Evidence-based Practice: What’s the Big Deal? Carol Hatler, PhD, RN Director, Nursing Research St. Joseph’s Hospital & Medical Center

Why bother? Healthcare errors represent the 7 th leading cause of death in the U.S. ( K deaths per year) % of patients do not receive care in line with current evidence; 20-25% of care provided is unnecessary or potentially harmful. Example Potential for use of evidence to enhance authority and accountability for practice

Decision Making when information is inadequate Trial and error Reliance on authority(ies) Experience or intuition Evidence

What is Evidence? The word "evidence" relates to what is manifest and apparent and involves -clarity, obviousness, -information (given personally, or drawn from documents etc.) tending to establish fact. Involves actions or information that can be independently observed and verified

Sources of Evidence Intuitive judgment Peer-aided judgment System-aided judgment Case study Clinical practice guidelines Descriptive study # Correlational study Quasi-experimental or experimental study Systematic review/meta-analysis * Ability to control circumstances, replicate methods, predict outcomes

Rosswurm & Larrabee EBP Model Ask an answerable research question Synthesize best evidence Design practice change Implement practice change Evaluate practice change Assess the need & readiness for practice change Design inquiry

EBP is Not-So-Easy Evidence Difficult to obtain, understand Volume of information Sometimes conflicting results Organization Incompatible organizational priorities Lack of structures to facilitate process Communication networks Culture Users Knowledge deficit (problem definition, finding/appraising information) “Language” Time Preference for own paradigm

Capacities for EBP A spirit of inquiry Ability to locate relevant evidence Skill in identifying evidence or strategy that is scientifically sound and feasible Expertise in ways to apply evidence Esp. persuasion, audit/feedback Which of these are nurses taught? Which are expected?

Getting Started What exactly is the problem? PICO What need will a change in practice meet? How important is the topic? How closely does the proposed change fit with the environment? What is the level of evidence that supports the proposed change or problem? Who needs to be involved?

Abstract Example Laferton,J., Mora, M., Auer,C., et al Enhancing the efficacy of heart surgery by optimizing patients' preoperative expectations: Study protocol of a randomized controlled trial. (Am Heart J. 165:1-7.) In coronary heart disease (CHD) and heart surgery, there is sound evidence for the relationship between patients' expectations and treatment outcome, especially for outcome variables such as disability and quality of life. In addition, patients' expectations have been shown to be modifiable through psychological interventions. Therefore, targeting patients' expectations might offer a promising opportunity to enhance heart surgery outcome. However, few studies have tried to actively change patients' expectations before surgery. The purpose of this clinical trial is to optimize patients' outcome expectations before undergoing coronary artery bypass graft surgery (CABG) through a brief psychoeducational program. The present article describes the study protocol and reports preliminary data on feasibility. Using a randomized controlled design, 180 patients who are scheduled to undergo elective CABG are randomly assigned to either (1) standard medical care (SMC) alone, (2) to an additional expectation manipulation intervention during the 2 weeks before surgery, and (3) to an additional attention-control group (“supportive therapy”). The main goal is to test (a) whether expectation manipulation intervention can optimize patients' expectations and (b) whether optimized expectations lead to enhanced surgery efficacy. The primary outcome variable is illness-related disability 6 months after surgery, whereas secondary outcome variables will be quality of life, return to work, physical activity, and medical outcome variables. First, feasibility data of 36 patients show that the patients appreciated the additional psychological intervention before CABG. Satisfaction of those who received psychological interventions was very high.

Examples of Peri-operative Topics Explored by Nurses Safety by Preventing: wrong site/procedure retained surgical items medication errors pressure injuries infection perioperative hypothermia Other Topics Anxiety reduction, esp. mind-body strategies Post-op pain management Managing patient expectations Staff competence ERAS protocol

We have always … I wonder why we … What if...

Small Group Activity Identify 2 practices, ideas, topics Important to patient outcome, nursing practice Identify the “changeability” of your environment Write down 2 things you can/will do to start the exploration

Resources Registered Nurses Association of Ontario: Toolkit and Best Practice Guidelines PubMed for Nurses Tutorial : Cochrane Collaboration – The Joanna Briggs Institute (Library of Systematic Reviews) ‐ U. S. Agency for Healthcare Research and Quality – Health Sciences Librarian