Application of Research into Practice: Using Evidence-Based Practice T. Heather Herdman, RN; PhD Executive Vice President Matousek & Associates, Inc.

Research in Practice Evidence-based practice A problem solving approach to practice that involves the conscientious use of current best evidence in making decisions about patient care

Problem-Solving Approach Incorporates: Systematic search for and critical appraisal of the most relevant evidence to answer a burning clinical question One’s own clinical expertise Patient preferences and values

Why Evidence-Based Practice? If your child was born prematurely, would you want her healthcare providers to give you information about how other parents have coped with parenting a preterm infant, based on evidence from well-designed qualitative and/or descriptive studies? If your mother was diagnosed with breast cancer and needed to decide what type of treatment to choose, would you want to know the evidence regarding the risks and benefits of each treatment option as determined from clinical trials with other similar cancer patients? If you were in a car crash and were paralyzed, would you want to know and use the most effective, empirically supported treatment established through randomized controlled trials to increase your chances of regaining mobility and sensation?

Clinical Decision Making Health care professionals face complex decisions daily regarding patient care—and must do so with decreased resources (less staff—less money for equipment and supplies—less TIME!!!) What is an appropriate outcome for this patient? What intervention is most effective for getting this patient to meet that outcome? What is the most efficient method for providing appropriate care for this patient?

Research – Practice Gap Evidence indicates that patients receiving care based on most up-to- date information from research studies experience 28% better outcomes than those patients receiving non-research based care Only a small percentage of healthcare providers incorporate research findings into patient care »Melnyk & Fineout-Overholt (2005)

Research – Practice Gap It can take as long as 17 years to translate research findings into practice How many lives are lost? How many unnecessary hospitalizations? How many ineffective treatments? How much unnecessary cost? How much time wasted out of your work day?

Patient Satisfaction There is some evidence to indicate that healthcare providers using evidence-based practice receive higher patient satisfaction scores that those who do not Provides more ability for nurses to control their own practice Increases nurse morale Decreases nurse turnover

Key Steps of Evidence-Based Practice Ask the burning question (PICO format whenever possible) Patient population of interest Intervention of interest/Interest area Comparison of interest Outcome of interest Collect the most relevant and best evidence to answer the clinical question

Key Steps of Evidence-Based Practice Critically appraise the evidence for its validity, relevance and applicability Integrate the evidence with one’s own clinical expertise, assessment of patient condition & available healthcare resources, along with patient preferences and values to implement a clinical decision Evaluate the change resulting from implementing evidence into practice

Barriers to Evidence-Based Practice “I’m a practitioner not a researcher!” Lack of knowledge regarding EBP strategies Misperceptions/negative views about research Lack of time and resources to look for, read, critique and implement research Peer pressure—”We’ve always done it this way” Too much information to process Lack of belief that EBP can improve outcomes of care

Facilitators of Evidence-Based Practice Support/encouragement from administration Time to critically appraise studies and implement their findings Clearly written research reports Implementation infrastructure Shared vision/mission within the healthcare team Credibility of the research/guidelines

Questioning Clinical Practice Encourage clinicians to ask questions about their clinical practice (rather than penalize them for being “difficult”!!!) Does sucrose decrease pain in neonates? Does nonnutritive sucking decrease pain in neonates? Does kangaroo care decrease pain in neonates? Which of these treatments is most effective? Is one more effective than the others? What does a cost-benefit analysis show when comparing one treatment to the other? Can we make a good clinical case for one treatment over the other?

Questioning Clinical Practice Encourage a reflective, inquiring approach in all professional and assistive staff “Asking the right questions takes as much skill as giving the right answers!” Robert Half

Questioning Clinical Practice Use staff meetings more effectively to discuss key areas of clinical practice How do patients respond to interventions being used? Are there alternative treatments you can think of that might have a better impact? Are there things that you find really dissatisfying about your practice? What things cause patients the most dissatisfaction?

Questioning Clinical Practice Identify staff that are responsible for scanning research literature on certain topics and bringing in new articles for clinical practice review Consider research taking place in other clinical practice settings Look to the Centers for Evidence-Based Practice that exist around the world Germany, New Zealand, Australia, United Kingdom, United States, Canada

Adopting Practice Change Critique and synthesize research studies and evidence-based clinical practice guidelines Team up with academicians Find win-win situations for practice settings and university settings Decide whether or not findings should be implemented into practice in your setting, given your organization’s resources and patient population

Adopting Practice Change Consider: How relevant is the research to practice? Are the findings consistent across studies? Are there adequate studies and/or sample sizes to make the findings meaningful? Is this change practical for your setting? What is the risk of harm for the patients and how does that compare to the potential benefit for them?

Developing EBP Protocols or Guidelines Protocols or Guidelines provide: Comfort for practitioners that the practice changes are based on evidence versus opinion or cost factors The level of evidence available on the topic Guidance on how to implement the practice change, and what parts of that change are based on what level of evidence

Implementing Practice Change Diffusion of an innovation Nature of the innovation Manner in which it is communicated to healthcare providers Barriers include: Conflicting research results Research reports that are hard to understand Lack of compilation of research evidence Lack of providers knowledgeable about research

Changing Clinical Practice Results of 44 systematic reviews focused on the effectiveness of strategies to change practice of healthcare professionals Passive dissemination of research is ineffective Range of interventions found effective in changing behaviors Multifaceted interventions more likely to be effective than single intervention Individual provider beliefs, attitudes & knowledge impact behaviors but organizational, economic and community environments are also important Diagnostic analysis should be done to identify barriers and supportive factors likely to influence proposed changes in practice Successful strategies to change practice need to be adequately resourced and require people with appropriate knowledge and skills

Strategies for Changing Clinical Practice One-on-one sessions with health care educators and staff to explain desired change Manual & computerized reminders to prompt behavior change Educational meetings or in-services requiring active participation of learners Computerized information sources that are interactive in nature Audits & feedback in which clinical performance is monitored through electronic database or chart review Direct observation and feedback

Conclusions EBP is critical if we are to provide the best care at the right time and at the lowest cost Efficiency Effectiveness Best outcome