Transcript Theory and Evidence-Based Practice in Nursing

Chapter 12
Evidence-Based Practice and
Nursing Theory
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Overview of Evidence-Based Practice
• Evidence-based practice (EBP) was
introduced in the 1970s by Dr. Archie
Cochrane.
• Dr. Cochrane focused on critical review
of research (emphasis on RCTs) to
improve medical practice.
• Application in nursing has been delayed
but has been growing over the past 10
years.
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Overview of Evidence-Based
Practice—(cont.)
• EBP is based on the premise that
health professionals should not base
practice on tradition and belief but on
information grounded in research.
• EBP is not synonymous with research.
– Research focuses on discovery.
– EBP focuses on application.
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Overview of Evidence-Based
Practice—(cont.)
• EBP involves:
– Identifying a clinical problem
– Searching the literature and
critically evaluating research
evidence
– Determining appropriate
interventions
• EBP integrates research, theory, and
practice.
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Evidence-Based Practice
• EBP is “the conscientious, explicit, and judicious use of
theory-derived, research-based information in making
decisions about care delivery . . . in consideration of
individual needs and preferences”
• Key concepts of EBP
– Best evidence
– Expertise
– Patient values
• Careful review of research findings according to
guidelines.
• De-emphasizes ritual, isolated, and unsystematic clinical
experiences, options, and tradition as basis for practice
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Question
Which of the following is NOT considered to be a key
concept of EBP?
A. Best evidence
B. Patient values
C. Provider expertise
D. Traditional practices
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Answer
D. Traditional practices
Rationale: EBP de-emphasizes ritual, unsupported
practices, and tradition and focuses on researchsupported interventions that considers patients’ desires
and needs and provider expertise.
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Evidence-Based Nursing
• Some sources for EBP
information/guidelines
– Cochrane Collaboration/Cochrane
Database of Systematic Reviews—
network that helps health care
providers make informed decisions
about health care
– Agency for Healthcare Research
and Quality (AHRQ)—maintains
database of evidence-based clinical
practice guidelines
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Evidence-Based Nursing—(cont.)
• Concerns
– Too much focus on EBP could result in “cookbook
care” and loss of “art” of nursing.
– Lessening of attention to holistic care
– Health care reimbursement might drift exclusively
to interventions substantiated by “evidence.”
– Not all health care practices can or should be
based on science per se (What about “care”?).
• Consensus agreement that EBP in nursing should
consider all types of evidence (not just RCTs), as well
as clinical experience, patient experiences and
desires, and relevant local/organizational influences.
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Practice-Based Evidence
• PBE is a relatively new concept in nursing and health
care.
• Based on the observation that many interventions have
limited formal research support
• PBE recognizes the importance of the environment in
determining practice recommendations.
• Premise of PBE is that large databases should be
reviewed or “mined” to gather data on quality and
effectiveness.
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Practice-Based Evidence—(cont.)
• PBE seeks to determine what works best for which patients, under
what circumstances, and at what costs.
• More comprehensive picture than RCTs
• Sources include:
–
Benchmarking data
–
Clinical expertise
–
Cost-effective analyses
–
Infection control data
–
Medical record data
–
National standards of care
–
Quality improvement data
–
Patient and family preferences
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Relationships among practice, theory, research, and the
PBE/ EBP cycle.
(From Walker, L. O., & Avant, K. C. [© 2011]. Strategies for theory
construction in nursing [5th ed., Fig. 2-3; p. 46]. Reprinted by permission of
Pearson Education, Inc., Upper Saddle River, NJ.)
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Theory and Evidence-Based Practice
• More awareness of EBP has renewed
appreciation for linkages among
research, theory, and practice.
• Research and clinical data provide
evidence for EBP and/or PBE and can
generate practice guidelines and/or
situation-specific theories.
• Preference for term “theory-guided,
evidence-based practice”
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Models for Evidence-Based Practice
• For some EBP models, the goal is to
create or establish EBP protocols,
procedures, or guidelines.
• Some EBP models focus on
implementation of EBP in the setting or
institution.
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Models for Evidence-Based Practice—
(cont.)
• Most commonly used and described in nursing literature
are:
– Academic Center for Evidence-Based Practice Star
Model (ACE Star Model) (Stevens, 2004)
– Advancing Research and Clinical Practice Through
Close Collaboration (ARCC Model) (Melnyk &
Fineout-Overholt, 2011)
– Iowa Model (Titler et al., 2001)
– Johns Hopkins Nursing Evidence-Based Practice
Model (JHNEBP) (Newhouse et al., 2007)
– Stetler Model of Evidence-Based Practice (Stetler,
2001)
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Evidence-Based Practice Models—
ACE Star Model
• Developed by faculty at University of Texas
Health Science Center at San Antonio
• Depicted by five points of sequential knowledge
transformation
– Discovery research
– Evidence summary
– Translation to guidelines
– Practice integration
– Process and outcome evaluation
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Diagram of the ACE star model for evidence-based practice.
(Used with permission from Stevens, K. R. [2012]. ACE Star Model: Knowledge
transformation©. Academic Center for Evidence-Based Practice. Available at
http://www.acestar.uthscsa.edu/acestar-model.asp)
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Evidence-Based Practice Models—
ACE Star Model—(cont.)
• Knowledge transformation (KT) consists of
eight premises.
– KT is necessary prior to using research for
clinical decision making.
– KT is derived from multiple sources (e.g.,
research, experience, authority).
– Research process is the most stable
source of knowledge.
– Evidence can be classified by strength of
evidence based on rigor.
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Evidence-Based Practice Models—
ACE Star Model—(cont.)
• Knowledge transformation (KT) consists of eight
premises—(cont.)
– As research is converted through a system of
steps, other knowledge is created.
– The form in which knowledge exists can be
referenced to its use.
– The form of knowledge determines its
usability.
– KT takes place through steps
(summarization, translation, application,
integration, and evaluation).
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Evidence-Based Practice Models—ACE Star
Model—(cont.)
• ACE Star Model has been shown useful
in teaching the process of research
evidence.
• For more information, see:
http://www.acestar.uthscsa.edu/index.
asp
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Evidence-Based Practice Models—
ARCC Model
• The Advancing Research and Clinical
Practice Through Close Collaboration
(ARCC) Model was developed to
advance and sustain EBP (Melnyk &
Fineout-Overholt, 2002).
• Basis in control theory and cognitive
behavioral theories
• Appropriate in clinical practice—
particularly acute care
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Evidence-Based Practice Models—
ARCC Model—(cont.)
• Central constructs of the ARCC Model
– Assessment of organizational culture and
readiness for EBP
– Identification of strengths and barriers to
EBP
– Development and use of EBP mentors
– EBP implementation
– Outcome evaluation (providers’ satisfaction,
cohesion, intent to leave, turnover,
improved patient outcomes, hospital costs)
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Evidence-Based Models—ARCC
Model—(cont.)
• Several scales have been developed to
measure implementation of EBP using
the ARCC Model.
• Among them are scales to measure
organizational readiness and EBP
beliefs.
• Considerable amount of research
support for the ARCC model
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Evidence-Based Practice Models—
Iowa Model of EBP to Promote
Quality Care
• The Iowa Model of EBP was developed
in the 1990s.
– Intent to promote quality care
through research utilization
– It was developed to provide
guidance for nurses in making
decisions about practice.
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Question
Tell whether the following statement is true or false:
The rationale for development of the Iowa Model of EBP
was to manage the costs of health care.
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Answer
False
The Iowa Model for EBP was developed to promote quality
nursing care through incorporation of research into
practice.
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Evidence-Based Practice Models—Iowa
Model of EBP to Promote Quality Care—
(cont.)
• Organized into starting points, decision points, and feedback loops
–
Starting points are problem-focused triggers or knowledgefocused triggers
–
Decision points:
• Is the topic a priority?
• Is there sufficient research base?
• Is change appropriate for adoption in practice?
–
There are numerous feedback loops based on the model.
–
After implementation of practice change, monitor and analyze
the structure, process, and outcome data; then disseminate
results.
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Diagram of the Iowa method
of evidence-based practice.
(Reprinted with permission from
University of Iowa Hospitals and Clinics.
© 1998. For permission to use or
reproduce the model, please contact
University of Iowa Hospitals and Clinics
at 319-384-9098.)
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Evidence-Based Practice Models—
Iowa Model of EBP to Promote
Quality Care—Resources
• For more information, see:
http://www.nnpnetwork.org/ebp-resources/iowa-model
http://www.hinursing.org/pdf/IowaModel.pdf
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Evidence-Based Practice Models—
Johns Hopkins Nursing EBP Model
• The JHNEP Model is a problem-solving
approach to clinical decision making.
• Developed to accelerate research into
nursing practice and promote nursing
autonomy, leadership, and engagement
with colleagues
• Combines the nursing process, the ANA
Standards of Practice, critical thinking,
and research utilization
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Evidence-Based Practice Models—
Johns Hopkins Nursing EBP Model—
(cont.)
• Three core elements (PET)
– Practice question
– Evidence
– Translation
• Several phases composed of 18 steps.
– Each step helps clarify the processes.
– Assist in understanding how to proceed
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Evidence-Based Practice Models—
Johns Hopkins Nursing EBP Model—
(cont.)
• Model begins with an EBP question (PICO) consisting
of:
Practice question (patient, population and problem)
Intervention
Comparison as appropriate
Desired Outcome(s)
• Other steps involve defining the scope of the question,
assigning reasonability for leadership, recruiting a team
and scheduling conferences.
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Question
When developing a PICO question, the “C” represents
which of the following?
A. Care options
B. Comparison with a baseline or standard
C. Consideration of patient or provider values/wishes
D. Costs of interventions
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Answer
B. Comparison with a baseline or standard
Rationale: A PICO question consists of:
Practice question (patient, population, and problem)
Intervention
Comparison as appropriate
Desired Outcome(s)
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Evidence-Based Practice Models—
Johns Hopkins Nursing EBP Model—
(cont.)
• Evidence phase includes:
– Literature search
– Team appraisal and recommendations
• Translation phase:
– Team decides whether and how to
implement changes.
– Evaluation of implementation
– Communicate the findings PRN
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Evidence-Based Practice Models—
Johns Hopkins Nursing EBP Model—
Resources
• For more information (optional course):
http://www.hinursing.org/pdf/IowaModel.pdf
• Data collection tool:
http://www.nursingworld.org/DocumentVault/Nursi
ngPractice/Research-Toolkit/JHNEBP-ResearchEvidence-Appraisal.pdf
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Evidence-Based Practice Models—
Stetler Model
• Originally implemented in the 1970s as a quality
improvement effort
• Similar to the nursing process thus easily implemented
• Five steps or phases
– Preparation
– Validation
– Comparative evaluation/decision making
– Translation/application
– Evaluation
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Evidence-Based Practice Models—
Stetler Model—(cont.)
• Preparation
–
Propose, control, and source research evidence
• Validation
–
Determine credibility of findings and potential for qualifiers for
application
• Comparative evaluation/decision making
–
Synthesis of information and decisions for recommendations for
criteria and applicability
• Translation/application
–
Create operational definitions for use and actions for change
• Evaluation
–
Determine alternate types of evaluation
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Evidence-Based Practice—Summary
• EBP has become one of the key tenets of
quality nursing care.
• In nursing, it is critical that EBP go beyond
research and be theory based.
• Growing attention to the concept of PBE has
renewed attention to the critical role of
theory in excellent nursing practice.
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