به نام خالق بهار 110/16/2015EBN dr yekefalah-phd of nursing2012

بهار خالق نام به

104/21/23 EBN dr yekefalah-phd of nursing2012

EBNEBN


ObjectivesObjectives

• Describe evidence based practice from a nursing perspective

• Compare and contrast evidence based nursing and medicine

• Identify challenges to using evidence based practice in nursing

• Identify resources relevant to nursing

3EBN dr yekefalah-phd of nursing2012

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What is - Evidence?What is - Evidence?

Anything that provides material or

information on which a conclusion or proof

may be based; used to arrive at the truth,

used to prove or disprove the point at issue. (Webster)


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What is ‘evidence-based’?What is ‘evidence-based’?

Intervention, not description

Evaluation, not common sense

Knowledge about ‘what works’ must come from …


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::طبابت مبتني بر شواهدطبابت مبتني بر شواهد::طبابت مبتني بر شواهدطبابت مبتني بر شواهدپيشينه:پيشينه:

تفک�ر اس�تفاده از نت�ايج حاص�ل از تحقيق�ات و پژوهش�هاي انج�ام ش�دهل پيش بر مي گردد. سادر درمان بيماريها به صدها

ديوي�د توس�ط » 1990ي ب�ر ش�واهد« ب�راي اولين ب�ار در س�ال نواژه »مبت�و اص�طالح پزش�کي مبت�ني ب�ر ش�واهد ب�راي اولين ش�د ب�ه ک�ار ب�رده ادي«

اس�تفاده «در مقال�ه اي ب�ه نوش�ته » گوي�ات و همک�اران 1992ب�ار در س�ال شد.

تدريجا و پس از آنک�ه پزش�کي مبت�ني ب�ر ش�واهد جايگ�اه خ�ود را پي�دانم�ود، اين تفک�ر )مبت�ني ب�ر ش�واهد ب�ودن( بت�دريج وارد اک�ثر حيطه ه�اي م�راقبت س�المت و سياس�تگذاري س�المت گردي�د. و ب�دين ت�رتيب در کن�ار

Evidence Based Medicine :حيطه هايي چونEvidence Based NursingEvidence Based ManagementEvidence Based Decision makingEvidence Based PhysiotherapyEvidence Based LibrarianshipEvidence Based teachingEvidence Based PracticeEvidence Based policy making .......پديد آمد

يا رد براي تنها نه شواهد کنوني دنياي درمي روند، کار به علمي فرضيه يک اثبات

نيز افراد حرفه اي فعاليتهاي تمامي بلکه . عمل باشند شواهد اساس بر بايد

در را راهکارها بهترين شواهد براساسافراد اختيار در حرفه اي، توسعه جهت

با تضاد در است فرآيندي و مي دهد قرارانجام هميشه آنچه اساس بر عمل

است .مي شده

يا رد براي تنها نه شواهد کنوني دنياي درمي روند، کار به علمي فرضيه يک اثبات

نيز افراد حرفه اي فعاليتهاي تمامي بلکه . عمل باشند شواهد اساس بر بايد

در را راهکارها بهترين شواهد براساسافراد اختيار در حرفه اي، توسعه جهت

با تضاد در است فرآيندي و مي دهد قرارانجام هميشه آنچه اساس بر عمل

است .مي شده


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::طبابت مبتني بر شواهدطبابت مبتني بر شواهد::طبابت مبتني بر شواهدطبابت مبتني بر شواهد :تالشي شواهد بر مبتني طبابت تعريف

آمده بدست شواهد بکارگيري جهت در استمختلف هاي جنبه در علمي، هاي روش از

شواهد ارزيابي در خصوص به باليني، طبابت. سالمت خدمات معايب و مزايا به مربوط

بر مبتني پزشکي جامع، تعريف يک در : است کليدي جز سه تلفيق حاصل شواهد،

بر مبتني bشواهد جديد ترين و بهترينمند نظام مطالعات

پزشک باليني تجربه و تخصص بيمار و جامعه ارزشهاي


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نياز و الزام

به افزايش

آگاهي و به روز شدن

و دانش کاهش

ارائه آگاهي

دهندگان

سالمت خدمات

آمدن وجود آمدن به وجود بهاطالعات و اطالعات دانش و دانش

جديدجديدشدن شدن فراموش فراموشدانسته از دانسته برخي از برخي

گذشته صحيح گذشته هاي صحيح هايبرخي علمي برخي رد علمي رد

اطالعات اطالعات از ازها ها ودانسته ودانسته

زياد حجم

خام و اطالعات

قطعه قطعه

33انتشار بيش از انتشار بيش از ميليون مقاله در ميليون مقاله در

سالسال

دو برابر شدن کل دو برابر شدن کل دانش بيومديکال در دانش بيومديکال در

ماه ماه2020

کل شدن برابر کل دو شدن برابر دواينترنتي هاي اينترنتي داده هاي داده

ماه ماه 88در در

گذشت از گذشت پس از پستنها سال تنها چند سال چند

حدود حدود در تا تا 1010دراز 2020 از درصد درصد

يک يک اقدامات اقداماتمبتني مبتني پزشک پزشک

شواهد شواهد بر بر..استاست

در شواهد بر مبتني طبابت به آوري روي از در ناگزير شواهد بر مبتني طبابت به آوري روي از ناگزيرترين قالبقالب دسترس در و ترين علمي ترين کاملترين، دسترس در و ترين علمي کاملترين،

موجود موجود شواهد ..هستيمهستيمشواهد

Increasing Medical Knowledge/dayIncreasing Medical Knowledge/day

• 27Kg of Guidelines

• New papers 3,200

• Medline New articles 1,000

• RCT’s 60

10

Understanding Some Work Processes Inherently Dangerous

Understanding Some Work Processes Inherently Dangerous

Medication administration

– 770,000 annually killed or injured

from adverse drug events in

hospitals

– In two studies, 34-38% of

medication errors occurred11EBN dr yekefalah-phd of

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Time spent to publish new findings as books (considering the half-life & doubling time of knowledge)

Coverage of knowledge included in books

Large volume of a book cause never be fully seen

Carrying books in hand or in mind are impossible

Outdated knowledge of practitioners because of:


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بر مبتني پزشکي که باشيم داشته خاطر بر به مبتني پزشکي که باشيم داشته خاطر به

انکار شواهد شواهد را پزشکان باليني تجربه انکار اهميت را پزشکان باليني تجربه اهميت

را نمي کند،نمي کند، بيماران ترجيحات و را ارزشها بيماران ترجيحات و ارزشها

آشپزي کتاب يک مانند و نمي گيرد، آشپزي ناديده کتاب يک مانند و نمي گيرد، ناديده

يا مراقبت يک ارائه مراحل تمام که يا نيست مراقبت يک ارائه مراحل تمام که نيست

کند ديکته يک به يک را درمان يک کند انجام ديکته يک به يک را درمان يک توان انجام توان و و

. نمايد سلب پزشک از را گيري .تصميم نمايد سلب پزشک از را گيري تصميم13EBN dr yekefalah-phd of

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Evidence Based MedicineEvidence Based Medicine

Available evidence

Evidence that gets incorporated

into practice

EBM helps shift this balance so

that more research gets translated into

medical practice


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Definition Evidence-based nursing

Definition Evidence-based nursing

“Process by which nurses make clinical decisions using best available evidence, clinical expertise, & patient preferences in the context of available resources”


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DefinitionsDefinitions

Evidence-based nursing is an approach to health care practice that enables nurses to provide the highest quality care based on the best evidence available to meet the needs of their patients.

Melnyk & Fineout-Overholt, 2005

The integration of the best research evidence with clinical expertise and patient values.


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EBP in NursingEBP in Nursing


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Wh

at is E

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Wh

at is E

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Evidence-Based Nursing

.

PatientPreference

BestEvidence

Clinician’sexperience

• Asking Answerable Questions

• Finding the Best Evidence

• Appraising Validity of Evidence

• Integrating Evidence (clinician/patient)

• Evaluating Effectiveness Sackett et al (2000)

Applied to diagnosis, interventions (treatments), and outcomes20EBN dr yekefalah-phd of

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What is Evidence-Based Nursing Practice

What is Evidence-Based Nursing Practice

• Builds on process of research use, but more encompassing

• More specific than term ‘best practices’

• Does not foster rigid adherence to standardized guidelines

• Recognizes the role of clinical expertise• EB nursing practice is a state of mind!


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What Is Evidence-based Practice?

What Is Evidence-based Practice?

• EBP is a decision-making approach that places emphasis on evidence to:– guide decisions about which interventions

to use;– evaluate the effects of an intervention.

Professional Judgment

Best available evidence

Client Values

Professional Professional JudgmentJudgmentBest Available EvidenceBest Available EvidenceClient Client

ValuesValues


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Why Practice EBN?Why Practice EBN?

• Standard of Care: EBNER recommendations• Assures patient receives most up-to-date care possible

• Assists practitioner in dealing with increasing volume of medical literature

• Allows patient and practitioner to work together to make informed decisions


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Why Evidence-Based Practice in Nursing


• Potential to improve quality, reduce variations in care

• Focus on practices that result in best possible outcomes at possibly lower cost

• Provides a way to keep pace with advances


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• Potential to narrow the ‘research-practice gap’: adoption of research findings into practice can take as long as 17 years (Balas & Boren)

• Provides a means to answer problematic clinical • practice issues

• supports/improves clinical decision-making skills

• Bedside nurse as conduit!!


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Closing the Gap…Closing the Gap…

EBN leads to:

• improved patient outcomes

• avoidance of unnecessary procedures

• reduction of complications Nurses should feel empowered to change practice

using proven methods


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MisconceptionMisconception

EBN is not a collection of statistical summaries, ignoring patient preferences and clinical expertise.


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Goals of EBNGoals of EBN• Provide practicing nurses with evidence-

based data

• Resolve problems in the clinical setting• Introduce innovation

• Reduce variations in nursing care• Assists with efficient and effective decision-

making28EBN dr yekefalah-phd of

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The Ultimate Goal

Keeping up with valid information to provide quality patient care and feel good about what we do.

Information Mastery


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Values and PreferencesValues and Preferences

EBN - integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families and communities …


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Evidence-based Steps

1. Formulation of a question

2. Literature search

3. Critical appraisal

4. Clinical decision

5. Performance evaluation32EBN dr yekefalah-phd of

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What EBN originally advocated…What EBN originally advocated…

Ask a Focused Clinical Question

Appraise itFor validity

Incorporate it in your practice

Go to the medline and search for the

Best available evidence

Become a life-long learner


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مراحل•


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EBN Steps:EBN Steps:

• Problem Identification

• Discovery

• Critique

• Summary

• Translation

• Evaluation


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Step 1: Step 1:

• Problem Identification: Converting information needs into an answerable question–PICO

• Patient or Problem

• Intervention

• Comparison Intervention

• Outcomes36EBN dr yekefalah-phd of

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• P= Participant

• I= Intervention

• C= Comparison

• O= Outcome

: PICOفرمول : PICOفرمول


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کنندگان شرکت

و نظر مورد که شرایطی یا بیماریماست عالقه

سودمند یا مضر بالقوه عواملشناسی جمعیت عوامل


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: مداخالت : مداخالتدرمانها•تشخیصی • تستهایکننده • ایجاد عواملکننده • پیشگیری عوامل


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نتایج :مقایسه

می کمک افراد به که مهمی نتایج تمامدرمان موفقیت میزان تشخیص با کند

. نمایند گیری تصمیم نظر، مورد


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بازده

بیماری نهایی سرانجام به مربوط نتایج


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اول اول :گام :گام

مشکل • بر متمرکز کامال و شفاف سوالی بیمار

دادن، • پاسخ قابل مشکل، به مربوطارزشمند و روشن و شفاف

از • موثر استفاده به منجر دقیق سوالمرتبط مقاالت یافتن و زمان


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What is the 1st step toward EBP for the practicing nurse?What is the 1st step toward EBP for the practicing nurse?

• Asking good clinical questions

• Nurses must be empowered to ask critical questions in the spirit of looking for opportunities to improve nursing care and patient outcomes

• Risk-taking environment


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Clinical Nursing QuestionsClinical Nursing Questions

• In postoperative patients, does prn or ATC analgesic administration yield better pain relief?

• Among critically ill patients, is controlled or open visitation more effective in reducing patient anxiety?


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What kind of questions might the Nurse Manager ask?

What kind of questions might the Nurse Manager ask?

• On medical-surgical units, do 12 hour or 8 hour shifts result in more medication errors?


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Key Questions to Ask When Considering EBP


• Why have we always done “it” this way?

• Do we have evidence-based rationale? • Or, is this practice merely based on tradition?

• Is there a better (more effective, faster, safer, less expensive, more comfortable) method?

• • What approach does the patient (or the target group) prefer? • What do experts in this specialty recommend?


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• Do the findings of recent research suggest an alternative method?

• Are organizational barriers inhibiting the application of best practices in this situation?

• Is there a review of the research on this topic?• Are there nationally recognized standards of

care, practice guidelines, or protocols that apply?


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• Once we agree upon the question that poses an opportunity for improvement, then we must find the evidence

• Where should we look?

• Are all forms of evidence equivalent in quality?


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Step 2:Step 2:

• Discovery:

• Finding, with maximum efficiency, the best evidence with which to answer the question


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دوم : گام

شواهد بهترین دسترس جستجوی در: روشها

همکاران- 1 از سوالدر 2 مرجع کتابهای لیست کردن چک

موجود کتابهایفایل- 3 در مربوط مقاله یک یافتن

شخصی4 ) مهارت- اطالعاتی بانکهای در جستجو

پرستاری بکارگیری برای اصلی و پایهشواهد بر مبتنی و ) مدرن


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Step 3: Step 3:

• Critique:

• Determining the merit, feasibility and utility of evidence.

– The process of systematically examining research evidence to assess its validity, results, and relevance before using it to inform a decision.

(http://www.evidence-based-medicine.co.uk)


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http://www.evidence-based-medicine.co.uk/

سوم : گام سوم : گام

• = سوم شواهد گام و مقاالت سه( نقد به پاسخگویی( زیر سوال

می 1. ما به معتبر نتایج شده یافت شواهد آیادهد؟

است؟ 2. مهم آیا است، معتبر شواهد اگر

بکار 3. را آنها بیمار از مراقبت در توان می آیا گرفت؟

که • است مهارتی شواهد منتقدانه ارزشیابیفرا کافی ممارست و صحیح آموزش با تنها

. شود می گرفته52EBN dr yekefalah-phd of

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Step 4: Step 4:

• Summary:

• Combining findings from all evidence to make a practice recommendation


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چهارم : گام

بیمار در حاصله نتایج آیا مطرح سوالدارد؟ کاربرد ما نظر لزوم( مورد

( زیر اقداماتفواید 1. و مضرات از ای برگه تهیه

مداخلهلغات 2. با مضرات و فواید میزان تعیین

مشخصبا 3. مضرات و فواید کردن مشخص

نظر مورد بیمار به توجهمضرات 4. بر فواید ارجحیت تعیین


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Step 5: Step 5:

• Translation: Placing evidence into context, incorporating recommendation into a clinical setting or organization


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پنجم : گام

تاثیر و سودمندی میزان ارزشیابیشواهد اجرای و در کاربرد حاصل

نظر مورد بیمارخارجی ناظر توسط ارزشیابی


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Step 6:Step 6:

• Evaluation:

• Determining and measuring the effectiveness of the practice change over time


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خدا قوت

• Most nurses agree that EBP is important… but how do we make it happen?


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Factors Contributing to Emphasis on Evidence-Based Nursing Practice


• Scientific knowledge expansion– Knowledge expands exponentially q 2 yrs

• Knowledge availability -- The Internet

• Highly educated nurses in clinical settings– APNs – focusing on evidence-based clinical

problem-solving– Clinical Nurse Researchers– DNP Movement


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• Aggressive pursuit of cost-effectiveness• Focus on quality of care, Risk & error

reduction• Highly educated consumers • Increased attention to institutional image

–


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What is Evidence?What is Evidence?

• Primary Studies:– Clinical Trials– Randomized Controlled Trials– Multicenter studies

• Secondary Studies– Reviews– Meta-analyses


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Establishing ValidityEstablishing Validity

• What are the results of the study?

• Are the results valid?

• How do the results affect the patient?


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Levels of EvidenceLevels of Evidence


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AACN Levels of Evidence (Armola, et al. , C C Nurse, 2009)

AACN Levels of Evidence (Armola, et al. , C C Nurse, 2009)

• Level A

• Level B

• Level C

• Level D

• Level E

• Level M

• Meta-analysis or metasynthesis of multiple controlled studies, supporting a specific action

• Controlled, randomized, or nonrandomized studies, supporting a specific action

• Qualitative, descriptive or correlational studies or systematic reviews with consistent results

• Peer-reviewed prof. organ. standards with studies to support them

• Theory-based evidence from expert opinion or case studies

• Manufacturer’s recommendations only


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Levels of EvidenceLevels of EvidenceLevels of EvidenceLevels of Evidence

• I Evidence - Systematic reviews, meta-analysis RCTs, EB clinical practice guidelines based on RCTs• II Evidence - One well designed RCT• III Evidence - CTs without randomization• IV Evidence - Well-designed case control or cohort studies• V Evidence - Systematic reviews of descriptive or qualitative studies• VI Evidence - Single descriptive or qualitative study• VII Evidence – Opinions of authorities, reports of experts 67EBN dr yekefalah-phd of

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Levels of Evidence Hierarchy(Stetler et al.)*

Levels of Evidence Hierarchy(Stetler et al.)*

• Level I: Meta-analysis of multiple RCTs

• (‘gold standard’)

• Level II: Individual RCTs

• Level III: Quasi-experimental

• Level IV: Non-experimental; qualitative

• Level V: Program evaluation; QI; RU; case reports

• Level VI: Opinion of respected authorities 68EBN dr yekefalah-phd of nursing2012

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Strength of EvidenceStrength of Evidence

• Level I - meta-analysis of multiple studies

• Level II - experimental studies, RCTs

• Level III - quasiexperimental studies

• Level IV - nonexperiemental studies

• Level V - case reports, clinical examples

AHCPR/AHRQ

• At what level is most nursing evidence?69EBN dr yekefalah-phd of

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Preprocessed EvidencePreprocessed Evidence

(A. DiCenso, 2009) 70EBN dr yekefalah-phd of nursing2012

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Types of Research EvidenceTypes of Research EvidenceExperimentalQuasi-Experimental

Counterfactual

SurveysAdmin DataComparativeQualitative

Cost-BenefitCost-Effectiveness

Cost-UtilityEconometrics

ExperimentalQuasi-Experimental

QualitativeTheories of Change

Social EthicsPublic Consultation

SurveysQualitative

Impact Evidence

Implementation Evidence

Descriptive Analytical Evidence

Economic and

Econometric Evidence

Ethical Evidence

Statistical Modelling

Attitudinal Evidence

Linear and LogisticRegression 71EBN dr yekefalah-phd of

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CRITICAL APPRAISALCRITICAL APPRAISAL


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Critical Appraisal Questions Critical Appraisal Questions

• Are the results of the study valid?

• What were the results?

• Will the results help me in caring for my patients?


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Critical Appraisal terminologyCritical Appraisal terminology

• Null Hypothesis

• P-value

• Confidence intervals

• Relative vs Absolute Risk Reduction


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Null hypothesisNull hypothesis

• States that there is no relationship between the variables being studied.

• Opposite of what you are trying to find out.

• Tylenol is better than Advil for headaches

• Exercising 30 minutes a day is good for your health

• Lefthanders are prone to accidents


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P-valueP-value

• Probability that the outcomes are due to chance

• Accepted reference point is .05

• Less than .05 is statistically significant

• Small p-value dismiss chance

• Large p-value means that anything is possible (chance, actual effect, or confounding factors)


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Confidence intervalsConfidence intervals

• The ranges of values within which a researcher can be confident that the population value falls.

• A 95% confidence interval (CI 95) means that one can be 95% confident that the population value falls within a certain range

• Example: A study states that 40% of a sample of 1000 people are smokers with a CI of 95% +/- 3% means the frequency of smoking is between 37% and 43%.


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RiskRisk

RR (Relative Risk) is the risk for achieving an outcome in the treatment group relative to that in the control group


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Challenges of EBNChallenges of EBN

• New, Unfamiliar

• Need to develop good search strategies

• Must identify best databases

• Need to do critical appraisals

• Much of relevant research is qualitative; need more systematic reviews of qualitative research


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Challenges and MisconceptionsChallenges and Misconceptions

• Merely a collection of statistics?

• Need more qualitative research

• Nurses need to develop good search strategies

• Nurses must learn to do critical appraisals

• Faculty members must embrace and learn EBP


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Problems with Finding and Using Evidence

Problems with Finding and Using Evidence

• Sheer amount and flow of information/research

• Variable quality of research outputs

• Problems of publication bias

• Need for the balance of evidence

• Limitations of single studies81EBN dr yekefalah-phd of

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BARRIERS TO EVIDENCE-BASED PRACTICEBARRIERS TO EVIDENCE-BASED PRACTICEBARRIERS TO EVIDENCE-BASED PRACTICEBARRIERS TO EVIDENCE-BASED PRACTICE

• Knowledge… lack of knowledge/awareness .… unfamiliar with guidelines and guideline accessibility

• Attitudes …. lack of confidence in the guideline developer, lack of motivation to perform the guideline recommendations

• Behaviors …. inability to incorporate patient preferences into the clinical decision making process

Melnyk & Fineout-Overholt 2005


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BARRIERS TO EVIDENCE-BASED PRACTICEBARRIERS TO EVIDENCE-BASED PRACTICEBARRIERS TO EVIDENCE-BASED PRACTICEBARRIERS TO EVIDENCE-BASED PRACTICE

• Overwhelming patient workloads• Misperceptions about EBP and research• Lack of time and resources to search for and appraise

evidence• Organizational constraints – lack of support• Peer pressure to continue with practices that are steeped

in tradition – “we’ve always done it this way and we are not changing now”

Melnyk & Fineout-Overholt 2005


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Overcoming the Barriers Overcoming the Barriers Summary of Barriers Strategies for Success

• Difficult to find the right program

• Fear of change• Organizational

barriers: personnel rules, staff turnover

• Limits to the flexibility of the system

• Cultural competency

• Administrative support

• Teacher/educator/stakeholder support

• Secure financial resources

• Provide high-quality training to ensure program fidelity

• Align intervention with school/community goals, policies and programs

• Make program outcomes visible

• Develop strategy for staff turnover


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: موجود موانع خالصه طور بهشامل:

: موجود موانع خالصه طور بهشامل:

تحقیقات • نتایج به دسترسی در توانایی عدمتحقیقات • نتایج کارگیری به جهت نیاز مورد هزینه و زمانبهداشتی • سازمان در تغییر مقابل در مقاومت وجودجستجو • از حاصل های یافته بین ارتباط وجود عدمتحقیقات • نتایج با موافقت یا و درک عدمتحقیقات • از حاصل نتایج کارگیری به در گذاری ارزش عدم

بالین در• ) از خصوصا مدیریتی نظر از سازمان در همکاری وجود عدم

( پزشکان طرفگذاشتن • اجرا به جهت الزم امکانات سازی فراهم عدم

تحقیقات از حاصل نتایجتحقیقات • نتایج مطالعه برای کافی وقت اختصاص عدم

)2005ملنیک،(و) 2005کورتنی،(

EBN dr yekefalah-phd of nursing2012

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بر لزوم مبتني مراقبت ارائه:شواهد پرستاری در

بر لزوم مبتني مراقبت ارائه:شواهد پرستاری در

عملکرد • که است شده تاکید پرستاران المللی بین انجمن بیانیه درچالشی را آن و است پرستاری حرفه خاص نشانه تحقیق بر مبتنیفوق بیانیه طبق حتی و داند می پرستاران برای چشمگیر و قویاخالقی غیر نباشد تحقیق مبنای بر پرستاری حرفه در که عملکردی

است.

در • يادگيري نوعي شواهد بر مبتني ودرماني بهداشتي مراقبت ارائهمراقبت سيستم از جزيي عنوان به پرستاران و است زندگي طولعنوان به پرستاري تا بپردازند بدان بايد جدي بطور ودرماني بهداشتي

شود مطرح علم بر مبتني حرفه .يك

بهترين • اساس بر بايستي مراقبت امر كه معتقدند خود نيز پرستاران

باشد دسترس در .شواهد86EBN dr yekefalah-phd of

nursing201204/21/23

87

: پرستاری در :کاربرد پرستاری در کاربرد

و • سیستماتیک فرایندی شواهد بر مبتنی پرستاری. است منظم

از • استفاده با بالینی تصمیمات اخذ به را پرستارانهای اولویت و بالینی تجارب موجود، شواهد بهترین

. کند می تشویق بیمارپرستاران • بیمار، مشکل بر آن تمرکز به توجه با

: باشند داشته مهارت و آگاهی زیر موارد در بایستیبالینی 1. های پژوهش نتایج کاربردبیمار 2. فیزیکی و عاطفی نیازهای به نسبت حساسیتبیمار 3. رنج درکآن 4. پاتوفیزیولوژی بر تاکید با بیماری دانستنمربوطه 5. مراقبت دانستن


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88

بر مبتنی پرستاری فوایدشواهد:

بر مبتنی پرستاری فوایدشواهد:

احترام • شامل بیمار برای حاصل فوایداجازه دادن و وی ارزشهای به گذاشتن

پیشنهادات بین وی به گیری تصمیممی بهداشتی متخصص از کرده دریافت

.باشد


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•: شامل پرستار برای حاصل فوایداز • حاصل های یافته آخرین از استفاده امکان برقراری

جهت نظامدار ساختاری به توجه با شده انجام های پژوهشکارگیری به و انتخاب دادن، قرار ارزشیابی مورد یافتن،

نظر مورد مددجوی برای شواهد بهتریندنبال • به را اطالعات شدن ریز سر خطر امکانی چنین ایجاد

پرستاری اساس بر جستجویی چنین اگر که حالی در داردرسید خواهد حداقل به خطر این باشد، شواهد بر مبتنی

در • مراقبت دهنده ارائه تیم و مددجو با ارتباط برقراری امکاننظر مورد مددجوی مراقبتی طرح و تصمیمات و علل با رابطهعملکرد متخصص پرستاران تربیت نیازمند امر این ولیمراقبت ارائه از اطمینان که است شواهد بر مبتنی پرستاریدارای و دارند عادات جای به موجود حقایق اساس بر هایی. باشند می خویش عملکرد به نسبت قانونی جوابگویی توانایی


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90

بهداشتی • سازمان برای حاصل فوایدبر فعلی رقابت عرصه در حضور شاملمی باال کیفیت با مراقبت ارائه اساس

باشد صرفه • بودن، مفید احساس همچنین

مخارج از جلوگیری و ها هزینه در جوییارمغان به سازمان برای نیز اضافی

دارد.


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91

شامل • جامعه برای حاصل فوایدتحقیقات، • نتایج بیهودگی از جلوگیری

بهترین ارائه و ها درمان عوارض کاهشبرای ها مراقبت نوع موثرترین و

. باشد می مددجویان

)2005کورتنی، (


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92

بر مبتنی پرستاری های محدودیت شواهد:

بر مبتنی پرستاری های محدودیت شواهد:

–. نیست مناسب بیمار هر برای و بوده تجربه نوعی تنها

مالی • حمایت از که کند می پشتیبانی مداخالتی ازباشد برخوردار

افراد ( • برای اطالعات زیاد حجم نیست دسترسی قابلمبتدی)

دهد • پاسخ سواالت از بعضی به تواند نمیارزش • بهداشتی خدمات مشتریان و خریداران برای

دارد محدودی•. است تعبیر سو و استفاده سو دچار•. است تورش دارای


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بر مبتنی پرستاری های چالششواهد:

بر مبتنی پرستاری های چالششواهد:

: پرستاری پژوهش در موجود های چالش

خدمات - و آموزش بین عمیق فاصله وجودنتایج - به توجه با شده ارائه های مراقبت کیفیت افزایش

شده انجام های پژوهش از حاصل: پرستاری آموزش در موجود های چالش

بر - مبتنی پرستاری آموزش برای پرستاری آموزش نظام تغییرشواهد

بالین - در علم این گیری کار به برای پرستاران سازی آمادهنحوه - پرستاری های دانشکده برای موجود چالش

است شواهد بر مبتنی پرستاری ،عملکرد . تدریس


04/21/23

Creating an EBP cultureCreating an EBP culture

• Internal Expertise– Identified leaders for EBP– Collaboration with outside experts

• Educating Frontline staff– Enhancing staff awareness and

understanding– Grooming staff to become leaders in EBP


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StrategiesStrategiesStrategiesStrategies• Strong supportive leadership

• Mentorship

• Staff education regarding research and evidence based practice.

• Time to conduct or use research

• Routine performance expectations in research use

(Fink, et al, 2005)

96

Key Message

RECOMMENDATION NO. 1


The many faces of advanced practice registered nurses in 2011

High quality,

safe, affordable health care

provided by teams of

health care professionals


““Messaging”Messaging” ““Messaging”Messaging”

Barriers to practice reduce access to care

Main issue is access to care and this should define our focus


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99

Key Message


New graduates and nurses in transition


100

Key Message

RECOMMENDATION NO3


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101

Key Message



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Institute of Medicine October 2010 Report: The Future of Nursing Leading Change, Advancing

Health

1. Remove scope-of-practice barriers2. Expand opportunities for nurses to lead and diffuse

collaborative improvement efforts3. Implement nurse residency programs4. Increase the proportion of nurses with a baccalaureate

degree to 80% in 20205. Double the number of nurses with a doctorate by 20206. Ensure that nurses engage in lifelong learning7. Prepare and enable nurses to lead change to advance

health8. Build an infrastructure for the collection and analysis of

interprofessional health care workforce data


Key point:

EBN should be considered as:

- A part of educational

curriculum


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LITERATURE SEARCHINGLITERATURE SEARCHING


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Resources to Support Evidence-Based PracticeResources to Support Evidence-Based Practice

• Government agencies

• Cochrane Collaboration

• Professional Organizations

• Benchmark Institutions


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AHRQ – Agency for Healthcare Research and Quality


04/21/23


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Cochrane Collaboration Cochrane Collaboration

• “an international, independent, not-for-profit organization of over 27,000 contributors from more than 100 countries, dedicated to making up-to-date, accurate information about the effects of health care readily available worldwide.

• Contributors produce systematic assessments of healthcare interventions, known as Cochrane Reviews, which are published online in The Cochrane Library.

• Rely heavily on RCTs• Primarily focused on effectiveness of interventions, more

medical and pharmaceutical than nursing


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http://www.cochrane.org/cochrane-reviews

http://www.thecochranelibrary.com/

Cochrane Collaboration http://www.cochrane.org

Cochrane Collaboration http://www.cochrane.org


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http://www.cochrane.org/

http://www.cochrane.org/


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Professional Nursing Organizations Supporting Evidence-Based PracticeProfessional Nursing Organizations Supporting Evidence-Based Practice

• AACN

• AWHONN

• AORN

• ONS

• Sigma Theta Tau


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Am. Assoc. of Critical Care NursesAm. Assoc. of Critical Care Nurses

Succinct dynamic directives…supported by evidence to ensure excellence in practice and a safe and humane work environment.

• Venous Thromboembolism Prevention• Oral Care in the Critically Ill• Noninvasive BP Monitoring• Verification of Feeding Tube Placement• Ventilator Associated Pneumonia• Dysrthymia Monitoring

• Published since 2005 • Available free on AACN website• Include ppt presentations and audit tools 11304/21/23 EBN dr yekefalah-phd of

nursing2012

Oncology Nursing SocietyOncology Nursing Society

• EBP Resource Center • http://onsopcontent.ons.org/toolkits/evidence/

• Also provides topical toolkits, on specific topics, plus:

• How To Find The Evidence • How To Critique Evidence• How To Develop An Evidence Based Presentation• Evidence Based Practice Education Guidelines• Evidence on Clinical Topics• How to Change Practice• Levels of Evidence Table


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http://onsopcontent.ons.org/toolkits/evidence/

Sigma Theta Tau EBP Initiatives Sigma Theta Tau EBP Initiatives

• Strategic Plan• Online Resources

– NKI http://www.nursingknowledge.org > 200 resources for EBP – some free, some for purchase

• New Award for EBP (formerly Clin Scholarship)

• Conferences – International EBP and Research Congress– July, 2010 – Orlando– July, 2011 – Cancun– July, 2012 – Australia


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http://www.nursingknowledge.org/

Journals Supporting EBPJournals Supporting EBP

– Evidence-Based Nursing– Online Journal of Clinical Innovations– WorldViews on Evidence-Based Nursing– The Online Journal of Knowledge Synthesis for

Nursing – (archived, no longer being published)– Reflections on Nursing Leadership (Vol 28, 2)


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ResourcesPubMed/Medline

ResourcesPubMed/Medline

• Citations and Abstracts • Includes over 4600 journals worldwide• More than 17 million citations• Approximately 1/3 full text articles available• Uses MeSH controlled vocabulary• Updated daily• Available anywhere, anytime• Searching help available• Must do one’s own quality filtering• Must learn how to search the database 117EBN dr yekefalah-phd of

nursing201204/21/23

Medline:Medline:

• The National Library of Medicine in Maryland, USA produces Medline (Index Medicus).

• It contains over 73,000 citations indexed as medical education and over 300,000 additional citations that are considered educationally relevant.


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CINAHL:CINAHL:

• The Cumulative Index to Nursing and Allied Health Literature is the world’s largest database for nursing and the professions allied to medicine

• Although there are less than 1,500 citations indexed as medical education there are over 100,000 educationally relevant ones that could inform a medical education query


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ResourcesCINAHL

ResourcesCINAHL

• Dates back to 1981• Contains more than a million records• Indexes almost 3,000 journals• Searchable cited references for more than 1,200

journals• Full text for 71 journals• Covers nursing, biomedicine, health science

librarianship, alternative/complementary medicine, consumer health and 17 allied health disciplines

• Now features Clinical Query Functionality


04/21/23


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Evidence-Based Policies and Indicator Systems Conference,

2003

Evidence-Based Policies and Indicator Systems Conference,

2003

http://cem.dur.ac.uk/EB2003

http://cem.dur.ac.uk/EB2003


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Embase:Embase:• This is the second largest medical

database and is owned by Elsevier Science, Netherlands.

• Embase contains over 43,000 citations indexed as medical education and more than 100,000 that are related to education in a health environment.


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ERIC: ERIC: • The Education Resource Information Centre is

the world’s largest education database (1,000,000 + records)

• Although the emphasis on primary and secondary education, there are over 17,000 citations related to medical education

• Many more will be relevant in a supporting context, providing evidence in education that could be applied to medical education


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British Education IndexBritish Education Index

• The British Education Index is much smaller than ERIC but contains citations that are relevant to answering queries in medical education


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PsycINFO:PsycINFO:

• While PsycINFO obviously concentrates on psychiatric and psychological content, there are over 4,000 records indexed as medical education with well over 100,000 concerning education in a broader context, as well as teaching and learning.


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Additional Indexed DatabasesAdditional Indexed Databases

• Allied and Complementary Medicine Database (AMED)

• Applied Social Sciences Index and Abstracts (ASSIA)

• British Nursing Index (BNI)

• Health Management Information Consortium (HMIC)

• SOCIOFILE


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Models of EBPModels of EBP

• John Hopkins Model

• Stetler Model

• CURN

• Iowa Model of Evidence Based Practice


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Steven’s ACE Star ModelSummary

Steven’s ACE Star ModelSummary

• Synthesize all research into a single meaningful whole

• This step differentiates research utilization from Evidence-based practice

• Can be called evidence synthesis• Increase power and effect of data• Reduce bias• Assess consistencies• Establish generalizability• Reduce data into an manageable form


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Steven’s ACE Star ModelSteven’s ACE Star Model

• Discovery

• Summary

• Translation

• Implementation

• Evaluation


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Steven’s ACE Star ModelDiscovery

Steven’s ACE Star ModelDiscovery

• Original research

• Conduct a literature search utilizing recognized techniques


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Steven’s ACE Star ModelTranslation

Steven’s ACE Star ModelTranslation

• Scientific evidence is considered in the context of clinical expertise and values

• Results in clinical practice guidelines, best practices, protocols, standards or clinical pathways


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Steven’s ACE Star ModelImplementation

Steven’s ACE Star ModelImplementation

• Translation of research into practice

• Where changes take place


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Steven’s ACE Star ModelEvaluation

Steven’s ACE Star ModelEvaluation

• Impact of the change is measured

• Assess variables (health outcomes, efficiency, cost or satisfaction)


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Iowa ModelIowa Model

• Successfully implemented since 1994 internationally

• Infuses research into practice to improve quality of care

• Planned change principles integrate research and practice

• Utilizes a multidisciplinary team approach

• Utilizes feed-back loops136EBN dr yekefalah-phd of

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Why the Iowa Model?Why the Iowa Model?

• Multiple resources available to aid in implementation

• Algorithm that can easily be applied to practice

• Applicable to quality improvement projects as well as nursing research


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Problem Focused Triggers Knowledge Focused Triggers

Priority forOrganization

Consider other triggers

NO

Form a team

YES


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Assemble Relevant Research & Related Literature

Critique and Synthesize Research for Use in Practice

SufficientResearch?

Pilot Change inPractice Base Practice on other

Types of Evidence

ConductResearch


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Should weAdopt this change

into practice?No Yes InstituteChange

Continue toEvaluate qualityCare and New

Knowledge

Monitor and AnalyzeStructure, Process, and

Outcome Data

DisseminateResults


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ResourcesResources• Yale University Nursing Library and Information Resources

http://www.med.yale.edu/library/nursing/education/ebhc2.html • Oncology Nursing Society

http://onsopcontent.ons.org/toolkits/evidence/ • United States Department of Health and Human Services –

Agency for Healthcare Research and Quality

http://www.ahrq.gov/clinic/epcix.htm • University of Iowa Hospitals and Clinics Nursing Services

and Patient Care

http://www.uihealthcare.com/depts/nursing/rqom/evidencebasedpractice/index.html


http://www.med.yale.edu/library/nursing/education/ebhc2.html

http://onsopcontent.ons.org/toolkits/evidence/

http://www.ahrq.gov/clinic/epcix.htm



Resources (con’t)Resources (con’t)

• University of Texas Health Science Center at San Antonio – Acedemic Center for Evidence-Based Practice

http://www.acestar.uthscsa.edu/About.htm • Medical Library Association – Nursing and Allied

Health Resources Section

http://nahrs.library.kent.edu/resource/symposium/ • University of Minnesota – Evidence-based Health

Care Project

http://evidence.ahc.umn.edu/ebn.htm 14204/21/23 EBN dr yekefalah-phd of

nursing2012

http://www.acestar.uthscsa.edu/About.htm

http://nahrs.library.kent.edu/resource/symposium/

http://evidence.ahc.umn.edu/ebn.htm

ResourcesResourcesAddressing Barriers to Learning. (2007). Evidence-based practices in

schools: Concerns about fit and implementation. UCLA Center, 12(3).

Dunifon, R., Duttweiler, M., Pillemer, K., Tobias, D., & Trochim, W.M.K. (2004). Evidence-based extension. Journal of Extension, 42(2).

Forman, S.F., Olin, S.S., Hoagwood, K.E., Crowe, M., & Saka, N. (2008). Evidence-based interventions in schools: Developers’ Views of implementation barriers and facilitators. School Mental Health, 1.

Henderson, M.L., Mathias-Humphrey, A., & McDermott, M.J. (2008). Barriers to effective program implementation: Rural school-based probation. Federal Probation, 72(1).

Identifying barriers to evidence-based uptake. (2006). National Institute of Clinical Studies, Melbourne VIC.

Research Development Associates. Evidence-based Practices. Power Point retrieved from http://www.resourcedevelopment.net/projects/workshops.html


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http://www.resourcedevelopment.net/projects/workshops.html

ReferencesReferences

• Chitty, K.K. (2005). Professional nursing: Concepts and challenges. 4th ed. Philadelphia: Saunders.

• Spector, N. (n.d.). Evidence-Based Health Care in Nursing Regulation. Retrieved on October 8, 2006 from Nation Council of State Boards of Nursing web site on World Wide Web:

http://www.ncsbn.org/pdfs/Evidencebased_NSpector.pdf#search=%22evidence%20based%20practice%20in%20nursing%22

• Yale University. (2005). Evidence-Based Practice. Nursing

Library and Information Resources. Retrieved on October 8, 2006 from World Wide Web: http://www.med.yale.edu/library/nursing/education/ebhc2.html 14404/21/23 EBN dr yekefalah-phd of

nursing2012



http://www.med.yale.edu/library/nursing/education/ebhc2.html

• Burns & Grove (2005). The Practice of Nursing Research (5th ed).St. Louis: Elsevier Saunders

• • Polit & Beck (2008). Nursing Research: Generating and Assessing

Evidence for Nursing Practice. Philadelphia : Lippincott Williams & Wilkins

• Melnyk & Fine-Overholt (2005). Evidence-Based Practice in Nursing & Health Care.

Philadelphia: Lippincott Williams & Wilkins• ACE Star Model: http://www.acestar.uthscsa.edu/Learn_model.htm

REFERENCESREFERENCES


http://www.acestar.uthscsa.edu/Learn_model.htm

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