EVIDENCE BASED PRACTICE ATHANASIA KOSTOPOULOU ERASMUS IPs

THE ORIGINS OF EBP Evidence-based medicine (EBM) forms the foundation of the current evidence-based movement (Clarke, 1999;Estabrooks, 1998; Ingersoll, 2000). The term EBM was coined in Canada in the 1980s to describe the clinical learning strategy used at McMaster Medical School (Rosenberg &Donald, 1995). The tenets of EBM represent a profound paradigm shift for both medical education and medical practice because the EBM paradigm is predicated on rules of evidence that lower the value of authority opinion and raise the value of data-based studies and research critiques.

BUT WHAT IS EBP ? ( During the last decade the health personnel recognized the need for evidence-based practice. ) Evidence-based practice defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based nursing means integrating individual clinical expertise with the best available external clinical evidence (Ingersoll 2000).

THE DEFINISION OF EBP Levels of evidence are assigned to studies based on the methodological quality of their design, validity, and applicability to patient care. These decisions gives the "grade (or strength) of recommendation". The definitions of EBP are highly variable and are not straightforward.

1 st categorie-AHCPR 1994 According to the EBP rules, RCTs reside at the top of evidence hierarchies because they represent the strongest form of evidence in support of the effectiveness of interventions (Cullum, 1998a; Gray, 1997; Guyatt et al.,1995; White, 1997) TABLE:Ia Meta-analysis of randomized controlled trials 1994, Ib One randomized controlled trial IIa One well-designed controlled study without randomization IIb One well-designed quasi-experimental study III Well-designed nonexperimental studies IV Expert committee reports expert opinions, consensus statements, expert judgment.

2 nd categorie-Stetler 1998 An important adaptation of the AHCPR evidence schema by Stetler and colleagues (1998b) is highly relevant to nursing. It enlarges admissible evidence to explicitly include qualitative studies as well as quality improvement and program evaluation data. TABLE: I: Meta-analysis of multiple controlled studies II: Individual experimental study II:I Quasi-experimental study IV: Nonexperimental study (e.g., descriptive, qualitative, case study) V: Systematically obtained, verifiable quality improvement program evaluation or case report data VI: Opinions of nationally known authorities based on their experience

SYSTEMATIC REVIEW AND META-ANALYSIS A systematic review is a method of summarizing the findings of all methodologically sound studies addressing the same research question.They allow for a more objective appraisal of the evidence than traditional narrative reviews and may contribute to resolve uncertainty as also demonstrate the lack of adequate evidence in nursing practice and thus identify areas where further studies are needed.

ESPECIALLY: Level I: Evidence from a systematic review of all relevant randomized controlled trials (RCT's), or evidence-based clinical practice guidelines based on systematic reviews of RCT's Level II: Evidence obtained from at least one well-designed Randomized Controlled Trial (RCT) Level III: Evidence obtained from well-designed controlled trials without randomization, quasi-experimental Level IV: Evidence from well-designed case-control and cohort studies Level V: Evidence from systematic reviews of descriptive and qualitative studies Level VI: Evidence from a single descriptive or qualititative study Level VII: Evidence from the opinion of authorities and/or reports of expert committees.

After considering the status of the term ‘evidence’ it is now possible to consider the action element of the symbolism,that is evidence–based practice. According to Stetler-1998

BUT THERE ARE MANY THEORIES FOR THE LEVELS OF EBP!!! FOR EXAMPLE!!! 1 ST: The Grade working Group has developed another system for grading evidence and recommendathion. It is a six level system.The one key difference from the all the other systems is:itincludes guides for working through recommendations to arrive at a grade of methological quality and strength of recommendation. 2 nd: The Canadian Task Force on preventive Health Care developted another system of three levels. The strongest (1) is derived from at least one well-designed randomized controlled trial and the weakest level (3) is derived from opinions of respected authorities and clinical experience. …………………………..

Conclusion: The urgent need for evidence upon which to base practice is a compelling reason for nurses to recognize the significance of EBP. If the evidence-based movement is more than a fleeting fad, then it behooves nurses to consider the conflicting and controversial aspects of EBP as a call to action.!!!! It has argued that equal recognition should be given to the level of evidence, the context into which the evidence is being implemented, and the method of facilitating the change. By explicitly acknowledging equal importance, the framework can begin to explore the actual relations between these three core elements.

The confusion surrounding EBP was captured by Estabrooks(1998) who noted the nursing literature “does not…reflect an understanding that the term embodies more than just good nursing practice” “Evidence-based nursing [is] practice that relies on information generated from results of scientific research.”- Stevens & Paugh,1999.

References -OREGON,health and science university :Levels of evidence -SAINTS MARY UNIVERSITY,qualitative and quantitative research, e.php -canadian searching association,making best practice guidelines a reality, -WIKIPEDIA,Evidence based medicine, Clinical scholarship. Journal of nursing scholarship, 2001; 33:2, ©2001 sigma theta tau international. Quality in Health Care 1998;7:149–158. Library of Hospital AXEPA