1. Evidence-based Practice What Does it Mean for Nursing?

2. Definition of EBP
What is evidence-based practice?

3. Evidence-based Practice
Process by which clinical decisions are made using:
Best available research evidence
Clinical expertise
Patient preference

4. Three Areas of Research Competence
Interpreting & using research
Evaluating Practice
Conducting Research

5. Evidence Based Practice
To carry out EBP, the following factors must be considered:
Has sufficient research been published on the specific topic ?
Does the nurse have skill in accessing and critically analyzing research?
Does the nurse’s practice allow him/her to implement changes based on EBP?

6. Historical Perspective
Variation in practice leads to:
Variable quality of care
Higher cost of care
Potential for errors that may cause harm

7. Translating research into practice

8. Clinical Decision Making
Drawing conclusions based on EBP, clinical expertise, patient preference, and other factors such as cost-benefit analysis, availability of alternatives, etc.

9. Skills Required for EBP
Clearly identify practice problem or new knowledge ( innovation)
Search/find relevant research literature
Critically evaluate research findings using established criteria regarding scientific merit
Choose interventions/justify selection with the most valid evidence
Apply to practice through change process

10. Research Utilization Transfers research findings to nursing practice
Carried out by individual nurses, groups of nurses working together to solve problems, by interdisciplinary teams, and by institutions and organizations seeking to make system-wide improvements in care outcomes

11. Identifying Practice Problem
Why are we doing this?
Why are we doing it this way?
Can we produce better outcomes with greater consistency?

12. Clinical practice problems in your setting?

13. Critically Evaluating Research
Literature review: scholarly analysis of a body of research about a specific issue
Integrative literature review: integration of a body of research findings (including theory, statistics) which concludes by addressing issues for future research

14. Critically Evaluating Research
Systematic literature review: comprehensive, unbiased analysis of findings which use strict scientific design.
Meta-analysis: merged statistical results from a number of related studies which combines various research studies with the goal of discovering consistencies and differences between studies

15. Strength of the Evidence
Level I – systematic review, met-analysis, well-designed RCTs
Level VII - opinion

16. Resources for Reviews Nursing journals Clinical work station sites
Up-to-date
Zynx
Eskind Digital Library
Cochrane Reviews

17. Clinical Practice Guidelines
Agency for Healthcare Research & Quality (AHRQ)
Early examples
Skin integrity
Acute pain guideline
Urinary incontinence

18. AHRQ Evidence-based Reports
Examples of reports available
Cancer symptom management (2002)
Coronary heart disease in women, systematic review (2003)
Mechanical ventilator criteria for weaning (2000)
Wound healing, laser treatment and vitamin-assisted closure (2004)

19. Evidence-based Nursing Practice
AHRQ clinical nursing practice guidelines
To be released in December
Joanna Briggs Institute (JBI)
JBI Connect
National Guideline Clearinghouse
Guidelines.gov

20. Application to Practice
Does the research apply to my patient population?
Would this practice change improve process of care? Patient outcomes?
Is there support for this practice change?

21. EBP Models CURN project  Research utilization
Review, synthesis, application, evaluation
Stettler Model of Research Utilization
Critical thinking & decision making
Iowa Model of Research in Practice
Quality assurance meets research utilization

22. Planned Change Assess current practice (processes and outcomes)
Identify and implement changes to modify processes
Evaluate effects on processes and/or outcomes

23. Evaluation
Processes of care
Outcomes of care

24. Documentation of Groin Sites
Investigators: Stacy Sherrard, Grace Vincente & Felicia Lowe
1 month trial of education and coaching to improve documentation of groin sites post-catheterization

25. Groin Site Documentation

26. Summary of Purposes Reduce variations in practice
Improve the quality of care provided
Maintain or improve patient outcomes

27. Barriers to use of EBP Accessibility of research findings
Anticipated outcomes of using research
Organizational support/lack of support to use research
Support from others to use research

28. EBP Talking Points
EBP is a way of thinking and practicing that requires discipline and practice to continually asse4ss, “where is the evidence for this?”, and to weight the validity and reliability of daily practice activities.

29. EBP Talking Points
Ongoing skill building is required once a basic understanding is acquired
Nurses and other health professions daily confront questions about assessment, treatment, prevention, and cost-effectiveness of care.

30. EBP Talking Points
The principles of critical appraisal span health professions and disciplines and overlap with epidemiology and science in general
Our patients expect nursing care based on best practice evidence

31. EBP Talking Points
The art of nursing, never to be underestimated, also needs to be studied to validate those contributions to quality care.
In the future, Qualitative research will be included

32. EBP: A Practical Approach
Step 1: formulating a well-built question
Step 2: Identifying articles and other evidence based resources that answer the question
Step 3: Critically appraising the evidence to assess its validity
Step 4: Applying the evidence
Step 5: Re-evaluating the application of evidence and areas for improvement

33. Step 1: Formulating the Question
Clinical cases often present many details in putting the case together
It is important to first decide what details are most important to the question at hand in order to effectively search the literature

34. Step 1: Formulating the Question
Components of a well-built clinical question: PICO acronym:
P=patient/problem(disorder or disease)
I=intervention (or finding under review)
C=comparison intervention (if applicable)
O-outcomes
T=timeline

35. Example of Clinical Question
A 55-year-old patient with a 35 year history of chronic smoking. Would the administration of bupropion as compared to a nicotine replacement therapy (NRT) be a better therapy in causing long-term abstinence from smoking?
Disorder/disease?
Intervention or finding under review?
Comparison intervention?
What is the outcome?

36. PICOT continued Use of PICOT is a state of mind
Applying it systematically helps to identify important concepts in a case
It also helps to formulate a question for searching
Often, you will not have a comparison intervention, so may not use all components in your search at all times
Always start with PICOT, as it helps to think strategically

37. Forming Good Questions
Describe the subject of the questions
Example: “How would I describe a group of patients similar to this one?”
Define the intervention y9ou are thinking about. Possibly think of another intervention to compare it to the first (e.g. a traditional x-ray vs MRI)
Define the outcome you wish to assess. Examples: changes in physical sign, prognostic indicator, outcome of diagnostic test, response to therapy, cost effectiveness

38. Practice Scenario
A 9-year-old patient presents to the ED with diffuse abdominal pain and loss of appetite. The nurse suspects appendicitis and needs to decide which imaging modality is best for making the diagnosis (CT vs ultrasound)
Write your clinical question in PICOT format

39. Example of Good Question
P=child with suspected appendicitis
I=CT
C=ultrasound
O=reliable diagnosis of appendicitis

40. Data Base/Resource Searching
Find the relevant evidence
Major categories of information sources
-General information or background
resources
-Filtered resources
-Unfiltered resources
Many are subscription based

41. Search Decisions
Would background information on topic answer your question? Then use background resources:
-UpToDate, Stat!Ref, or MD Consult
(Examples: differential diagnosis list,
types of therapies, presentation
information)

42. Search Decisions
Are you trying to decide on best course of action for diagnosis or treatment and want recent reliable evidence for decision-making?
Consult filtered resource: Cochroane, National Guideline Clearinghouse, InfoPOEMS, ACP PIER, MD Consult (Fist Consult), National Standard, etc.

43. Search Decisions
Are you unable to find your answer in a filtered resource?
Do you want to check journal literature for original research studies?
Try unfiltered resource such as:
medline/PubMed, PsychINFO, BIOSIS, or CINAHL, OVID MEDLINE

44. Critical Appraisal
Must read articles and look at information critically
In the study from a primary source providing original data with no commentary-should do a validity check. Ask questions r/t diagnosis, therapy, harm and prognosis.

45. Applying the Evidence
Next, decide how the study or other information applies to your question
Consult questions related to diagnosis, therapy, harm, prognosis
May need to confer with others depending on criteria, skill and experience in interpretation

46. Applying the Evidence Appendicitis Example:
Ask from a diagnosis perspective:
1. Is the test affordable and available in
my hospital?
2. What is the estimate or probability of
appendicitis in the patient (pre-test)
3. Will the post test information affect my
management of the patient?

47. Re-evaluating the Evidence
Continuously monitor the decision made for patient care
Ask: was the diagnosis and/or treatment successful?
Is there new information/data in the literature?
How can I improve and/or update my clinical decisions?

48. Resources EBP.www.biomed.lib.umn.edu
Cathy Thompson, University of Colorado, Denver, College of Nursing
Nancy Wells, Vanderbilt Medical Center