EBN Application

EBN ApplicationEBN Application

莊情惠莊情惠 , , MSN, RNMSN, RN

Head Nurse, Head Nurse, Chang Gung Chang Gung

QualityQuality ofof CareCare• Broad topicBroad topic

• Critically importantCritically important

• Implementation key concernImplementation key concern

• Many component partsMany component parts

Component PartsComponent Parts• Patient, clinicians, systemsPatient, clinicians, systems

• Problem identification and refinementProblem identification and refinement

• Use of evidenceUse of evidence

• Interventions Interventions

• Implementation Implementation

• Adoption into practice Adoption into practice

Quality of Care Quality of Care

• Similar to: Similar to:

–Evidence based nursing (EBN)Evidence based nursing (EBN)

–Quality improvementQuality improvement

• Uses evidence & clinical expertise Uses evidence & clinical expertise

• Patient outcomes and preferencesPatient outcomes and preferences

• Within systems of careWithin systems of care

Why is EBN important?Why is EBN important?• Manage explosion Manage explosion

– LiteratureLiterature

– TechnologyTechnology

• New way to think New way to think – PracticePractice

– ResearchResearch

– Knowledge developmentKnowledge development

EBN Promotes TranslationEBN Promotes Translation

Research LiteratureResearch Literature

intointo

Individualized careIndividualized care

What Nurses Do with EBNWhat Nurses Do with EBN

Obtain valid informationObtain valid information

Search for, assess & use literatureSearch for, assess & use literature

Use information (evidence)Use information (evidence)

Develop interventionsDevelop interventions

andand

Apply to clinical situationsApply to clinical situations

EBN Promotes:EBN Promotes:

Systematic observation Systematic observation plusplus

Experience Experience andand

Research literatureResearch literature

to supportto support

Nursing decisionsNursing decisions

Origins of EBM in 1970sOrigins of EBM in 1970s

• Started in MedicineStarted in Medicine

• Synthesis of research literature Synthesis of research literature

• Guidance for practiceGuidance for practice

EBP History in NursingEBP History in Nursing

• First (1970’s) calledFirst (1970’s) called– Research utilizationResearch utilization

– Translation into practiceTranslation into practice

• Now called Now called – EBNEBN

– Evidence based nursingEvidence based nursing

Our OutlineOur Outline

• What is evidence based nursing (EBN)What is evidence based nursing (EBN)

• Goals of EBNGoals of EBN• ProductsProducts

• Procedures for EBN reviewsProcedures for EBN reviews

• Strengths and WeaknessesStrengths and Weaknesses

EBN GoalsEBN Goals• Improve patient outcomeImprove patient outcome

• Reduce healthcare costsReduce healthcare costs

EBN Growing RapidlyEBN Growing Rapidly• Nursing - 2,500 citationNursing - 2,500 citation

• Medicine - 21,000 citationsMedicine - 21,000 citations

Types of EBN ReportsTypes of EBN Reports

• EBN to guide clinical decisionsEBN to guide clinical decisions

• How to do EBNHow to do EBN

Can be confusing to newcomerCan be confusing to newcomer

Where Are EBN Reports ?Where Are EBN Reports ?

• Professional journalsProfessional journals

• World Wide Web (WWW)World Wide Web (WWW)

• BooksBooks

How Do I Get EBN Reports?How Do I Get EBN Reports?

• Your libraryYour library

• WebWeb

Many are freeMany are free

Professional JournalsProfessional Journals

• Evidence Based NursingEvidence Based Nursing• World Views on EBNWorld Views on EBN - Sigma Theta Tau - Sigma Theta Tau

productproduct

• Your professional journal?Your professional journal?

Book Most CitedBook Most Cited

DiCenso, Ciliska & GuyattDiCenso, Ciliska & Guyatt (2005)(2005). . Evidence-based nursing; A guide to Evidence-based nursing; A guide to clinical practiceclinical practice. . St. Louis, Elsevier St. Louis, Elsevier MosbyMosby..

Other Sources on WebOther Sources on Web–Practice guidelinesPractice guidelines

–Governmental sourcesGovernmental sources

–Cochrane DatabaseCochrane Database



• Goals of EBNGoals of EBN

• ProductsProducts – – A model and aA model and an n example example



EBN – ExampleEBN – Example• ProblemProblem

– Type II Diabetes MellitusType II Diabetes Mellitus

– Clinic management Clinic management

• Goal - Process improvementGoal - Process improvement

Assess SupportAssess Support• Nursing managementNursing management

• Other departmental leadersOther departmental leaders

• Nursing teamNursing team

Problem or QuestionProblem or Question• Current guidelines not followedCurrent guidelines not followed

• Lacked measures Lacked measures – Glycosylated hemoglobin (HbA1c)Glycosylated hemoglobin (HbA1c)– Lipids (LDL)Lipids (LDL)

• Lacked performance Lacked performance – Blood pressure checksBlood pressure checks– Annual foot exams Annual foot exams – Monofilament testingMonofilament testing

Establish Desired Patient Establish Desired Patient OutcomesOutcomes

• Control of HbA1c and LDLControl of HbA1c and LDL

• Improve performance to >80%Improve performance to >80%– Foot exams Foot exams

– Filament testingFilament testing

• Improve patient involvementImprove patient involvement

Challenges EncounteredChallenges Encountered

• Data base accuracyData base accuracy

• Staff turnoverStaff turnover

• Computer software upgradesComputer software upgrades

• SustainabilitySustainability


• What is evidence based practice (EBN)What is evidence based practice (EBN)


• ProductsProducts

• Procedures for EBN reviewsProcedures for EBN reviews• Strengths and WeaknessesStrengths and Weaknesses

How Do I Get Started? How Do I Get Started?

• Read research reportsRead research reports

• Develop skills for research critiqueDevelop skills for research critique

• Understand research reportsUnderstand research reports– ConceptsConcepts

– TerminologyTerminology

Develop Internet SkillsDevelop Internet Skills

• Use data basesUse data bases

• Use major EBN sourcesUse major EBN sources– PubMedPubMed

– CIHAHLCIHAHL

– Google Scholar Google Scholar

Ask for HelpAsk for Help andand Help Yourself Help Yourself

• LibrarianLibrarian

• WWWWWW

• LecturesLectures

• ConferencesConferences

Work with OthersWork with Others

• Sharing helps refine processSharing helps refine process

• Improves reliabilityImproves reliability

• Increase commitmentIncrease commitment

Steps in a EBN reviewSteps in a EBN review

• AskAsk

• AccessAccess

• AppraiseAppraise

• ImplementImplement

• EvaluateEvaluate

Ask the questionAsk the question• Identify a questionIdentify a question

• Define and refine the questionDefine and refine the question

Sources of QuestionsSources of Questions

• Practice question, problem or practicePractice question, problem or practice• Basis for questionBasis for question

– Concern about adverse outcomesConcern about adverse outcomes

– CostCost

– Time useTime use

– Patient complaintPatient complaint

Components of Question - Components of Question - PICOTPICOT

• PPatientsatients

• IInterventionntervention

• CComparison (current practice)omparison (current practice)

• OOutcomeutcome

• TTime frameime frame

Access the LiteratureAccess the Literature

• Search literature – Search literature – Reports are sampleReports are sample

• Develop sample criteriaDevelop sample criteria– InclusionInclusion

– ExclusionExclusion

• Obtain reportsObtain reports

PICOTPICOT Advantages Advantages• Pushes clear definitionsPushes clear definitions

– PopulationPopulation– ComparisonComparison– OutcomeOutcome

• Focuses searchFocuses search– Too narrow – miss important onesToo narrow – miss important ones– Too broad – not apply to contextToo broad – not apply to context

Appraise literatureAppraise literature Answer 3 QuestionsAnswer 3 Questions

• Quality high enough to use (valid)?Quality high enough to use (valid)?

• Findings fit my setting?Findings fit my setting?

• What impact would EBN have on my What impact would EBN have on my patients?patients?

Is Report Quality Good Enough Is Report Quality Good Enough (Valid)?(Valid)?

• Use research critique skillsUse research critique skills

• Consider statistical significanceConsider statistical significance

Does Report Fit My Setting?Does Report Fit My Setting?

• Comparison = Comparison = Current practiceCurrent practice

• Consider Consider – PatientsPatients

– ColleaguesColleagues

– SettingSetting

– ResourcesResources

Extract Data from Each ReportExtract Data from Each Report

• Write a summaryWrite a summary

• Include specific informationInclude specific information

• Develop data collection formsDevelop data collection forms

• Establish a code bookEstablish a code book

Code Book IncludesCode Book Includes

• Methodological featuresMethodological features

• Quality assessmentQuality assessment

Code MethodsCode Methods• Study sourceStudy source

• Publication yearPublication year

• Research design Research design

• Authors/investigators Authors/investigators characteristicscharacteristics

Quality Assessment Quality Assessment • Scientific meritScientific merit

• Intervention descriptionIntervention description

• Study outcomesStudy outcomes


• AskAsk

• AccessAccess

• AppraiseAppraise• ImplementImplement

• EvaluateEvaluate

Critical AppraisalCritical Appraisal• Uses individual report/articlesUses individual report/articles

• Assembles body of evidenceAssembles body of evidence

• Focuses on a single practice issueFocuses on a single practice issue

Critical Appraisal Critical Appraisal Two GoalsTwo Goals

• Internal consistencyInternal consistency

• Clinical significanceClinical significance

Internal Consistency Internal Consistency QuestionsQuestions

• Did authorsDid authors– Answer the question?Answer the question?– Measure variables as planned?Measure variables as planned?

• Were measurements Were measurements – Reliable?Reliable?– Valid?Valid?

Internal ConsistencyInternal Consistency (continued)(continued)

• Were analyses appropriate?Were analyses appropriate?

• Were conclusions Were conclusions – Reasonable?Reasonable?

– Supported by results?Supported by results?

– Matched to initial question/aim?Matched to initial question/aim?

Hierarchy of EvidenceHierarchy of Evidence

• Single-case reportSingle-case report

• Case series reportCase series report

• Case-control studiesCase-control studies

• Cohort studiesCohort studies

• Nonrandom trialsNonrandom trials

• Randomized controlled trials (RCT)Randomized controlled trials (RCT)

• Meta-analysis and evidence reviews Meta-analysis and evidence reviews

Hierarchy Hierarchy • From single-case report to RCTFrom single-case report to RCT

• Internal validity increased Internal validity increased

• Bias in studies reducedBias in studies reduced

Rating the EvidenceRating the Evidence

• Several approachesSeveral approaches– Endorsed by professional bodiesEndorsed by professional bodies

– Consensus reached when RCTs numerousConsensus reached when RCTs numerous

• Quality of evidence ratedQuality of evidence rated– HighHigh– ModerateModerate– Low or very lowLow or very low

Rating the EvidenceRating the Evidence

• Study limitationsStudy limitations

• Inconsistency of resultsInconsistency of results

• Indirectness of evidenceIndirectness of evidence

• ImprecisionImprecision

• Publication biasPublication bias

Clinical SignificanceClinical Significance

• Will it make a difference in clinical Will it make a difference in clinical my setting?my setting?

• How important is the study?How important is the study?

• Clinical expertise valuable here at Clinical expertise valuable here at this point.this point.


• AskAsk

• AccessAccess

• AppraiseAppraise

• ImplementImplement• EvaluateEvaluate

ImplementImplement

• Identify stakeholdersIdentify stakeholders

• Seek support of stakeholdersSeek support of stakeholders– Nursing managersNursing managers

– Hospital administrationHospital administration

– Other departmentsOther departments

Consider Effect of EBNConsider Effect of EBN

• Others EBN would affectOthers EBN would affect

• Processes that would be affectedProcesses that would be affected

• Educate nurses Educate nurses – Who make changeWho make change

– Who are affected by changeWho are affected by change

EvaluateEvaluate• Assess cost effectivenessAssess cost effectiveness

• Patient Patient –AcceptanceAcceptance

–Satisfaction Satisfaction

–ComplaintsComplaints

Measure Relevant InformationMeasure Relevant Information

• Wait times Wait times

• Patient census Patient census

• Staff turnover Staff turnover

• Medication errors Medication errors

Evaluate Patient OutcomesEvaluate Patient Outcomes• Diabetes clinic careDiabetes clinic care

– HbA1cHbA1c– Filament testingFilament testing

• Intensive careIntensive care– Pneumonia in intubated patientsPneumonia in intubated patients– EBN EBN

• head elevation head elevation • hand washing hand washing

Use Information Already Use Information Already CollectedCollected

• Incident ReportsIncident Reports

• Satisfaction surveysSatisfaction surveys

Evidence Based Nursing Evidence Based Nursing OverviewOverview






StrengthsStrengths• Reduces variations in practiceReduces variations in practice

• Gives consistent resultsGives consistent results

• Reduces knowledge/practice gapReduces knowledge/practice gap

EBN Success RequiresEBN Success Requires• System wide supportSystem wide support

• Support of leadersSupport of leaders

• EvaluationEvaluation

• Monitoring adherenceMonitoring adherence

Nursing InterventionsNursing Interventions

• Behavioral Change Interventions Behavioral Change Interventions – PatientsPatients

– NursesNurses

– Others in systemOthers in system

• Few RCT trialsFew RCT trials

• Fewer systematic reviews Fewer systematic reviews

Forces Pushing EBN Forces Pushing EBN TodayToday

• CostCost

• SafetySafety

Allows nurses to do more with lessAllows nurses to do more with less

SummarySummary• EBN – What it isEBN – What it is





Thank You

Documents

EBN Application