Evidence Based Evidence Based Nursing:Nursing:

A Seminar in Literature, Clinical A Seminar in Literature, Clinical Practice and Patient EducationPractice and Patient Education

Darra BallanceDarra Ballance

Lindsay BlakeLindsay Blake

Kevin BradfordKevin Bradford

Three Elements Three Elements of Evidence-Based Practiceof Evidence-Based Practice

Clinician Experience +Clinician Experience +

Patient Preferences +Patient Preferences +

Scientific Findings =Scientific Findings =

Evidence-Based Practice Evidence-Based Practice

How is Evidence Based How is Evidence Based Nursing different from Nursing different from

Medicine?Medicine?

Nursing = Care Medicine = Cure

What Is Evidence-Based Practice?What Is Evidence-Based Practice? Evidence-based medicine (EBM) has been

defined as “… a conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients."(1)

EBP has also been described as “…an approach that enables clinicians to provide the highest quality of care in meeting the multifaceted needs of their patients and families."(2)

1. David Sackett, et al. "Evidence Based Medicine: What It Is and What It Isn't," BMJ 312, no. 7023 (1996) 2. Melnyk, Bernadette & Fineout-Overholt, Ellen. Evidence-Based Practice in Nursing and Healthcare. Philadelphia, Lippincott Williams & Wilkins (2005)

What EBP Is NotWhat EBP Is Not

NOT “Cookbook” medicine NOT a tool for

administrators and insurers NOT restricted to

randomized trials and systematic reviews

NOT opposed to patient-centered care

NOT just for physicians or those doing research

Why use Evidence-Based Why use Evidence-Based Practice?Practice?

Assistance in making informed decisions Higher levels of patient satisfaction Encourages individualized treatment of

patients resulting in better outcomes Keeping current on best treatments Promotes innovation and

practice change Respects professional

judgment

5 Steps of Evidence-Based 5 Steps of Evidence-Based PracticePractice

1. Posing a Clinical Question

2. Finding Relevant Evidence

3. Appraising the Evidence

4. Combining the Evidence with Nursing Experience and Patient Preferences

5. Evaluating the Outcomes

Moving from the Clinical Problem Moving from the Clinical Problem

to the answerable questionto the answerable question Observe your daily Observe your daily

interactions, note any interactions, note any questions that arise. questions that arise.

Could you investigate Could you investigate this question? this question?

Is there a better method Is there a better method than what you are using than what you are using that you have seen or that you have seen or heard about? heard about?

Melnyk, Bernadette & Fineout-Overholt, Ellen. Evidence-Based Practice in Nursing and Healthcare. Philadelphia, Lippincott Williams & Wilkins (2005)

Posing a Clinical Question: Posing a Clinical Question: the PICO Modelthe PICO Model

P = Patient / Population / Problem

I = Intervention / Area of interest

C = Comparison intervention / Status

O = Measurable outcome of interest

Does group intervention for Does group intervention for parents and children achieve parents and children achieve greater weight loss in obese greater weight loss in obese children than routine care?children than routine care?

Http://ebn.bmj.com/cgi/reprint/11/2/43

P – obesity, children, families or parents

I – Group or Family interventionIncludes diet. Physical activity, behavior change

C – Routine Care or Individual intervention

O – greater weight loss

Posing a Clinical QuestionPosing a Clinical QuestionWhat kind of Question is it?What kind of Question is it?

1. Therapy

2. Diagnosis

3. Prognosis

4. Etiology

5. Prevention

6. Meaning

7. Quality Improvement

Clinical Question to Study DesignClinical Question to Study Design

Levels of EvidenceLevels of Evidence

LoBiondo-Woo, G. P., RN, FAAN and Judith Haber, PhD, APRN, BC, FAAN. (2006). Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice (6th ed.). St. Louis, Mo.: Mosby Elsevier.

Level I

Level II

Level III

Level IV

Level V

Level VI

Level VII

Systematic review, meta-analysis , or evidence based guideline

At least one well-designed Randomized Controlled Trial

A well-designed controlled trial without randomization

Non experimental studies, such as case-control and cohort studies

Systematic reviews of descriptive or qualitative studies

A single descriptive or qualitative study

Opinion of authorities and/or reports of expert committees

Best Evidence

OtherEvidence

Types of Literature/ResearchTypes of Literature/Research

Systematic/Integrative Research Review

Meta-analysis

Research

Review

Clinical Trial

Controlled Trial

Randomized controlled clinical trials

Types of Literature/ResearchTypes of Literature/Research

Case Control Studies

Cohort Studies

Qualitative Studies

Descriptive Studies

Case Reports

Case SeriesCase Series

Expert OpinionExpert Opinion

Acquiring the evidence - Acquiring the evidence - PoliciesPolicies

MCGHI Policy Manual– http://hi.mcg.edu/Hospital/pcs/policy.htm

Acquiring the evidence – Acquiring the evidence – Protocols/GuidelinesProtocols/Guidelines

Mosby’s - http://app32.webinservice.com/MosbySkills/skillsMain.asp

Acquiring the evidence – Acquiring the evidence – Guidelines & StandardsGuidelines & Standards

Protocols/Guidelines– National Guidelines Clearinghouse -

http://www.guideline.gov/– Centers for Disease Control - http://www.cdc.gov/

Critical Pathways – http://www.utmb.edu/cpg/

Standards of Care– AACN –

http://www.aacn.org/aacn/practice.nsf/vwdoc/scp– LSU Health Sciences Center –

http://www.medcom.lsuhsc-s.edu/cfdocs/policies/Std_of_Care.cfm

MEDLINE - Contains over 12 million citations to research articles, case reports, letters, editorials, and animal studies published in biomedical journals. Search Filters for: Therapy, Diagnosis, Prognosis, Etiology, Qualitative Studies.

Acquiring the evidence - Acquiring the evidence - databasesdatabases

CINAHL Plus with Full Text - the world's most comprehensive source of full text for nursing & allied health journals. With full text coverage dating back to 1937, CINAHL Plus with Full Text is the definitive research tool for all areas of nursing.

Acquiring the evidence - etcAcquiring the evidence - etc Other databases Evidence-based reviews

– ACP Journal Club– Cochrane databases -

http://www.cochrane.org/– Joanna Briggs Institute -

http://www.joannabriggs.edu.au/about/home.php In-Print

– Evidence-Based Nursing - http://ebn.bmj.com/contents-by-date.0.dtl

– Worldviews on Evidence-Based Nursing - http://www3.interscience.wiley.com/journal/121371704/grouphome/home.html

Combining the Evidence: Combining the Evidence: Patient-Centered PerspectivePatient-Centered Perspective

Are the results of Are the results of this study this study appropriate for my appropriate for my patients? patients?

Do my patients meet Do my patients meet the criteria for the criteria for inclusion and inclusion and exclusion? exclusion?

Do the treatment Do the treatment benefits outweigh benefits outweigh the potential harm the potential harm and/or costs?and/or costs?

Study Design Study Design Good Quantitative EvidenceGood Quantitative Evidence

– Background/Literature review – Study Design

Control/comparison groupRandomization & BlindingPopulation (size, traits) & time

frame Follow-up (>80%)

– Results of study Well defined outcome criteriaApplicable to patients

Study DesignStudy DesignGood Qualitative EvidenceGood Qualitative Evidence

– Purpose & problem clearly statedPurpose & problem clearly stated– Data Collection ProceduresData Collection Procedures

Method & time frame specifiedMethod & time frame specifiedOrganization & analysis of dataOrganization & analysis of data

– Study ParticipantsStudy ParticipantsSelection process & number Selection process & number

of participants of participants Nature of setting(s) utilizedNature of setting(s) utilized

– Results of studyResults of studyImpact on clinical practiceImpact on clinical practiceSuggestions for future Suggestions for future researchresearch

Results - StatisticsResults - StatisticsWhy use Statistics?Why use Statistics?

Types of Statistics - DescriptiveTypes of Statistics - Descriptive

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Searching Techniques

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Percentage Distribution

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Descriptive StatisticsDescriptive Statistics

Measures of central Tendency57, 51, 49, 43, 37, 36, 35, 31, 26, 26

Mean 39.1

Mode26

Median36 & 37

Descriptive StatisticsDescriptive Statistics

Measures of Dispersion57, 51, 49, 43, 37, 36, 35, 31, 26, 26

Range31

Standard Deviation Normal Distribution

Graphs courtesy of wikipedia

Types of Statistics -Types of Statistics - Inferential Inferential

P or Probability ValueP or Probability Value Paired t-testPaired t-test Independent t-testIndependent t-test ANOVAANOVA Chi-SquaredChi-Squared Mann-Whitney U testMann-Whitney U test Spearman RhoSpearman Rho

Make friends with a statistician !

Evaluating the OutcomesEvaluating the OutcomesHow did the implementation proceed?How did the implementation proceed?

Were staff receptive?Were staff receptive?

Were there areas that could Were there areas that could

have been smoother? have been smoother?

Ones that went well?Ones that went well?

Did the process improve Did the process improve

outcomes?outcomes?

Three Elements Three Elements of Evidence-Based Practiceof Evidence-Based Practice

Clinician Experience +Clinician Experience +

Patient Preferences +Patient Preferences +

Scientific Findings =Scientific Findings =

Evidence-Based PracticeEvidence-Based Practice