INTRODUCTION TO EVIDENCE-BASED PRACTICE IN A MAGNETIC WORLD

Sheila Snow-Croft

Outreach Education Coordinator

NN/LM SE/A

OBJECTIVES

By the end of this class, attendees will be able to:

define the levels of evidence, formulate literature searches to find such

evidence, use acquired skills to critique search results, and articulate the library’s role in the Magnet

Recognition Program.

AGENDA

Introduction Theory of Evidence Based Practice (EBP) Critical Appraisal

Null Hypothesis and P Value Critical Appraisal Tools

Literature Searching Magnet Recognition: Partnership between

Libraries and Nurses Standards you can impact Discussion Practice Exercise

THEORY OF EBP

DEFINITIONS

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

The integration of the best research evidence with clinical expertise and patient values.

Sackett, Straus, Richardson, Rosenberg & Haynes, 2000

Evidence-based medicine: how to practice and teach EBM

2d ed. London, UK: Churchill Livingstone

TERMINOLOGY

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.

RESEARCH UTILIZATION

Traditional nursing practiceUsing research to support data

collection, interventions, and evaluation in patient care

Sometimes involves choosing studies to support current practice

EVIDENCE-BASED NURSING

Analyzes ALL research dataCompliments local experts’

experienceEmphasizes skills to make

independent assessmentsUses active learning model

WHY PRACTICE EBN?

Standard of Care: EBNER recommendations

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

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

MISCONCEPTION

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

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Salmond S.

Advancing Evidence-Based Practice: A Primer

Orthopaedic NursingMarch/April 2007  Volume 26 Number 2 Pages 114 - 123

EBN STEPS:

Problem IdentificationDiscoveryCritiqueSummaryTranslationEvaluation

STEP 1:

Problem Identification: Converting information needs into an answerable questionPICO

Patient or ProblemInterventionComparison InterventionOutcomes

STEP 2:

Discovery: Finding, with maximum efficiency, the best evidence with which to answer the question

STEP 3:

Critique: Determining the merit, feasibility and utility of evidence.The process of systematically examining

research evidence to assess its validity, results, and relevance before using it to inform a decision.

(http://www.evidence-based-medicine.co.uk)

STEP 4:

Summary: Combining findings from all evidence to make a practice recommendation

STEP 5:

Translation: Placing evidence into context, incorporating recommendation into a clinical setting or organization

STEP 6:

Evaluation: Determining and measuring the effectiveness of the practice change over time

CRITICAL APPRAISAL

CRITICAL APPRAISAL TERMINOLOGY

Null Hypothesis

P-value

Confidence intervals

Relative vs Absolute Risk Reduction

NULL HYPOTHESIS

States that there is no relationship between the variables being studied.

Opposite of what you are trying to find out.

Tylenol is better than Advil for headaches

Exercising 30 minutes a day is good for your health

Lefthanders are prone to accidents

P-VALUE

Probability that the outcomes are due to chance

Accepted reference point is .05

Less than .05 is statistically significant

Small p-value dismiss chance

Large p-value means that anything is possible (chance, actual effect, or confounding factors)

CONFIDENCE INTERVALS

The ranges of values within which a researcher can be confident that the population value falls.

A 95% confidence interval (CI 95) means that one can be 95% confident that the population value falls within a certain range

Example: A study states that 40% of a sample of 1000 people are smokers with a CI of 95% +/- 3% means the frequency of smoking is between 37% and 43%.

RISK

RR (Relative Risk) is the risk for achieving an outcome in the treatment group relative to that in the control group

RRR (Relative Risk Reduction) is the increase in outcome with the treatment compared to the control (often expressed as a percentage)

ARR (Absolute Risk Reduction) is the difference in outcome rates for two groups, usually treatment and control

RELATIVE RISK REDUCTION

Not a good way to compare outcomes Amplifies small differences and makes

insignificant findings appear significant Does not reflect the baseline risk of the

outcome event Can make weak results look good Making weak results look good makes them

popular, thus they are reported in many journal articles

RRR can mislead – DO NOT USE

ABSOLUTE RISK REDUCTION

A better statistic to evaluate outcome Does not amplify small differences, but

shows the true difference between the experimental and control interventions

CRITICAL APPRAISAL QUESTIONS

Are the results of the study valid?

What were the results?

Will the results help me in caring for my patients?

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WHAT IS EVIDENCE? Primary Studies:

Clinical Trials Randomized Controlled Trials Multicenter studies

Secondary Studies Reviews Meta-analyses

LEVELS OF EVIDENCE

ESTABLISHING VALIDITY What are the results of the study?

Are the results valid?

How do the results affect the patient?

LITERATURE SEARCHING

RESOURCESPUBMED/MEDLINE

Citations and Abstracts Includes over 4600 journals worldwide More than 17 million citations Approximately 1/3 full text articles available Uses MeSH controlled vocabulary Updated daily Available anywhere, anytime Searching help available Must do one’s own quality filtering Must learn how to search the database

RESOURCESCINAHL

Dates back to 1981 Contains more than a million records Indexes almost 3,000 journals Searchable cited references for more than

1,200 journals Full text for 71 journals Covers nursing, biomedicine, health science

librarianship, alternative/complementary medicine, consumer health and 17 allied health disciplines

Now features Clinical Query Functionality

RESOURCESTHE COCHRANE LIBRARY

To scan many types of information pre-filtered for quality

Includes the Cochrane Database of Systematice Reviews (Cochrane Reviews), Database of Abstracts of Reviews of Effectiveness (DARE), Cochrane Controlled Trials Register (Clinical Trials) and others Systematic reviews aggregate randomized

controlled trials Review process is labor intensive, so not all

topics are covered Small database

RESOURCESCRITICAL APPRAISAL

Critical reviews of published studiesACP Journal ClubInfoPOEMSClinical Inquiries

High quality evidence with commentaryHigh specificityAbstracts accompanied by commentaryIncomplete coverage of literatureSmall databases

RESOURCESPOINT OF CARE WITH EVIDENCE

Quick answers to clinical questions with evidence based analysis embedded in resourceACP PierFIRSTConsultNatural Medicines Comprehensive

DatabaseUpToDate

Grades rate quality of evidenceGrades different for each sourceRating criteria sometimes difficult to locate

INFORMATION AGGREGATOR RESOURCES

To scan many types of information pre-filtered for qualityThe Cochrane LibraryIncludes the Cochrane Database of

Systematic Reviews (Cochrane Reviews), Database of Abstracts of Reviews of Effectiveness (DARE) ,Cochrane Controlled Trials Register (Clinical Trials) and othersSystematic reviews aggregate randomized

controlled trialsReview process is labor intensive, so not all

topics are coveredSmall database

OTHER RESOURCES THAT SUPPORT EBP

Clinical Practice Guidelines National Guideline Clearinghouse

http://www.guidelines.gov Health Services/Technology Assessment Text (HSTAT)

http://text.nlm.nih.gov

Specialized Journals ACP Journal Club Evidence Based Medicine Evidence Based Nursing

FOR MORE INFORMATION Centre for Evidence-Based Medicine

http://cebm.jr2.ox.ac.uk/ Health Information Research Unit Evidence-Based

Health Informatics http://hiru.mcmaster.ca/

MAGNET RECOGNITIONPartnerships between Libraries and Nurses

MAGNET RECOGNITION: LIBRARIAN AND NURSE PARTNERSHIP

What is the Magnet Recognition Program

Standards you can impact

Discussion Practice Exercise

WHAT IS THE MAGNET RECOGNITION PROGRAM?

The Magnet Recognition Program® was developed by the American Nurses Credentialing Center (ANCC) to recognize health care organizations that provide nursing excellence.

WHY IS IT IMPORTANT?

Nursing Recruitment and Retention

Better patient outcomes

Cost of Magnet Recognition Program is about 51 thousand dollars

Cost to recruit one registered nurse can be up to 60 thousand dollars

MAGNET HOSPITALS

2003 – 97 magnet hospitals

2006 – 231 magnet hospitals

2007 – 281 magnet hospitals

FORCES OF MAGNETISM

1. Quality of nursing leadership2. Organization structure3. Management style4. Personnel policies and progress5. Professional models of care6. Quality of care7. Quality improvement8. Consultation and resources9. Autonomy10. Community and the hospital11. Nurses as teachers12. Images of nursing13. Interdisciplinary relationships and 14. Professional development

HIGHLIGHTED FORCES PART 1 (5) Professional models of care – Give nurses the

responsibility and authority for the provision of direct patient care. Nurses are accountable for their own practices, as well as for the coordination of care.

(7) Quality Improvement – Educational process: staff nurses participate in the process and view it as one that improves the quality of care delivered.

(8) Consultation and resources – Adequate consultation and human resources are available. Knowledgeable experts, including APNs, are available and used. Peer support is given within and outside the nursing division.

HIGHLIGHTED FORCES PART 2 (9) Authority – Nurses are permitted and

expected to practice autonomously, consistent with professional standards; independent judgment is exercised within the context of multidisciplinary approach to patient care.

(10) Community and the hospital – Community presence established through ongoing, long-term outreach programs resulting in the hospital being perceived as a strong, positive, and productive corporate citizen.

(13) Interdisciplinary relationships – A sense of mutual respect among all disciplines results in positive interdisciplinary relationships.

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.

EBP STANDARDS YOU CAN IMPACT

Standard 4.4 – Integrate and implement evidence-based practice findings into organizational processes across the continuum of care.

Standard 9.2 – Participate in educational opportunities that address current evidence-based care strategies, technological advances, and other skills so that knowledge, skills, and abilities promote quality in the delivery of services to clients.

Standard 13.3 – Use research findings in clinical practice.

Standard 13.6 – Promote research so that the nursing practice is evidence-based and knowledge depended.

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MAGNET SURVEYGOALS

Assess library resources & services at ANCC certified Magnet facilities

Enhance Magnet coordinator's awareness of skills & services librarians can contribute to the process

Sherwill-Navarro / Allen

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THE PROCESS Development – NAHRS Task Force

Followed section programs Evidence to the Point of Care & Magnet accreditation

Approval – MLA Board, May 2007 Distribution – Magnet Coordinator’s list

Instructions: librarian input Follow up – DOCUSER database contacts

Sherwill-Navarro / Allen

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MLA

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RESPONSES

251 ANCC Magnet certified facilities

191 unique responses 70 completed by Magnet

coordinators 144 completed by

librarians 2 completed by Magnet

coordinator with librarian 19 by Magnet

coordinator & librarian

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SELECT QUESTIONS Internet access

92.7% (178) access on floors & in library

2.1% (4) access only in library5.2% (10) other

Library access98.3% (180) Within institution complex4.7% (9) Yes, but not within complex1.6% (3) Only virtual access

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LIBRARY SERVICES

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Searches ILL Articlecopying

Classes Studentnurse

services

Staff asstudents

Others

No

Provided

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BIBLIOGRAPHIC DATABASES

0% 20% 40% 60% 80% 100%

Web of Science

PsycINFO

Mosby's Nursing Index/EMCARE

Vendor MEDLINE

PubMed

MEDLINE

CINAHL Plus

CINAHL

Cambridge Scientific Abstracts

Available Not available

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POINT OF CARE/EBP RESOURCES(SOME WITH ONLINE BOOKS)

0% 20% 40% 60% 80% 100%

Others, includingdatabases not on list

Up-to-date

Mosby's NursingConsult

MD Consult

Info Poems orInfotriever

DynaMed

Cochrane Library ofSystematic Reviews

AvailableNot available

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PARTNERSHIPS BETWEEN LIBRARIES AND NURSES

Get Involved!