rese method workshop 2010

•Paradigm shift from expert or opinion based practice to Evidence-based practice.

•Has potential to increase patients’ involvement in clinical decision making.To improve health outcomes.

Introduction

INTRODUCTION

The concept of EBP emerged out of the Evidence-Based Medicine (EBM) movement, which is rooted in the work of A.L. Cochrane.

In the 1970s, Cochrane strongly encouraged his colleagues to use evidence

from random controlled trials to determine the effectiveness and efficiency of medical interventions (The Cochrane Collaboration, 2002).

Evidence-based practice(EBP)

Is the acknowledgement of uncertainty followed by the seeking, appraising and implementation of new knowledge.

It enables us to accept the difference, possibly more effective, methods of care than those currently employed.

"Evidence-based nursing (EBN) means using the best available evidence from research, along with patient preferences and clinical experience, when making nursing decisions."

Evidence-based nursing

Evidence Based Nursing Evidence Based Nursing is the

process by which nurses make clinical decisions using the best available research evidence, their clinical expertise and patient preferences.

Three areas of research competence are: interpreting and using research, evaluating practice, and conducting research.

Model for clinical decisions

Patients' preferences

Researchevidence

Clinical Expertise

Resources

The EBP- processEvidence-Based Practice is a five-step

process: Identify a knowledge need and

formulate an answerable clinical question

Locate the best available evidence Critically evaluate the evidence Integrate the evidence with patient’s

unique biology ,preferences and values

Evaluate the outcome

•Select a topic •Collect appropriate and accurate data to generate evidence for nursing practice.•Analyze data from clinical practice.•Design interventions based on evidence.•Predict and analyze outcomes.•Examine patterns of behavior and outcomes.•Identify gaps in evidence for practice.•Evaluate project to determine and implement best practices

Steps in EBN

Sources of EBP

•The IOWA Model of nursing utilization

•Rogers diffusion of innovation-model

•Stetler model for research utilization

•Disciplined clinical inquiry model

Various Models-EBNP

•Conduct and utilization of Research in Nursing (CURN) model

•Translational research model

Various Models-EBNP cont’d

•Is a research utilization model and modified to include more emphasis on EBP .

•The model is renamed, The IOWA Model of evidence-based practice to promote quality care.

•Problem focused triggers & knowledge focused triggers

The IOWA Model

•Assess, pilot the change in practice•Continue to evaluate quality of care and the new knowledge

•Institute the change in practice

•Monitor and analyze structure ,process &outcome

The IOWA Model-cont’d

The IOWA Model

Rogers diffusion of innovation-model

Major concepts are : •innovation•Communication•Time•Social system

Rogers diffusion of innovation-model

I Phase- preparationII Phase-validationIII Phase – comparative evaluation/decision making IV Phase-translate or apply the research in the V Phase –evaluate the out come as of the change in practice

Stetler model for research utilization

Stetler model for research utilization

Professional practice model

Evidence-based practiceThe quality of the evidence is based on:

Is this the best available evidence? Best sources included peer reviewed

journals & reports no more than 3-5 years old.

Will the recommendations work for my practice to solve the client’s problems?

Do the recommendations fit well with the preferences & values of the clients the nurse commonly works with?

Phase I-Needs assessment

Phase 2- learning and knowledge generation

Phase 3- knowledge assimilation

Phase 4 –knowledge application

Phase 5- Outcomes & impact evaluation

Disciplined clinical inquiry model

Disciplined clinical inquiry model

Phase INeeds assessmentCurrent

state

Desired state

DCIPrinciplesTools & process

EBNP

Phase 3

Phase 2

Phase 4

Phase 5

EBPCKD&CA

RE

PC

Outcomes& impact Evaluation

Nursing practices are examined for:

• Feasibility which relates to the practicality of implementing the action.

•Appropriateness refers to whether it is acceptable & justifiable with in ethical guidelines.•Meaningfulness provides the rationale for the practice being adopted.•Effectiveness relates to how much evidence supports the practice & what evidence provides divergent view points

Benefits of using evidence base for clinical practice: A sound foundation for practice Enhanced self-confidence,

autonomy, critical thinking skills and professional self-concept

Cost-effective patient care Increased job satisfaction &quality

of care

BENEFITS cont’d..

Improved patient outcomes A stimulus for collaborative

practice, retention & recruitment

An improved image of nursing An ever –increasing scientific

nursing knowledge base

•Information about the patient •Domain information and knowledge (“the evidence”) from systematic inquiry and other sources   

What Data Do We Need for Evidence-Based Practice? 

•Building the evidence •Retrieving the evidence •Analyzing the evidence •Applying the evidence    

Informatics Supports 

(a)consistent long-term vision and support from senior leadership;

(b) resources such as trained personnel, finances, and time; and

(c) structured approach to create an environment that facilitates the process.

A successful EBP program requires:

•Health professionals are already doing it•Evidence –based health care is ‘’cook book’’ health care•Evidence –based practice relies on RCT &Meta -analyses•There is no evidence•Theory is more important than evidence in guiding practice

Criticisms of the evidence –based approach

•Resistant to changes in nursing practice.•Ability to critically appraise research findings.•Time, workload pressures, and competing priorities.•Lack of continuing education programs. •Fear of "stepping on one's toes"•Poor administrative support .

Challenges to EBP

•Relevant research based evidence bases are not comprehensive ( there is gap in the practice)•The relevant evidence bases are not static•Life long-learning is generally accepted as an important priority in the 21st century

Challenges to EBP-cont’d

•The piece of research conducted does not mean that the finding s should be transferred directly in to the clinical setting•Demands from patients for a certain type of treatment

Challenges to EBP-cont’d

•Peer pressure to continue with practices that are stepped in tradition•Inadequate content and behavioral skills regarding EBP in educational programs•Lack of commitment and computer skills

Challenges to EBP-cont’d

•Support and encouragement from administration•Time to critically appraise studies and important findings•Clearly written research reports•Adequate resources and time•Characteristics of health care team(shared vision & mission)•Guideline characteristics

Facilitating conditions to enhance EBP

•Providing superior educational opportunities •Enhancing health-related quality of life through development, acquisition, and application of knowledge •Generating and using empirical data to develop informed nursing policies and practice

Strategies that guide our work include:

•Developing a dynamic nursing culture that is embraced and respected, both internally and externally •Fostering excellence in practice and continuity of care •Synchronizing best practices throughout to quality outcomes

Strategies that guide our work-cont’d

•Reduction in IM injection•Chlorhexidine Hand rub in ICU to prevent infection•Preparation of patient education materials to enhance increase patient outcomes•Most patient friendly strategies to improve Quality of care•Strategies to minimize patient fall, pressure sore care•Independent nursing practice( nurse educators in the specialty areas)

EBP-CMC

•Open and closed endo tracheal suctioning

•Use of coconut oil instead of powder to reduce pressure sore

•Use of vegetable oil instead of glycerine to prevent glossitis

•Use of NRS to assess pain management• use of Postoperative check list

EBP –C MC, cont’d

•use of lactulose enema instead of bowel wash for hepatic encephalopathy•Use of dry/empty humidifier to prevent infections•Use of mild sedation instead of mechanical restraints in the ICU•Use of tap water to clean RTA wounds in Emergency unit•Kangaroo care for neonates•No skin preparation and soap and water enema for woman in labour

EBP –CMC, cont’d

Best evidence to guide clinical practice:

Exercise improves glycemic control and reduces plasma triglycerides and visceral adipose tissue in type-2 diabetes; evidence obtained from -14 RCT, Meta-analysis(JEBN-2007).

A low protein diet delays ESRD in chronic kidney disease.

Best evidence to guide clinical practice-cont’d…

Peri operative education coordinated at one facility identified the occurrence of deep vein thrombosis as a significant problem. Nurse conducted a literature review ,created an evidence –based practice change.

Life style education programmes lower glucose concentrations & reduce the incidence of type 2 diabetes

McCormack investigated existing evidence-based literature to answer the clinical question How effective is the use of wrist splints as a single first-line therapy for the relief of symptoms in adults Carpel Tunnel Syndrome-suggest the Wrist splints as a first-line therapy.

Best Evidence cont’d..

•Allowing wounds to be uncovered and wet in the first 48 hours after minor skin excision did not differ from standard dry management for wound infection.

•Meta-analysis of (28 RCTs) exercise training decreased long term cardiac mortality, MI recurrence & major cardiac risk factors( BP, total serum cholesterol, weight ).

Best evidence-cont’d

Best evidence contd….

RCTs (19 studies) to evaluate the effectiveness of nurse delivered smoking cessation intervention for adults, had >2 groups & had > 6 months of follow-up. At longest follow up, pts’ who received advice from a nurse were more likely to stop smoking than received usual care.

Best evidence cont’d..

RCT to compare the effectiveness and cost-effectiveness of aggressive versus symptomatic therapy in established rheumatoid arthritis(2005).

The finding reported that there was no significant difference between the groups for any of the clinical outcome measures.

Best evidence cont’d…

Research makes a difference in practice. A meta-analysis designed to determine the contribution of research-based practice to patient outcomes.

Heater & Colleagues reported that patients who receive research based nursing care make “sizable gains” compared to those receiving routine nursing care.

Best Evidence cont’d..

Interventions involving family care givers to improve outcomes of hospitalized elders; the finding of studies suggest that family member involvement has benefits for both the elder and the family members.

•Evidence based nursing started in the 1800s with Florence Nightingale. •EBN is a problem solving approach to clinical decision making. •EBN integrates providers' clinical expertise with the best external clinical evidence.

Summary

EBN is the process of integrating • Clinical knowledge • Judgement • Proficiency skills • with the best available clinical

evidence, such as nursing practice in to patient care (TRIP &GRIP).

Summary-cont’d

•A commitment to the continued preparation of nurses as scientist is vital to achieve excellence in nursing practice

•we can continue to shape the future of nursing and healthcare...through the planning, implementation and dissemination of quality research studies.

Conclusion

THANK YOU SO MUCH FOR YOUR TIME

REFERENCES: Ellis, J. R & Hartley C. L (2005). Managing and Coordinating nursing care (4thed.).

PhiladelphiaLippincott Williams & Wilkins Company. Heidenthal, P.K (2004).Essentials of Nursing Leadership &Management. USA, Delmar learning. Journal of Evidence Based Nursing, January, 2007. Kathuric, O. (2003).Evidence Based Nursing practice. The Nursing Journal of India.

No.11.p251-252

Rose, M., Best, D & Higgs, J (2005). Transforming practice through Clinical Education, Professional Supervision & Mentoring. Philadelphia, Elsevier Company.

Vanwicken, W. Cantrell, W. (2006). Implementing a research utilization plan for prevention of deep vein thrombosis.AORNJ,83(6) 1353-62

References contd.. Melnyk,B. & Fineout-Overholt, E.(2005). Evidence-based Practice in Nursing &

Health care. Philadelphia. Lippincott Williams & Wilkins Company.

Web sites: www.ebn.bmj.com/cgi/ www.cebm.utoronto.ca/syllabi/nur/ www.ahrq.gov/qual/ www.himiss.org/content/ www.tripdatabase.com