Transcript adn-cip.waketech.edu - NC Associate Degree Nursing

Evidence Based Nursing
Practice
Julia Wetmore, RN, PhD
What is EBP?
The conscious and intentful use of
research and theory based information
to make decisions about patient care
delivery (Macnee, 2004).
EBP is a problem-solving approach
integrating:
 The
most relevant evidence from literature to
answer the clinical question.
 One’s
own clinical expertise.
 Patient
preferences and values.
EBP originated in medicine.

Dr. Archie Cochrane, Epidemiologist

Crossing the Quality Chasm (IOM, 2001)

Studies in medicine and nursing indicating
that interventions based on evidence have
better outcomes.
How do we establish which evidence
is “best”?
Five Key Steps of EBP
Step 1. Formulate the question (PICO).
Step 2. Search for the best evidence.
Step 3. Critically appraise the evidence.
Step 4. Integrate the evidence.
Step 5. Evaluate its effectiveness.
The “PICO” format
P
Population
I
Intervention or Interest
C
Comparison intervention or status
O
Outcome
What are the types of evidence we
are likely to find?
 Clinical
Guidelines
 Systematic Reviews or Meta-analyses
 RCTs
 Quasi-experimental Studies
 Descriptive or Qualitative Studies
Handy links to library web pages
At WCU, a link takes our students directly to
the EBP web page, designed by the
university librarian.
It is placed on the content page of every
online nursing course.
Definitions of different types of
evidence syntheses (Melnyk &
Overholt, 2005)

Systematic review: A compilation of like
studies to address a specific clinical question
using a detailed, comprehensive search
strategy and rigorous appraisal methods for
the purpose of summarizing and
communicating the results and implications
of contradictory results or otherwise
unmanageable quantities of research.
Definitions of different types of
evidence syntheses (continued)

Meta-analysis: A statistical approach to
synthesizing the results of a number of
studies that produces a larger sample size
and thus a greater power to determine the
true magnitude of an effect. Used to obtain a
single-effect measure (i.e. a summary
statistic) of the summarized results of all
studies included in a review.
Definitions of different types of
evidence syntheses (continued)
Integrative review: A systematic review that
does not have a summary statistic because
sample sizes cannot be summarized in an
integrative review (usually due to
heterogeneous studies/samples).
 Narrative review: A review that includes
published papers that support an author’s
particular point of view; serves as a general
background discussion of a particular issue.

Example of an Integrative Review

Armstrong, D. & Bortz., P. (2001). An
integrative review of pressure relief in
surgical patients. AORN Journal, 73(3), 645,
647-648. (copy of article available upon
request).

Many good examples of SRs, meta-analyses
and integrative reviews in Evidence-Based
Nursing.
How do we critically appraise the
evidence?

Rate the evidence based on a hierarchy.

Ask three questions:
1.
2.
3.

Are the results valid?
Are the results significant?
Can I generalize the results?
Use a review team to appraise the
literature.
Rating System for the Hierarchy
of Evidence
(Melnyk, 2006)

Level I. Evidence obtained from a systematic
review or meta-analysis of all relevant, randomized
clinical trials (RCTs), or clinical practice guidelines
based on systematic reviews of RCTs.

Level II. Evidence obtained from at least one welldesigned RCT.

Level III. Evidence obtained from well-designed
controlled trials without randomization (quasiexperimental).
Rating system (continued):

Level IV. Evidence from well designed case-control
and cohort studies.

Level V. Evidence from SRs of descriptive and
qualitative studies.

Level VI. Evidence from a single descriptive or
qualitative study.

Level VII. Evidence from opinion of authorities
and/or reports of expert committees.
The Ace Star Model (Stevens, 2005)
Discovery
Summary
Translation
Integration
Evaluation
Other models of EBP include:

Iowa Model.

Rosswurm and Larrabee Model.

Stetler Model.
What needs to be taught to the student
of nursing?
o Essential competencies from ACE
(Stevens, 2005).
o AACN competencies identified in
Essentials of baccalaureate education
(AACN, 1998).
Stevens (2005) Essential Competencies
From: Stevens, K. (2005). Essential competencies for evidence-based
practice in nursing. (1st ed.). San Antonio, TX: ACE, UTHSCSA.
Define EBP in terms of evidence, expertise,
and patient values.
 Critically appraise original research reports
for practice implications.
 Classify clinical knowledge as primary
research, evidence summary, or practice
guideline.
 Recognize ratings of strength of evidence
when reading literature.

Essential competencies (cont.)




Use evidence summary databases to locate
systematic reviews and evidence summaries on
clinical topics.
Participate on a team to develop agency-specific
evidence-based clinical guidelines.
Deliver care using evidence-based clinical practice
guidelines.
Choose evidence-based approaches over routine
as basis for own clinical decision-making.
AACN Essential Competencies (1998)
Related to Critical Thinking
o
Apply research-based knowledge from nursing
and sciences as the basis for practice.
o
Evaluate nursing care outcomes through the
acquisition of data and questioning of
inconsistencies.
AACN essentials (cont.)
Related to Provider of Care
o
Integrate theory and research-based
knowledge from the arts, humanities and
sciences to develop a foundation for
practice.
o
Participate in research that focuses on the
effectiveness of nursing interventions.
o
Utilize outcome measures to evaluate
effectiveness of care.
Teaching principles of EBP to students
What? When? How?

Components of EBP.
 EBP
versus RU.
 EBP
versus “best practice.”
 EBP
applied to patient care.
 EBP
assignment in NSG 470.
Barriers to EBP in Clinical Settings from Pravikoff et al.,
(2005). Readiness of US Nurses for Evidence-Based
Practice. AJN, 105.
 Lack
of knowledge about EBP.
 Lack of knowledge about library and
online resources.
 Inconvenient/inaccessible
library/internet.
 Misperceptions or negative views of
research.
 Devotion to traditional care.
Barriers (continued)






Overwhelming patient care load.
Voluminous amounts of literature.
Difficult patient care situations.
Organizational constraints.
Inadequate information in
prelicensure nursing program.
Laziness/lack of motivation/
burnout.
EBP Facilitators






Educational emphasis in nursing schools and
hospitals.
Administrative support and encouragement.
Time to think through patient care situations.
Time to critically appraise studies and
implement findings.
Clearly written, well-done research reports.
Library and internet access in the clinical area.
EBP Controversies





Is it just a new term for RU?
Is it too “cookbook” to be realistic?
Patient care realities are too varied
and complex…how can guidelines
be practical?
Few guidelines, hard to find.
It requires RCTs which are
impossible in health care settings.
References
American Association of Colleges of Nursing. (1998). The essentials of
baccalaureate education for professional nursing practice. Washington, DC:
AACN.
Burns, N. & Grove, S. (2007). Understanding nursing research. Building an
evidence-based practice. (4th ed.). St. Louis, Missouri: Saunders/Elsevier.
Institute of Medicine. (2001). Crossing the quality chasm. Washington, DC:
National Academy Press.
Heater, B., Becker, A. & Olson, R. (1988). Nursing interventions and patient
outcomes. A meta-analysis of studies. Nursing research, 37, 303-307.
Macnee, C.L. (2004). Understanding nursing research: Reading and using research
in practice. Philadelphia: Lippincott, Williams, & Wilkins.
Melnyk, B. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing &
healthcare. Philadelphia: Lippincott, Williams & Wilkins.
Pravikoff, D.S., Tanner, A.B. & Pierce, S.T. (2005). Readiness of U.S. Nurses for
Evidence-Based Practice. American Journal of Nursing, 105, 40-51.
Stevens, K.R. (2005). Essential competencies for evidence-based practice in
nursing. (1st ed.). San Antonio, TX: Academic Center for Evidence-Based
Practice, UTHSCSA.