1. 1 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Chapter 13 Building an Evidence-Based Nursing Practice

2. 2 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Evidence-Based Practice  Conscientious integration of best research evidence with clinical expertise and patient values and needs in delivery of quality cost- effective health care  Has a broader focus than research use  Goal is implementation of quality cost- effective care to promote positive outcomes

3. 3 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Barriers to EBP  Practical  Conceptual  May create a “cookbook” approach to care

4. 4 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Benefits to EBP  Improved patient outcomes for patients, providers, and agencies  Leads to best treatment (Gold Standard) plan  An integral part of the Magnet Status process

5. 5 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Evidence-Based Sources  Systematic reviews  Meta-analyses  Integrative reviews  Metasummaries  Metasyntheses

6. 6 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Developing Evidence-Based Practice for Nursing  Findings from a study are different from research evidence.  Research evidence is a synthesis of quality, relevant studies to form a body of empirical knowledge for selected area of practice.

7. 7 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Synthesis of Research Findings  Knowledge comes from quantitative, qualitative, and outcomes research.  Content clustering: integration of findings from scientifically sound research to determine what is currently known or not known  Accomplished through: Integrative reviews Systematic reviews Meta-analyses, metasummaries, metasyntheses

8. 8 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Integrative Reviews  Identifies, analyzes, and synthesizes results from independent quantitative and qualitative studies to determine current knowledge  Includes multiple types of research designs and literature types  A complicated review, but gives breadth and depth to conclusions  Annual Review of Nursing Research publishes integrative reviews.

9. 9 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Qualitative Research Contributions to Integrative Reviews  Identifies and refines questions and outcomes  Identifies types of participants and interventions  Augments and provides data for research synthesis  Highlights inadequacies in methods  Explains findings and interpretation of findings  Helps make recommendations

10. 10 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Systematic Reviews of Research  A narrowly focused synthesis of research findings from quantitative studies  Looks at studies of similar methodology  Has same standards of clarity, rigor, and replication as primary research studies

11. 11 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Steps in Systematic Reviews  Formulate purpose and identify scope.  Develop specific questions or hypotheses.  Establish criteria for inclusion/exclusion of studies.  Conduct extensive literature search of all sources. (Melnyk & Fineout-Overholt, 2005; Whittemore, 2005)

12. 12 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Steps in Systematic Reviews (cont’d)  Develop questionnaire and contact authors to gather data.  Critique studies for scientific merit and data analysis.  Analyze and interpret data.  Report the review. (Melnyk & Fineout-Overholt, 2005; Whittemore, 2005)

13. 13 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Meta-analyses of the Research Literature  Statistically pools results from previous studies into single quantitative analysis  Allows for application of scientific criteria  For example, sample size, level of significance, variables

14. 14 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Results of Meta-analysis  A large, diverse sample that is more representative of target population  Determination of overall significance of probability of pooled data  Indication of the efficacy of the intervention from the average effect size determined from several quality studies  Strength of relationship between variables

15. 15 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Metasummaries in Qualitative Research  Definition: a synthesis of multiple primary qualitative studies to produce a narrative about a selected phenomenon  Expands our knowledge base

16. 16 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Metasynthesis of Qualitative Research  Synthesizes qualitative research with a critical analysis of primary studies and synthesis of findings into a new theory

17. 17 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Best Evidence for Use in Practice  The strength of the evidence is on a continuum from high-quality results to lower- quality results.  Evidence-based guidelines are essential in developing evidence-based practice for nursing.

18. 18 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Continuum of Strength of Research Evidence

19. 19 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Strength of Evidence  Strongest evidence 1. Meta-analysis 2. Integrative reviews 3. Experimental studies  Weakest evidence 1. Descriptive surveys 2. Qualitative studies 3. Correlational studies 4. Quasi-experimental studies

20. 20 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Stetler Model of Research Utilization  Phase I: Preparation  Phase II: Validation  Phase III: Comparative Evaluation/Decision Making  Phase IV: Translation/Application  Phase V: Evaluation

21. 21 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Iowa Model of Evidence-Based Practice  Provides direction for development of evidence-based practice in an agency  Looks at triggers for change, such as:  Risk management data  Financial data  Organizational standards  Philosophy of care

22. 22 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Iowa Model of Evidence-Based Practice (cont’d)

23. 23 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Application of the Iowa Model  What are effective strategies for implementation?  What are outcomes from using the research findings?  Do the data support the change?  Is the proposed change an agency priority?

24. 24 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Scientific Merit Critique  According to the Iowa model, research should be examined for: 1. Conceptualization and internal consistency of the study 2. Methodological rigor of the design, sample methods, data, and analysis 3. Generalizability of the findings 4. Number of replications

25. 25 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Determining Agency Compatibility with the Change in Practice  Who needs to approve the change in the agency?  What steps are needed to get the change approved in the institution?  Do physicians support the change?  Do nurses support the change?  Who are the leaders and will they support the change?

26. 26 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Instituting the Change in Practice  Will the implementation take a long time?  What support is needed to make the change?  Are there barriers to instituting change in the agency?

27. 27 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Utilization Barriers  Administration barriers  Research not valued  Limited change in agency or change not based on research  Limited resources to make research-based change

28. 28 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Utilization Barriers (cont’d)  Clinician barriers  Do not read research reports  Lack education about research process  Do not believe research findings  Do not know how to implement findings

29. 29 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Monitoring Outcomes  After the change is effected, the outcomes must be monitored for effectiveness.  Change should be documented regarding improved quality of care, decreased costs, saved nursing time, and improved access to care.  Feedback is needed.

30. 30 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. The Cochran Collaboration  P – Population or participant of interest  I – Intervention needed for practice  C – Comparison of interventions to determine best practice  O – Outcomes needed for practice

31. 31 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Development of Evidence-Based Guidelines  AHRQ helps with guidelines through development of an expert panel.  The group designates the scope of the guidelines.  They synthesize the findings to develop recommendations for practice.  Guidelines developed are presented at meetings and published.

32. 32 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Examples of AHRQ Practice Guidelines  Pain management  Decubiti prediction/prevention  Cataract treatment in adults  Depression treatment  Screening, diagnosis, management of sickle cell disease in newborns and infants  Otitis media treatment in children  Availability of cardiac rehabilitation services

33. 33 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Access to Evidence-Based Guidelines  Agency for Healthcare Research and Quality (AHRQ)  National Guideline Clearinghouse (NGC)  Academic Center for Evidence-Based Nursing  American College of Physicians  American Academy of Pediatrics

34. 34 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Implementing a Model of Evidence- Based Practice  Identify practice problem.  Search for best research evidence.  Determine quality of guideline by assessing:  Authors  Significance of problem  Strength of evidence  Link to national standards  Cost-effectiveness of guideline

35. 35 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. Translational Research  An evolving concept defined by the NIH as the translation of basic scientific discoveries into practical application  Encouraged by nursing and medicine to increase the implementation of evidence- based interventions in practice and determine if these interventions are effective