ebn application
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EBN Application. 莊情惠 , MSN, RN Head Nurse, Chang Gung. Quality of Care. Broad topic Critically important Implementation key concern Many component parts. Component Parts. Patient, clinicians, systems Problem identification and refinement Use of evidence Interventions - PowerPoint PPT PresentationTRANSCRIPT
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EBN ApplicationEBN Application
莊情惠莊情惠 , , MSN, RNMSN, RN
Head Nurse, Head Nurse, Chang Gung Chang Gung
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QualityQuality ofof CareCare• Broad topicBroad topic
• Critically importantCritically important
• Implementation key concernImplementation key concern
• Many component partsMany component parts
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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
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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
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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
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EBN Promotes TranslationEBN Promotes Translation
Research LiteratureResearch Literature
intointo
Individualized careIndividualized care
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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
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EBN Promotes:EBN Promotes:
Systematic observation Systematic observation plusplus
Experience Experience andand
Research literatureResearch literature
to supportto support
Nursing decisionsNursing decisions
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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
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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
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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
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EBN GoalsEBN Goals• Improve patient outcomeImprove patient outcome
• Reduce healthcare costsReduce healthcare costs
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EBN Growing RapidlyEBN Growing Rapidly• Nursing - 2,500 citationNursing - 2,500 citation
• Medicine - 21,000 citationsMedicine - 21,000 citations
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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
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Where Are EBN Reports ?Where Are EBN Reports ?
• Professional journalsProfessional journals
• World Wide Web (WWW)World Wide Web (WWW)
• BooksBooks
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How Do I Get EBN Reports?How Do I Get EBN Reports?
• Your libraryYour library
• WebWeb
Many are freeMany are free
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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?
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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..
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Other Sources on WebOther Sources on Web–Practice guidelinesPractice guidelines
–Governmental sourcesGovernmental sources
–Cochrane DatabaseCochrane Database
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Our OutlineOur Outline
• What is evidence based nursing (EBN)What is evidence based nursing (EBN)
• Goals of EBNGoals of EBN
• ProductsProducts – – A model and aA model and an n example example
• Procedures for EBN reviewsProcedures for EBN reviews
• Strengths and WeaknessesStrengths and Weaknesses
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EBN – ExampleEBN – Example• ProblemProblem
– Type II Diabetes MellitusType II Diabetes Mellitus
– Clinic management Clinic management
• Goal - Process improvementGoal - Process improvement
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Assess SupportAssess Support• Nursing managementNursing management
• Other departmental leadersOther departmental leaders
• Nursing teamNursing team
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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
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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
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Challenges EncounteredChallenges Encountered
• Data base accuracyData base accuracy
• Staff turnoverStaff turnover
• Computer software upgradesComputer software upgrades
• SustainabilitySustainability
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Our OutlineOur Outline
• What is evidence based practice (EBN)What is evidence based practice (EBN)
• Goals of EBNGoals of EBN
• ProductsProducts
• Procedures for EBN reviewsProcedures for EBN reviews• Strengths and WeaknessesStrengths and Weaknesses
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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
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Develop Internet SkillsDevelop Internet Skills
• Use data basesUse data bases
• Use major EBN sourcesUse major EBN sources– PubMedPubMed
– CIHAHLCIHAHL
– Google Scholar Google Scholar
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Ask for HelpAsk for Help andand Help Yourself Help Yourself
• LibrarianLibrarian
• WWWWWW
• LecturesLectures
• ConferencesConferences
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Work with OthersWork with Others
• Sharing helps refine processSharing helps refine process
• Improves reliabilityImproves reliability
• Increase commitmentIncrease commitment
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Steps in a EBN reviewSteps in a EBN review
• AskAsk
• AccessAccess
• AppraiseAppraise
• ImplementImplement
• EvaluateEvaluate
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Ask the questionAsk the question• Identify a questionIdentify a question
• Define and refine the questionDefine and refine the question
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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
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Components of Question - Components of Question - PICOTPICOT
• PPatientsatients
• IInterventionntervention
• CComparison (current practice)omparison (current practice)
• OOutcomeutcome
• TTime frameime frame
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Access the LiteratureAccess the Literature
• Search literature – Search literature – Reports are sampleReports are sample
• Develop sample criteriaDevelop sample criteria– InclusionInclusion
– ExclusionExclusion
• Obtain reportsObtain reports
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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
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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?
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Is Report Quality Good Enough Is Report Quality Good Enough (Valid)?(Valid)?
• Use research critique skillsUse research critique skills
• Consider statistical significanceConsider statistical significance
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Does Report Fit My Setting?Does Report Fit My Setting?
• Comparison = Comparison = Current practiceCurrent practice
• Consider Consider – PatientsPatients
– ColleaguesColleagues
– SettingSetting
– ResourcesResources
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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
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Code Book IncludesCode Book Includes
• Methodological featuresMethodological features
• Quality assessmentQuality assessment
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Code MethodsCode Methods• Study sourceStudy source
• Publication yearPublication year
• Research design Research design
• Authors/investigators Authors/investigators characteristicscharacteristics
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Quality Assessment Quality Assessment • Scientific meritScientific merit
• Intervention descriptionIntervention description
• Study outcomesStudy outcomes
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Steps in a EBN reviewSteps in a EBN review
• AskAsk
• AccessAccess
• AppraiseAppraise• ImplementImplement
• EvaluateEvaluate
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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
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Critical Appraisal Critical Appraisal Two GoalsTwo Goals
• Internal consistencyInternal consistency
• Clinical significanceClinical significance
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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?
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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?
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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
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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
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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
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Rating the EvidenceRating the Evidence
• Study limitationsStudy limitations
• Inconsistency of resultsInconsistency of results
• Indirectness of evidenceIndirectness of evidence
• ImprecisionImprecision
• Publication biasPublication bias
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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.
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Steps in a EBN reviewSteps in a EBN review
• AskAsk
• AccessAccess
• AppraiseAppraise
• ImplementImplement• EvaluateEvaluate
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ImplementImplement
• Identify stakeholdersIdentify stakeholders
• Seek support of stakeholdersSeek support of stakeholders– Nursing managersNursing managers
– Hospital administrationHospital administration
– Other departmentsOther departments
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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
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EvaluateEvaluate• Assess cost effectivenessAssess cost effectiveness
• Patient Patient –AcceptanceAcceptance
–Satisfaction Satisfaction
–ComplaintsComplaints
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Measure Relevant InformationMeasure Relevant Information
• Wait times Wait times
• Patient census Patient census
• Staff turnover Staff turnover
• Medication errors Medication errors
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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
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Use Information Already Use Information Already CollectedCollected
• Incident ReportsIncident Reports
• Satisfaction surveysSatisfaction surveys
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Evidence Based Nursing Evidence Based Nursing OverviewOverview
• 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
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StrengthsStrengths• Reduces variations in practiceReduces variations in practice
• Gives consistent resultsGives consistent results
• Reduces knowledge/practice gapReduces knowledge/practice gap
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EBN Success RequiresEBN Success Requires• System wide supportSystem wide support
• Support of leadersSupport of leaders
• EvaluationEvaluation
• Monitoring adherenceMonitoring adherence
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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
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Forces Pushing EBN Forces Pushing EBN TodayToday
• CostCost
• SafetySafety
Allows nurses to do more with lessAllows nurses to do more with less
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SummarySummary• EBN – What it isEBN – What it is
• Goals of EBNGoals of EBN
• ProductsProducts
• Procedures for EBN reviewsProcedures for EBN reviews
• Strengths and WeaknessesStrengths and Weaknesses
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Thank You