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EBP Integration: At the Heart of Nursing Practice

12th Annual Seattle Nursing Research, Quality Improvement & EBP Conference

January 31, 2017

Melissa V. Taylor, PhD, RN Associate Chief Nurse for Research VA Pittsburgh Healthcare System

Disclosure Statement

I do not have any financial interest or other relationship with any organizations

that could be perceived as a real or apparent conflict of interest in the context

of the subject of this presentation.

Vision

“It was the vision of transforming health care with EBP, in any setting, with one client-clinician encounter at a time and the belief that this can be the daily experience of both patients and clinicians….”

Melnyk & Fineout Overholt, (2015) Preface, pg xviii

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Evidence-Based Practice Evolution

1992 Guyatt

EBP Workgroup

“A new paradigm for

medical practice … stressed

examination of evidence from clinical research.”

1996 Sackett,

et al

“… it’s about integrating individual

clinical expertise and

the best external

evidence.”

“Evidence-based care concerns the incorporation of evidence from

research, clinical experience, and

patient preferences into decisions

about the health care of individual

patients.”

1996 Mulhall

2005 Straus, et al

“…requires the integration of the research

evidence with our clinical

expertise and our patient’s

unique values and

circumstances.”

2008

2012 Sigma Theta Tau

Dearholt & Dang

“… process of shared decision-making

between the practitioner, patient

and others significant to them based on research evidence,

the patient’s experiences and

preferences, clinical expertise and other

available robust sources of

information.”

“EBP considers internal and

external influences on practice and

encourages critical thinking in the

judicious application of such

evidence to the care of individual patient, a patient population, or a

system.”

The process of shared decision-making between the practitioner, patient and others significant to them based on best available evidence, the patient’s experiences & preferences, and clinical expertise.

Best Available Evidence

Clinical Expertise

Patient Preferences

Evidence-Based Practice CONTEXT

Occurs within and is influenced by the context of the healthcare environment.

EBP as a Framework for Practice

Best Available Evidence

Clinical Expertise

Patient Preferences

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EBP as a Framework for Practice

Best Available Evidence

Clinical Expertise

Patient Preferences

EBP Process: a systematic, rigorous methodology used to identify best available evidence and translate said evidence into interventions.

ASK

AQUIRE

APPRAISE

APPLY

ASSESS

Implementation of evidence-based

intervention

Evidence Focus

Practice Recommendation

Evid

en

ce S

tren

gth

Is the strength of evidence good enough to use the results?

Pra

cti

ce C

on

text

Are the findings applicable in my setting?

Pati

en

t C

en

tere

d

What do the results mean for my patients?

Making a Practice Recommendation

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Evid

en

ce S

tren

gth

Is the evidence strong enough to use the results?

Qu

ality

Qu

an

tity

Co

ns

iste

nc

y

The Decision to Change Practice

Pra

cti

ce C

on

text

Are the findings applicable in my practice setting?

• Relevance

• Feasibility

• Shared Governance

• Internal Policies

• Cost / Resources

• Impact on Other Disciplines - Stakeholders

The Decision to Change Practice

Pati

en

t C

en

tere

d

What do the results mean for my unique patients?

• Patient Characteristics

• Patient Goals

• Patient Experiences

• Patient Resources

• Risk / Benefit

The Decision to Change Practice

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Evidence-Based Interventions and the Principle of One-Size…

http://www.compendian.com/wp-content/uploads/2014/12/one-size-fits-all.jpg

EBP as a Framework for Practice

Best Available Evidence

Clinical Expertise

Patient Preferences

Patient Preferences

• “Relative value that patient place on varying health states” DiCenso, Guyatt & Ciliska (2005)

• Patient Values…“unique preferences, concerns and

expectations each patient brings to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patient” Straus, Richardson, Glasziou & Haynes (2005)

• “Values the patient holds, concerns the patient has regarding

the clinical decision, treatment, situation, and choices the patient has/prefers regarding the clinical decision, treatment, situation” Melnyk & Fineout-Overholt (2011)

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Common Themes

Patient preferences are unique

Patient preferences are predicated on values

Concerns & choices extend to healthcare states, treatments, and outcomes.

Best Available Evidence

Clinical Expertise

Patient Preferences

Preferences are dynamic and complex; may change over time

Triggering Attributes

Values

Culture

Resources

Abilities

Knowledge of options

Social Networks

Others …

Influenced By

Past experiences

Present context

Consideration of the future

Treatment option evident / evidence clear

More than one choice / evidence

unclear

Preference-Sensitive Conditions

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EBP ... “the process of shared decision making …”

Passive Paternalistic

Decision Making

Active Independent

Decision Making

Shared Decision Making

Shared Decision-Making DELIBERATION

Initial Informed Preferences Preferences

Choice Talk

Option Talk

Decision Talk

Decision

Decision Support Brief as well as extensive

Model Tenets: 1. Process of Deliberation 2. Not prescriptive ... by necessity fluid, iterative and recursive 3. Relationship-based 4. Informed preferences 5. Ethical Principles = Self-determination & Relational Autonomy

Elwyn, G., et al. (2012)

Patient Preferences for SDM: What is the Evidence?

Quantitative Studies • Demographic Variables

• Age • Gender • Class, Occupation, Income • Ethnicity

• Experience of Illness and Medical Care • Health Status • Type of Decision • Information Preference

Clark, et al. 2009; Say, Murtagh, & Thomson, 2006

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Patient Preferences for SDM: What is the Evidence?

Qualitative Studies • Type of decision • Ability to understand medical information &

assess risk • Different roles in different stages of illness • Fear of making the “wrong” decision –

“right” or “wrong” outcomes • Attitudes toward illness • Clinicians’ decision-making style

Clark, et al. 2009; Say, Murtagh, & Thomson, 2006

Patient Preferences for SDM: What is the Evidence?

Highly variable and Complex • Involvement is a process • Develop over time • Change at different stages in illness • Type of decision / Amount of knowledge • Attitude toward decision-making & role

perceptions • Relationship with provider

Clark, et al. 2009; Say, Murtagh, & Thomson, 2006

EBP as a Framework for Practice

Best Available Evidence

Clinical Expertise

Patient Preferences

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How we communicate with patients

makes a difference.

https://creativemarket.com/blog/models-for-decision-making

“Nothing about me without me…”

Making Evidence Meaningful for Patients

1. Understand the patient’s (and family members) experience and expectations

2. Build partnerships / relationship

3. Provide the evidence – include a balanced discussion of uncertainties

4. Present recommendations and options

5. Check for understanding and agreement

Epstein, Alper, & Quill (2004)

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Helpful Communication Skills

• Use nontechnical language

• Tailor amount and pace information to patient needs & preferences

• Draw diagrams

• Consider patient values while weighing options

• Explain probability and risk for each option

• Encourage patient involvement

Epstein, Alper, & Quill (2004)

Helpful Communication Skills

• Evaluate information patient brings (e.g. internet information)

• Create environment where patients feel comfortable asking questions

• Give patients time to process information

• Declare equipoise when present

• Check patient understanding

• Negotiate

Epstein, Alper, & Quill (2004)

Decision Aid Tools

http://shareddecisions.mayoclinic.org/

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“It in not possible to practice patient-centered medicine that is not based on evidence, nor is it possible to practice evidence-based medicine at a distance

from the patient” Sacristan, 2013

“It was the vision of transforming health care with EBP, in any setting, with one client-clinician encounter at a time and the belief that this can be the daily experience of both patients and clinicians….” Melnyk & Fineout-Overholt, 2015

Moving Forward…

Best Available Evidence

Clinical Expertise

Patient Preferences

Integration

Intentional Commitment

and Knowledge

References Clark, N. M., Nelson, B. W., Valerio, M. A. Gong, M., Taylor-Fishwick, J. C., & Fletcher, M. (2009). Consideration of shared decision making in nursing: A review of clinicians’ perceptions and interventions. The Open Nursing Journal, 3, 65-75.

DiCenso, A., Guyatt, G., & Ciliska, D. (2005). Evidence-Based Nursing A Guide to Clinical Practice. Elsevier Mosby: St. Louis.

Elwyn, G., et al. (2012). Shared decision making: A model for clinical practice. JGIM, 27(10), 1361-1367

Epstein, R.M., Alper, B.S., & Quill, T.E. (2004). Communicating evidence for participatory decision making. JAMA, 291(19), 2359-2366.

Guyatt, G., et al. (2002) The philosophy of evidence-based medicine. In Guyatt, G., Rennie, D., Meade, M., & Cook, D.J. (Eds.). Users’ Guide to the Medical Literature, 2nd Edition. McGraw-Hill Co: New York.

Makoul, G., & Clayman, M.L. (2006). An integrative model of shared decision making in medical encounters. Patient Education and Counseling, 60, 301-312.

Melnyk, B.M., & Fineout-Overholt, E. (2011). Evidence-Based Practice in Nursing and Healthcare, 2nd Edition. Wolters Kluer/Lippincott Williams & Wilkins: Philadelphia.

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References Melnyk, B.M. & Fineout-Overholt, E. (2015). Evidence-Based Practice in Nursing and Healthcare, 3rd Edition. Wolters Kluer/Lippincott Williams & Wilkins: Philadelphia.

Say, R., Murtagh, M., & Thomson, R. (2006). Patients’ preference for involvement in medical decision making: A narrative review. Patient Education and Counseling, 60, 102-114.

Sigma Theta Tau (2008) Sigma Theta Tau International Position Statement on Evidence-Based Practice February 2007 Summary. Worldviews on Evidence-Based Nursing, 5(2), 57–59.

Sacristan, J.A. (2013). Patient-centered medicine and patient-oriented research: improving health outcomes for individual patients. BMC, 13(6), http://bmcmedinformdecismak.biomedcentral.com/articles/10.1186/1472-6947-13-6.

Straus, S.E., Richardson, W.S., Glasziou, P., & Haynes, R.B. (2005). Evidence-Based Medicine How to Practice and Teach EBM, 3rd Edition. Elsevier Churchill Livingstone: Edingurgh.