Ebp Lab Sum 09 A (2)

Evidence-Based Nursing Evidence-Based Nursing PracticePracticeClinical LabClinical LabNursing V Nursing V

Summer 2009Summer 2009Judith Van Sant, PhD, RN, CNEJudith Van Sant, PhD, RN, CNE

ObjectivesObjectives Describe evidence-based practice (EBP)Describe evidence-based practice (EBP) Discuss the five steps of EBPDiscuss the five steps of EBP Ask at least one clinical question to be Ask at least one clinical question to be

researchedresearched Search, collect, and evaluate level of Search, collect, and evaluate level of

evidence on a clinical questionevidence on a clinical question Disseminate search findings to lab Disseminate search findings to lab

participantsparticipants

What is Evidence-Based Practice?What is Evidence-Based Practice?

Definition: “…a systematic approach Definition: “…a systematic approach to problem solving for health care to problem solving for health care providers” providers” (Pravikoff, Tanner, & Pierce, 2005).(Pravikoff, Tanner, & Pierce, 2005).

Integrated components:Integrated components: clinical expertise (best practice)clinical expertise (best practice) external evidence from systematic external evidence from systematic

researchresearch patient preferences patient preferences

(Sackett, et al., 1996)(Sackett, et al., 1996)

Process of Evidence-Based Process of Evidence-Based PracticePractice

Assess and define problem.Assess and define problem. Formulate specific question.Formulate specific question. Locate and evaluate appropriate evidence.Locate and evaluate appropriate evidence. Integrate evidence into planning andIntegrate evidence into planning and

implementing interventions.implementing interventions. Evaluate process and results.Evaluate process and results.

(Sackett, et al., 1996)(Sackett, et al., 1996)

Sources for Evidence-Based Sources for Evidence-Based PracticePractice

Guidelines and Best PracticesGuidelines and Best Practices Data base of evidence-based clinical practice guidelinesData base of evidence-based clinical practice guidelines Best practice information sheets Best practice information sheets

Systematic Literature ReviewsSystematic Literature Reviews Research method which produces a synthesis of the Research method which produces a synthesis of the

literature on a specific question and a discussion of literature on a specific question and a discussion of concomitant implicationsconcomitant implications

Cochrane Data-base of Systematic ReviewsCochrane Data-base of Systematic Reviews

Other ResourcesOther Resources Abstracted information and commentary on research Abstracted information and commentary on research

studies from various international journalsstudies from various international journals

Why Evidence Based Practice?Why Evidence Based Practice? Knowledge explosionKnowledge explosion ++ Nursing shortageNursing shortage

TimelyTimely research evidence research evidence translationtranslation into best practice. into best practice.

(Heater, Becker & Olsen, l988, cited in Melynk & Fineout-Overholt, 2005).(Heater, Becker & Olsen, l988, cited in Melynk & Fineout-Overholt, 2005).

(Melnyk & Fineout-Overholt, 2005; Salmon, 2007)

Mandate

Why Evidence Based Practice?Why Evidence Based Practice? Traditional practice Traditional practice

Knowledge gained in schoolKnowledge gained in school Pathophysiological rationalePathophysiological rationale IntuitionIntuition Experiences (past & usual practice)Experiences (past & usual practice) Workplace colleaguesWorkplace colleagues


17-year lag between research findings and practice application

Why Evidence Based Practice?Why Evidence Based Practice? EBP can lead to:EBP can lead to:

Increased practitioner satisfactionIncreased practitioner satisfaction Decreased “burnout” and turnover Decreased “burnout” and turnover Third party reimbursement Third party reimbursement


Why Evidence Based Practice?Why Evidence Based Practice? Evidence continually evolvesEvidence continually evolves

Evidence-based practice

Opinion-based

Melnyk & Fineout-Overholt, 2005; Salmon, 2007

WARNING!!!!!WARNING!!!!! ““EBP EBP does not replacedoes not replace clinical clinical

reasoning or judgment.”reasoning or judgment.”

20% medical practice20% medical practice<20% nursing practice<20% nursing practice

Supported by solid evidence

(Gray, et al., 2002)

Evidence Gaps

>Primary Research(Salmon, 2007)

What is Evidence Based Practice?What is Evidence Based Practice? Conscientious Conscientious use of use of bestbest evidence in evidence in

clinical decision making:clinical decision making: Systematic search for best evidenceSystematic search for best evidence Critical appraisal of most relevant Critical appraisal of most relevant

evidence to answer clinical questionevidence to answer clinical question Clinical context or circumstancesClinical context or circumstances One’s own clinical experienceOne’s own clinical experience Patient preferences and valuesPatient preferences and values

(Melnyk & Fineout-Overholt, 2005; Salmond,2007)

EBP is more than research utilization

History of EBP MovementHistory of EBP Movement Dr. Archie Cochrane, British Dr. Archie Cochrane, British

epidemiologistepidemiologist In 1972 criticized medical profession for In 1972 criticized medical profession for

lack of systematic review lack of systematic review of available of available evidenceevidence to direct clinical decision making to direct clinical decision making

Landmark case – several RCTs supporting Landmark case – several RCTs supporting effectiveness of corticosteroid therapy to halt effectiveness of corticosteroid therapy to halt premature labor in high risk women premature labor in high risk women had not had not been systematically analyzedbeen systematically analyzed

1,000’s of low-birth-weight premature infants 1,000’s of low-birth-weight premature infants continued to die needlesslycontinued to die needlessly

Review data showed therapy decreased death from Review data showed therapy decreased death from 30% to50%30% to50%

Melnyk & Fineout-Overholt, 2005

History of EBP MovementHistory of EBP Movement 2000 IOM report, 2000 IOM report, To Err is HumanTo Err is Human

Preventable medical errors were 8Preventable medical errors were 8thth leading cause of death in USleading cause of death in US

2002 IOM report, 2002 IOM report, Crossing the Crossing the Quality ChasmQuality Chasm Major lag between medical science and Major lag between medical science and

technology advancements and technology advancements and healthcare deliveryhealthcare delivery

Salmon, 2007

Steps in EBPSteps in EBP

1.1. Ask the “burning” question (PICO).Ask the “burning” question (PICO).2.2. Collect the most relevant & best Collect the most relevant & best

evidence.evidence.3.3. Critically appraise evidenceCritically appraise evidence4.4. Integrate all evidence with one’s clinical Integrate all evidence with one’s clinical expertise/patient preferences/values.expertise/patient preferences/values.5.5. Evaluate the practice decision or Evaluate the practice decision or

change.change.

Melnyk & Fineout-Overholt, 2005

1. Ask the “burning” question using 1. Ask the “burning” question using PICOPICO

P:P: Patient, population, or problem Patient, population, or problem being being addressedaddressed

I:I: Intervention or dimension of interestIntervention or dimension of interest C:C: Comparison interventionComparison intervention O:O: OutcomeOutcome

Format helps focus the question by Format helps focus the question by determining the important conceptsdetermining the important concepts

Not necessary to follow above orderNot necessary to follow above order


PICO ExamplesPICO Examples Intervention focused clinical question:Intervention focused clinical question:

““In teenagers (patient population), how effective In teenagers (patient population), how effective is Depo-Provera (intervention) in the prevention of is Depo-Provera (intervention) in the prevention of pregnancy (outcome)?pregnancy (outcome)?

Non-intervention focused question:Non-intervention focused question: What is the duration of breast feeding (outcome) What is the duration of breast feeding (outcome)

in new mothers (population) who have breast-in new mothers (population) who have breast-related-complications (area of interest) in the first related-complications (area of interest) in the first 3 months after the infants birth versus those who 3 months after the infants birth versus those who do not have breast related complications do not have breast related complications (comparison)?(comparison)?

(Salmon, 2007)

2. Collect most relevant and 2. Collect most relevant and best evidencebest evidence

1.1. Systematic review/meta-analysis of all RCTs Systematic review/meta-analysis of all RCTs or evidence-based clinical practice guidelinesor evidence-based clinical practice guidelines

2.2. At least one well-designed RCTAt least one well-designed RCT3.3. Well-designed controlled trials without Well-designed controlled trials without

randomizationrandomization4.4. Well designed case-control and cohort Well designed case-control and cohort

studiesstudies5.5. Systematic review of descriptive and Systematic review of descriptive and

qualitative studiesqualitative studies6.6. Single descriptive or qualitative studySingle descriptive or qualitative study7.7. Opinion of authorities and/or reports of Opinion of authorities and/or reports of

expert committeesexpert committees(Melnyk & Fineout-Overholt; 2005)


Evidence Based Clinical Practice Evidence Based Clinical Practice GuidelineGuideline Based on scientific literatureBased on scientific literature Explicitly documents process used to Explicitly documents process used to

develop statementdevelop statement Grades strength of evidence usedGrades strength of evidence used

(www.chestnet.org/education/guidelines/currentGuidelines.php; cited in Melnyk & Fineout-Overholt, 2005)

http://www.chestnet.org/education/guidelines/currentGuidelines.php


Systematic Review:Systematic Review: Rigorous systematic review of primary Rigorous systematic review of primary

studiesstudies Preplanned comprehensive search strategyPreplanned comprehensive search strategy Relevant articlesRelevant articles

appraisedappraised data synthesizeddata synthesized results interpretedresults interpreted summary of best available evidence providedsummary of best available evidence provided

(Salmon, 2007)

Precise; minimizes error & bias


Meta-analysis:Meta-analysis: Integrates results of similar descriptive or Integrates results of similar descriptive or

qualatitative studiesqualatitative studies

Meta-synthesis:Meta-synthesis: Statistical methodStatistical method Integrates results of several independent studies Integrates results of several independent studies

addressing a set or related research hypothesesaddressing a set or related research hypotheses Objective appraisalObjective appraisal Precise estimate of treatment effectPrecise estimate of treatment effect

(Salmon, 2007)


RCT:RCT: ““Gold Standard” for intervention studiesGold Standard” for intervention studies Most reliable Most reliable Treatment randomization eliminates large amount Treatment randomization eliminates large amount

of biasof bias

Cohort Study:Cohort Study: Observational longitudinal study with 2 patient Observational longitudinal study with 2 patient

groupsgroups One group receives treatmentOne group receives treatment Groups measured over time for development of Groups measured over time for development of

outcomes outcomes (Salmon, 2007)


Case-control studies:Case-control studies: Compares patients who have a specific Compares patients who have a specific

condition to people who do notcondition to people who do not Uses medical records and/or patient Uses medical records and/or patient

recallrecall Less reliable than RCTs and cohort Less reliable than RCTs and cohort

studies studies showing a statistical relationship does not showing a statistical relationship does not

necessarily mean clinical causal relationship necessarily mean clinical causal relationship

(Salmon, 2007)


Qualitative Research:Qualitative Research: Collects data through observations and interviewsCollects data through observations and interviews Generates ideas and hypotheses through Generates ideas and hypotheses through

inductiveinductive

Descriptive Studies:Descriptive Studies: Can be quantitative or qualitativeCan be quantitative or qualitative Describe what is going on Describe what is going on

Expert OpinionExpert Opinion(Salmon, 2007)

Search StrategySearch Strategy1.1. Determine appropriate data base for questionDetermine appropriate data base for question2.2. Determine type of study design that would best Determine type of study design that would best

answer questionanswer question3.3. Enter a subject heading (e.g., MeSH in PubMed) Enter a subject heading (e.g., MeSH in PubMed)

and/or textword search guided by the PICO and/or textword search guided by the PICO components of the questioncomponents of the question

4.4. Combine searches to find relevant evidenceCombine searches to find relevant evidence5.5. Further restrict combined searches for study Further restrict combined searches for study

design, methods, indicators of clinical design, methods, indicators of clinical meaningfulness, English, humanmeaningfulness, English, human

6.6. Apply pre-established inclusion & exclusion Apply pre-established inclusion & exclusion criteria to studies gathered by the searchcriteria to studies gathered by the search

(Salmon, 2007)

Pre-appraised literature is golden

3. Critically Appraise Evidence3. Critically Appraise EvidenceRCTRCT

Rapid ScreeningRapid Screening Random allocation of interventions?Random allocation of interventions? Blindness to interventions by Blindness to interventions by

Researchers?Researchers? Participants?Participants? Involved health care professionals?Involved health care professionals?

(Melnyk & Fineout-Overholt; 2005)

3. Critically Appraise Evidence3. Critically Appraise EvidenceSystematic ReviewSystematic Review

Rapid AppraisalRapid Appraisal Relevant papers identified?Relevant papers identified? Method of assessing quality of papers?Method of assessing quality of papers? Method of summarizing results?Method of summarizing results?


3. Critically Appraise Evidence3. Critically Appraise EvidenceQualitative ResearchQualitative Research

Lincoln & Guba’s Evaluative Criteria:Lincoln & Guba’s Evaluative Criteria: TrustworthinessTrustworthiness

Credibility (internal validity)Credibility (internal validity) Transferability (external validity)Transferability (external validity) Dependability (reliability)Dependability (reliability) Confirmability (objectivity)Confirmability (objectivity)


4.Integrate Evidence/Patient 4.Integrate Evidence/Patient Preferences/Values/Clinical ExperiencePreferences/Values/Clinical Experience

Evidence assists but does not replace Evidence assists but does not replace sound clinical reasoning.sound clinical reasoning. EvidenceEvidence AnalogyAnalogy ExperienceExperience Meaning Meaning TheoryTheory

Salmon, 2007)

4.Integrate Evidence/Patient 4.Integrate Evidence/Patient Preferences/Values/Clinical ExperiencePreferences/Values/Clinical Experience

Is evidence useful for this particular Is evidence useful for this particular patient?patient?

Cost effective?Cost effective? Patient values and preferences?Patient values and preferences? Clinician expertise?Clinician expertise?

Best clinical decision making isintegrative and collaborative! Salmon, 2007)

5. Implement & Evaluate Impact5. Implement & Evaluate Impact Track outcomesTrack outcomes

Include patients’ evaluationsInclude patients’ evaluations Requires informatics for imputing & Requires informatics for imputing &

trackingtracking PatientPatient TreatmentTreatment OutcomeOutcome

Health & Medicine

Ebp Lab Sum 09 A (2)