Transcript Slide 1
Indiana Association of School Nurses Evidence Based Practice: Will you know it when you see it? Learning Series November 2014 Ways of knowing • Authority • Tradition • Common Sense • Logic • Trial and Error • Experience • Apprenticeship • Consensus • Intuition • Empirical evidence How do you know? • What is the most significant health intervention to improve student achievement? • What is the most effective school based program to curtail obesity? Evidence Based Practice Pyramid Systematic EB Reviews Meta analyses Randomized Clinical Trials Clinical Guidelines Case Studies Expert Opinion ACHIEVING A BALANCE Research • Randomized Control Studies • Systematic Reviews • Meta-analyses • Other studies Knowledge • Case studies • Personal experience • Anecdotes • Expert opinion Evidence of? • Effect of nursing and community interventions • What works? What interventions work? • What are the outcomes? • Not research on the problem, research on solution EB interventions? • A study of recess before versus after lunch on BMI • Clinical guidelines for BMI screening • Descriptive research study of Colorado’s child obesity • Standardized script for communicating child’s BMI Public health / school health evidence Cross-sectional & quasi-experimental studies versus “Gold Standard” randomized controlled trials • • • • Often lack a comparison group Multiple caveats Often large-scale environmental & policy change Needs & preferences of large, diverse, groups “Proven” Practices • • • • Significant change in one outcome Comparison / control group Sample sizes of at least 30 in each group Publicly available Promising Practices • Potential to become evidence-based ▫ Promising practice ▫ Emerging practice ▫ Theoretical rationale Goal ▫ Achieve higher levels of evidence practice to become practice models Programs Proven Promising • FluText • Nurse Family Partnership • Project Alert • Universal Breakfast • Asthma Action Plans • Case Management • Hip Hop to Health Jr • Text4Health – Adolescents • Triple P (Boys & Girls Clubs) • Yoga *Additional considerations play a role on a case-by-case basis. These may include attrition, quality of outcome measures, and others. Type of Information Proven Program Program must meet all of these criteria to be listed as "Proven". Promising Program Not Listed on Site Program must meet at least all of If a program meets any of these these criteria to be listed as conditions, it will not be listed on "Promising". the site. Type of Outcomes Affected Program must directly impact Program may impact an one of the indicators used on the intermediary outcome for which site. there is evidence that it is associated with one of the PPN indicators. Substantial Effect Size At least one outcome is changed Change in outcome is more than No outcome is changed more by 20%, 0.25 standard 1%. than 1%. deviations, or more. Statistical Significance At least one outcome with a substantial effect size is statistically significant at the 5% level. Study design uses a convincing comparison group to identify program impacts, including randomized-control trial (experimental design) or some quasi-experimental designs. Comparison Groups Program impacts an outcome that is not related to children or their families, or for which there is little or no evidence that it is related to a PPN indicators (such as the number of applications for teaching positions). Outcome change is significant at No outcome change is significant the 10% level (marginally at less than the 10% level. signficant). Study has a comparison group, but it may exhibit some weaknesses, e.g., the groups lack comparability on pre-existing variables or the analysis does not employ appropriate statistical controls. Study does not use a convincing comparison group. For example, the use of before and after comparisons for the treatment group only. Sample Size Sample size of evaluation exceeds Sample size of evaluation exceeds Sample size of evaluation 30 in both the treatment and 10 in both the treatment and includes less than 10 in the comparison groups. comparison groups. treatment or comparison group. Availability of Program Evaluation Documentation Publicly available. Publicly available. Distribution is restricted, for example only to the sponsor of the evaluation. EBP PROCESS Steps • ASK - an answerable clinical question • ACQUIRE - select appropriate resource(s) • APPRAISE - appraise evidence for validity • APPLY - integrate evidence into practice • ASSESS - evaluate outcomes Asking an Evidence Based question P problem/population I intervention C comparison O outcomes Asking an Evidence Based question • Interventions: Which are the most effective? ▫ In elementary school children, what treatment best decreases headache symptoms and decreases time out of class? Asking an Evidence Based question • Interventions: Which are the most effective? ▫ In middle school students, do lunchtime walking programs decrease BMI after one year? Asking an Evidence Based question • Interventions: Which are the most effective? ▫ For school staff, does use of Food Allergy Action Plan training in September orientation result in emergency plan initiation at the onset of symptoms? What works for ……. ? • Rural – urban – suburban • Large schools - small schools • School climate • Geography • SES • Ethnicity • Religion • • • • • • • • Personality Physical environment Climate Safety / violence Public transportation Temperature Class size Education level Practices • Asking the answerable question • Finding the evidence • Will it work here • Staying current Interventions that work Interventions that work • Low dose • High dose Interventions • Low dose ▫ Nutrition education ▫ BMI awareness • High dose Interventions • Low dose ▫ Nutrition education ▫ BMI awareness • High dose ▫ Wellness committee/ PTA / City Hall / Businesses ▫ On campus nutrition policy ▫ Increased PE ▫ Increased PE intensity ▫ Recess ▫ Label / Cooking / Shopping ▫ Portion sizes ▫ Open gyms ▫ Changes BEHAVIOR Interventions • Low dose • High dose ▫ Education only ▫ Comprehensive ▫ One system ▫ Multi system: Child, family, community ▫ Changes BEHAVIOR Evidence Based Practice Childhood Obesity Interventions GUIDELINE.org • Primary prevention of childhood obesity ▫ ▫ ▫ ▫ ▫ Small group activities Goal setting Social support Interactive food-related activities (e.g., cooking, taste-testing) Family participation Interventions GUIDELINE.org • Primary prevention of childhood obesity ▫ ▫ ▫ ▫ Physical activity behavior modification Low intensity gradually increased Sustained, repeated interventions Reduce watching TV, playing video games, & recreational computer use Interventions GUIDELINE.org • Primary prevention of childhood obesity ▫ ▫ ▫ ▫ ▫ ▫ ▫ Integrate into curricula Daily physical education by physical education teachers Quality daily physical activity (vigorous physical activity) Youth driven approaches Healthy choices in cafeterias \ vending Increase physical activity at recess and lunch Form community partnerships and coalitions Interventions GUIDELINE.org • AAP ▫ ▫ ▫ ▫ ▫ Social marketing Comprehensive community sports Lived environment Role models Reduce financial disincentives Interventions CLOCC: 5 4 3 2 1 GO! http://www.clocc.net/partners/54321GO/ 5 servings of fruits and vegetables a day 4 servings of water a day 3 servings of low-fat dairy a day 2 or less hours of screen time a day 1 or more hours of physical activity a day Evaluation • Did the intervention / program work? • Were the objectives and goals achieved? • Resolved or • Revise Weighing the evidence • School Nurse News • Journal of the American Medical Association Case study • Journal of School Nursing Literature review • School Nurse Dissertation Meta-analysis Asking an Evidence Based question P problem/population I intervention C comparison O outcomes Asking an Evidence Based question P I problem/population asthma in adolescent children intervention Open Airways C comparison O outcomes Parent education control of symptoms Asking an Evidence Based question • Interventions: Which are the most effective? ▫ In elementary school children, what treatment best decreases headache symptoms and decreases time out of class? Asking an Evidence Based question • Interventions: Which are the most effective? ▫ In middle school students, do lunchtime walking programs decrease BMI after one year? Where to look? • pubmed.gov • guideline.gov • thecommunityguide.org • Promising Practices Network (June, 2014) http://www.promisingpractices.net/ • ahrq.gov/clinic/pocketgd.htm • www.ahrq.gov/about/nursing/ Be skeptical • Association programs ▫ Read the small print ▫ Objectives ▫ Outcomes • Packaged programs ▫ Initially free ▫ Marketing Be skeptical • • • • • Do the interventions work? In what populations? (age, culture, urban/rural, etc) Strength of the evidence? What are the objectives? What are the outcomes? Are those the objective/outcomes YOU are trying to achieve? • Low dose or high dose? • Costs? • Compare the interventions Find the evidence: 1. Immunization – ▫ No exclusions ▫ 98% immunization rate 2. Preventing skin cancer / sun exposure ▫ Decrease in reported sun exposure ▫ No sun burns 3. Preventing pediculosis ▫ No exclusions Take away message • Skeptical • Stay current • Quality and effectiveness depends on: ▫ Structure ▫ Implementing evidence based interventions: Fidelity ▫ High versus low dose ▫ Evaluating and reporting outcomes Reference Melnyk B. M. & FineoutOverholt (Eds.) (2011).Evidence-based practice in nursing and health: A guide to best practice Philadelphia: Lippincott Reference Selekman, J., & Vessey, J.A, Bergren, M.D. (2013). The school nurse’s role in research and the development of evidence-based practice. In J. Selekman (Ed). School nursing: A comprehensive text. Philadelphia: F.A. Davis. Reference Adams, S. & McCarthy, A.M. (2005). Evidence based practice and school nursing. Journal of School Nursing, 21, 258 – 265.