Evidence-Based Practice in Nursing
Nursing Diagnosis
process by which the assessment data are sorted and analyzed so that specific actual and potential health problems are identified
Scientific Method
step by step process with observable results used by scientists to solve problems
The Nursing Process
the tool for identifying patients problems and an organized method for meeting patients needs
Nursing Process
way of thinking and acting based on the scientific methods
5 Components of the Nursing Process
-assessment -nursing diagnosis -planning -implementation -evaluation
Critical Thinking in Nursing
A way of thinking in nursing practice Reflective thinking Critical thinking Quality of thinking improves over time Novice to Expert Creative approach to thinking Dynamic approach to patient care
Disseminate Outcomes of the EBP Decision or Change
- Too often in healthcare, positive outcomes are not shared with others. - There are numerous strategies for accomplishing this goal, from personal communications, conference presentation, and peer reviewed article publication.
Research Utilization (RU)
- Use of study findings in a practical application unrelated to the original research. - Instrumental (direct) - Conceptual (indirect) - Persuasive (symbolic)
Appraising the Evidence
- What is the quality of the evidence? - What is the magnitude of effects? - How precise are estimates of effects? - Is there evidence of side effects? - What are the costs? - Is there relevance to my clinical situation?
Problem Solving Process
-define the problem clearly -consider all possible alternatives as solutions -consider the possible outcomes for each alternative -predict the likelihood of each outcome occurring -choose the alternative with the best chance of success
Goals of the nursing process
-explore patient health status -identify health problems -determine outcomes -deliver specific interventions -evaluate the care given
Research Process
Identify a researchable problem Review the literature Form a research question or hypothesis Design of the study Implementation of the study Drawing conclusions based on findings Discussion and/or clinical implications Dissemination of findings
5. How should the nurse initiate the research process?
Identify a researchable problem. [The first step in the research process is to identify a researchable problem.]
Academician role in research
Independent research with external funding (e.g., NIH, foundation grants)
Evaluation
assessing the patients response to the nursing interventions
Implementation
carrying out the nursing interventions in a systemic way
Drawing conclusions based on findings, Answer the question:
"What do these findings mean?"
Steps of Research Utilization Similarities to Nursing Process
(ADPIE) - Identification of clinical problem (D). - Gathering information form existing studies, critical evaluation of research (A). - Relevance to practice setting/patient population (P), definition of patient outcomes (P). - Education/training (protocol) needed for change (I). - Evaluation/follow-up of new practice (E).
Asking the Nursing Question
(PICOT) - *P*atient population - *I*ntervention or issue of interest - *C*omparison intervention or group - *O*utcome - *T*ime frame - not always specified.
After formulation of the research question or hypothesis, the next step in the research process is to: A. Select the population B. Review the literature C. Design the study protocol D. Discussion and/or clinical implications
*C. Design the study protocol* After formulation of the research question or hypothesis, the next step in the research process is to design the study. The study design will influence the data collection process. Selecting the population is a component of this phase of the research process. Obtaining necessary approvals is part of conducting the study, which follows the design phase in the research process. Identification of the instrument to use for data analysis occurs during the process of designing the study protocol. This step would occur during the study design phase of the research process after the problem identification and literature review has taken place.
During the first step of evidence-based practice (EBP), development of a clinical question: A. Must follow the sequence of PICOT B. Does not allow for identification of key words C. Must contain all of the PICOT elements D. Does not have to follow the sequence of PICOT
*D. Does not have to follow the sequence of PICOT* A well designed PICOT question does not have to follow the sequence of PICOT. In addition, Intervention (I), comparison (C), and time (T) are not appropriate to be used in every question. The aim is to ask a question that contains as many of the PICOT elements as possible. Proper question formatting allows you to identify keys words to use when conducting your literature search
Implementation of the study involves two main task:
*Data collection* (collected by those familiar with the study) *Data analysis* (arrange information into meaningful patterns
Research is the same as problem solving. T or F
*False* Research is different from problem solving. Problem solving is specific to a given situation and is designed for immediate action, whereas research is generalizable (transferable) to other situations and deals with long-term solutions rather than immediate ones.
PICO four-step process
*P* - population of interest *I* - intervention *C* - comparison *O* - outcome
PICOT question
*P* = Patient population of interest *I* = Intervention of interest *C* = Comparison of interest *O* = Outcome *T* = Time
Two major categories in designing study
*experimental* (require quantitative methodology) *nonexperimental* (can be quantitative or qualitative methodology)
RU Beginnings
- 1970s research begins to be incorporated in nursing curricula. - 1970s WICHE Western Interstate Commission for Higher Education. - 6 year project to address feasibility of fostering research through regional collaborations. - First major project addressing RU. - Findings: resulted in increase in RU, but not enough sounds, reliable studies with implications for nursing care. - 1970s CURN: Conduct and Utilization of Research in Nursing project (run by MNA, funded by Division of Nursing). - Major objective --> increase use of research findings in clinical nursing practice by: disseminating current findings, facilitating organizational changes, encouraging collaborative research. - Must have relevance to practice and be widely disseminated.
RU 1980s-1990s
- 1980s and 1990s RU generally at institutional level, innovation effectiveness evaluation. - 1990s push for EBP.
Evidence Based Practice
- A life-long problem-solving approach to clinical practice that integrates... - Search, critical appraisal, and synthesis of the most relevant and best research *(external evidence).* - One's own clinical expertise, which includes *internal evidence* generated from outcomes management or quality improvement projects, patient assessment, and evaluation. - Patient preferences and values.
Cochrane Collaboration
- Archie Cochrane - Systematic way to evaluate evidence. - Dissemination of evidence. - Evidence hierarchy.
Iowa Model
- Ask clinical question. - Search literature - Critically appraise literature - Implement practice change - Evaluate - Organizations change practice
Evidence Based Practice (EBP)
- Based clinical decisions on best possible evidence typically high quality research. - Use of best evidence unmaking patient care decisions.
EBNP
- Best evidence: findings of quantitative research studies. - Clinical expertise: expert panels; consensus statements; practice groups; practitioner experience. - Patient preferences: satisfaction; QOL; treatment burden; Qualitative studies.
Search For Evidence
- CINAHL - MEDLINE - Cochran collaboration (www.cochrane.org) - Agency for Healthcare Research and Quality (www.ahrg.gov) - National Guideline Clearinghouse (www.guidelines.gov, www.guidelines.gove/content.aspx?id=32669&search-falls)
Research Utilization
- Clinical Problem ID - Use existing research to solve problem. - Follow steps of RU - Findings usually applied at organizational level.
Evidence Based Nursing Practice
- Clinical problem ID - Use existing research - Synthesize all evidence, integrate patient preference and clinical expertise. - Findings applied at bedside, tailored to individual patient.
Steps of Evidence Based Practice
- Cultivate a spirit of inquiry. - Ask the burning clinical question in PICOT format. - Search for and collect the most relevant best evidence. - Critically appraise the evidence (i.e., rapid critical appraisal, evaluation, and synthesis). - Integrate the best evidence with one's clinical expertise and patient preferences and values in making practice decision or change. - Evaluate outcomes of the practice decision or change based on evidence. - Disseminate the outcomes of the EBP decision or change.
Research Utilization (RU): Instrumental
- Direct - Explicit application of knowledge gained from research to a practice.
Evidence Based Medicine/Evidence Based Practice
- Distinct - Not just RCT's - Evidence hierarchies - Philosophical differences
*Case Study:* - A group of nurses working in a community health center were unsure of how to answer questions from patients about appropriate means of cleansing children's wounds in home settings. - Most nurses felt that sterile saline should be recommended to minimize the risk of infection, but others believed that tap water was adequate fro cleansing acute wounds. - The nurses decided to examine the evidence and located a systematic review in the Cochrane database. Among the studies that had been conducted, the review concluded that there were no differences in rates of infection or healing with use of tap water versus sterile saline win the cleansing of wounds. - However, few of the studies that had been done involved the use of childcare, and most had been conducted in health-care settings. - The nurses decided to initiate a new study to gather more focused and informative evidence about the effects of saline solution versus tap water in cleansing children's wounds.
- Does this summary describe an EBP effort? - *Yes, the nurses wanted to determine the best practices with regard to cleaning of children's wounds.* - Would the trigger be described as problem-focused or knowledge focused? - *Problem-focused* - Did the nurses use pre-appraised evidence? - *Yes, a systematic review from the Cochrane database is an example of pre-appraised evidence.* - The nurses decided to initiate a new study because they deemed the evidence base inadequate. - Would their new study be a qualitative or quantitative study? - *Quantitative*
EBP Models
- Dozens of models exist. - The *Stetler Model* of research utilization to promote evidence based practice. - The *IOWA Model* of evidence based practice to promote quality of care. - Rogers' *Diffusion of Innovations Theory*.
Types of Questions
- Etiology - Diagnosis - Therapy - Prevention - Prognosis - Qualitative (meaning; insight into patients experience/perspective).
Research Utilization (RU): Conceptual
- Indirect - Use of findings to enhance one's understanding of a problem or issue in nursing.
EBP Initiatives
- Institute of medicine's Roundtable on EBM. - US Preventative Services Task Force (USPSTF). - Agency for Healthcare Research and Quality (AHRQ). - Nation Consortium for the Advancement of pEdiatric and Adolescent Evidence Based Practice (NCPAEP). - Magnet Recognition Program by the American Nurses Credentialing Center.
*Case Study:* Chris was caring for a 27 year old woman who just delivered her first infant by emergency Cesarean birth. The mother was upset because she believed she would have to deliver subsequent children by cesarean birth. She asked Chris about the risks of birth complications with vaginal birth after cesarean (VBAC). Chris decided to look for the best possible evidence to answer her question.
- Is Chris engaging in an RU or an EBP effort? - EBP - Would the trigger be described as problem-focused or knowledge-focused? - Problem-focused - Would Chris need to pose a clinical background question or a clinical foreground question to identify relevant evidence? - Clinical foreground question. - In searching for evidence, Chris would need to ask a well-worded clinical question that would include identifying the population. What would be the population? - Women who have had a cesarean birth. - Chris's clinical question would identify an intervention or exposure. What would that be? - Having a vaginal birth. - Would Chris likely find the answer to a question about future risks of birth complications from VBAC in a meta-synthesis? - No, the question is not about meaning or process; it is about the effect of a certain exposure. - Would Chris need to assess implementation potential in this effort? - No, this is an individual EBP effort, not an institutional effort.
Nursing Barriers
- Lack of knowledge - Information overload - Lack of role models - Lack of time or money - Resistance to change - Misperceptions - require education
Evaluate Outcomes of the Practice Decision or Change Based on Evidence
- Measurement of outcomes is important to determine and document impact of the EBP change on healthcare quality and/or patient outcomes. - Essential in determining whether the change based on evidence resulted in the expected outcomes when implemented in the real-world clinical practice setting.
Rating the Strength of Evidence
- Not necessarily synonymous with "hierarchy of evidence." - High-level study design does not necessarily mean high quality. - Grading the strength of a body of evidence addresses three domains - quality, quantity, and consistency.
EBP Continuum
- Nurses actively doing research - Assisting researchers, collecting information. - Participate in journal club. - Informed readers, up to date practice.
Components for Qualitative Evidence
- Population - Situation (processes, experiences, cultures, history, condition of interest).
Stetler Model
- Preparation - Validation of credible evidence - Comparative evaluation/decision making phase - Translate or apply the research - Evaluate outcomes - Individuals change practice
Research Process
- Problem identification - Conduct research - Follow steps of research process. - Findings usually not immediately applicable - need to be translated through RU/EBNP.
Foreground
- Questions that can be answered by current best research evidence on diagnosis, assessment, treatment or understanding meaning, cause or prognosis. - What is it like to be an elderly woman with osteoporosis in the northeast?
Evidence Hierarchies
- Rank evidence according to strength of evidence provided. - Typically related to effectiveness of healthcare interventions. - Not meaningful for certain questions: meaning, process.
Strategies/Role for Nurses in EBP
- Read widely and critically. - Attend professional conferences. - Learn to expect evidence that a procedure is effective. - Become involved in a journal club. - Pursue and participate in RU/EBP projects.
Barriers to RU/EBP
- Research-related barriers: scarcity of published replications. - Nurse-related barriers: insufficient skills in locating and appraising evidence. - Organizational barriers: lack of financial support and staff release time for EBP.
EBP in Organizational Setting
- Select a topic or problem. - Knowledge-focused triggers - begins with an innovation or research finding (e.g., might emerge in a journal club). - Problem-focused triggers - begins with a perplexing or troubling clinical situation.
Other Models of Quality Improvement
- Six Sigma: a disciplined, data-driven approach and methodology for eliminating defects (driving toward six standard deviations between the mean and the nearest specification limit) in any process - from manufacturing to transactional and from product to service. - Currently in use at UHS.
Facilitators
- Support from leaders and peers - Adequate time - Resources - Journal clubs and EBP rounds - Determined effort is often required in order to address barriers and facilitate the implementation of EBP.
Research Utilization (RU): Persuasive
- Symbolic - Use of evidence to change minds, especially decision makers.
RU/EBP Resources
- Systematic reviews that integrate evidence about a topic in a rigorous, systematic way. - Traditional narrative reviews are being placed. - Meta-analyses that integrate findings across quantitative studies statistically. - Meta-syntheses that integrate and amplify findings across qualitative studies. - Other reappraised evidence (clinical practice guidelines, syncopes of studies in EBP journals, critically appraised topics). - Models and theories for EBP or RU.
Question Templates
- Templates can greatly facilitate wording of questions, e.g., an intervention question: In (population), what is the effect of (intervention), in comparison to (comparison) on (outcome) in (timeframe)?
Rogers' Theory of Diffusion of Innovations
- Theory for communicating knowledge developed through research. Includes a five stage process: 1) Knowledge - knows but lacks info, not inspired to find info. 2) Persuasion - interested, seeks info. 3) Decision - weighs advantages/disadvantages, accepts of rejects. 4) Implementation - determines usefulness, many seek more info. 5) Confirmation - finalizes decision. May be interpersonal (cognitive dissonance) or interpersonal (good job group!).
Integrate Evidence, Clinical Expertise, Pt. Preference
- This is the "implementation" step. - EBP is not based solely on research and published evidence. - Patient's histories and circumstances have a significant bearing on the nurse's choice of intervention. - Availability of resources must also be considered: feasibility, cost benefit, transferability.
Background/Foreground
- When do complications of pneumonia usually occur? *Background question* - What bed rest elevation for mechanically ventilated patients is maximally effective in reducing the risk of ventilatory-associated pneumonia? *Foreground question* - What is it like for patients with HIV or AIDS to adapt to changes in body weight and ensuing body image changes? *Foreground question* - What is the pathophysiology of Lyme disease? *Background question* - Which large volume enema solution - tap water, soap suds, or polyethylene glycol-electrolyte solution - results in the greatest net output and least mucosal irritation in patients with constipation? - *Foreground question* - What is the risk of broncho-pulmonary aspiration during enteral feeding? *Background question* - Do patiens receiving an intradermal injection experience greater discomfort with bevel up or bevel down needle injection? *Foreground question* - Does depression contribute to morbidity and mortality among patients with heart failure? *Foreground question* - What is it like for people with a history of severe phobias to overcome their phobia? *Foreground question* - What effect does altitude change have on circadian physiology? *Background question*
Other Quality Measurements
- You may hear the following terms in regard two quality improvement at hospitals: - HCAPS - Hospital Consumer Assessment of Healthcare Providers and Systems --> National survey analyzed by centers for medicare and medicaid services (CMS). - Press Ganey - Private, for profit organization that polls health care consumers to assess quality of care (HCAPS included in survey).
Background
- foundation questions about a clinical issue. - What is osteoporosis and what is it's pathology?
Levels of Evidence
1) Systematic reviews of RCTs 2) Individual RCT 3) Systematic reviews non-RCT (correlational) 4) Individual correlational studies 5) Systematic reviews of descriptive studies 6) Individual descriptive studies 7) Exert opinion of respected authorities or expert panels *Highest level of evidence is systematic review of findings from MULTIPLE RCTs.*
Six steps to EBP
1. Ask a clinical question 2. Collect the most relevant and best evidence 3. Critically appraise the evidence you gather 4. Integrate all evidence with one's clinical expertise and patient preferences and values in making a practice decision or change 5. Evaluate 6. Share outcomes of EBP changes with others
Assessment
data collection, collecting, organizing, documenting, and validating data
PPT: A nurse compares patient compliance after an interactive video instruction compared to usual verbal instructions among patients with a new diagnosis of diabetes mellitus. The study design most likely describes: 1. Descriptive research design 2. Exploratory research design 3. Modified experimental design 4. True experimental design
3. Modified experimental design
6. The nurse researcher is presenting a lecture on data-collection instruments. Which statement indicates the need for further education? A. "Data collection tools must be high tech and complex to be accurate." B. "Researchers must consider how the data will be collected." C. "The selected instrument must be reliable." D. "The tool must be valid."
A. "Data collection tools must be high tech and complex to be accurate." [data collection tools, range from simple survey forms to complex radiographic scanning devices. ]
9. Which statement about financial support for nursing research indicates a need for further teaching? A. "Nursing research is often fairly inexpensive." B. "Over the years, more funding for nursing research has been identified." C. "It is difficult for new researchers to obtain funding." D. "Nursing associations fund nursing research."
A. "Nursing research is often fairly inexpensive." [Nursing research can be EXPENSIVE, and often support takes many different forms]
7. The nurse is listening to a lecture on the outcomes of research in the nursing practice. Which statement indicates a need for further education? A. "Research has not created a lot of changes in nursing." B. "Research has improved the care of patients with skin breakdown." C. "Research has prevented sleep deprivation by decreasing light and noise." D. "Research has led to scheduling pain medication more frequently after surgery."
A. "Research has not created a lot of changes in nursing."
Critical Thinking
directed, purposeful, mental activity by which ideas are evaluated, plans are constructed, and desired outcomes are decided
Expert Thinking
Assesses then acts, aware of resources and how to use them, knows how to bend the rules, focused.
8. Which statement by the nurse indicates an understanding of how nursing research positively affects nursing? A. "Research creates changes that are not always good." B. "Research expands the nursing profession." C. "Research creates more work for staff nurses." D. "Research leads to less pay for union nurses."
B. "Research expands the nursing profession."
3. The student nurse is listening to a lecture on inductive and deductive reasoning. Which statement indicates that further teaching is needed? A. "Inductive reasoning begins with a particular experience and proceeds to generalizations." B. "Research requires the use of only inductive reasoning." C. "Deductive reasoning proceeds from the general case to the specific." D. "Conclusions drawn from deductive reasoning are called valid rather than true."
B. "Research requires the use of only inductive reasoning." [Research requires both inductive and deductive reasoning]
Qualitative Research
Because there are no variables being manipulated - qualities of the human experience are described and interpreted.
2. The nurse professor is presenting a lecture on pure science. Which statement from one of the students indicates that the teaching has been effective? A. "Pure science involves systematic distortion of a finding from the data." B. "Pure science involves manipulation of variables." C. "Pure science summarizes and explains the universe without regard for whether the information is immediately useful." D. "Pure science is the practical application of scientific theory and laws."
C. "Pure science summarizes and explains the universe without regard for whether the information is immediately useful."
EBM (Evidence Based Medicine)
David Sackett, McMaster Medical School
Mixed-Methods Research
Combination of Qualitative and Quantitative Research
1. The student nurse is listening to a lecture on the different types of research. Which statement by the student nurse indicates that teaching has been effective? A. "Quantitative research involves systematic distortion of a finding from the data." B. "Quantitative research is known as naturalistic inquiry." C. "Qualitative research requires standardized experimental designs." D. "Qualitative research does not involve manipulation of variables."
D. "Qualitative research does not involve manipulation of variables."
4. The nurse professor is giving a lecture on the difference between research and problem solving. Which statement by one of the students indicates that teaching has been effective? A. "Research is specific to a given situation." B. "Research is designed for immediate action." C. "Problem-solving is generalizable." D. "Research deals with long-term solutions."
D. "Research deals with long-term solutions." [Research is generalizable, can be used in other situations and deals with long-term solutions.]
10. The nurse is would like to research how to best keep confused patients from wandering. What is the first step that the nurse should take? A. Review the literature. B. Create a study design. C. Call the local community college about funding. D. Identify a researchable problem
D. Identify a researchable problem
Novice Thinking
Focus on action with out assessment, unaware of resource, need clear cut rules, anxiety and lack of self confidence.
Doctorate role in research
Generate and test theory; establish independent research career
BSN role in research
Identifies problems that can be studied; may do data collection for research studies
Nursing student role in research
Learning about research: doing honors projects or assisting in labs
Quantitative Research
Measurable variables
MSN role in research
Replicates earlier research; beginning independent research
SMART Goals
S - Specific M - Measurable A - Attainable R - Realistic / Relevant T - Time
Define: Evidence-based practice
Systematic approach to rational decision making that facilitates achievement of best practices
Rating the Strength of Evidence: Quality
The event to which a study's design, conduct, and analysis has minimized selection,measurement and confounding biases (internal validity).
Rating the Strength of Evidence: Quantity
The number of studies that have evaluated the question, overall sample size across all studies, magnitude of the treatment effect, strength from causality assessment, such as relative risk or odds ratio.
Rating the Strength of Evidence: Consistency
Whether investigations with both similar and different study designs report similar findings (requires numerous studies).
Planning
a series of steps by which the nurse and the patient set priorities and goals to eliminate or diminish the identified problems
Evidence-based Practice (EBP)
an approach to the delivery of health care that "integrates the best evidence from [research] studies and patient care data with clinician expertise and patient preferences and values."
Ask a clinical question
• A problem or area of interest that could be performed more efficiently, consumes healthcare dollars, or does not make sense • A knowledge focused trigger • Clinical trends • Utilization of PICOT format to state your clinical question
Dissemination of findings two major vehicles:
• Articles published in professional journals • Presentations given at conferences
Review of the literature
• Comprehensive and covers all relevant research • Essential to locate similar or related studies that have already been completed and on which a new study can build • Answer the question "what have other researchers and theorists written about this problem?"
Evaluate and share outcomes
• Did it work? Is it effective? • Communicate the results to various groups of nurses or other care providers (facility nursing practice council or research committee)
Integrate the evidence
• How will you incorporate the evidence into practice? • Integrate evidence with use of teaching tools, clinical practice guidelines, policies and procedures, and new assessment documentation tools • Consider staff support and available resources • Conduct a pilot study and attempt to answer your PICOT question
Utilization of the research process
• Identification of a researchable problem • Review of the literature • Formulation of the research question or hypothesis • Design of the study • Implementation of the study • Drawing conclusions based on findings • Discussion of clinical implications • Dissemination of findings
Collect the best evidence- what kind and includes
• Search for evidence! • *Evidence includes but is not limited to*: agency policy and procedure manuals, quality improvement data, existing clinical practice guidelines, agency experts, staff educators, risk managers, infection control nurses, and peer reviewed articles (specifically within the most recent 5 years from the present date)
Identification of a researchable problem
• Sources: * clinical situations * the literature * theories • Repeat the study or design a similar one • Test theoretical models
Discussion of clinical implications
• Suggest actions that can be taken as a result of the research findings in the future • Other questions to answer: Will the procedure be effective with patients who have a different diagnosis? • Will age make a difference? What else do we need to know to improve the care of patients? • Also known as the rigor (potential threats to the validity and reliability of the study)
Critically appraise the evidence you gather
• The most difficult step in the EBP process • Involves evaluation, determining if information is valuable and can be easily applied, and if there is enough evidence for making a nursing practice change • Thorough review of elements included in evidence-based articles
Why should I use PICOT format to state my clinical question?
• The questions you ask will eventually lead you to the evidence for an answer • You want to be able to read the BEST four-to-six articles that specifically address your practice question • The more focused a question you ask, the easier it becomes to search for evidence in the scientific literature
