INTRODUCTION TO EVIDENCE BASED NURSING Assoc Prof Majda Pajnkihar, PhD

Winter School 2015  Introduction Every day nurses perform interventions e.g. administering medication, educating clients, provide therapeutic interventions etc; This should stimulate questions about the evidence supporting their use of various interventions.

What do we base our decision on? Winter School 2015  What do we base our decision on?

How nurses base their nursing care? Winter School 2015  How nurses base their nursing care? Pravikoff et al., 2005 surveyed 760 USA registered nurses working in clinical practice and found that: 67% get information for practice from other nurses, 58% do not use research reports to support their practice, 82% never used a hospital library, 54% were not familiar with term Evidence Based Practice, 67% never searched CINAHL Database, 72% hadn’t evaluated research reports.

Evidence Based Practice Winter School 2015  Evidence Based Practice „Integration of best research evidence with clinical expertise and patient values“ (Dave Sackett, 1996) “Doing the right thing in the right way for the right patient at the right time.” (Royal College of Nursing 1996, p. 3)

Evidence Based Practice Winter School 2015  Evidence Based Practice Evidence Based Practice EVIDENCE BASED HEALTHCARE EVIDENCE BASED MEDICINE EVIDENCE BASED NURSING

Evidence Based Nursing Winter School 2015  Evidence Based Nursing Context BEST RESERCH EVIDENCE CLINICAL EXPERIENCE/ EXPERTISE EBN PATIENT VALUES

What do you understand by the word ‘evidence’? Winter School 2015  What do you understand by the word ‘evidence’?

Winter School 2015  Evidence Evidence is a collection of facts that are belived to be true (Melnyk, & Fineout-Overholt, 2011). Current best evidence from clinical research: implies hierarchy of evidence.

Hierarchy of Evidence Winter School 2015 Level 1 Systematic review of RCTs Systematic review of nonrandomized trials Level 2 Single RCT Single nonrandomized trial Level 3 Systematic review of correlational / observational studies Level 4 Single correlational / observational study Level 5 Systematic review of descriptive / qualitative / psychologic studies Level 6 Single descriptive / qualitative / psychologic studies Level 7 Opinions of authoities, expert committees

Winter School 2015  Hierarchy of Evidence Is this hierarchy of evidence suitable for grading the evidence for a question: What is the perception of pain in patients with multiple sclerosis? Clinical question determines the type of research required for searching. We cannot reserach experiencing pain in patients with RCT. http://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=oxford

Randomized controlled trial Winter School 2015  Randomized controlled trial selection performance outcome exclusion detection intervention Patients control outcome An experimental comparison study in which participants are allocated to treatment/intervention or control/placebo groups using a random mechanism. Best for study the effect of an intervention.

Archie Cochrane – supporter of RCT Winter School 2015  Archie Cochrane – supporter of RCT „I had considerable freedom of clinical choice of therapy: my trouble was that I did not know which to use and when. I would gladly have sacrificed my freedom for a little knowledge. I had never heard then of 'randomised controlled trials', but I knew there was no real evidence that anything we had to offer had any effect on tuberculosis, and I was afraid that I shortened the lives of some of my friends by unnecessary intervention."

Systematic review Winter School 2015 Sum up ov the best available research on a specific question; using transparent procedures to find, evaluate and synthesize of relevant research.

Winter School 2015 

Winter School 2015  Why EBN? Patients experience 28% better outcomes if they receive care based on the best and latest evidence from well-designed studies compared to traditional practice (Heater et al. 1988). Without current best evidence practice is rapidly outdated often can be the detriment of patients (Melnyk & Fineout-Overholt, 2005)

Why is EBN important? Main aim is to improve client outcomes; Winter School 2015  Why is EBN important? Main aim is to improve client outcomes; Ensure clinically effective health care; Improve people’s experience of illness & health care; Clients expect it; Improves clinician’s knowledge; Communicates a profession’s research base; Stimulates clinically relevant research; Accountability.

Winter School 2015  Why is EBN important? Failing to use available science is costly and harmful. It leads to overuse of unhelpful care, underuse of effective care and errors in execution

Overarcing Goal Safe, Effective Nursing Care. Winter School 2015  Overarcing Goal Safe, Effective Nursing Care. Our nursing care is only safer if we put into practice what we learn from research.

Winter School 2015  Why EBP matter to you? Higher level of satisfaction among healthcare providers who use evidence-based approach in delivering patient care than those who deliver care steeped in tradition (Dawes 1996).

Show me the Evidence I wonder… Winter School 2015  I wonder… Having two nurses check medication orders prior to dispensing medication reduces the incidence of medication errors. Is that really the case? Show me the Evidence

Show me the Evidence I wonder… Winter School 2015  I wonder… A Group therapy programme is more effective than a self help programme in promoting smoking cessation. How so? Show me the Evidence

GOSH, should we do someting about this? Winter School 2015  I wonder… Special toileting needs such as incontinence, urgency or diarrhoea is a factor that increases the likelihood of a patient falling in hospital. GOSH, should we do someting about this? Show me the Evidence

Winter School 2015  Keeping up to date Nurses need to keep up to date and offer best practice from the best evidence. EBN processes focus on incorporating good information seeking habits into daily routine (Melnyk & Fineout-Overholt, 2005).

EBN process Winter School 2015 (Polit, & Beck, 2012) Asking the right question - ASK Search for the best evidence - ACQUIRE Critically appraise evidence - APPRAISE Integrate the evidence - APPLY Evaluate the outcomes - ASSESS (Polit, & Beck, 2012)

Asking the right question Winter School 2015  Asking the right question P Population, problem I Intervention or issue (C) Comparison O Outcome (T) Time In patients living in a long-term care facility who are at risk for pressure ulcers (P), how does a pressure ulcer programme (I) compared to the standard of care (e.g. turning every 2 hours) (C) affect signs of emerging pressure ulcers (O)?

Asking the right question Winter School 2015  Asking the right question

Search for the best evidence Winter School 2015  Search for the best evidence Systems Summaries Synopses Syntheses Studies Systems for Clinical Decision Support S-model Evidence Based textbooks Clinical Evidence, UpToDate (Haynes, 2006) Other reviews in DARE-database (Cochrane Library) Evidence Based Journals Evidence Based journal abstracts Cochrane Reviews (Cochrane Library), Clinical Queries (Ovid, Pubmed), Systematic reviews CENTRAL (Cochrane Library) Clinical Queries (Ovid, Pubmed) Original journal articles

Winter School 2015  Cochrane Library

Critically appraise evidence Winter School 2015  Critically appraise evidence Are the results valid (validity)? What are the results (reliability)? Can I apply the results in practice (applicaiblity)?

Critically appraise evidence Winter School 2015  Critically appraise evidence Using different critical appraisal questions, checklist and tools: CASP ...

Integrate the evidence Winter School 2015  Integrate the evidence Research evidence alone is not sufficient to justify a change in practice. Implementation of EBN is highly influenced by institutional and clinical variables.

Winter School 2015  Evaluate the evidence After implementing EBN, it’s important to monitor and evaluate any changes in outcomes so that positive effects can be supported and negative ones remedied.

Evidence lost in translation Winter School 2015  Evidence lost in translation Studies on evidence based recommendations in practice: 30-50% is not used. Studies on compliance: 30-50% of patients do not adhere well. For some clinical care and public health recommendations 50-75% of patients may not profit (enough) from evidence. Many best practices in quality and safety are not adopted widely in health care (Flottorp, 2015).

Barriers of EBN Winter School 2015 (Melnyk & Fineout-Overholt, 2011) Lack of EBN knowledge and skills. Lack of belief that EBN will result in more positive outcomes than traditional care. Lack of time and resources to research for and appraise evidence. Lack of EBN mentors. Resistance to change. Volumnous amounts of information in professional journals. (Melnyk & Fineout-Overholt, 2011)

Barriers of EBN Winter School 2015 (Melnyk & Fineout-Overholt, 2011) Mispertceptions or negative attitudes about research and evidence based care. Overwhelming patient loads. Organizational contraints. Demands from patients for a certain type of treatment. Peer pressure to continue with practices that are seeped in tradition. ???? (Melnyk & Fineout-Overholt, 2011)

Knowledge: the enemy of disease Winter School 2015  Knowledge: the enemy of disease „The application of what we know already will have a bigger impact on health and disease than any drug or technology likely to be introduced in the next decade.“ Sir Muir Gray Director UK NHS National Knowledge Service & NHS Chief Knowledge Officer

Viva La Evidence Never stop questioning! (Susan L. Hendrix) Winter School 2015  Viva La Evidence Never stop questioning! (Susan L. Hendrix) https://www.youtube.com/watch?v=QUW0Q8tXVUc

Go find the evidence.