Ebn Practice

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INTRODUCTION

Evidence based nursing practice is the integration of best researchevidence with clinical expertise and patient values to facilitate clinical decisionmaking. This decision making should incorporate consideration of the patients

clinical state, clinical settings and clinical circumstances. A key element ofevidence- based clinical decision making is personalizing the evidence to fit aspecific patient circumstances. Clinical expertise refers to our ability to useclinical skills and past experience to identify the health state of the patients orpopulation, their tasks, their, their preference and action and the potentialbenefits to of interventions; to communicate information to patients and theirfamilies; and to provide them with an environment they find comforting andsupportive.

DEFINITION {DICENSO GUYATT CILISKA-2005}

It is the integration of best research evidence with clinical expertise andpatient values to facilitate clinical decision making.

GOALS OF PRACTICE GUIDELINES

To document preferred practices

To increase consistency in care

To enhance quality of care

To increase staff productivity

To reduce cost

GUIDELINES CAN VARY IN SEVERAL WAYS

Clinical orientation:-Whether the focus is on a clinical condition, technologyor process

Clinical purpose:- Whether information is presented in screening andprevention, evaluation or diagnosis or various aspects of treatment.

Complexity:-Whether the guidelines is related straightforward or presentedwith detail, complicated logic, lengthy narrative and pragmatic manner.

Format: - Whether the guidelines are presented as free algorithms, tables,critical pathways or decision pathways.

Intended guidance:-Whether the guidelines is intended for practitioners,patients, regulations or prayers


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LIMITATIONSo Patients characteristics

o Nature of communication skills

o Treatment prevention

o Placebo effect

BASES FOR NURSING PRACTICE

Traditional:-It includes rituals, unverified rules, anecdotes, customs, opinionsand unit culture. It is the lowest level.

Regulatory Bases:-It includes state practice act reimbursement and otherregulatory requirement.

Philosophical or Conceptual:-It includes mission, values and vision of theorganization; professional practice model; untested conceptual framework and

professional codes.

Evidence Based Practice:- It includes research findings, performance data andconsensus recommendations of recognized experts.

MISCONCEPTIONS OF EVIDENCE - BASED NURSING [ EBN ]PRACTICE

Ignores patients values:-The fundamental principle of EBN is that researchevidence alone is never sufficient to make a clinical decision. Clinicians mustalways trade the benefits and risks, inconvenience and cost associated withalternative management strategies and in doing so, consider the patients values.

Study results indicate that this program is effective, both patient preferences andcost may influence whether the intervention is practical and cost effective.

Atheoretical:-Some nurses believe that the current call for EBN practice has setthe debate in conventional, atheoretical, medically dominated, empirical modelof evidence, which threatens the foundation of nursings disciplinary practice.This concern is based on a perception- that even through multiple patterns ofknowing exists in nursing, EBN focuses only on empirical knowledge.

Only about quantitative research: - Quantitative methods have been thefoundation of most biomedical research and because the concept of EBN

practice, many nurses incorrectly include the EBN is only about quantitativeresearch. Quantitative designs are best for evaluating the effectiveness andsafety of nursing interventions, the accuracy and precision of nursingassessment measures etc.Qualitative designs are best for understanding themeaning of illness or patient experience, attitude and belief.


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BARRIERS OF EBNMost nurses have a positive attitude about EBN. However, there are

substantial barrier to EBN at both organizational and individual levels.

Organizational level:-

Lack of skills

Lack of confidence

Lack of interestIndividual:-

Lack of organizational supports

Lack of motivation

Lack of leadership

Lack of vision, strategy and direction among managers

However, this organizational support is crucial in situationsin which nurses dont believe. They have the authority or autonomy

changes in patient care.

CLINICAL SKILLS, HUMANISM, SOCIAL RESPONSIBILITY AND EBN

The essential skill of assessing a patient or a population and stateformulation of the health problem come only with through background trainingand extensive experience. Nurses make use of reasoning to interpret the resultof history, physical examination or needs assessment. Nurses also rely on theirexpertise to define feature that influence the generalizability or relevance of studyfindings to their individual patient population. Nurses must judge the extent towhich difference in intervention characteristics or patient characteristics may

affects the benefits and risks that a patient can expect from an interventionknowing the tools of evidencebased practice in necessary but not sufficient fordelivering highest- quality patient care. In addition to clinical knowledge nursesrequire compassion, sensitive listening skills and broad perspectives from thehumanities and social sciences. Nurses are effective advocates for their patientsboth in direct context of the health system in which they work and broader healthpolicy issues.


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A MODEL FOR EVIDENCE- BASED CLINICAL DECISIONS

Clinical

state

setting

Resea

evide

Health

care

resources

Patient

preferenc

e and

action

Clinical expertise

Clinical expertise overlaid as the means to integrate the 4 components, thus constituting the 5 thelement in the model. Clinical expertise refers to our ability to use clinical skills and past

experience to identify the health state of patients or population, their risk, their preferences andactions and the potential benefits of intervention.

Ref:-Dicenso guyatt,[2005], Evidence based nursing practice, published by honor society of

nursing,1st edition,1-7


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DEVELOPING EVIDENCE - BASED CARE

Define clinical question:-It involves defining the patients problem, identifyingthe existing nursing interventions and specifying the expected outcome. This

process should be completed in partnership with patient and family in allocationwith other health care providers.

Finding the evidence:-Most nurses rely on textbooks, journals, articles and drybooklets to help guide their practice. Another strategy is that of using systemicreviews prepared by others. Systematic reviewer uses explicit methods ofsearching for and critically appraising the primary studies. The reviewer may thenperform a formal question quantitative synthesis. Called metaanalysis.Acess toelectronic database such as MEDLINE is now widespread increasingly journalsoften worldwide web pages on the internet, abstracts. etc.

Analyzing Evidence: - Nurses develop ability to understand and usesappropriate research findings and it follows.

Systematic review [metaanalysis] of all relevant randomized controlledtrials.

At least one properly designed randomized trials

Well designed controlled trials without randomization

Well designed cohort, case controlled or quasi- experimental study.

Non experimental descriptive study

Expert committee reports and opinions of respected authorities based onclinical experience.

Using the evidence:-The nurses have to be able to apply research in practicalway.

Evaluating outcome:-Here the nurses ask whether the application of evidenceleads to an improvement in care.


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HIERARCHY OF PREPROCESSED EVIDENCE OR DEVELOPING EVIDENCEBASED NURSING PRACTICE

Syst

ems

Synopses of

synthesis

E.g. E.B journal

Synthesis

E.g. EB journal

Synopses of single studies

E.g. EB abstract journals

Single studies

E.g. Medline

Ref:- Hayness R B ,Evolution of services for finding current best evidence,ppno 37-

39


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ORGANIZATION OF EVIDANCE- BASED CARE

Define clinical question

Trade down best evidence:

Medline

Systemic review

Cochrane library

Journals of

secondary and

primary review Current text book

Evidence does not supportcurve of practice

Change practices adopt:

E.B Recommendation

Evidence is unclear

Continue current

practice if safe to do

Continue to review

emerging evidence

Evidence supportcurrent practice

Continue practices

Evaluate patientoutcome

Ref:-guyatt dicenso ,evidence nursing practice,honor ofsociety of nursing,2005,pp no18


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CORE PUBLIC HEALTH FUNCTIONS AND RELATED EVIDENCE BASEDNURSING INTERVENTIONS

Core functions of the public health are to assess the health of thecommunity or population. Develop comphrensive public health policy and assure

that services are provided to the community. These are functions have beenexpanded to include to public health services. [Public health function Steeringcommittee-1994]

NURSES INTERVENTIONS

AssessmentDiagnosis and investigate health problems and hazards in the community.

Mobilize community partnership to identify and solve health problems link peopleto needed health services. Use evidencebased practice for new insights andinnovative insights and solution to the health problems.

Policy developmentInform educate and empower communities about health issues. Develops

policies and plans using evidence based nursing practice that supportsindividual and community health efforts.

AssuranceMonitor health status to identify health problems [community

health].Enforce laws and regulations that protect health and ensure safety.Ensure the provision of health care that is otherwise unavailable. Ensure acompetent public health and personal health care work force. Use evidence-

based practice to evaluate effectiveness, accessibility and quality of personal andpopulation based practice to evaluate effectiveness, accessibility and quality ofpersonal and population based services.

DEVELOPING AN EVIDENCE BASED PRACTICE GUIDE TO ACOMMUNITY PREVENTIVE SERVICES

o Form a development team, preferably interdisciplinary, to choose a topic

based on a community issue that needs to be a address.o Develop a structured approach to organize, group, select and evaluate

interventions from the literature that work to address the issue.o

Select the interventions the group wishes to evaluate for use.o Assess the quality of evidence found in the literature.

o Summarize the findings

o Make recommendations

o Write a protocol or step- by- step guide to resolving the community issue.


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EVALUATING EVIDENCE

1] Sample selection:-It should be as unbiased as possible. For e.g.: Asample is randomly selected when each subject has an equal chance ofbeing selected from the population of interest. Random selection often theleast bias of any type of sample selection.

2] Randomization:-For a study that testing an intervention, participantsshould be randomly assigned to theIntervention or control group. This type of assignment is less biased .Then if

participants are allowed to choose the group they want to gain.

3] Blinding:-The researcher or evaluator should not know which participants

are in the experimental group or which are in the control group. Theresearcher or evaluator is blinded as to who is requiring or receiving thetreatment and who is not receiving treatment.

4] Sample Size:-The sample size should be large enough to show an effectof the intervention.

5] Description Of Intervention:- It should be described in detail andexplicitly enough that another person could duplicate study if desired.

OUTCOME

It should be measured accurately.

I. Length of follow-up:-Depending on the intervention participantsshould be followed for a long enough. Period of time to determine ifthe intervention continued to work or if the results were just bychance.

II. Attrition:-Few subjects should have dropped out of the study.III. Confounding variables:-Variables that could affect the outcome

should be accounted for either by statistical methods or by studymeasurements.

IV. Statistical analysis:-It should be appropriate to determine thedesired outcome.


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SUMMARYIt is the integration of best research evidence with clinical expertise and

patients values to facilitate clinical decision making. There are different bases fornursing practice, traditional, regulatory and philosophical. The goals are

document preferred practices, enhance quality of care; improve staff productivityetc.CONCLUSION

It is key element of clinical decision making is personalizing the evidenceto fit a specific patient circumstances. Most criticism of EBN are based on adifferent understanding of its philosophy than the one we offer. An accurateunderstanding of EBN is growing in the nursing community, and with this growth;enthusiasm for EBN increases. We must now address the challenges toevidence based practice and teaching by facilitating efficient access to theevidence and discovering better ways into the process of health care provision.


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BIBLIOGRAPHY

Guyatt dicenso [2005] Evidence based nursing practice, published by honorSociety of nursing, 1st edition, page no: 1-17

Potter and perry, fundamentals of nursing, mosbys publication, 5th

editionPage no:200-210

Marcia Stanhope, public health nursing,mosbys publication, 7th edition,Page no: 434-438

Net reference from[ wwwguidelines.gov,www.pubmed org.in]
http://www.guidelines.gov/http://www.guidelines.gov/

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Ebn Practice