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8/13/2019 Evidance Based Nursing Practice
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e f i n i t i o n s
! Evidence-based practice can be thought of as requiring"the integration of the best research evidence with our
clinical expertise and our patient's unique values and
circumstances." (Straus, et al., 2005)
! "Fortunately, evidence-based practice (EBP) is anapproach that enables clinicians to provide highest
quality of care in meeting the multifaceted needs of their
patients and families." (Melnyk & Fineout-Overholt, 2005)
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Definitions
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Goals of E P
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Why the rapid spread of
evidence-based practice?
Some of major reasons cited by Sackett et al (1997)
for the spread of the EBP movement have been :
" the lack of research-based information to supportclinical decision making
" the lack research-based guidelines and protocols to usein clinical practice
" the overwhelming volume and variability of new journalinformation
" the inadequacy of traditional sources of information (e.g.textbooks out of date)
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What are the benefits ofevidence based practice?1. To patients/consumers
Patient typically accept recommended carefrom health professionals with the unspokenassumption that the practitioner know what
works
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What are the benefits ofevidence based practice?2. To nurses! EBP allows a more structured and streamlined way of
keeping abreast of relevant new developments withoutbecoming over-whelmed by information overload
! EBP also allows nurse to communicate effectively withtheir patients and with the healthcare team about the
rationales for decision making and care plans! An EBP nurse is a confident professional, feeling
assured that they are providing care that is supported byfacts rather than habits, and can take legalaccountability for their practice
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What are the benefits of
evidence-based practice?
3. To the healthcare organization! EBP philosophy allow healthcare organization to position themselves
in the market as quality institution.! An EBP-compliant institution should be less likely to attract
litigation, or to successfully defend the care delivered.
! EBP allows the scrutinizing of practice for effectiveness.! This process often results in practice changes that allow significant
cost savings, or alternatively justify necessary additionalexpenditure
! This is attractive to organizations frequently struggling to meetassigned budgetary limits, or lobbying government for additionalfunds
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W hat are the benefits ofevidence-based practice?FG H7 05+ %7
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1.Ask or identify the important clinical question2. Collect the best and more pertinent evidence3. Critically analyze and rate the evidence4. Integrate the evidence into clinical decisions5. Implement best evidence in clinical practice6. Evaluation
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1. Ask or identify the important
clinical question
! HOW?? PICO! Patient
!Age, sex, ethnicity, etc.! Condition, diseases, general health status
! Intervention! Education, diagnostics, treatment plan, self-care, etc.
! Comparison Intervention! Placebo, etc.
! Outcome! Expected and actual effects on patient
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PICO
! The nurses want to know:What is the best way of obtaining a urine specimen
culture, from a child?
Population: Children suspected of having UTI (Urinary
tract infection), who are not yet toilet training
Intervention: Bag-catch urine specimen, clean-catch urine
specimen
Comparison: Suprapubic aspiration
Outcome: Culture contamination
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PICO
The revised question:
In children suspected having of UTI, who are not yet toilet
training, what is the risk of culture contamination when
urine is obtained by bag-catch or clean catch, as
compared with urine obtained by suprapubic aspirationdirectly from the bladder?
! Not all questions are of a clinical nature! Intervention can be interpreted very broadly
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! Do nurse led tobacco cessation interventionsresult in decreased smoking rates after hospitaladmission for coronary heart disease?
! What are the factors, identified by mothers wholive in the deprived inner city areas, that
influences them to breastfeed or to bottle-feed
using infant milk formula
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2. Collect the best and more
pertinent evidence
Where is the evidence located?
! CINAHL (Cumulative Index to Nursing and the Allied Health Literature)! Medline www.ncbi.nlm.nih.gov/PubMed/.! Proquest
http://www.proquest.com/pqdweb
username: 0NQTKKWNKM& Password:brawijaya
! Ovidhttp://gateway.ovid.com/
ID & Password : hsll199
! EBSCOhttp://search.epnet.com/
user : cathedral & password : dc
NEW: http://search.ebscohost.com
Id: n5000145, passwords
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3. Critically analyze and rate the
evidence
! Critical Appraisal of the evidence! Grading of the evidence
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Grading of research studies that measure theeffect of an intervention treatment or therapyLevel ofevidence
Study designs
I Evidence obtained from a systematicreview or meta-analysis of all relevantrandomized controlled trials
II Evidence obtained from at least oneproperly designed randomized controlledtrial
III-1 Evidence obtained from well-designedpseudo-randomized controlled trials
Source : NHMRC 1999
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Grading of research studies that measure theeffect of an intervention treatment or therapyLevel ofevidence
Study designs
III-2 Evidence obtained from comparative
studies with concurrent controls andallocation not randomized (Cohort studies,case-control studies or interrupted time-
series with control group)
III-3 Evidence obtained from comparativestudies with historical control, two or more
single-arm studies, or interrupted time-series without a parallel control group
Source : NHMRC 1999
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Levels of evidence of effectivenessLevel Evidence of effectiveness
1 Systematic review (with homogeneity) of experimentalstudies, or one or more large experimental studies withnarrow confidence interval
2 Quasi-experimental studies (e.g without randomization)
3a Cohort studies (with control group)
3b Case-controlled
3c Observational studies without control groups
4 Expert opinion without explicit critical appraisal, orbased on physiology, bench research or consensus
Source:The Joanna Briggs Institute.Available at www.joannabriggs.edu.au/pubs/approach.php.
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TRIP = turning research into practice
Simultaneously searches evidence-based sources of systematic reviews, practice
guidelines, and critically-appraised topics and articles
QUALITY OF EVIDENCE
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4. Integrate the evidence into
clinical decisions
Key points:
Research evidence is, on its own, insufficient to ensurethe robust clinical decisions necessary for clinically
effective health care
Good clinical decisions require the sophisticatedapplication of research findings in the context ofclinical expertise, patient preferences and values, andthe individual decisions
The availability of resources influences how researchevidence is interpreted and applied
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4. Integrate cont
The seven rights of the clinical effectiveness
(Royal College of Nursing, 1996)
1.
Right thing for the2. Right patient from the3. Right person at the4. Right time in the5.
Right way to achieve the
6. Right outcome at the7. Right cost
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4. Integrate cont
Influences on clinical decision making
Decisionmaking
Clinicalexpertise
Intuition
Research
AvailableResources
Media
Experts
Values andbelief
Consensus
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4. Integrate cont
Clinical expertise:The ability to use our clinical skills and past experience to rapidly
identify each patients unique health state and diagnosis, theirindividual risks and benefits of potential interventions, and theirpersonal values and expectations (Sackett et al 2000)
Intuitive practice:
A way in which we know and behave about the situation that is notbased on conscious reasoning or rational thought process(Parahoo 1997)
Builds on repeated practice situations, it is context specific and it
enables the integration of complex pieces of a data to derive adecision that is difficult to articulate through linear rules(Greenhalgh 2000)
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5. Implement best evidence in
clinical practice
Where to start?
Identifying appropriate topics to address" Consider local and national views on the topic" Attitudes to using research evidence
Choosing a project manger Diagnosing the situation
The organizational environment, stakeholders andpractitioner opinion leaders, grassroots workers, Users views,the way we do things round here, SWOT analysis
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5. Implement cont
How to implement the changes?
Developing a dissemination and implementationstrategy
General/ specific approaches to manage changeEducational approach, epidemiological stances,marketing of a product, information or strategies,behavioural changes, social interactionism,organizational approach, resources and management
issues, realistic goals and time frames, reviewing.
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6. Evaluation
Evaluating the progress and effects of thechanges?
Maintaining close contact with the progress and effects Formal evaluation and dissemination
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How Do I Participate in an Evidence-
Based Practice?
!Ask an authority or expert in the field! Consult a textbook!
Look for an article in a nursing journal! Look for an article in a scholarly journal!Ask a nursing peer! Use simple trial and error! Use your intuition, judgment, or reasoning skills
to solve the particular problem
Godshall, Maryann 2010
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