EVIDENCE BASED NURSING PRACTICE

Submitted to: Mrs. Sunita Sharma Lecturer, N.I.N.E P.G.I.M.E.R, Chandigarh

Submitted By: Ms Prabhjot Kaur M.Sc.(Nursing) 1st Year 8/26/2009

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NTRODUCTION

When there is a lack of research reported in literature to guide clinical practice, it becomes necessary to design and conduct studies to generate evidence. There are many areas in clinical practice that do not have an established evidence base (e.g. care for dying children, primary care intervention to improve mental health outcomes in high risk individuals) as a result, their is an urgent need to conduct studies so that health care providers can base their treatment decisions on sound evidence from studies. Evidence based practice is an approach that enables clinicians to provide the highest quality of care in meeting the multifaceted needs of their patients and families. When health care providers know find, critically appraise and use the best evidence and patients are confident that their health care providers are using evidence based bare optimal outcomes are achieved for all.

for example, If you are caring for a patient who sustained head injury in a motor vehicle accident, would you want to know and use the most effective, empirically supported treatment established from randomally controlled triad to decrease his/her intracranial pressure. If you are diagnosed with cancer today and when faced with the decision about which type of chemotherapy to choose, would you want to know the evidence regarding the risks and benefits of each chemotherapeutic agents.
Without current best evidence, practice is rapidly outdated, often to the detriment of patients. e.g. for years paediatric primary care providers adviced parents to place their infants in a prone position while sleeping with the underlying reasoning that this is the best position to prevent aspiration in event of vomiting. With evidence indicating that the prone positioning increases the risk of Sudden infant death Syndrome, the American Academy of Paediatrics released a clinical practice guidelines recommending a supine position for infant sleep (AAP, 2000) Research utilization emphasizes the transfer of specific research based knowledge into practice.

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Research Utilization.
The term research utilization and evidence based practice are sometimes used synonymously. It is the process of transferring research knowledge into practice; thus facilitating an innovative change in practice protocols. Research utilization is the use of findings from a disciplined study or a set of studies in a practical application that is unrelated to the original research. Research utilization can be defined very broadly as the use of research findings in any and all aspects of one's work as a registered nurse. While there are specific kinds of research utilization, such as instrumental, conceptual, and persuasive (Estabrooks, 1997), at its simplest it is the use of research.

Evidence-Based Nursing Practice

EBN is, this author believes, much broader than research utilization, encompassing not only research findings, but other forms of practice knowledge as well. Evidence based practice involves making clinical decision on the basis of the best possible evidence. It is defined as the use of current best evidence by clinicians when making patient care decisions, it entails finding the best evidence , critically evaluating it, integrating it with clinical expertise and patient preferences and applying the results to the clinical practice.

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Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. (Sackett et al., 1996, p. 71) Evidence-based medicine de-emphasizes intuition, unsystematic clinical experience, and pathophysiologic rationale as sufficient grounds for clinical decision making and stresses the examination of evidence from clinical research. Evidence-based medicine requires new skills of the physician literature searching and the application of formal rules of evidence evaluating the clinical literature. (Evidence-Based Working Group, 1992, p. 2420) It is a problem solving approach to clinical practice that integratesA systematic search for and critical appraisal for the most relevant evidence to answer a burning clinical question Ones own clinical expertise Patients preference and values

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Components of Evidence Based Practice

evidence from research,/theor ies/expert panels

information about patient preferences & values

evidence based clinical decision making

evidence from assessment of patients history & physical exam &availability of health care resources

clinical expertise

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History of movement

The evidence based practice movement was founded by Dr. Archie Cochrane, british epidemiologist, who struggled with the efficacy of health care and challenged the public to pay for care that had been empirically supported as effective (Eukin, 1992) In 1972, Cochrane published a landmark book that criticized the medical profession for not providing rigorous review of evidence so that policy makers and organization could make decisions about health care. Cochrane was a strong proponent of using evidence from randomized clinical trials because he believed that this was the strongest evidence to base clinical practice decisions.He asserted that reviews of research evidence across all speciality needs to be prepared systematically through a rigorous process and they should be maintained to consider the generation of new evidence(Cochrane Collaboraton,2001) Cochrane noted that thousand of LBW premature infants died needlessly. He emphasized that the results of several randomized clinical trials supporting the effectiveness of corticosteroid therapy to halt premature labour in high risk woman had never been analyzed and compiled in the form of systematic review. The data from systematic review showed that corticosteroid therapy reduced the odds of premature infant death from 50% to 30%. Dr. Archie Cochrane died in 1998. However, as a result of his influence and care for updates of systematic reviews of randomized controlled trials, the Cochrane centre was launched in Oxford England in 1992, and Cochrane Collaboration was founded a year later.

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Key steps of Evidence based practice

Evidence-Based Practice (EBP) is a thoughtful integration of the best available evidence, coupled with clinical expertise. As such it enables health practitioners of all varieties to address healthcare questions with an evaluative and qualitative approach. EBP allows the practitioner to assess current and past research, clinical guidelines, and other information resources in order to identify relevant literature while differentiating between high-quality and low-quality findings. The practice of Evidence-Based Practice includes five fundamental steps.

Step 1: Asking the burning clinical question in the format that will yield the most relevant and best evidence (i.e. PICO Format)

Step 2: collecting the most relevant and best evidence to answer the clinical question including searching for systematic reviews/ meta-analysis or clinical practice guidelines

Step 3: Critically appraising the evidence that has been collected for its validity, relevance and applicability. Step 4: integrating the evidence with ones clinical expertise, assessment of patients condition and available health care resources along with the patients preferences and values to implement a clinical decision

Step 5: Evaluating the change resulting from implementing the evidence in practice.

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Steps of evidence based practice

1. Asking a searchable, answerable question

The first step to accomplish this goal is to formulate the clinical issues ito a searchable answerable question. There are two type of questions- Background questions and foreground questions. Background questions are those that need to be answering as a foundation of asking the searchable answerable foreground questions. Sackett and collegues(2000) describe background questions as that ask for general information about a clinical issue. It has two components: the starting place of questions(e.g. what, where,why, how) and outcome of questions (clinical diagnosis) e.g. How does drug Acetaminophen work to affect fever? The answer to this question can be found in a drug pharmacokinetic text.

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Foreground questions are those that can be answered from scientific evidence about diagnosing, treating, and assisting patients with understanding their prognosis. These questions form on specific knowledge e.g. which is more effective in reducing fever in children Acitaminophen or Ibuprofen? Or which is more effective in patients with ARDS Prone or supine positiong? The first question is based on the knowledge of how acetaminophen works but can be answered only by a study that compare the two listed medications. The second question requires knowledge of how positioning changes haemodynamics but the two types of positioning must be compared In specific population of patients in order to answer it. Posing the question using PICO Patient population of interest Intervention of interest Comparison of interventions Outcome of interest

P I C O

The patients population or disease of interest e.g. age, gender, ethnicity, and certain disorders (e.g. Hepatitis) Intervention or range of intervention of interest e.g. exposure to diseases, risk behavior What you want to compare the intervention against e.g. no disease, placebo or no intervention/ therapy, absence of risk factors Outcome of interest e.g. risk of disease, accuracy of diagnosis,rate of occurance of adverse outcomes (death)

As for example, for patients of 65 years old (P) does the use of an influenza vaccine (I) reduces the future risk of Pneumonia (O) compared with patients who have not received the vaccine (C).

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2. Assembling and evaluating the evidence

Once a clinical practice question has been selected, the next step is to search and assemble research evidence on the topic. In doing a literature review as a background for a new study, the central goal is to discover where the gap are and how best to advance knowledge. cochrane reviews are an important resource. They have been found to be more rigorous than published in journals (jaded etal,1998). Another critical resource available for integrative review is the agency for health care research and quality (AHRQ). Research based evidence sites are CINAHL and Medline databases, Cochrane library(www.cochrane.org) , American college of physician pier, National Guideline Clearinghouse (www.guideline.gov), Turning research into practice (www.tripdatabase.com) Professional association Guidelines /Standards of care, expert opinion/clinical expertise (clinical articles, web search)

3. Critically Appraising the Article

In determining the implementation potential of an innovation in a particular setting, several issues should be considered, particularly the transferability of the innovation, the feasibility of implementing it and its cost benefit ratio. If the implementation assessment suggest that there might be problems in testing the innovation in that particular practice setting, then the team can either identify a new problem and begin the process anew or consider adopting the plan to improve the implementation potential (e.g seeking external resources if cost were the inhibiting factors)

4. Integrating the evidence with ones clinical expertise

if the implementation criteria are met the team can design and plot the innovation. Based on the IOWA model the following activities can be involved: o developing an evaluation plan (identifying outcomes to be achieved, determining how many clients to involve in the pilot, deciding when and how often to take measurements)

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o collecting baseline data relating to those outcomes to develop a counterfactual against which outcomomes would be assessed. o Developing a written EBP guideline based on the synthesis of the evidence, preferably a guideline that is clear and user friendly and that uses such devices as flow charts and decision trees o Training the relavant staff in the use of the new guideline and if necessary marketing the innovation to user so that it i s given a fair test. o Trying the guideline out on one or more units or with the sample of clients.

5. Evaluating the change The last step in EBP is evaluation of the pilot project in terms of both process (e.g how the innovation received, to what extent were the guidelines actually followed, what implementation problems were encountered?) and outcomes ( in terms of client outcomes and cost effectiveness) A variety of research designs can be used in the evaluation ,of course ,with the most rigorous being an experimental design. In most cases however, a less formal evaluation will be more ractical, comparing collected out comes data or hospital records before and after the innovation and gathering information about patient and staff satisfaction. Qualitative and mixed method research designs can also contribute to evaluating an innovation. Valuable information on the feasibility and participant burdens can be obtained. Evaluation data should be gathered over a sufficiently long period to allow for a true test of a mature innovation the end result of this process is a decision about whether to adopt the innovation , to modify it for on going use or to revert it to prior practices.

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Models for evidence based Nursing practice

The models offer guidelines for designing and implementing a utilization project in a practice setting. The two models stelter model and Iowa model incorporate evidence practice processes rarther than research utilization alone.

THE STELTER MODEL The stelter model was designed with the assumption that Research Utilization could be undertaken not only by organizations but by individual clinicians and managers. It was a model designed to promote and facilititate critical thinking about the application of research findings in practice. The current model presented graphically involves five sequential phases: 1. Preparation In this phase, the nurse defines the underlying purpose and outcomes of the project, search, sort and select sources of research evidence. She consider external factors that can influence potential application and internal factors that can diminish objectivity and affirm the priority of perceived problem. 2. Validation This phase involves a utilization of focused critique of each source of evidence, focusing in particular on whether it is sufficiently sound for potential application in practice. 3. Comparative evaluation and decision- making This phase involves a synthesis of findings and application of criteria, that taken together are used to determine the desirability and feasibility of applying findings from validated source to nursing practice. The end result of the comparative evaluation is to make a decision about using the study findings.

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4. Translation/Application This phase involves activities to conform how the findings will be used(e.g formally or informally) and spell out the operational details of the application and implement them. 5. Evaluation In the final phase, the application is evaluated. Informal use of the innovation versus formal use would lead to different evaluative strategies.

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IOWA Model
Efforts to use research evidence to improve nursing practice are often addressed by group of nurses interested in the same practice issues. This model, like the stelter model, was revised recently and renamed the Iowa Model of evidence Based Practice to promote quality of care. The current version of Iowa Model acknowledges that formal RU/EB Project begins with a trigger an impetus to explore possible changes to practice. The start point can be either knowledge focused trigger that emerges from awareness of innovative research findings. The model outlines a series of activities with three clinical decision points. I. Deciding whether the problem is a sufficient priority for the organization exploring possible changes; if yes, a team is formed to proceed with the project: if No, a new trigger would be sought. Deciding whether there is sufficient Research base; if Yes, the innovation is piloted in the practice setting. If No, the team would either search for other sources of evidence or conduct its own research. Deciding whether the change is appropriate for adoption in practice; if Yes, a change would be instituted and monitored. If No; the team would continue to evaluate quality of care and search for new knowledge.

II.

III.

The point of entry to this model were problem and knowledge focused triggers. Problem focused triggers encompassed frequently encountered clinical problems, risk management and quality improvement data and total quality management programs/ in contrast, Knowledge focused triggers include new information that resulted from such sources as the Agency for Health care policy and Research, speciality organizations and research publications. When a trigger was identified the next step included assembling, critiquing, and evaluating the applicability of relevant research literature.

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After the research base was evaluated and critiqued, a decision was made regarding whether or not a change in practice was warranted. If, however, a sufficient and appropriate research base was found that supported modification of current practice, changes were initiated that were congruent with those suggested by the research results. If research base had insufficiencies, further research was conducted, experts were consulted and application of scientific principles were considered. To translate research findings into practice several steps were necessary: 1. Expected outcomes of the change and baseline or current status were documented. 2. Nursing/ multidisciplinary interventions were designed 3. Practice changes were implemented on a pilot unit. 4. Process and outcomes were evaluated; and 5. The interventions were modified as necessary The next critical decision point involved determination of whether practice changes should be made for all patient populations affected by the research based interventions. Considerations included cost of implementations, overall impact on quality of care, staff competency and support of administration. This model used a process of planned change . staff need to be empowered with ownership of the change, as well as, with the knowledge and resources necessary to make this change. This model supported the monitoring of patient outcomes by unit staff members for atleast two consecutive quarters after implementation. These activities assisted in maintaining the practice change and facilitating feedback to the staff. Outcome measurements are also focused on the effects of change on the staff and fiscal parameters. Without thorough monitoring of all these areas an accurate refklection of the cost/benefit relationship could not be realized.

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Barriers to using Research in Nursing

Research Related Barriers One impediment to using Resarch in practice is that for many nursing problems, a solid base of valid and trustworthy study results has not been developed. Single studies rarely provide an adequate basis for making changes in nursing practice. Therefore another constraint to using research evidence is the dearth of published replications. TIP : Some tips for researchers interested in promoting the use of research findings in clinical practice are as follows: Collaborate with clinicians. Practicing nurses will be more willing to use research findings if researchers addresses clinical questions. Do high quality research. The quality of nursing studies has improved dramatically in the past two decades, but progress remains to be made to ensure valid and transferable findings. Replicate use of research results can rarely be justified based on a single study, so researchers must replicate studies and publish the results. Communicate clearly A general aim should be to write research reports that are user-friendly with a minimum of research jargon. Present findings amenable to meta-analysis integrative reviews of research findings are essential to EBP, and such reviews are increasingly using statistical methods of integration. Suggest clinical implications if an implications section with suggestion for clinical practice became a standard feature of research reports, then the burden of using research evidence would be lighter for nurse clinicians. Disseminate aggressively and broadly if researcher fails to communicate the results of a study to other nurses it is obvious that the results will never be used by practicing nurses. The researcher should report their results in journals especially nursing research journals, take steps to disseminate study findings at conferences, workshops attended by nurse clinicians.

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Nurse related Barriers

Many Nurses have not received any formal instruction in research and they lack skill to judge the merits of a study. Nurses attitude toward research and their motivation to engage in EBP have been identified a potential barrier. people are often resistant to change. Change requires effort, retraining and restructuring of work habits. Thus there is likely to be some opposition to introducing innovations in practice setting. TIP: Every nurse can play a role in using research evidence. Here are some strategies: Read widely and critically. Professionally accountable nurses should read journals relating to their speciality, including research reports in them. Attend professional conference. Conference attending give opportunities to meet researchers and to explore practice implications. Learn to expect evidence that a procedure is effective. Nurses need to develop expectations that the decisions they make in their clinical practice are based on sound rationales. Become involved in a journal club. Many organizations that employ nurses sponsor journal clubs that meet to review research articles that have potential relevance to practice. Pursue and participate in EBP projects. Nurses who are involved in research related activities develop more positive attitudes toward research and better research skills.

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Organizatonal Barriers

Many of the major impediments to using research in practice stem from the organizations that train and employ nurses. Organizations have failed to motivate or reward nurses to seek ways to implement appropriate findings in their practice. In several studies of barrirers to RU , one of the greatest reported Barrier was insufficient time on the job to implement new ideas. Organizations may be reluctant to expand resources for RU, EBP activities or for changing organizational policy. TIP: To promote the use of research evidence, administrators can adopt the following strategies: Foster a climate of intellectual curiosity. Open communication is important in persuading staff nurses that their experiences and problem are important and that the administration is willing to consider innovative solutions. Offer emotional or moral support. Administrators need to make their support visible by informing staff by establishing EBP committees, by helping to develop journal clubs and by serving as role models for staff nurses. Offer financial or research support for utilization. Reward efforts for using research. RU should not be the primary criterion for evaluating nurses performance but its inclusion is an important criteria to affect their behavior. Seek opportunities for institutional RU/EBP projects. Organizational efforts and commitment are essential for the type of projects.

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Barriers relating to Nursing Profession

There is a shortage of appropriate role models- nurses who can be emulated for their success in using or promoting the use of research in clinical practice. The nurses feel that he or she didnt have enough authority to change patient care procedures TIP: Educators could help to promote the use of research evidence through the following strategies: Incorporate research findings into curriculum. Research findings should be integrated throughout the curriculum and when possible, the efficacy of specific procedures should be documented by referring to relevant studies. Encouraging research and research use. Either by acting as role models to students or by demonstrating positive attitudes towards research and its use in nursing. Place demands on researchers. Faculty review of research proposals should demand that researchers demonstrate the proposed studies potential for clinical use; they can also demand that the researchers include a specific plan for dissemination or utilization

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References

1. Polit Denise F, Beck Cheryl Tatano. Nursing Research principles and Methods: Utilizing Research: Putting Research Evidence Into Nursing Practice . 7th edition. Lippincott Williams and Wilkins 2008 :673-99. 2. Melnyk Bernadette Mazurek, Fineout Overhot Allen. Evidence Based Practice In Nursing and Health Care. 1st edition. Lippincott Williams and Wilkins 2005 : 4,5,23-9

3. Katheleen S. Oman, Christine Duran, Regina Fink.Evidence based Policy and Procedures: An Algorithm for Success. The Journal Of Nursing Administration 2008; 38(1): 47-51 4. Diane S. Pravikoff, Susan T Pierce, Annelle Tanner. Evidence Based Practice readiness study supported by academy nursing informatics expert panel. Nursing Outlook 2003; 53(1): 49-50

5. Constance l Milton. Evidence Based Practice: Ethical Ouestions for Nursing. Nursing Science Quarterly 2007; 20(2): 123-26 6. Makhija Neelam. Applicaton and Utilization of Research in Practice: Evidence Based Practice. Nursing Nightingale Times 2007:18-20

7. Marianne Matzo. Evidence for Excellence. American Journal Of Nursing 2008; 108(8):73-74
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