1. 1 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 15 Evidence-Based Practice

2. 2 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Objectives 1. Define evidence-based practice (EBP). 2. Understand the history of EBP in health care. 3. Analyze the relationship between EBP and the practice of nursing in the community. 4. Provide examples of EBP in the community. 5. Identify barriers to EBP. 6. Apply evidence-based resources in practice.

3. 3 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Introduction  EBP is an approach to providing the highest quality of health care in all settings to improve health outcomes  The Institute of Medicine has set a goal that by 2020, the best available evidence will be used to make 90% of all health care decisions, yet most nurses continue to be inconsistent in implementing EBP.

4. 4 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Definitions of EBP  Evidence-based practice (EBP)  Evidence-based public health  Evidence-based nursing  External evidence  Internal evidence

5. 5 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. History of EBP  In mid-1970s, growing consensus among nursing leaders that scientific knowledge should be used as a basis for nursing practice  Research utilization  Three projects funded by Division of Nursing  1992 Journal of American Medical Association  Article expanded concept of evidence-based medicine  Called for paradigm shift  Acknowledged clinical experience as crucial but not sufficient part of clinical decision making

6. 6 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Types of Evidence  Double-blind randomized controlled trial (RCT)  Non-randomized clinical trials  Quasi-experimental studies  Case-controlled reports  Qualitative studies  Expert opinion  Non-research–based published articles  Professional guidelines  National guidelines  Organizational opinions  Panels of experts  Nurse’s clinical expertise

7. 7 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Factors Leading to Change or Barriers to EBP  Knowledge of research and current evidence  Ability to interpret the meaning of the evidence  Individual professional’s characteristics  Time needed to implement EBP and to engage in education and directed practice  Hierarchy of the practice environment, level of support of managers, and ability to engage in autonomous practice

8. 8 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Factors Leading to Change or Barriers to EBP, Cont’d  Philosophy of the practice environment and the willingness to embrace EBP  Resources available to engage in EBP  Practice characteristics  Links to outside supports, such as teaching facilities  Political constraints and the lack of relevant and timely public health practice research

9. 9 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Steps in the EBP Process  Cultivating a spirit of inquiry  Asking clinical questions  Searching for the best evidence  Critically appraising the evidence  Integrating the evidence with clinical expertise, client preferences, and values  Evaluating the outcomes of the practice decisions or changes based on evidence  Disseminating EBP results

10. 10 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Approaches to Finding Evidence  Systematic review  Meta-analysis  Integrative review  Narrative review

11. 11 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Approaches to Evaluating Evidence  Grading the strength of evidence  Quality Sample selection, randomization, blinding, sample size, description of intervention, outcomes, length of followup, attrition, confounding variables, statistical analysis  Quantity  Consistency

12. 12 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Approaches to Implementing EBP  First step is recognizing the current status of one’s own practice  EBP is new concept for many practicing nurses  Will only be successful when practicing in an environment that supports evidence-based care

13. 13 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Current Perspectives  Cost versus quality  Individual differences  Appropriate EBP methods for population- centered nursing practice

14. 14 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Healthy People 2020  Objectives offer a systematic approach to health improvement.  Several objectives are devoted to improving clients’ understanding of EBP and how they can contribute to health care decisions.

15. 15 Copyright © 2012 by Mosby, an imprint of Elsevier Inc. Copyright © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Examples  The Intervention Wheel  Originally developed using a qualitative, grounded theory process but did not include a systematic review of evidence to support the interventions or their application to practice Systematic review done later to examine the evidence underlying the interventions and levels of practice  The 17 interventions grew out of an extensive analysis of the actual work of 200 practicing public health nurses in a variety of work settings.