Evidence Based Practice: Core Concepts

Evidence-Based
Practice:
Core Concepts
Adapted from PPT by Caroline E. Brown, UCSD
& “Evidence-Based Practice: Step-by-Step”
AJN series by Melnyk & Stillwell (CE)
March 2011

Objectives
At the end of this presentation you will be able to:
 Define evidence-based practice
 Describe process & outline steps of EBP
 Understand PICO elements & search strategy
 Identify resources to support EBP

Why do you do what you do
each day?????
What information do you base
your nursing care on?
” The goal of EBP is to change practice – to
locate the best evidence and put it into
practice.” RN.com EBP CE

The sources of information that shape
clinical practice…
 Colleagues
 Textbooks
 The internet
 Educational events
 Pharmaceutical or other Industry
 Reading the Journal articles
 What you learned in school

Bases for nursing care
Pravikoff et al., A 2005 survey of 760 RN‟s in the
US, working in clinical practice, found that:
 67% get information for practice from other nurses
 58% do not use research reports to support their
practice
 82% never used a hospital library
 54% were not familiar with term EBP
 67% never searched CINAHL
 72% hadn‟t evaluated research reports

“Most nurses practice according
to what they learned in nursing
school, their experience, and
what colleagues share in the
clinical setting.”
Estabrooks, 1998; 2003 &
Pravikoff 2005

Common Drivers
How Patient Care is Practiced…
 Ritual…accepted practices versus
research proven practices…The “that’s the
way we’ve always done it” syndrome.
 Tradition…the way I learned how to do it.
 Personal opinion… without assessment
of underlying assumptions.
 Arrogance…I have to be right syndrome.
 Lack of concern… for patients values‟.

The Need for EBP
 “EBP is essential to transform healthcare
by providing proven effective treatments.
At present there is a gap between theory
and practice that results in diminished
patient care, inefficient practice, and an
excessive time lag between the discovery
of knowledge and its incorporation into
clinical practice.” (Salmond 2007) p.460
 „Knowledge translation‟ ~ 17 years

The Need for EBP
 “An extensive body of research knowledge
exists now that needs to be incorporated into
practice.” (Drenning 2006)
 Practices supported by research improve
outcomes
 Knowledge explosion makes it impossible to
“keep up”
 EBP provides means to
• Standardize best practices
• Improve adherence to best practices
• Makes relevant data available at the bedside when
needed

Why does EBP Matter?
“Research shows that EBP leads to higher
quality care, improved patient outcomes,
reduced costs, and greater nurse
satisfaction than traditional approaches to
care.” (Melnyk, 2010)

EBP has demonstrated that…
 28% better patient outcomes if patients
receive care based on the best and latest
evidence from well-designed studies
compared to traditional practice (Heater 1988)
 “Patients should receive care based on
the best available scientific knowledge”
 IOM, Crossing the Quality Chasm: A New Health System for
21st Century, 2001

Why Does Evidence-Based
Practice Matter to You?
“Higher level of satisfaction among
healthcare providers who use evidence-
based approach in delivering patient care
than those who deliver care steeped in
tradition.” Dawes, M. (1996)

Status of EBP
 Abundance of knowledge exists waiting to be put
into practice (@17 years lag time)
 Growing expectation that EBP is part of
everyday clinical practice
 IOM wants 90% compliance by 2020
 only 10~15 % of clinicians currently take a
consistent EBP approach to care
 One study that surveyed 1200 practicing nurses
found that only 21% had implemented a new
research finding in the previous six months.

What are the top
barrier‟s to EBP ?

Barriers to EBP in Nurses
 The nurse does not have enough time to read research,
or implement new ideas
 Overwhelming patient loads
 The nurse is unaware of the research, or doesn‟t
perceive it as informing practice
 The nurse does not have authority to change practice
 The amount of research is overwhelming
 Inadequate resources and lack of administrative support
 Lack of EBP mentors to work with providers

Other Deficits Among Nurses
 Inadequate EBP knowledge and skills
 EBP only recently included in nursing education
 never learned how to search an electronic database
 not able to differentiate between research reports and
other types of literature
 lack the ability to critically evaluate research reports or
assess the quality
 still lack comfort, skills, time, access to appropriate
materials to engage in EBP

Factors that Facilitate EBP
 EBP knowledge and skills
 Belief in the value of EBP & the ability to
implement it
 A culture that supports EBP and provides
the necessary tools to sustain evidence-
based care
 EBP mentors

Transition Towards EBP
The movements that have been involved in
transitioning health care delivery away
from ritual practice include:
 Quality Assurance/ Process Improvement
 Knowledge Translation movement
 Evidence-based practice
 Research and it‟s utilization
 Evidence-based Consumer/Patient Choice

Evidence-Based Practice is
Defined as…
“ a problem-solving approach to the delivery of
health care that integrates the best evidence
from studies and patient care data with clinical
expertise and patient preferences and values.”
“an approach to providing care that integrates
nursing experience and intuition with valid and
current clinical research to achieve best
outcomes.” (p.460)

Clinical
Expertise
Research
Evidence
Patient
Preferences

Evidence Based Practice: Core Concepts

(Melnyk & Fineout-
Overholt, Stillwell 2010)
EBP: Seven Steps
Step Zero: Cultivate a spirit of enquiry
1. Ask the burning clinical question in PICOT format
2. Search & collect the most relevant and best evidence
3. Critically appraise the evidence
4. Integrate all evidence with one‟s clinical expertise,
patient preferences, and values in making a practice
decision or change
5. Evaluate the outcomes of the practice decisions or
changes based on evidence
6. Disseminate EBP results.

The process of doing EBP is
similar to the nursing process
 Assess
 Ask
 Acquire & Appraise
 Apply
 Analyze
 Advance & Adopt
 Assess
 Diagnosis
 Plan
 Implement
 Evaluate

Asking
Appraising
Applying
Analyzing
Assessing
Acquiring
Advancing
&
Adopting
The Process of Doing Evidence-Based Practice
Catalyst
Adapted by the San
Diego Consortium for
Nursing Excellence

The Catalyst…
 Inquiring clinicians set the process of EBP
in motion. Inquiring clinicians possess
curiosity and inquisitiveness, they question
the status quo!!!
 The catalyst may come from many
sources.
 Some examples are new research, ineffective
systems for providing care, new technologies,
and questioning ritual practices.

Becoming an Inquiring Nurse Starts
with…
 Understanding Why…
By Asking Questions!!!
 Why are you giving care this way?
 Why do you do what you do each day?
 Is there evidence to support the current
practice?
 Is there a better way?

Step Zero: A Spirit of Inquiry
Strategies for Building a
Spirit of Inquiry:
Think about these clinical
questions when caring for
your patients…
 Ask why? .. why am I
doing what I am doing
with my patients?
 Where can I find the best
evidence to answer my
clinical questions?
(Melnyk, 2010)
 Who can assist me to
enhance my EBP
knowledge and skills?
 Who can be my mentor?
 Which of my practices are
currently EB and which
don‟t have supporting
evidence?
 When is the best time to
question my current
clinical practices and with
whom?

Strategies to Promote EBP
 Integrate into philosophy and mission
 Administrative commitment
 Integrate throughout organization
 Create an environment that promotes
critical thinking, autonomous decision
making, empowerment
 Introduce staff to EBP
 Provide tools and access

Assessing…
 Leads the inquiring provider to gather
information about why a practice is done
the way it is.
 Assessing involves gathering evidence
from colleagues, policies, and data
sources to understand the history of the
practice and to confirm that a problem
exists with the practice.

Assessing confirms the relevance
 Once you know more about why
something is done a certain way you can
make a determination of the relevance and
importance of the problem for the
particular unit and the organization.

Step One:
Asking the Right Question
 Facilitates literature searches
 Guides your plan
 Narrows your focus
 Searchable
 Answerable

The Evidence-Based Practice Process
1. Asking a clinical question (PICOT)
2. Searching for the best evidence
3. Critically appraising the evidence
4. Integrating evidence into practice
5. Evaluating the results
6. Disseminating the evidence

Comparison of Background &
Foreground Questions
 Background question:
A broad, basic-knowledge
question commonly
answered in textbooks.
May begin with what / when.
1) What is the best method to
prevent pressure ulcers?
2) What is sepsis?
3) When do the effects of
furosemide peak?
 Foreground question:
A specific question that,
when answered, provides
evidence for clinical
decision making.
Includes PICOTelements:
(1) population (P),
(2) intervention /issue of
interest (I)
(3) comparison intervention or
issue of interest (C),
(4) outcome (O)
(5) and sometimes time (T).

Why is the PICOT question
so important?
 The PICOT format provides a consistent,
systematic way to identify the components
of a clinical issue.
 Structuring a clinical question with PICOT
helps to clarify the components which will
guide the search for evidence.
 A well-built PICOT question increases the
likelihood of finding the best evidence
quickly and efficiently.

PICOT Format
 Foreground questions ask for specific
knowledge to inform clinical decisions or
actions.
PICOT Format:
 Problem/Population
 Intervention
 Comparison Intervention
 Outcome
 Timeframe (optional)

The Basic PICO Question:
 In or among your patient or population,
does your intervention, (versus your
comparison), result in or affect your
outcome?

Asking A Question with PICO
P:
Population
Describe
as
specifically
as possible
I:
Intervention
Describe the
intervention
of interest,
this may be a
treatment,
risk factor,
perception
C:
Comparison
Use a
comparison if
it fits to do so,
this may be a
alternative, a
placebo,
usual care
O:
Outcome
What is the
clinical
outcome ~
add the
timeframe if
important
(T)

Asking the Clinical Questions
 In mechanically ventilated patients (P),
how does a weaning protocol (I) compared
with no weaning protocol (C) affect
ventilator days (O) during ICU length of
stay (T)?
 In hospitalized adults (P), how does hourly
rounding (I) compared with no rounding
(C) affect fall rates (O)?

P:
Population
I:
Intervention
C:
Comparison
O:
Outcome
Example In post
cardiac
surgery
patients
do
identification
protocols
as compared
to usual care
reduce risk of
skin tears?
Example In patients
undergoing
diagnostic
procedures
does listening
to taped music
as compared
to live music
reduce
anxiety and
increase
patient
satisfaction?
Example In acute care
units
does nurse
walking
rounds
as compared
to taped report
increase
patient
satisfaction
and missed
treatments?,

Exercise: Scenario
 Scenario - You are interested in reducing
the number of elderly patients that fall
during their hospital stay and the severity
of injury. Currently the rate of falls is
higher in your unit than in other units in the
hospital and the national benchmark.
There are a variety of interventions
currently being used in the hospital and
you want to know where to start on your
unit to address this problem.

What is your PICO Question?
 Question
 Population – in elderly hospitalized
patients does
 Intervention – fall assessment
 Comparison – usual care
 Outcome – prevent or reduce the
number and severity of falls

Exercise: Scenario
 Scenario - You are interested in knowing
the best approaches to teaching acute
care nurses how to teach patients about
diabetic self-care.

What is your PICO Question?
 Question
 Population – In acute care nurses does
 Intervention – a self-learning module
 Comparison – compared to a interactive
class session
 Outcome – provide the knowledge and
skills required to teach patients diabetic
self-care management?

BERNARD BECKER
MEDICAL LIBRARY
Washington University
School of Medicine
Step 2:
Search for the Best Evidence
 Developed PICOT question
 Identify keywords and terms from PICO
 Identify standardized subject headings
 Combine subject headings and keywords
to narrow or broaden your search
 Evaluate your search results
 Revise the search in light of your results

 Answering the background question. A
number of textbooks, handbooks and
databases may be consulted to effectively
answer background questions.
 Answering the foreground question. The
highest level of research evidence
available to answer the question.
The evidence you search for should be
driven by your PICO question…

Levels of Evidence
…but it was in a nursing
journal – so doesn‟t that
mean it is good???

Types of Questions
 Diagnosis
 Therapy (treatment)
 Prognosis
 Etiology / harm
 Prevention
 Cost-effective
 Quality of life

Levels of Evidence:
Treatment (Therapy) Questions
Systematic reviews or meta-analysis or clinical guidelines
One well-designed RCT
Well-designed research without randomization
Well-designed case-control or cohort studies
Single descriptive or qualitative study
Expert opinion, expert committee

“Not everything that counts can
be counted, and not everything
that can be counted counts.”
~ Albert Einstein

Levels of Evidence:
Experiential (Quality of Life)
Questions
Systematic Reviews of Qualitative and Descriptive Research
Single Qualitative Research
Expert Opinion, Expert Committees
Evidence from Quantitative Research

Where to find Evidence /
EBP Guidelines?
 The Cochrane Library
 National Clearinghouse Guidelines
 Registered Nurse Association of Ontario www.rnao.org
 Clinical Decision Support Tools:
 JAMA Evidence, BMJ Best Evidence, Clinical Evidence, etc.
 www.nursingsociety.org
 Worldviews on Evidence Based Practice (Journal)
 Schools and Universities
 Pubmed
 EBSCO host ~ Medline, CINAHL, Nursing Reference
Center, DynaMed, etc.
 Check links on the ARL Nursing & Clinical Toolkits

Strategy for Finding Evidence
 Start with a meta-search engine
 Trip database or Sum Search
(links on ARL Nursing Toolkit)
 First look for systematic reviews, meta-
analysis and clinical guidelines, Cochrane
 Next search major databases, EBSCO
 PubMed, CINAHL, Medline, PsychINFO
 Next search regulatory agencies,
professional organizations (list p.464)

 Scenario - You are interested in reducing the
number of elderly patient that fall during their
hospital stay and the severity of injury.
 Question
 Population – in elderly hospitalized patients
does
 Intervention – fall assessment
 Comparison – usual care
 Outcome – prevent falls or reduce the
number and severity ?

Step 3: Critically Appraise
the Evidence
 Purpose of critical appraisal is to
determine value of evidence for practice.
 Rapid critical appraisal of a study‟s worth
asks 3 questions…

Rapid Critical Appraisal
Attempt to answer three questions:
 Are the results of the study or systematic
review valid?
(Validity of the evidence)
 What are the results and are they reliable /
important?
(Reliability of the evidence)
 Are the findings clinically relevant to my
patients?
(Applicability of the evidence to your population)

Step 4:
Integrate the evidence with clinical
expertise and patient preferences
and values.
“Research evidence alone is not sufficient
to justify a change in practice.”
(Melnyk, 2010)

Can you draw conclusions based
on your literature base?
 Have you completed an exhaustive search?
 Do themes emerge from your literature base/
research summary ?
 What levels of evidence are contained with in
the articles found?
 What conclusion can you make?
 A body of reliable evidence
 Inconclusive evidence
 No evidence

Is there a
sufficient
literature base?
yes no
Design Practice
Change
Best Practices
with other types
of evidence
Conduct research

Balancing the literature…
Clinical
Expertise
Health care
resources
Clinical
context
Evidence
Patient
Preferences
Evidence
Based
Decision

Moving Forward Applying the
Evidence to your Practice
 Develop recommendations for practice.
 Integrate the evidence recommendations,
with collaboration with patients, into a plan
of care.
 Complete human subject protection
requirements.

Making the project a reality
1. Define project plan
2. Define the protocol (what you are changing)
3. Specify outcome measures
4. Determine method for data collection
1. Develop a system for managing data collected
2. Plan to maintain integrity of data collection
5. Implement process
6. Draw conclusion about success: adopt
change – reject change – modify change

Analyzing
This step involves
answering the questions:
 Did you do what you set
out to ?
 Were there any
unintended
consequences of the
change in practice?
Step 5:
Evaluate the
outcomes of
the practice
decisions or
changes based
on evidence.

Analyzing…
 Evaluating outcome in health care
providers‟ own setting.
 Important to consider bias and
confounding influences.
 Patient evaluations of experiences as well
as nurses‟ evaluation must be considered.
 Interdisciplinary collaboration is essential.

Step 6: Disseminate EBP Results
Advancing
 This step involves
sharing what your
experience was with
others.
 It involves
disseminating the
outcomes of your
project and the
lessons you learned
though the process.
Adopting
 This step involves
planning for broader
adoption of the
practice beyond your
patient, unit, service
or division. Not all
projects will proceed this
far.

EB Nursing Practice Tutorials
 http://cwml-
tutorials.blogspot.com/search/label/Evidence-
Based%20Practice
 http://hsl.lib.umn.edu/biomed/help/evidence-based-
practice#toc20146
 http://www.libraries.psu.edu/psul/tutorials/ebpt.html
 http://nursingandhealth.asu.edu/node/6393
 http://ktclearinghouse.ca/cebm/syllabi/nursing
 http://www.hsl.unc.edu/services/tutorials/ebm/welco
me.htm

Sources of Evidence:
EBP Sources
The TRIP Database
 started in 1997 as a small search engine with
a focus on medical articles considered
evidence-based.
 aim is to allow health professionals to easily
find the highest-quality material available on
the web.
 http://www.tripdatabase.com

Another Google for EBP
Sum Search
 is a search engine that searches other EBP
databases as a “one-stop-shop model”
 http://sumsearch.uthscsa.edu

Cochrane Collaboration
This international organization supports
informed health care decision-making by
preparing, maintaining, and making
available systematic reviews of the effects
of health care interventions.
 www.cochrane.org (main website- paid)
 http://cochrane.bireme.br/portal/php/index.
php?lang=en (free access in Caribbean via PAHO)

National Institute for Health and Clinical
Excellence
The National Institute for Health and Clinical
Excellence (NICE)
 is an independent UK organization responsible for
providing national guidance on the promotion of good
health and the prevention and treatment of ill health.
 NICE produces guidance in three areas of health:
• public health
• health technologies
• clinical practice
http://www.nice.org.uk/

 The Registered Nurses Association of
Ontario (RNAO):
Nursing Best Practice Guidelines Program
(NBPG)
 http://www.rnao.org/Page.asp?PageID=861&Sit
eNodeID=133
 Some Topics: IV line care, crisis intervention,
constipation, continence, pain, wounds, stroke
assessment, breastfeeding…

 What is Bandolier?
 The first issue of Bandolier, an independent
journal about evidence-based healthcare,
written by Oxford scientists, 1994.
 It has appeared monthly ever since and has
become the premier source of evidence
based healthcare information in the UK and
worldwide for both healthcare professionals
and consumers
 http://www.medicine.ox.ac.uk/bandolier/

Nursing Research:
Show me the evidence!
 http://evidencebasednursing.blogspot.com/
 The Saint Joseph Hospital (Orange, California)
Nursing Research Blog communicates nursing
research activities at SJO to staff. Posts include
announcements of Nursing Grand Rounds,
Nursing Journal Clubs, Nursing EBN classes,
ongoing nursing research and relevant medical
library announcements and news.
 Provides an open discussion forum for nurses
and librarians interested in evidence-based
nursing.

Evidence Based Practice: Core Concepts

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