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Evidence-based Nursing Practice


Sources of Knowledge. Experience. Nursing School. Workplace Sources. Physician Sources. Intuitions. Literature rated bottom 5 for frequency. Estabrook CA. – PowerPoint PPT presentation

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Title: Evidence-based Nursing Practice

Evidence-based Nursing Practicegetting started
Keystones of Evidence-based Practice
  • Integration of the best possible
  • with clinical expertise and with patient

Why Evidence-based Practice?
  • Patients who receive care based on the best and
    latest evidence experience 28 better outcomes
    (Heater, Becker, Olson, 1988)
  • Healthcare providers who use an EBP approach to
    delivering patient care experience higher levels
    of satisfaction (Dawes, 1996)
  • Without EBP, practice is rapidly outdated, often
    to the detriment of patients. It often takes as
    long as 17 years to translate research findings
    into practice (Balas Boren, 2000)

Sources of Knowledge
  • Experience
  • Nursing School
  • Workplace Sources
  • Physician Sources
  • Intuitions
  • Literaturerated bottom 5 for frequency

Estabrook CA. Will evidence-based nursing
practice make practice perfect? CJ Nurs Res 1998
Barriers to Evidence-based Practice
  • Lack of knowledge regarding EBP strategies
  • Misperceptions or negative views about research
    and evidence based care
  • Lack of time and resources to search for and
    appraise evidence
  • Overwhelming patient loads
  • Organizational constraints, such as
    administrative support or incentives
  • Demands from patients for a certain type of
  • Peer pressure to continue with practices steeped
    in tradition
  • Inadequate content and behavioral skills
    regarding EBP in educational programs

Barsteiner Prevost, 2002 Cronenwett, 2002
McKibbon, 1999 Melnyk, 2002 Menyk et. al.,
2000 Silagy Haines, 1998.
Facilitating Conditions
  • Organizational capacity for change that includes
    strong support and interest at all levels of
  • Implementation infrastructure (adequate resources
  • Characteristics of the healthcare team (a shared
    vision and mission)
  • Guideline characteristics (Importance of the
    guideline to clinicians, credibility of the
  • (Solberg et al., 2000)
  • Mentorship in EBP (Melnyk Fineout-Overholt,

The power of observation
  • The most important practical lesson that can be
    given to nurses is to teach them what to
    observe-how to observebut if you cannot get the
    habit of observation one way or other, you had
    better give up being a nurse

Florence Nightingale
What are we observing?
  • Observe patients and families for their responses
    to treatment and for cues that the current plan
    of care may not be effective.
  • Question current practice and identifies issues
    amenable to change.
  • PI data
  • Nursing report cards
  • Staff practice concerns
  • New knowledge shared
  • Policies and Procedures
  • Question significance of the clinical issue.

Five Steps ofEvidence-based Practice
  • Ask the burning clinical question.
  • Collect the most relevant and best evidence.
  • Critically appraise the evidence.
  • Integrate all evidence with ones clinical
    expertise, patient preferences, and values in
    making a practice decision or change
  • Evaluate the practice decision or change.

Model for Evidence Based Practice from Larabee
and Rosswurm as published in Sigma Theta Tau
Whats the question?
  • Background vs. Foreground Information
  • Therapy
  • Etiology
  • Diagnosis
  • Prevention
  • Prognosis
  • Meaning

PICOT asking the question
  • P Population
  • I Intervention
  • C Compared to
  • O Outcome
  • T Timeframe

What are your resources?
  • Polices and Procedures
  • Leadership
  • Clinical Nurse Specialists/APN/Medical Staff
  • Clinical Instructors
  • Educators
  • Directors
  • Nursing Practice and PI Committees
  • Medical Library
  • Internet

Start with guidelines!
  • Evidence Based Practice Centers
  • http//www.ahcpr.gov/clinic/epc/
  • Cochrane Collaboration
  • http//www.cochrane.org
  • National Guideline Clearinghouse
  • http//www.guideline.gov/
  • Agency for Healthcare Research and Quality
  • http//www.ahrq.gov
  • University of York Center for Reviews
  • http//www.york.ac.uk/inst/crd/crddatabases.htm
  • The Joanna Briggs Institute for Evidence-Based
  • http//www.joannabriggs.edu.au/about/home/php

List not complete
Burkholder Medical Library
  • Requests can be faxed to 381-4317, phoned to Ext.
    12276 or e-mailed to library_at_slrmc.org.
  • Information to include in fax Please complete a
    search for memore pertinent information is
    better than less if in question

Literature Search Results
  • Search output--parts
  • Title
  • Who ,When, Where and What published
  • Peer reviewed
  • Qualitative vs. Quantitative

Quantitative Rating System for the Hierarchy of
  • Level I Evidence from a systematic review or
    meta-analysis of all relevant randomized
    controlled trials (RCTs), or evidence-based
    clinical practice guidelines based on systematic
    reviews of RCTs
  • Level II Evidence obtained from at least one
    well-designed RCT
  • Level III Evidence obtained from well-designed
    controlled trials without randomization
  • Level IV Evidence from well-designed
    case-control and cohort studies
  • Level V Evidence from systematic reviews of
    descriptive and qualitative studies
  • Level VI Evidence from a single descriptive or
    qualitative study
  • Level VII Evidence from the opinion of
    authorities and/or reports of expert committees

Melnyk Fineout-Overholdt Evidence-Based
Practice in Nursing Healthcare, 2005
Qualitative Rating System for the Hierarchy of
  • Level I Evidence from systematic reviews of
    descriptive and qualitative studies
  • Level II Evidence from a single descriptive or
    qualitative study
  • Level III Evidence from the opinion of
    authorities and/or reports of expert committees
  • Level IV Evidence-based clinical practice
    guidelines based on systematic reviews of RCTs
  • Level V Evidence obtained from well-designed
    controlled trials without randomization and from
    well-designed case-control and cohort studies
  • Level VI Systematic review or meta-analysis of
    all relevant RCTs
  • Level VII Evidence obtained from at least one
    well-designed RCT

Melnyk Fineout-Overholdt Evidence-Based
Practice in Nursing Healthcare, 2005
AACN Levels of Evidence
  • Level I Manufacturers recommendation only
  • Level II Theory based, no research data to
    support recommendations Recommendations from
    expert consensus group may exist
  • Level III Laboratory data, no clinical data to
    support recommendations
  • Level IV Limited clinical studies to support
  • Level V Clinical studies in more than one or two
    patient populations and situations to support
  • Level VI Clinical studies in a variety of
    patient populations and situations to support

Reading a research article
  • Purpose of study
  • Methodology
  • Analysis
  • Discussion of Results
  • Key findings
  • Significance for nursing
  • Implications for use
  • Bottom line do you have confidence in the TRUTH
    value of the results?

Putting It All Together Burning Clinical Question
  • P Population (Laboring Women)
  • I Intervention (Sterile Water Injections in
    lower back)
  • C Compared to (Epidural, Stadol, or
    non-pharmacological methods)
  • O Outcome (Sterile Water Injections will help
    relieve the lower back pain?)
  • T Timeframe (Start in Spring 2010)

Putting It All Together Evidence and Appraisal
of the Evidence
  • National Guideline Clearinghouse
  • Several articles from different resources
  • Looked at the References for Sentinel Articles
  • Tools for appraisal

Putting It All Together Integration and
  • Part of a research study
  • Staff to notify research personnel when patient
    requested the intervention
  • Pain monitored after intervention
  • Patient and nurse talked to after delivery about
    the intervention

Evidence in Practice
  • Knowledge of the research process alone does not
    ensure translation of that knowledge into
  • Seymour et al. 2003

(No Transcript)
Lessons from the field
  • Most successful transformation focuses on the
    needs of the patient.
  • Appropriate use of data is a key element in
    successful efforts to transform.
  • Outcomes are the most important measures to
    create transformation.
  • Most of the successful instances of
    transformation involved a local change champion.
  • Local input is important to customize approaches
    in order to obtain buy-in and create sustainable
  • Leadership/Infrastructure to hold people

Agency for Healthcare Research and Quality,
October 2004
Diffusion of Innovations
  • Innovators (2.5)
  • Venturesome
  • Early Adapters (13.5)
  • Respect
  • Early Majority (34)
  • Deliberate
  • Late Majority (34)
  • Skeptical
  • Laggards (16)
  • Traditional

Mechanism of Diffusion
  • Knowledge person becomes aware of an innovation
    and has some idea of how it functions,
  • Persuasion person forms a favorable or
    unfavorable attitude toward the innovation,
  • Decision person engages in activities that lead
    to a choice to adopt or reject the innovation,
  • Implementation person puts an innovation into
  • Confirmation person evaluates the results of an
    innovation-decision already made.

Diffusion of Innovation Process
  • The four main elements are
  • (1) innovation - an idea, practices, or objects
    that is perceived as new by an individual or
    other unit of adoption.
  • (2) communication channels - the means by which
    messages get from one individual to another.
  • (3) time - the three time factors are
  • a) innovation-decision process,
  • b) relative time with which an innovation is
    adopted by an individual or group,
  • c) innovation's rate of adoption.
  • (4) social system - a set of interrelated units
    that are engaged in joint problem solving to
    accomplish a common goal.

Journal Clubs
  • Purpose The purpose of the Nursing Journal Club
    is to foster excellence in nursing practice by
    promoting evidence-based practice
  • Goals
  • Improve nursing knowledge of current research
  • Foster the application of clinical research and
    best practice modules to nursing practice.
  • Provide a means by which to address clinical

Journal Clubs
  • Format for Presentations
  • Introduce topic and presenter
  • Give brief synopsis
  • Discuss major findings of study
  • Discuss other relevant research that
    supports/does not support this study

Journal Clubs
  • Discuss implications of article in terms of
    impact on nursing practice
  • What is the relevance of this article to our
  • Should we change our practice based on this

Staff nurses must do and use research.
  • Staff nurses provide direct patient care and are
    the link between research and practice,
  • Staff nurses have the opportunity to identify
    clinical problems amenable to research, and
  • The number of nurses with research preparation at
    the doctoral level will always be small.
  • Dr. Janelle Krueger, Promoting Nursing Research
    as a Staff Nursing Function 1980.

Evidence Based Practice and Research at St. Lukes
  • Nursing Research Fellowship
  • Johns Hopkins Evidence-Based Practice Model
  • www.ijhn.jhmi.edu

Why do we observe?
  • In dwelling upon the vital importance of sound
    observation, it must never be lost sight of what
    observation for. It is not for the sake of piling
    up miscellaneous information or curious facts,
    but for the sake of saving life and increasing
    health and comfort.

Florence Nightingale
How will we know weve arrived?
  • Nurses will pause to ask what does the data
  • Patients will have an individualized, evidence
    based care plan
  • Policies and Procedures will be evidenced-based
  • Nursing research will be conducted regularly
  • Nursing-Sensitive Quality IndicatorsOur
    outcome and process measures will reflect nursing

The illiterate of the 21st century will notbe
those who cannot read and write, but those who
cannot learn, unlearn and relearn.
-Alvin Toffler
  • Discussion
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