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How Tos of Evidencebased Practice for RNs

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Title: How Tos of Evidencebased Practice for RNs


1
How Tos of Evidence-basedPractice for RNs
  • Pat Quigley, PhD, ARNP, CRRN
  • Deputy Director,
  • VISN 8 Patient Safety Center of Inquiry
  • James A. Haley Veterans Hospital
  • Tampa, FL

2
Objectives
  • Compare at least 2 strategies to find evidence to
    guide practice.
  • Examine levels of practice and research
    expectations
  • Evaluate strategies for implementation of
    evidence-based practice

3
Integration of Complementary Perspectives
Innovation Diffusion
Knowledge Transfer
Knowledge
Outcome
  • Evidence-based Practice

4
Three Perspectives
  • Evidence-based Practice (Sackett)
  • the conscientious use of current best evidence
    in making decisions about the care of individual
    patients or the delivery of health services.
  • Innovation Diffusion (Rogers)
  • The process of communicating new ideas through
    certain channels over time among members of a
    social system
  • Knowledge Transfer (Dixon)
  • Sharing of common knowledge, that is the
    knowledge that employees learn from doing the
    organizations tasks.

5
When to Use...
  • Evidence-based Knowledge
  • Practice Transfer
  • Scientific evidence Common knowledge
  • Knowledge is clinical Knowledge may be clinical
  • Clinical practice Knowledge is tacit (or
    guidelines explicit)
  • Health care perspective Organizational learning
    orientation

6
VISN 8 Patient Safety Center
  • Commitment to clinical practice and practical
    knowledge (for elderly persons and persons with
    disabilities)
  • Falls and fall-related injury prevention
  • Restraint-free environments
  • Pain management
  • Pressure ulcer prevention
  • Safe patient handling and movement
  • Safe transitions between care settings
  • End of life care

7
Strategies to Find Evidence
  • Critique of the Literature
  • Determine the Evidence of Research Findings
  • Use of Expert Consensus and Panels

8
Evolution of Evidence-Based Practice (EBP)
  • Concept from medicine
  • Wide variations in practice clinical focus
  • Recommendation from Institute of Medicine
    Crossing the Quality Chasm
  • Resources for EBP
  • Cochrane Collaboration
  • Agency for Healthcare Research and Quality
    http//www.ahrq.gov/
  • Centre for Evidence-Based Nursing
    http//www.evidencebasednursing.com/

9
Evidence
  • What is it?

10
Definitions
  • Evidence-Based Practice Evidence-based
    practice is the integration of best research
    evidence with clinical expertise and patient
    value. (Sackett, 2000)
  • Evidence-Based Nursing (EBN) The process by
    which nurses make clinical decisions using the
    best available research evidence, the clinical
    expertise and patient preferences.
  • (University of Minnesota Evidence-Based Health
    Care Project, 2002)

11
Evidence-Based Medicine
  • the conscientious, explicit and judicious use
    of current best evidence in making decisions
    about the care of individual patients. This
    practice means integrating individual clinical
    experience with the best available external
    clinical evidence from systematic research.
    (Sackett, 1996)

12
Critical Factors for EBN
  • Sufficient research on a specific topic
  • Skill in accessing and critically analyzing
    research
  • Nurses area of practice must allow her/him to
    implement changes based on the evidence
  • (University of Minnesota Evidence-Based Health
    Care Project, 2002)

13
Resources Cochrane Collaboration
  • An international endeavor that prepares,
    maintains and promotes the accessibility of
    systematic reviews of the effects of health care
    interventions.
  • Collaborative Review Groups
  • Cochrane Centers
  • Methods Working Groups
  • The Cochrane Consumer Network
  • The Cochrane Collaboration Steering Group
  • http//www.cochrane.org/cochrane/general.htm

14
Resources Cochrane Library
  • Cochrane Database of Systematic Reviews
  • The Database of Abstracts of Reviews of
    Effectiveness
  • The Cochrane Controlled Trials Register
  • The Cochrane Review Methodology Database

15
Issues in Getting the Evidence Straight
  • What counts as evidence?
  • How to judge the quality of a review?
  • How to reconcile conflicting recommendations from
    different groups?
  • How to evaluate quality of guidelines?

16
Components of EBP
  • COMPONENTS PRODUCTS
  • Systematic reviews Practice guidelines
  • Meta-analysis Pathways of care
  • Clinical trials Clinical algorithms
  • Economic analysis Performance measures
  • Decision analysis Process-based
  • Outcomes-based

17
Resources for EBP
  • Agency for Health Care Policy Research
  • http//www.ahrq.gov/
  • Clinical practice guidelines
  • Evidence-based practice centers
  • Clearinghouse http//www.guideline.gov/index.asp
  • Evidence reports

18
Resources
  • Centre for Evidence-Based Nursing (Subscription
    only)
  • http//www.evidencebasednursing.com/
  • ACP Journal Club http//www.acponline.org/journals
    /acpjc/jcmenu.htm
  • Centre for Evidence-Based Medicine
  • POEMS (J. of Fam Pract) http//www.medicalinforet
    riever.com/poems/poemsearch.cfm

19
Strength of Evidence
  • Grading the Evidence and Making Recommendations.
    The proposed schematic was used for judging
    quality ratings and recommendations, derived from
    American Geriatrics Society (AGS) i and
    previously used by the Registered Nurses
    Association of Ontario (RNAO).ii
  • Level I Evidence from at least one properly
    randomized controlled trial.
  • Level II Evidence from at least one
    well-designed clinical trial without
    randomization, from cohort or case-controlled
    analytic studies, from multiple time-series
    studies, or from dramatic results in uncontrolled
    experiments.
  • Level III Evidence from respected authorities,
    based on clinical experience, descriptive
    studies, or reports of expert committees. This
    level includes qualitative studies, case reports,
    consensus statements, and panel guidelines. iii
  • i AGS Panel on Persistent Pain in Older
    Persons. (2002). The management of persistent
    pain in older persons. Journal of the American
    Geriatrics Society, 50(6 suppl), S205-224.
  • ii Registered Nurses Association of Ontario
    (RNAO). (2002). Assessment and management of
    pain. Toronto (ON) Registered Nurses Association
    of Ontario.
  • iii AGS Panel on Persistent Pain in Older
    Persons. (2002). The management of persistent
    pain in older persons. Journal of the American
    Geriatrics Society, 50(6 suppl), S205-224.

20
Making Recommendations
  • Recommendations schema based on strength of
    evidence
  • A Good evidence to support the use of a
    recommendation clinicians should do this all
    the time.
  • B Moderate evidence to support the use of a
    recommendation clinicians should do this most
    of the time.
  • C Poor evidence either to support or to reject
    the use of a recommendation clinicians may or
    may not follow the recommendation.
  • D Moderate evidence against the use of
    recommendation clinicians should not do this.
  • E Good evidence against the use of a
    recommendation, which is therefore
    contraindicated.i
  • i AGS Panel on Persistent Pain in Older
    Persons. (2002). The management of persistent
    pain in older persons. Journal of the American
    Geriatrics Society, 50(6 suppl), S205-224.

21
Steps in Application of Evidence
  • 1. Select clinical questions
  • 2. Getting the evidence straight
  • Search literature/databases for information
  • Evaluate validity and usefulness of evidence
  • 3. Implement findings in clinical practice
  • Developing clinical policy at right place/ time
  • Applying the policy at right place/time

22
Why Nurses Do Not Use (or think they do not use)
Research in Practice
  • Research findings do not address their problems
  • Nurses do not know about research findings or how
    to use them
  • Nurses do not understand or believe published
    findings
  • Nurses are not allowed to use them
  • Nurse lack the time and right resources
  • (Hunt, 1997, 1981)

23
Experience
  • What level of practice are you?

24
Novice to Expert
  • Novice Stimulus-response thinking rule
    governed behavior
  • Advanced Beginner Begins to identify recurring
    meaningful situational aspects, applies to new
    situations
  • Competent Aware of all aspects of situation
    plans are conscious, abstract, analytic
    contemplation
  • Proficient Performance guided by maxims deep
    understanding web of perspectives of situation
    perception
  • Expert Intuitive grasp of each situation- zeros
    in on the accurate region of the problem
  • (Benner, 1984 Benner, Tanner, Chelsea, 1997)

25
ANA Standards of Professional Performance
  • Basis for VA Qualification Standards
  • Appointment
  • Position statements
  • Performance appraisal
  • 9 Dimensions of practice
  • Practice
  • Quality of care
  • Performance
  • Education/career development
  • Collegiality
  • Ethics
  • Collaboration
  • Research
  • Resource Utilization

26
Research Performance Expectation Novice Stage
  • Research Dimension Assists in identifying
    problem areas in nursing practice
  • Focus Questioning practice follows the rules,
    what was taught in nursing school
  • Interpretation
  • Questions traditions
  • Asks why
  • Observes incongruent practice and learning of
    formal education program

27
Research Performance Novice Stage
  • Behaviors/Examples
  • Why do you change heparin lock IV sites every
    72 hours? Where did that number come from?
  • We learned we must raise all 4 side rails if
    patients are confused to prevent falling from
    bed. Why did you take side rails off your beds?

28
Research Performance Expectation Advanced
Beginner Stage
  • Research Dimension Demonstrates an awareness of
    research application to practice
  • Focus Use of guidelines
  • Interpretation
  • Understands linkage of research and clinical
    guidelines
  • Uses nationally published guidelines

29
Research Performance Advanced Beginner Stage
  • Behaviors/Examples
  • Uses ACLS algorithms on individual patients
    demonstrating critical thinking skills
  • AHRQ guidelines for pressure ulcers family
    requests donut pressure relieving device
  • knows request does not follow national guidelines
  • educates family in current practice/rationale for
    alternatives

30
Research Performance ExpectationAdvanced
Beginner -Competent Stage
  • Research Dimension Uses a body of research to
    validate and/or change own professional practice
  • Focus Validation of own practice using research
  • Interpretation
  • Knows the rationale for and changes personal
    practice
  • Reads and shares current literature in the
    clinical specialty

31
Research Performance Advanced
Beginner-Competent Stage
  • Behaviors/Examples
  • Changes own practice given evidence on restraint
    use explains rationale
  • Uses decision algorithms to determine what type
    of equipment is appropriate to move a patient
    safely
  • Identifies unit level problem Why are we
    observing a high percentage of post-op CABG
    patients developing atrial fibrillation on
    post-op day 2-4?
  • Participates in unit level product trials

32
Transfer to and from Bed to Chair, Chair to
Toilet, Chair to Chair, or Car to Chair
Can patient bear weight?
Caregiver assistance not needed stand by for
safety as needed
Fully
Is the Patient Cooperative?
Partially
Stand and pivot technique using a Gait/transfer
belt (1 caregiver) or- Powered standing assist
lift (1 caregiver)
Yes
No
Is the Patient Cooperative?
No
Use full body sling lift and 2 caregivers
No
  • - For seated transfer aid, must have chair with
  • arms that recess or are removable.
  • For full body sling lift, select a lift that
    was specifically
  • designed to access a patient from the car
    (if the car is
  • the starting or ending destination).
  • - If partial weight bearing, transfer toward
  • stronger side.
  • - Toileting slings are available for toileting.
  • - Bathing mesh slings are available for
    bathing.
  • Source The Patient Safety Center of Inquiry
    (Tampa, FL), Veterans Health Administration
    Department of Defense, October 2001.

Yes
Does the Patient have upper extremity strength?
No
Yes
Seated transfer aid may use gait/transfer Belt
until the Patient is proficient in completing
transfer independently
33
Research Performance ExpectationCompetent Stage
  • Research Dimension Uses a body of research to
    validate and/or change work group practice
  • Focus Research appropriate for patient
    population work group practice
  • Interpretation
  • Identifies clinical issues/questions
  • Conducts literature and/or research review
  • Incorporates and uses knowledge to validate or
    change practice

34
Research PerformanceCompetent Stage
  • Behaviors/Examples
  • Fall analysis on a cardiovascular unit after
    restraint reduction
  • Lack of nursing-sensitive patient satisfaction
    measures in ambulatory care settings
    participation in instrument validation research
  • Decreased ability to meet patient education needs
    with increased workloads new patient education
    tool developed after journal club participation
  • Protocol development for rehabilitation of
    vent-dependent SCI patients

35
Research Performance ExpectationProficient Stage
  • Research Dimension Collaborates with others in
    research activities to improve care
  • Focus Outcomes at the program/service level
  • Interpretation
  • Practice validation and/or improvement
  • Application of research findings to practice or
    conducting research
  • Collaboration with colleagues
  • Reporting outcomes and results

36
Research Performance Proficient Stage
  • Behaviors/Examples
  • Partnership Effective management of Class III
    IV CHF patients
  • Long distance management of Class III IV CHF
    patients telemedicine technology
  • Aggregate RCA on falls
  • Institute/lead journal clubs in clinical areas

37
Research Performance ExpectationProficient-Exper
t Stage
  • Research Dimension Collaborates with staff,
    other disciplines, faculty and peers in
    developing, conducting and evaluating research
    activities.
  • Focus Collaboration beyond the organization and
    discipline Conducting funded research
  • Interpretation
  • Developing or evaluating a program of research/
    research utilization activities
  • Program development
  • Research focused
  • Large population groups or integrated programs

38
Research Performance Proficient-Expert Stage
  • Behaviors/Examples
  • Development of a program of pain management
    research use of pain resource nurses to improve
    cancer pain outcomes
  • Chronic disease self-management pilot program
    funded research at multiple sites
  • Falls research program assessment of high risk
    pt populations synthesis of evidence research
    proposals development of fall assessment tools,
    clinics, pathways evaluation of outcomes

39
Research Performance ExpectationExpert Stage
  • Research Dimension Promotes an environment that
    supports the conduct and utilization of research
    in practice and a spirit of inquiry
  • Focus Organization-wide regional and national
    involvement (administrative) or interdisciplinary
    research teams (researcher)
  • Interpretation
  • Nurse executives Research is demonstrated and
    promoted in clinical, educational and
    administrative practice areas
  • Nurse researchers Funded program of nursing
    research

40
Research Performance Expert Stage
  • Nurse Executive and Researcher Examples
  • Research function is formalized within structure
  • Mechanisms established to assure clinical
    practice is supported by evidence
  • Develops reward/recognition mechanisms for staff
    participation in research
  • Establishes a program of research conducts
    funded research assists staff with
    implementation or conduct of research shares
    knowledge formally partners with other experts

41
Review Research, Clinical and Laboratory
Information
Is evidence strong enough to warrant practice
change?
Yes
Implement evidence- based practice
No
Does evidence support clinical trials?
Technology Transfer
Clinical trial to test interventions
Yes
Equipment design or redesign with evaluation
Yes
No
Is equipment ready for Market?
Epidemiological study to identify modifiable risk
factors for adverse events or descriptive studies
to understand process and outcomes
Equipment design or redesign
OR
42
Magnet Nursing ResearchThink Tank 12/03
  • Research is needed to document clinical outcomes
    and administrative evidence. Have research done
    external to ANCC.
  • Expand scope to address organizational dynamics
    of research business practices by forming
    relationships with school and business entities.

43
Future Oriented Research
  • What is the role of health system and
    credentialing in the total curriculum?
  • What is the role of health systems and
    credentialing research in curricula?
  • Develop methods for studying credentialing and
    their outcomes.

44
Journal Clubs
  • Role in Practice

45
Research Committee Roles
  • Purpose and Functions
  • Link to Nursing Philosophy and Mission
  • Strategic Planning
  • Review of Proposals
  • Nursing
  • Medical
  • Interdisciplinary

46
Building Research Capacity
  • Research Committee
  • Funded Researchers
  • Fellowships
  • Grants
  • Collaborations

47
VISN 8 Patient Safety Center
  • Three Centers for Research
  • VHA HSRD REAP - outcomes
  • VHA RRD REAP technology
  • AHRQ DCERPS - transitions
  • One Center for Translation of research into
    practice
  • VISN 8 Patient Safety Center of Inquiry

48
Your Thoughts?!
  • Lets Share!

49
References
  • AGS Panel on Persistent Pain in Older Persons.
    (2002). The management of persistent pain in
    older persons. Journal of the American Geriatrics
    Society, 50(6 suppl), S205-224.
  • Registered Nurses Association of Ontario (RNAO).
    (2002). Assessment and management of pain.
    Toronto (ON) Registered Nurses Association of
    Ontario.
  • AGS Panel on Persistent Pain in Older Persons.
    (2002). The management of persistent pain in
    older persons. Journal of the American Geriatrics
    Society, 50(6 suppl), S205-224.
  • AGS Panel on Persistent Pain in Older Persons.
    (2002). The management of persistent pain in
    older persons. Journal of the American Geriatrics
    Society, 50(6 suppl), S205-224.
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