Evidence-Based Nursing An Overview What’s It All About? Betty Ackley, RN, MSN, EdS Mosby items and derived items © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.

Objectives Identify the advantages of Evidence-Based Nursing Explain the process of Evidence-Based Nursing

A portion of this presentation is adapted from the following text: Ackley B, Ladwig G, Swan B, Tucker S. (2008). Evidence-Based Nursing Care Guidelines: Medical-Surgical Interventions. Philadelphia: Mosby.

Evidence-based nursing is a systematic process that utilizes current evidence in making decisions about the care of patients, including evaluation of quality and applicability of existing research, patient preferences, costs, clinical expertise, and clinical settings (Fineout-Overholt, 2005). Here is one of the best definitions of evidence-based nursing, or EBN. Notice that EBN is much more than research alone.

How Do You Give the Best Care Possible? What interventions help prevent falls in the elderly? What interventions help prevent or treat stomatitis for the chemotherapy patient? How do you protect hospitalized patients from developing Clostridium difficile infection? Evidence guides nursing care, so that the best care possible can be given.

We answer these questions by referring to texts or expert nurses, and there is only beginning research. The nursing field is currently opinion or expert based. This does not allow nursing to meet the criterion of being a profession. Instead: The nursing field must become research based, building our practice on research and documenting better outcomes as a result. We will then be a profession, not an occupation. We are on the journey toward becoming professionals, as we conduct and disseminate more research on nursing practice.

EBN Critical Thinking Empowerment Excellence Growth EBN is critical thinking. It is empowering for nurses. EBN leads to excellence in nursing care. Using EBN, the nursing profession will continuously grow as an effective profession.

EBN Nursing’s Core Use of EBN needs to become one of the core values of nursing. We are not there yet. It needs to be the foundation on which we build our profession. All nursing students and practicing nurses need to understand the value EBN for it to be effective.

The EBN Nurse is Empowered The EBN nurse knows what needs to be done, how it should be done, and the evidence that supports her or his practice “Armed” with Evidence The EBN Nurse is empowered because she has control of her own practice and has the evidence to give the best care possible. It is as if the nurse develops another arm to use in providing nursing care, the evidence arm.

EBN vs EBP EBP EBN EB Psych EBM Nursing needs to examine nursing practice and develop excellence in nursing practice based on research. Then nursing can join with other professions collaboratively to promote Evidence-Based Practice, or EBP. Our primary focus needs to be nursing. Too many nurses focus on medicine when utilizing evidence-based care. Use of EBN can help increase the “smile” of EBP—notice that EBN is pushing up the EBP smile! EBM

EBP and EBN EBP is using all available information to make the most informed decision. This information can and should come from a variety of sources (that are credible) EBN is providing care using findings from credible research endeavors with the goal of providing quality care that is safe and efficacious

EBN: All Levels of Nursing Education All Nursing Specialties Licensed Practical Nurse Associate Degree Nurse Baccalaureate Nurse Master’s Degree Nurse PhD (conduct research) All nurses in all specialties needs to know about and practice EBN at their level of complexity. EBN must pervade nursing.

Key Components for EBN Describe the problem Identity what is known and what is not known or unclear Search the literature for supporting articles For argumentative articles, too! Confirm validity and reliability of the information Is this information relevant to your setting? Develop new work flows based on the findings Implement the work flows Evaluate the work flows Is it better? How? Is it worse? Why?

EBN vs Research Utilization Complex process Newer concept—developed 10 yrs ago Includes patient preference Includes a system to grade or level the quality of the research Includes evaluation of the evidence based on the clinical setting in which it will be applied Includes an evaluation of cost- effectiveness Includes evaluation of staffing and expertise of staff Less complex process Older concept—used in the 1970s to early 1990s Patient preference not included No defined system to evaluate research; may change practice based on one study Clinical setting is not considered Cost is not addressed Staffing and expertise are not addressed EBN is newer; Research utilization is older. EBN is more relevant in today’s health care environment. Costs are relevant, staffing is relevant, and certainly the patient’s perspective should always be addressed if possible.

Levels of Evidence (Adapted from Melnyk & Fineout-Overholt, 2005) Level I Systematic review or meta-analysis, or evidence-based clinical practice guidelines based on systematic reviews of randomized controlled trials (RCTs) or three or more RCTs of good quality that have similar results Level II Evidence obtained from at least one well-designed RCT Level III Evidence obtained from well-designed controlled trials without randomization Level IV Evidence from well-designed case control or cohort studies Level V Evidence from systematic reviews of descriptive and qualitative studies (meta-synthesis) Level VI Evidence from a single descriptive or qualitative study Level VII Evidence from the opinion of authorities and/or reports of expert committees EBN is using lots of research studies to direct practice. Use of a method to level the evidence allows the quality and quantity of the existing research to be addressed. There are a number of methods for labeling the Level of Evidence. This system was developed by Melnyk and Overholt and is commonly used in nursing.

Steps of Evidence-Based Nursing Ask the burning clinical question. Collect the best evidence available. Critically appraise the evidence. Integrate the available evidence with clinical expertise, client preference, and values in developing a practice decision or change. Measure the “before and after” of outcomes. Evaluate the EBN decision or change. (Adapted from Melnyk & Fineout-Overholt, 2005) Here are the steps of evidence-based nursing practice—a problem-solving process.

ASKMME! ©Copyright, The Betty Ackley LLC ASKMME is an acronym that provides an easily remembered way of learning the process of EBN.

Ask the burning question EBN always begins with THINKING—Why do we do it that way? Should the status quo be questioned? How could we do it better? A new research study shows . . .

Search and collect the most relevant and best evidence available. We’ll talk a lot about searching in the next session.

think As the nurse collects the evidence, it needs to be compiled, evaluated, rated, and leveled to determine the significance of the evidence. This all involves critical thinking.

Measure the outcomes before instituting the change Measure the outcomes before instituting the change. Measure the outcomes after the change. To know whether EBN has made a difference, it is important to measure the “before and after.”

Make it Happen! Rewrite a policy and procedure; write a clinical protocol; change a nursing supply. The EB change needs to be introduced but also reinforced and hardwired it into the system.

Evaluate the practice decision or change. Were there improved outcomes Evaluate the practice decision or change. Were there improved outcomes? Did it save money? Time? Is it realistic in the clinical setting? Evaluate if the EBN change made a difference – is it worth keeping? Should it be changed further? Any newer evidence that is relevant. And of course, evaluation of time spent, money expended, client satisfaction and much more.

Why Do You Do It That Way? The answer used to be: That’s how I was taught in school. That’s what it says in the textbook. That’s the way we’ve always done it here.

Now The Correct Answer Is: Evidence-based nursing shows that . . .

Use EBP and EBN Daily Make a commitment to strengthen the profession Look at the big picture and be a life-long learner Build relationships and partnerships with others Know your champions Be a change agent Challenge assumptions Promote knowledge and research findings Remember the results will be good, bad, or both Start locally-grow globally!

We will show the world that nursing care makes a difference!

References Ackley B, Ladwig G, Swan B, Tucker S. (2008). Evidence-Based Nursing Care Guidelines: Medical-Surgical Interventions. Philadelphia: Mosby. Fineout-Overholt, E & Melnyk, B. (2005). Building a culture of best practice. Nurse Leader 3(6):26-30. Melnyk, B & Fineout-Overholt, E. (2005). Evidence-based Practice in Nursing and Health Care. Philadelphia: Lippincott Williams & Wilkins.