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Transcript of Evidence Based Practice In Nursing Dr. Abdul-Monim Batiha Assistant Professor Critical Care Nursing...
Evidence Based Evidence Based Practice In NursingPractice In Nursing
Dr. Abdul-Monim BatihaDr. Abdul-Monim BatihaAssistant ProfessorAssistant ProfessorCritical Care NursingCritical Care Nursing
Philadelphia university Philadelphia university
Today’s health care system has become
increasingly more costly and complex.
Consequently, in this market-driven delivery
system, there is a greater emphasis on
outcomes, cost-effectiveness, and consumer
satisfaction.
These pressures operate in an
environment of rapid information
exchange, technological advancements,
and an increasing nursing workload
Nurses are challenged to maintain clinical
competence, to demonstrate how their
care positively affects patient outcomes, &
to participate actively in clinical decision-
making & practice improvements
Nurses are now mandated to demonstrate
cost-effectiveness and efficiency with the use
of time and resources, while continuing to
demonstrate their value added impact on
outcomes. These mandates provide a strong
rationale for adopting an evidence-based
model of practice
What Is Evidence- Based Nursing?What Is Evidence- Based Nursing?
Evidence – Based Nursing (EBN)Evidence – Based Nursing (EBN)
Process by which nurses make clinical decisions using the best available research evidence, their clinical expertise & patient preferences"
Clinical expertise Ability to use our clinical skills &
experience to rapidly identify each patient's unique health state &diagnosis, their individual risks & benefits of potential interventions, & their personal values & expectations
Patient valuesPatient values & preference& preference
Unique preferences, concerns &
expectations each patient brings to a clinical
encounter & which must be integrated into
clinical decisions if they are to serve the
patient
Goals of EBN are to apply valid & reliable
nursing research to clinical practice
"Research utilization" & to bring the most
current knowledge to clinicians. This is
particularly important due to the knowledge
explosion in nursing and health care
Steps to Evidence-Based Critical Steps to Evidence-Based Critical Care Nursing PracticeCare Nursing Practice
Accept the fact that health care is evolving, with the consequent need to base nursing care on evidence, rather than on tradition or previous education
Identify a need for change in practice by examining less-than-favorable patient outcomes; causes of patient, family/significant other, or staff dissatisfaction; or situations in which compelling new evidence exists in an aspect of care
Frame a clinical question and search the literature
for evidence regarding the topic
Once current research data and evidence have
been collected, evaluate the evidence for
scientific merit, quality, and applicability
Synthesize to determine the strength of the evidence
to support a change in practice
Conduct a comparison between current practice
recommendations and current research
If there is sufficient evidence to suggest a change
in practice and the change in practice is practical in
respect to costs, staff skill, and resources required,
application of the evidence into practice can occur
Implicit in the implementation of evidence are the issues
associated with change, including fear of change & the
need for information, staff training, leadership, & ongoing
evaluation of the change
Continue to evaluate the evidence through an ongoing and systematic review to promote state of- the-science nursing care
Converting information needs Converting information needs into clear questionsinto clear questions
Art to Phrasing Questions Art to Phrasing Questions
An art to phrasing questions in such a way as
to elicit a meaningful answer, there are three
key reasons for focusing questions:
Facilitating the search for relevant evidence. The more explicit the question, the easier it is to run searches on electronic databases such as those contained within the Library shelves, CINAHL (Cumulative Index of Allied Health and Nursing Literature, or MEDLINE
A non-focused question is more likely to yield larger numbers of non-relevant studies than a focused question, and valuable search time will be wasted trying to sift through the long list
of retrieved references for relevant studies
Sorting best evidence from weaker, less valid evidence
Deciding whether the evidence is applicable to our patients
The PICO (population, intervention, comparison
intervention, out come) framework, devised by Saekett et al
(1997), is a useful method for making questions more
focused. The question is built in four (or three) parts
PICO Frame PICO Frame Population or Problem, it may be necessary to specify
age, gender, disease type, disease severity or co-morbidity. This will depend on whether the results of a very broad, inclusive population could be applied to your specific patient group
Define who or what the question is about
PICO FramePICO Frame Intervention: Define which intervention, test or
exposure you are interested in. An intervention is a planned course of action. An exposure is something that happens such as a fall, anxiety. The intervention (or test or exposure) may need to be described in some detail to ensure clarity
Describe what it is you are considering doing or what it is that has
happened to the patient
PICO FramePICO Frame
Comparison intervention: Define the alternate intervention
Describe the alternative that can be compared with the intervention Outcomes:
Define the important outcomes, beneficial or harmful
Define what you are hoping to achieve or avoid
PICO FramePICO Frame
Outcomes: very general outcomes may be difficult to measure, and details of how outcomes can be objectively measured may need to be specified
Searching LiteratureSearching Literature
Basic search principlesBasic search principles
Analyzing the question
Generating a word list
Linking word lists( Boolean logic: AND,
OR, NOT)
Boolean OperatorBoolean Operator
Boolean OperatorBoolean Operator
Boolean OperatorBoolean Operator
Types Of Evidence UsedTypes Of Evidence Used
Health Care Indexes Research Retrospective or Concurrent Chart Review Quality Improvement & Risk Data &
Benchmarking International, National, & Local Standards Infection Control Data Pathophysiology Cost-effectiveness Analysis Patient Preferences Clinical Expertise
Health care indexesHealth care indexes
Two of the most common indexes used by nurses
are MEDLINE, produced by the National Library of
Medicine (NLM)
CINAHL (Cumulative Index for Nursing & Allied
Health Literature) produced by the C1NAHL
corporation. Both of these are available in print &
computerized forms
The International Nursing Index, Hospital
Literature Index, Psych Index, and Social Sciences
Index are other common used indexes that would
reference articles and books pertinent to nursing
practice
Many libraries subscribe to computerized
databases such as Ebsco and Proquest, which
provide citations, abstracts, and some whole
articles
The Cochrane library Collaboration prepares
maintains and disseminates systematic reviews of
health care interventions focusing primarily on
systematic reviews of controlled trials of
therapeutic interventions (the gold standard for
experimental research design)
ResearchResearch
Most experts consider the well-designed double-blind
experiment (often referred to as the randomized control trial)
the best type of evidence
Another type of evidence is found in research studies that have
fewer controls. Some of these types of studies are included in
the discussion of reading research. The Centers for Disease
Control and Prevention identify these types of research
evidence as the most important in demising their guidelines for
disease and injury prevention and control
Retrospective or concurrent chart Retrospective or concurrent chart reviews, Quality improvement and reviews, Quality improvement and
risk datarisk data Aggregating data across an institution or several institutions
provides an opportunity to assess how well current practices are working
Determining patient outcomes for large groups provides a firm foundation of data that, although not part of a research study, can guide practice
Individual health care institutions and health plans are compiling information for statistical analysis & making decisions about health care based on these statistical measures
International, national, and local International, national, and local standards standards
Bring together the opinions & expertise of many health care providers
The standards are based on the collective experience & goals of individuals who are intimately involved with health care practice
Individuals who have worked with many patients, seen the results of multiple trials, & identified at first hand the complexity of the care have a special insight into effective practice. Because of this involvement & knowledge, the standards provide guidance and support for practice
Infection control dataInfection control data Because infection remains a major complicating factor in
health care, infection control data assume major
importance as guide for practice
The incidence of infection is of critical importance to both
the patient and the entire system in terms of its impact on
overall health outcomes
Practices that decrease the potential for infection have high
priority
Modern understanding of Modern understanding of pathophysiology pathophysiology
Modern understanding of pathophysiology at even
the cellular level has changed thinking about many
health care practices
Information regarding cost-Information regarding cost-effectiveness analysis effectiveness analysis
Helps an institution weigh possible benefits
against costs
It compares how much improvement a certain
practice makes versus how much that practice
costs
Patient preferencesPatient preferences
the importance of self-care in managing health
and illness, practices to which patients will adhere
and ones that make their lives simpler are more
likely to be incorporated
Failure to take into consideration patient
preferences may make the best-designed therapy
ineffective
Opinions of clinical expertsOpinions of clinical experts
Remain an important aspect of evidence.
Individuals who have worked with many patients,
seen the results of multiple trials, and identified at
first hand the complexity of the care have a special
insight into effective practice
Systematic Analysis of Information Systematic Analysis of Information &Evidence&Evidence
Not all published research evidence can be used for making
decisions about patient care
Deficiencies in research design can make an intervention
look better than it really is
The location and subjects of a particular research study may
affect the results in a unique way
Assess the quality, importance and applicability of any
research evidence that is being consulted to answer a specific
clinical question critical appraisalcritical appraisal
Critical AppraisalCritical Appraisal
The purpose of the critical appraisal for evidence-based practice is to decide whether the quality of a research study is good enough for the results it provides to be used to answer a question posed by a health care practitioner or patient
Critical appraisal can be broken down into three distinct but related parts:
Is the quality of the study good enough to
use the results?
Are the findings applicable in my setting?
What do the results mean for my patients?
QuestionQuestion about the effectiveness
of a therapy or intervention
Question about whether a
particular diagnostic test or
method of assessment works
Question about finding out the
likely pattern and/or outcome
of a particular health problem/
disease
DesignComparative / prospective,
ideally randomized, controlled trial.
Cross-sectional/ comparative study
(longitudinal) cohort or case control study
SampleRandom allocation to
intervention or control group. Baseline group comparability
Appropriate spectrum of subjects
Defined, representative sample.
Assembled at a common (usually | early} point
MeasuresIntervention clearly described.
Appropriate outcome measuresNew test compared against a
reference standardAppropriate end points
ResearcherClinician/assessor/ patient
masked (blinded) as to which group the patient has been
allocated to
Clinician/assessor masked (blinded) as to the results of
the reference standard
No dependent relationship between subject &
investigator
Data collection
All entrants adequately accounted for at the end of the
study
All entrants given both new and reference standard test
Follow-up of adequate duration & completeness
Data analysisAnalysis carried out on an
intention to treat basisReliability reported Effect of time confounders
explored
Criteria & questions for use in assessing the quality of research studies
Matching study design to questions
Type of question Example question Research design
The effectiveness of a therapy or intervention
Does a nurse-led discharge package for children admitted
with acute asthma reduce readmission rates?
Comparative/prospective randomized controlled trial
Finding out the likely pattern and/ or outcome of a particular health problem or disease (i.e.
prognosis)
Are women oral contraceptive users who smoke at greater risk of
myocardial infarction (Ml
Cohort study: participants exposed to an agent (contraceptive pill) are followed forward in time to see if
they develop an outcome (Ml)Case-control study: participants
with the condition (Ml) are matched with controls (no Ml),
study looks back in time to identify exposure to an agent
(contraceptive pill)
Whether a particular diagnostic test or method of assessment
works
In primary care, does asking patients about feeling
depressed and loss of interest accurately identify those who
are clinically depressed?
Cross-sectional study where the 'new' test (or method of
assessment) is compared with a reference standard test
Factors to consider when assessing Factors to consider when assessing the quality of a studythe quality of a study
Randomization
The group to which the patient has been allocated must be concealed from the clinician/researcher until the patient has been accepted into the trial
Demographic and health status details for the two groups are of interest
It is helpful if the intervention is described in sufficient detail to allow clinicians to reproduce it in their own setting
Keeping patients, clinicians and researchers blinded as
to whether a patient is in the treatment or control group
is a useful way of minimizing bias
People drop out of studies for all sorts of reasons: death,
relocation to another geographical area, treatment found
to be too unpleasant, etc. It is important that the
researcher tries to identify whether the reasons relate to
the outcomes of interest
Factors to consider when assessing Factors to consider when assessing applicabilityapplicability
The characteristics of the participants in the study
Is it feasible to introduce the intervention or test
described in the study?
When thinking of the costs and benefits of the
intervention or test, think beyond purely financial
terms
Questions for assessing & screening Questions for assessing & screening applicabilityapplicability
Is it clear what the study about?
Is the same sample adequately considered?
Are my patients / context sufficiently different that results will not apply?
Is the action indicated, or the intervention available, or the change possible in my setting?
Do the benefits of any change for my patients / context outweigh the like costs?
Are the patient’s values and preferences satisfied by change? Are my colleagues and mine?
Questions that must be included in Questions that must be included in
deliberations for evaluating informationdeliberations for evaluating information
Is the source identified? Is the source reliable? Is the source biased? How timely is the information relative to the need? How does the information fit with the purpose for
which it will be used? How does the setting that originated the information
compare with your setting?
Evaluation the studies results Evaluation the studies results using the Meta analysis testusing the Meta analysis test
Meta Analysis TestMeta Analysis Test
Like all quantitative studies, systematic reviews often include a statistical analysis
A meta-analysis combines the results of several studies that address a set of related research hypotheses, in an attempt to overcome the problem of reduced statistical power in studies with small sample sizes; analyzing the results from a group of studies can allow more accurate estimation of effects
Meta-analysis is a collection of systematic techniques for resolving apparent contradictions in research findings
Meta-analysis translates results from different studies to a common
Metric and statistically explore relations between study characteristics and findings
Modern meta-analysis does more than just combine the effect sizes of a set of studies. It tests if the studies outcomes show more variation than the variation that is expected because of sampling different research participants
Steps in performing meta-analysis Steps in performing meta-analysis
Meta-analysis should be viewed as an observational study of the evidence. The steps involved are similar to any other research undertaking: Formulation of the problem to be addressed Collection and analysis of the data Reporting of the results
Researchers should write in advance a detailed research protocol that clearly states the objectives, the hypotheses to be tested, the subgroups of interest, and the proposed methods and criteria for identifying and selecting relevant studies and extracting & analyzing information
As with criteria for including and excluding patients in clinical studies, eligibility criteria have to be defined for the data to be included
Criteria relate to the quality of trials and to the combinability of treatments, patients, outcomes, and lengths of follow up
Quality and design features of a study can influence the results. Ideally, researchers should consider including only controlled trials with proper randomization
The strategy for identifying the relevant studies should be
clearly delineated. In particular, it has to be decided
whether the search will be extended to include unpublished
studies, as their results may systematically differ from
published trials
A standardized record form is needed for data collection. It
is useful if two independent observers extract the data, to
avoid errors. At this stage the quality of the studies may be
rated, with one of several specially designed scales
Blinding observers to the names of the authors and their institutions, the names of the journals, sources of funding, and acknowledgments leads to more consistent scores
This entails photocopying papers, removing the title page, and concealing journal identifications and other characteristics with a black marker, or scanning the text of papers into a computer and preparing standardized formats
Levels of evidenceLevels of evidence
1++ High-quality meta-analyses, systematic reviews of randomized controlled trials (RCTs) or RCTs with a very low risk of bias
I+ Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias
1 Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
2++ High-quality systematic reviews of case control or cohort studies. High-quality case control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal
Levels of evidenceLevels of evidence
2+
Well-conducted case control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal
2
Case control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal
3 Non-analytic studies, e.g. case reports, case series
4 Expert opinion
The process of changing practiceThe process of changing practice
Evidence- based guidelinesEvidence- based guidelines
Clinical guidelines are systemically developed statement to assist practitioner decisions about appropriate health care for specific clinical circumstances
Prioritizing topic areas for Prioritizing topic areas for guideline developmentguideline development
Situations where there is evidence of excessive morbidity, disability or mortality
Conditions for which available treatment offers the potential for improvement in any of the above
Those where there is evidence of wide variation in practice
Conditions that are resource intensive either because they are high cost or high volume
Situations involving cross-boundary issues, e.g., interprofessional working or the need for joint working between primary and secondary care
How are guidelines developed?How are guidelines developed? Selection of guideline topic Composition of the guideline development group Defining the scope of the guideline Systematic literature review Formation of recommendations Consultation and peer review Presentation and dissemination Local implementation Audit and review
skills are required in guideline skills are required in guideline development groupdevelopment group
Clinical expertise Other specialist expertise (e.g. Health
economics, research methods) Practical understanding of the problems
faced in the delivery of care Critical appraisal skills
Characteristics of effective Characteristics of effective guidelinesguidelines
Attribute Validity Cost-effectiveness Reproducibility Reliability Representative development Clinical applicability Clinical flexibility Clarity Scheduled review
Benefits of clinical guidelinesBenefits of clinical guidelines Ensure safe practice Improve consistency of care in different parts of the
country/settings patients receive correct treatment Build parity of knowledge amongst staff Bring the expert opinion to everyday clinical care Allow for individual patient variation - non-application is
not disallowed, it simply has to be justified Provide more information for patients about what they
should expect from the health care system Distill the vast array of knowledge relating to individual
clinical conditions into a manageable guide for busy clinicians
disbenefits of clinical guidelinesdisbenefits of clinical guidelines
Stifle individual clinical judgment
De-skill professionals by reducing their capacity to think for themselves
Limit quality of care by restricting care/treatment options
Introduce practice which could be ineffective or dangerous
Encourage the illusion that there is clear-cut direction to be taken in every clinical situation
Be very resource-intensive in relation to their development and implementation
Introducing guidelines into practice Introducing guidelines into practice
Dissemination
Implementation
Diagnosing the challenges to Diagnosing the challenges to changing practice changing practice
Identifying all the groups involved in, affected by, or influencing the proposed change (s) in practice
Assessing the characteristics of the proposed change that might influence its adoption
Assessing the preparedness of the health professionals to change and other potentially relevant internal factors within the target group
Identifying the potential external barriers to change
Identifying the likely enabling factors, including resources and skills
Methods exists for gaining Methods exists for gaining a purchase a purchase
Surveying key groups of stakeholders (such as senior staff, managers, and patient representatives
Adapting ward meetings or clinical supervision sessions so that potential problems can be identified, recorded and fed into the strategic planning process
Establishing a focus group of professionals, managers and, where appropriate, patient representatives, to identify pertinent barriers and drivers
Isolating some of the barriers to research uptake in clinical practice
Common complexities associated with nursing and research use
Professional culture Clinical information Environment Individual decision – maker Knowledge and educational attainment
Valuing research
Valuing change
Forces working for and against an evidence-based Forces working for and against an evidence-based organizational cultureorganizational culture
Planning for and managing Planning for and managing resistance and changeresistance and change
Social marketing modeSocial marketing modeThe model has six stages: Research the group(s) you wish to target and identify the
resources you have available to help you achieve the change
Select the 'raw materials' for the change you want to introduce
Develop and pilot the materials used to facilitate the change
Implement the change Evaluation Feedback
Precede—proceed modePrecede—proceed mode Its name is derived from the fact that it specifies the steps
that should precede any change and the ways in which
organizations should proceed with the change
The first stage of the precede-proceed model is concerned
with specifying the problem to be addressed and isolating
those factors which contribute to the presence of the
problem
This stage recognizes that problems will have
different priorities for different organizational
stakeholders & so it is important to try to reach
some form of consensus regarding the factors
which predispose & contribute to the problem, the
importance of these factors and their susceptibility
to change
Commonly, this takes the form of a ranking or rating approach. Common factors include:
Predisposing: the perceptions, attitudes, motivations
and beliefs of stakeholders involved with the change
Enabling: resources such as skills, knowledge (& funds)
Reinforcing: rewards or incentives - even if only in the
form of positive feedback
Strategic approaches for bridging Strategic approaches for bridging the gap between the research and the gap between the research and
practicepractice
GeneralGeneral
Continuing education
Clinical guidelines
Other broad approaches
Specific interventions classified according to Specific interventions classified according to
the degree of effect on clinical practicethe degree of effect on clinical practice
Educational outreach / detailing
Reminder
Multifaceted interventions
Mixed effectsMixed effects
Audit and feedback
Local opinion leaders
Local consensus approaches
Little or no effectLittle or no effect
Strategies to Overcome ChallengesStrategies to Overcome Challenges
Lack of knowledge or skill Identify resources
Staff development plans
Supervision and mentoring
Collaborative training and technical assistance
Developing shared vision and commitment
Strategies to Overcome ChallengesStrategies to Overcome Challenges Beliefs and Attitudes
Articulate existing beliefs and attitudes Hold frequent meetings to discuss change Utilize motivational strategies to move staff
ambivalence toward positive change Ensure a clear understanding of terms Enlist a neutral facilitator Affect beliefs through information Provide opportunities to speak with people who have
done it Provide incentives and recognition
Strategies to Overcome ChallengesStrategies to Overcome Challenges
Lack of Adequate Resources Resource sharing with other providers
Cross-site training and technical assistance
Community-wide collaboration
Strategies to Overcome ChallengesStrategies to Overcome Challenges
Lack of collaboration Implement a collaborative planning model Use stakeholder teams to make decisions Partner with other agencies implementing the
same intervention Develop a community-wide system of care where
the evidence-based practice is essential to producing desired outcomes