patient

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And also defined as …And also defined as …

• The best available evidence, moderated by patient circumstances and preferences, is applied to improve the quality of clinical judgments.

( McMaster University )

And, Evidence-based nursing is …And, Evidence-based nursing is …

• Evidence-based nursing is an approach to health care practice that enables nurses to provide the highest quality care based on the best evidence available to meet the needs of their patients.

Melnyk & Fineout- Overholt, 2005

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Evidence-Based Nursing ( EBN ) is defined asEvidence-Based Nursing ( EBN ) is defined as::

“ the application of valid, relevant, research-based information in nurse decision-making, used alongside our knowledge of our patients (their symptoms, diagnoses, and expressed preferences) and the context in which the decision is taking place (including the care setting and available resources) , and in processing this information we use our expertise and judgment. "

(Cullum, 2008)

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MAGNET DEFINITION OF EBP…MAGNET DEFINITION OF EBP…

• Evidence-based nursing de-emphasizes ritual, isolated and unsystematic clinical experiences, ungrounded opinions, and tradition as a basis for practice.

• It stresses the use of research findings and other operational and evaluation data, the consensus of recognized experts, and affirmed experience to substantiate clinical practice.

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Evidence-Based Health Services ManagementEvidence-Based Health Services Management

Is the “ systematic application of the best available evidence to the evaluation of managerial strategies for improving the performance of health services organizations. "

(Kovner & Rundall, 2006)

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When making clinical decision, it is essential to maintain and considered the following

EBP

The EBP Model

BestEvidence

Client Values and Expectations

Practitioner’s IndividualExpertise

Sackett et al., 1997

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WH

AT

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ICE

?

Salmond S. Advancing Evidence-Based Practice: A Primer Orthopaedic NursingMarch/April 2007 , Volume 26 Number 2 ,Pages 114 - 123

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Why is EBP important ?

• Assures patient receives most up-to-date care

possible.

• Assists practitioner in dealing with increasing

volume of medical literature.

• Allows patient and practitioner to work together

to make informed decisions.

• Clinical decisions can be clearly explained and

justified to clients and their families.

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Why is EBP important ?

• Maintaining and improving therapists knowledge base and the evidence base for the future.

• Provide practicing nurses with evidence-based data.

• Resolve problems in the clinical setting.

• Achieve excellence in care delivery.

• Assists with efficient and effective decision-making.

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CHALLENGES OF EBN

• New, Unfamiliar.

• Need to develop good search strategies.

• Must identify best databases.

• Need to do critical appraisals.

• Should be implemented from the top down, with

nursing faculty learning first.

• Much of relevant research is qualitative; need

more systematic reviews of qualitative research.

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CHALLENGES OF EBN

• Quality of the evidence.

• Dispersion of evidence sources (e.g.,

education, management, computer science).

• Skills in conducting research.

• Skills in disseminating research.

• Skills in interpreting research.

• Time !

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MISCONCEPTIONMISCONCEPTION

EBN is not a collection of statistical summaries, ignoring patient preferences and

clinical expertise.

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How do we establish which evidence is best ?

START

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Step 1.Step 1. Formulate the question (PICO)

Step 2.Step 2. Search for the best evidence

Step 3.Step 3. Critically appraise the evidence

Step 4.Step 4. Integrate the evidence

Step 5.Step 5. Evaluate its effectiveness.

Five Key Steps of EBPFive Key Steps of EBP

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Other stepsOther steps :

The 5 A's Step Model for Evidence Users

Ask: formulate the question.

Acquire: evidence - search for answers.

Appraise: the evidence for quality & relevance.

Apply: the results.

Assess: the outcome.

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Another Steps for EBP…Another Steps for EBP…

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How to Write a Review Question …

The “PICO” formatThe “PICO” format

A clinical question should incorporate at least 3 elements:A clinical question should incorporate at least 3 elements:

• Patient

– Age, sex, ethnicity, etc.

– Condition, diseases, general health status

• Intervention

– Education, diagnostics, treatment plan, self-care, etc.

• Comparison Intervention

– Placebo, etc.

• Outcome

– Expected and actual effects on patient

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PICO• Do nurse led tobacco cessation interventions result in

decreased smoking rates after hospital admission for coronary heart disease?

• PATIENT– (Adult) coronary heart patients, Smokers, Discharged from

hospital • INTERVENTION

– Nurse led tobacco cessation programmes• COMPARISON ( tobacco cessation programmes )

• Self-administered, non-nurse administered, etc.)– No comparison

• OUTCOME– Lower rates of tobacco use among Patient group

Intervention can be interpreted very broadlyIntervention can be interpreted very broadly

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By following these steps , the practitioner can form answerable questions and by identifying evidence, they can find support to base their decisions.

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Evidence Pyramid

• “ Important medical questions are typically studied more than once, often by different research teams in different locations.

• A meta-analysis combines results from different studies, hopefully averaging out any differences caused by random change or local variation and getting at something close to the real truth.

• In general a meta-analysis, if you can find one, will be a better guide to practice than an individual article. ”

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Search Protocol:Search Protocol:

• The pyramid is a graphical representation of how

to search efficiently for the best evidence. The

examples of EBM information sources in this

pyramid are placed from top to bottom according

to the "Usefulness of Medical Information"

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LEVELS OF EVIDENCE

http://tinyurl.com/nyupyramid

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The Evidence Pyramid for Treatment Effectiveness The Evidence Pyramid for Treatment Effectiveness

QuestionsQuestions

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Explanation …

• This model suggests that you start your search at

the top of the pyramid with systematic reviews

from the Cochrane Database of Systematic

Reviews.

• Cochrane is small in the amount of information it

currently contains, making it easier to search, but

large in the validity and relevance of the

information it contains for answering therapeutic

questions.

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Explanation …• MEDLINE and the other online medical literature

databases try to be as comprehensive as possible in their coverage. As a result, indexed material may have little direct application to present-day medical practice.

• The least clinically relevant at the bottom and the most clinically relevant at the top.

• The four layers above case reports and case series represent actual clinical research; the layers below can be useful as background resources.

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Rating System for the Hierarchy of Evidence Rating System for the Hierarchy of Evidence (Melnyk, 2006) (Melnyk, 2006)

• Level I. Evidence obtained from a systematic review or meta-analysis of all relevant, randomized clinical trials (RCTs), or clinical practice guidelines based on systematic reviews of RCTs.

• Level II. Evidence obtained from at least one well-designed RCT.

• Level III. Evidence obtained from well-designed controlled trials without randomization (quasi-experimental).

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Rating system (continued):Rating system (continued):

• Level IV. Evidence from well designed case-control and cohort studies.

• Level V. Evidence from SRs of descriptive and qualitative studies.

• Level VI. Evidence from a single descriptive or qualitative study.

• Level VII. Evidence from opinion of authorities and/or reports of expert committees.

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Critical appraisal of Evidence is:

The process of making a decision about The process of making a decision about whether a study can help to answer a clinical whether a study can help to answer a clinical question.question.

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Critical Appraisal:Critical Appraisal:

• Key characteristic of evidence based practice• Core skill needed to use evidence to support

nursing practice decisions• Ensures relevance and transferability of

evidence from the search to the specific population for whom the care will be provided.

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Critical Appraisal of Evidence Defined as :

1) Assessing the strength of the scientific

evidence ( Quality , Quantity, Consistency )

2) Evaluating the research for its quality and

applicability to health care decision making

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Critically appraising the evidenceCritically appraising the evidence

• Use of standardized a priori appraisal methods to answer:

• Is the evidence valid ?– Internal validity

• Is the evidence applicable/relevant ?– External validity

• Is the evidence clinically significant ?

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Clinical Decision-MakingClinical Decision-Making

• Clinical epidemiology discipline– study of determinants and consequences of clinical

decisions– apply EBP / 5A’s / critical appraisal at clinical

encounter to overcome automatic, unconscious decision-making biases (aka bad clinical intuition)

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Decision analysisDecision analysis

A method of analyzing decisions under conditions of A method of analyzing decisions under conditions of uncertainty.uncertainty.

• It can help to improve decision making when there is It can help to improve decision making when there is incomplete evidence to make the decision . incomplete evidence to make the decision .

• process of decision making make all elements of decision process of decision making make all elements of decision

• It can convey important information about an intervention It can convey important information about an intervention of a specific clinical problem .of a specific clinical problem .

• It can examine whether a treatment is beneficial or not.It can examine whether a treatment is beneficial or not.

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Evidence Based Resources Models

"Usefulness of Medical Information Equation"

Usefulness = Relevance x Validity 

Work

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MODELS FOR EVIDENCE-BASED NURSING PRACTICE

A number of different models of research utilization have been developed by nurse researchers in United States, Canada, the United Kingdom, and other countries during the past few decades. These include;

• Stetler Model of Research Utilization• Iowa Model of Research in Practice• Ottowa Model of Research Use• Evidence-Based Multidisciplinary Practice Model• Model for Change to Evidence-Based Practice• Center for Advanced Nursing Practice

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EBP ModelsEBP Models

• CURN project Research utilization– Review, synthesis, application, evaluation

• Stettler Model of Research Utilization– Critical thinking & decision making

• Iowa Model of Research in Practice– Quality assurance meets research utilization

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Nurses’ Role in Using Research EvidenceNurses’ Role in Using Research Evidence

Read widely and critically.

Attend professional conferences.

Learn to expect evidence that a procedure is effective.

Become involved in a journal club.

Pursue and participate in RU/EBP projects.

Wolters Kluwer Health, 2008 . Lippincott Williams & Wilkins

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BARRIERS TO RESERCH EVIDENCE-BASED BARRIERS TO RESERCH EVIDENCE-BASED PRACTICE IN NURSINGPRACTICE IN NURSING

1. Research-related barriers

2. Nurse-related barriers

3. Organizational barriers

4. Barriers related to the nursing profession

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Barriers to EBP conclude as :Barriers to EBP conclude as :

Some barriers to EBP that have been discussed in literature include:

• Access and availability to information

• Limited time

• Lack of EBP skills

• Confidence in the value of the evidence

• Support from management

• Conflict with client centered philosophy

HOWEVER, BARRIERS CAN ALWAYS BE OVERCOME HOWEVER, BARRIERS CAN ALWAYS BE OVERCOME

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Evidence Based LinksEvidence Based Links … …

• Source of clinically based evidence have increased in the last few years so that clinicians can more readily find resources to enhance their practice.

*** Excellent site contains pre-appraised evidence or evidence in a format such that it could be critically appraised

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Evidence-based resources:Evidence-based resources:

• Evidence-based Practice Centres:

These centers have been 'contracted' to provide overviews of the published literature in certain areas of expertise that include technology evaluation and specific areas of care.

• Canadian Coordinating Office for Health Technology Assessment:

Very well done!!! Contains links to many different comprehensive health technology reviews.

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• Canadian Task Force on Preventive Health Care:

This site provides direct links to full evidence-based reviews of preventive care strategies. Excellent site and a great resource.

• Agency for Health Care Policy Research:

Excellent resource.... contains links to evidence-based overviews, guidelines, summaries and other sites.

• EBM toolkit:

A pretty comprehensive set of tools to help understand the most important concepts from our friends in Alberta.

• Netting the Evidence:

A comprehensive list of links to EBM resources on the Net. If you're looking for something, this is the place to begin.

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• Evidence-based Medical Practice:

EditAn excellent intiative that critically appraises EBM

web sites regarding content and presentation. Excellent

links.

• CINAHL:

Mainly nursing literature but some allied health,

www.cinahl.com/

• Cochrane Library:

RCTs and Systematic Reviews, www.cochrane.co.uk/

• AMED:

rehab and therapy for allied health professions, accessed

through www.silverplatter.com/catalog/amed.htm

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How to assess the Quality of the study?How to assess the Quality of the study?

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Assessing the quality of studies is based on a Assessing the quality of studies is based on a number of criteria.number of criteria.

• The agency for health care research and quality evaluated system to rate the strength of scientific evidence that which can help to determine if the research body provide information to change practice and policy .

1.1. The magnitude of effectThe magnitude of effect2.2. Numbers of studiesNumbers of studies

3.3. Sample size and powerSample size and power

includes three domains …includes three domains …

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ConclusionsConclusions … …• Clinical decision about patient care should be based on

the best research evidence.

• The best research evidence refers to methodologically sound and clinically relevant research that incorporates the cost, safety, and effectiveness of interventions.

• EBP offers a systematic framework and set of tools for making decisions. By implementing the process of EBP individual clinicians as well as institutions foster an EBP environment that has the potential to improve patient care.

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SummarySummary … …

• The staff nurse is playing a critical link in bringing research-

based changes into clinical practice.

• We discussed different definition to EBNP.

• We discussed the Key Steps of EBP & how to implement Key Steps of EBP & how to implement

them.them.

• Useful resources included.Useful resources included.

• Barriers to EBP & how to overcome.Barriers to EBP & how to overcome.

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References …

• Polit DF., Beck CT. , 2006 . Essential of Nursing Research: Methods, Appraisal, and Utilization. 6th Edition . Lippincott Williams and Wilkins, Philadelphia, • Sackett, Straus, Richardson, Rosenberg & Haynes, 2000. Evidence-based medicine: how to practice and teach EBM 2d ed. London, UK: Churchill Livingstone.• http://www.chl.wales.nhs.uk/cpd/librarians/e-based.pdf• Joan M. Stanley, 2005. Advanced practice nursing : emphasizing common roles, 2nd ed. by F. A. Davis Company.USA.•Taylor, MC 2002, ‘Evidence Based Practice for Occupational Therapists,’ Taylor, MC 2002, ‘Evidence Based Practice for Occupational Therapists,’ Blackwell Science Ltd, USABlackwell Science Ltd, USA