EBP

steps of 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

Evidence based clinical decision making

-Evidence based theories/evidence from research -Patient preferences and values -Clinical expertise -Physical exam and assessment

Integrating Patient Preferences and Values and Clinician Expertise into Clinical Decisions

-Research evidence needs to be considered in light of patients' concerns and preferences as filtered through clinical expertise -Evidence must be used in light of the interpretations of the patient's concerns, history, family and cultural context, and disease trajectory as well as the reliability and validity of the existing research evidence

trustworthiness and rigor in qualitative studies

-credibility (accuracy & validity) -dependability (consistent & repeatable) -transferability (meaningful/important) -confirmability (participants perspective vs. researchers perception)

Appraisal of Qualitative Studies

1. Are the results valid/trustworthy and credible? 2. Are implications of the research stated? 3. What is the effect on the reader? 4. What were the results of the study? 5. How does the researcher identify the study approach? 6. Is the significance/importance of the study explicit? 7. Is the sampling strategy clear and guided by study needs? 8. Are data collection procedures clear? 9. Are data analysis procedures described? 1. 10. How are specific findings presented? 11. How are overall results presented? 12. Will the results help me in caring for my patients?

Five assumptions in evidentialism*** underpin the role of clinical wisdom and judgment in evidence-based decisions:

1.Only decisions that result from thoughtfully responsible behavior are justified. 2.External evidence that supports a conclusion about patient care may not be sufficient to make that conclusion clinically meaningful. 3.As available external evidence changes, the decision maker's responses should change too. 4.Decisions made from a set of external evidence depend on the validity, reliability, and applicability of that evidence and on the clinician's grasp of the evidence, which is clinical wisdom. 5.Having a "belief" without supportive external evidence is unwise, and therefore, that belief is unjustified. Not only will such a belief have an impact on decisions that are based on that belief, it will affect all decisions connected to that unjustified belief.

Asking Foreground Questions Using the PICOT Format

P: Population of interest I: Intervention or issue of interest C: Comparison of interest O: Outcome expected T: Time needed for the intervention to achieve the outcome or the time in the course of the disease/symptom that the intervention is applied NOTE: Since the purpose of the PICOT is to guide the systematic search of databases, time is option as it can limit your search

•Internal evidence is generated through such things as:

Practice initiatives •Outcomes management •Evidence-based quality improvement projects •Patient assessment and evaluation •Use of available resources within your organization External evidence includes systematic reviews, randomized control trials, best practice, and clinical practice guidelines that support a change in clinical practice. Internal evidence includes health care institution based quality improvement projects, outcome management initiatives, and clinical expertise.

qualitiative vs. quantitative

QUALITATIVE •research that involves the collection of data in a nonnumeric form, such as personal interviews, usually with the intention of describing a phenomenon or experience seeking an in-depth understanding within a natural setting. •Data is narrative, reflective, or anecdotal •Requires judgment to interpret the data •Answer the "why" for practice •Qualitative methods have evolved and expanded in recent years QUANTITATIVE •expressing a certain quantity, amount or range. Usually, there are measurement units associated with the DATA, e.g. meters, in the case of the height of a person. It makes sense to set boundary limits to such DATA, and it is also meaningful to apply arithmetic operations to the DATA

quality

The extent to which a study's design, conduct, and analysis have minimized selection, measurement, and confounding biases (internal validity)

consistency

Whether investigations with both similar and different study designs report similar findings, which requires numerous studies

clinical inquiry definition

a process in which clinicians gather data using narrowly defined clinical parameters to appraise the available choices of treatment to find the most appropriate choice of action

evidentialism

framework for understanding how research evidence and patients' concerns, history, family and cultural context, and disease trajectory are used in a decision-making process by clinicians to determine an evidence-based plan of care.

quantity

vThe number of studies that have evaluated the clinical issue, overall sample size across all studies, magnitude of the treatment effect, and strength from causality assessment for interventions, such as relative risk or odds ratio.

EBP is....

•A decision-making process •Based on a body of evidence that has been identified, critically appraised and synthesized •Generating new knowledge about practice through implementation of evidence-based recommendations •Not GENERALIZABLE, but rather TRANSFERRABLE •Sometimes requiring submission to Institutional Review Board (IRB) (NOTE: varies from organization to organization)

•Which of the following involves bringing the body of evidence together with clinical expertise and patient preferences and values to identify best practice? A.Evidence-based practice B.Research C.Translational research D.Research utilization Evidence-based quality improvement

•A. Evidence-based practice Rationale: Evidence-based practice is bringing together the best evidence with clinical expertise and patient preferences and values to make the best practice decisions.

PICOT Format: Etiology Template

•Are ________________(P) who have _________(I), compared to those without _________________(C) at ______________ risk for/of ___________ (O) over ____________(T)? •Example: Are women diagnosed with breast cancer (P) who have an oncotype DX score greater than 18 (I), compared to those without an oncotype DX score greater than 18 (C) at less risk for reoccurrence of breast cancer (O) the first five years post diagnosis (T)?

background questions

•Asks for general information about a clinical issue •Usually has two components: 1. The starting place of the question (e.g., what, where, when, why, and how) 2. The outcome of interest •Broader in scope than a foreground (PICOT) question Example: "How does acetaminophen lower fever?"

foreground questions (PICOT format)

•Asks for specific scientific evidence about diagnosing, treating, or educating patients •The focus is on specific knowledge •Creating a searchable question using PICOT format will drive a focused, efficient, effective literature search Example: "In children, how does acetaminophen compared to ibuprofen affect fever management?"

•Which of these would be an example of shared decision making (SDM)? A.The nurse brings discharge instructions to the patient that is being discharged from the urgent care. B.Hospitalized patients are provided with a menu allowing them to choose what they would like to eat for each of the day's meals. C.The nurse midwife sits down with the expecting couple and holds a conversation about what to expect during labor and delivery, answers all questions, and crafts a birth plan with them. D.The pharmacists asks if the patient has any questions when they go to the retail pharmacy to pick up their prescriptions.

•C. The nurse midwife sits down with the expecting couple and holds a conversation about what to expect during labor and delivery, answers all questions, and crafts a birth plan with them. Rationale: Answers A, B, and D reflect a paradigm in which patients/families cannot understand or are not able to participate in decisions about health care. Berwick's statements contradict these paternalistic assumptions about health care consumers.

central themes of evidentialism***

•Clinicians must find and know the information upon which decisions are made. •Decisions are based on current evidence, which means that they are based on what is presently known. That this might change in the future is acknowledged. •Experiences that a clinician and a patient have had can be counted as evidence.

critical appraisal

•Critical appraisal is the process of evaluating a study for its worth (i.e validity, reliability, and applicability to clinical practice). •Critique is an in-depth analysis and critical evaluation of a study that identifies its strengths and limitations. Critical appraisal is to EBP as CRITIQUE is to research.

•Scenario: EBP is identified as a core value in our organization's new strategic plan. This plan includes making sure all policies are supported by evidence within 3 years. In order to accomplish this, units begin hosting unit-based journal clubs from noon until 1 p.m. once a week to teach advanced critical appraisal skills. Staff are permitted to attend if census and staffing ratios allow. •Which of the following is the barrier in the scenario above A.Having a new strategic plan B.The plan goal of making sure all policies and procedures are supported by evidence within the 3 years. C.Hosting unit-based journal clubs D.The timing and stipulations for attendance of the unit-based journal clubs

•D. The timing and stipulations of for attendance at the unit-based journal clubs Rationale: Having a strategic plan that identifies EBP as a core value, setting a goal to have all policies and procedures be supported by evidence within 3 years, and hosting unit-based journal clubs to support advancement of EBP skills are all facilitators to EBP. However, proper support and structure must be put into place to allow nurses to be able to attend the journal clubs. The timing and stipulations for attendance at the unit-based journal clubs (held from 12 noon till 1 p.m. with no staffing support or release time) is a barrier to EBP.

•Which of the following components of a PICOT question is absent from the following clinical question? • "Among patients with dementia, how does the use of reorientation therapy compared with regular, supervised mobility affect patient agitation?" A.P (Population) B.I (Intervention) C.C (Comparison) D.O (Outcome) E.T (Time)

•E. T (Time) Rationale: This question specifies the patient population (patients with dementia), the intervention (reorientation therapy), the comparison (regular, supervised mobility), and the relevant outcome (patient agitation), but does not provide the time frame for an expected outcome.

Strategies to Eliminate Barriers to Using Evidence-Based Practice

•Establishing a clear philosophy and organizational vision in which EBP is valued and expected •Developing a strategic plan to create a culture and environment that fosters EBP •Dispelling misperceptions about EBP •Teaching the basics of EBP •Encouraging questions about currently used clinical practices •Developing EBP mentors

qualititative methodologies***

•Ethnography •Grounded Theory •Phenomenology •Hermeneutics

external evidence includes

•Evidence generated through RIGOROUS research •Systematic reviews •Evidence-based theories •National benchmarks •Opinion leaders and expert panels

•Is the following statement true or false? •Although organizational culture and context are important, they are not necessary for evidence-based practice to be implemented and sustained in the organization.

•False Rationale: An EBP culture and environment must be created within an organization if EBP is to be implemented and sustained.

•Is the following statement true or false? •Evidentialism is the process by which an evidence-based clinical decision is reached solely on external evidence.

•False Rationale: Evidentialism is the framework for understanding how research evidence can be combined through the practitioner's expertise with patients' concerns, history, family and cultural context, and disease trajectory to develop an evidence-based plan of care.

•Is the following statement true or false? •Foreground questions can often be answered by consulting an up-to-date nursing or science textbook.

•False Rationale: Foreground questions are clinical questions that can only be answered by specific scientific evidence that is usually found in original studies or systematic reviews of original studies (e.g., RCTs). This type of evidence is not available in textbooks, which are more appropriate for answering background questions.

•Is the following statement true or false? •According to Melnyk & Fineout-Overholt, there are six steps to the evidence-based practice process.

•False Rationale: Initially there were six steps to the evidence-based practice process according to Melnyk & Fineout-Overholt, but a seventh step (Step 0) was later added after research supported the importance of organizational culture to EBP implementation and sustainability. These steps must be implemented in sequence and rigorously engaged to accomplish the end goal of improved patient, provider, and system outcomes.

The Merging of Science and Art: The Interaction Between Culture, Context and EBP

•Figure 1.2: The merging of science and art: Evidence-based practice (EBP) within a context of caring and an EBP culture and environment result in the highest quality of healthcare and patient outcomes. © Melnyk & Fineout-Overholt, 2017.

PICOT Format: Meaning Template

•How do ________________(P) with _________(I) perceive _________________(O) during ____________(T)? •Example: How do oncology patients (P) with feeding tubes (I) perceive nutritional intake (O) during chemotherapy (T)?

the quadruple aim

•Improved patient experience •Improved outcomes •Cost reduction •Organization-driven and often includes such things as joy in work (improved clinician experience vs. equity vs. organizational readiness)

PICOT format: intervention template

•In ________________(P) how does___________(I) compared to __________(C) affect ___________(O) within (T)____________? •Example: In adolescents (P), how does oral contraception (I) compared to long-acting reversible contraception (LARC) (C) affect birth rates (O) within one year of onset of sexual activity (T)?

PICOT Format: Diagnosis Template

•In ________________(P) is ___________(I) compared to _____(C) more accurate in diagnosing (O) ____________? •Example: In patients with hip joint trauma (P) is CT Scan (I) compared to MRI (C) more accurate in diagnosing a fractured hip (O)?

PICOT Format: Prognosis Template

•In ________________(P), how does___________(I) compared to _____(C) influence/predict _______(O) over (T)____________? •Example: In firemen (P), how does protective gear plus a showering protocol post response to a fire (I) compared to protective gear alone (C) influence/predict diagnosis of cancer (O) over five years (T).

clinical inquiry extra info.

•Includes problem identification and clinical judgment across time •Organizational culture that not only supports, but encourages clinical inquiry is key to EBP implementation and sustainability. •Finding the right information to address clinical inquiry starts with using clinical inquiry to formulate a searchable, answerable question in PICOT format.

types of foreground questions

•Intervention questions ask what interventions most effectively lead to an outcome? •Prognosis/prediction questions ask what indicators are most predictive of an outcome? •Diagnosis questions ask what test most accurately diagnoses an outcome? •Etiology questions ask to what extent a factor, process, or condition is highly associated with an outcome (usually undesirable outcome) •Meaning questions ask how an experience influences either an outcome or the scope of a phenomenon or the influence of culture on behavior or healthcare.

Examples of Barriers to EBP

•Lack of administrative/management support •Resistance to change •Misperceptions or negative attitudes about EBP •Lack of EBP knowledge and skills •Lack of time and resources •Lack of EBP mentors

Barriers to Finding the Right Information at the Right Time

•Lack of proficiency in using computers •Lack of computer access at point of care •Low comfort level/lack of skill using search techniques •Lack of access to appropriate electronic databases •Lack of time to search for the best evidence

Qualitative Techniques

•Observation and field notes •Interviews and focus groups •Narrative and content analysis •Sampling strategies •Data management and analysis •Mixing methods

mixed methods

•Only used by experienced researchers who have a deep understanding of the paradigms of both quantitative and qualitative research •Useful for focusing on research questions that call for the understanding of real-life contextual, multilevel, and cultural perspectives on intervention success •Used when the intent is to combine qualitative and quantitative methods to draw on the strengths of each methodology

Rapid Critical Appraisal (RCA)

•Rapid Critical Appraisal (RCA) •Goal: identify "keeper studies" (studies that should be retained) •Evaluation •Goal: extract data from individual studies to establish agreement across studies •Synthesis •Goal: pull data together from studies within the body of evidence to paint the picture of what the body of evidence tells us •Recommendation •Goal: "next steps" for practice, based on the evidence, are clearly articulated

critical appraisal strength of evidence

•Strength of the evidence is determined by evaluating two components: •Level of evidence (from an evidence hierarchy) • PLUS •Quality (how well the research was conducted and reported) ***Critical appraisal helps us determine the strength of a study

Examples of Facilitators of EBP

•Support and encouragement from administration/management •EBP mentors with excellent EBP skills, knowledge, and proficiency in individual and organizational change strategies •Evidence-based policies and procedures •EBP education •Proper integration of EBP into health professions curricula •Proper tools to assist with and support EBP •EBP councils

research

•Tests an hypothesis •Generates new knowledge to fill a knowledge gap •Results are generalizable •Requires review by an Institutional Review Board (IRB) •NOTE: Research Utilization is use of results from a single study to inform practice decisions. •Translational Research studies how evidence-based interventions are translated into real-world settings.

•Is the following statement true or false? •A well-formulated PICOT question should specify the measurable patient outcomes that need to addressed.

•True Rationale: A PICOT question should always specify the outcome that is expected from the clinical question. It is important that the outcome be measurable in some way so that the effectiveness of the change can be evaluated.

Finding a quasi-experimental research study that tests a protocol for the frequency of turning for immobile patients published in a peer-reviewed journal is an example of external evidence. t/f?

•True Rationale: External evidence includes research articles published in peer-reviewed journals.

•Key initiatives to advance EBP include:

•United States Preventive Services Task Force (USPSTF) •Community Services Task Force •Patient-Centered Outcomes Research Institute (PCORI) •American Nurse Credentialing Center's (ANCC) Magnet Designation and Pathways to Excellence •Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare

Quality Improvement

•Uses a systematic process (quality improvement model such as PDSA/PDCA) to identify and address issues within the organization •Looks at structures and processes to identify issues that are impeding quality and safety •Uses internal evidence to identify and track trends •Results are not generalizable Typically does not require review by an Institutional Review Board (IRB)

validity

•Validity refers to whether the study results can be "believed" (internal validity) and whether the results can be generalized to other settings/patient populations (external validity). •CONFOUNDING VARIABLES are those factors that interfere with the relationship between the independent and dependent variables.

Barriers and Facilitators to Evidence-Based Practice

•Within healthcare organizations and settings where care is provided, both barriers and facilitators exist that influence the uptake and sustainability of EBP. •Practitioners must learn how to overcome barriers and leverage facilitators in order to implement EBP •Organizational barriers, facilitators, culture, and readiness for system-wide implementation of EBP should be assessed.

shared decision making (SDM)

•brings patients voice together as an equal with clinician voice to make mutually clinical decisions. Includes use of a common language that fosters engagement in SDM •GOAL: Achieving best outcomes and empowering patients and families •Two-way communication between patient and care provider. •Imperative to address both communication and perception issues when engaging in shared decision making •Clinicians must strive not to make judgments about what patients may or may not expect or desire related to their care needs

clinical significance

•defined as study findings that will directly influence clinical practice, whether they are statistically significant or not •Not influenced by sample size

Critical appraisal of quantitative studies....

•encompasses identifying a study's place on levels of evidence hierarchy and answers three broad questions: •Are the results of the study valid? (Validity) •What are the results? (Reliability) •Will the results help me in caring for my patients? (Applicability)

levels of evidence hierarchies

•provide guidance about the types of research studies, if well done, that are more likely to provide reliable answers to clinical questions. •There are a variety of different hierarchies of evidence

reliability

•refers to the "repeatability" of the study—that is, if the study were repeated under the same circumstances, would the results be the same?

statistical significance

•the result of statistical analysis of data are unlikely to have been caused by chance, at a predetermined level of probability. •Represented by p value ***Statistical significance is when p < .05 (false/rejected) •Statistical significance is influenced by sample size helps quantify whether a result is likely due to chance or to some factor of interest