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Evidence Based Nursing (EBN)

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Title: Evidence Based Nursing (EBN)


1
Evidence Based Nursing (EBN) Diagnostic Accuracy
  • Rona F. Levin, PhD, RN (New York, USA)
  • Margaret Lunney, PhD, RN (New York, USA)
  • Barbara Krainovich Miller, EdD, RN (New York,
    USA)
  • Diná Monteiro da Cruz, PhD, RN (Sao Paulo,
    Brazil)
  • Cibele de Mattos Pimenta, PhD, RN (Sao Paulo,
    Brazil)

2
Objectives
  • Explain accuracy of diagnosis as the foundation
    of EBN-M. Lunney
  • Describe an evidenced-based model (PCD) for use
    by nurses-R. Levin
  • Apply the PCD format to diagnose anxiety-B. K.
    Miller
  • Apply the PCD format to teach EBN- D. M. da Cruz
    C.M. Pimenta

3
Foundation of Evidence-Based PX Accurate
Interpretation of Data
  • Interpretations determine actions
  • Additional data to be collected
  • Subsequent interpretations
  • Possible outcomes to consider
  • Choices of interventions

4
Foundation of Evidence-Based PX Accurate
Interpretation of Data
  • High potential for inaccuracies
  • Human beings are complex and diverse
  • We do not know other people (Munhall, 1993)
  • Knowledge of nursing concepts varies
  • Critical thinking abilities vary

5
Foundation of Evidence-Based PX Accurate
Interpretation of Data
  • What is diagnostic accuracy?
  • Accuracy is a raters judgment of the degree to
    which a diagnostic statement matches the cues in
    a patient situation (Lunney, 1990).

6
Challenge of Achieving Accuracy
  • Puzzle What is the Diagnosis?

7
Research Findings
  • Studies 1966 to present
  • Conclusions Interpretations vary widely
  • Influencing factors
  • Diagnostic Tasks
  • Situational contexts
  • Nurse Diagnosticians

8
Diagnostic Tasks
  • Factors studied
  • Task complexity
  • Amount of data
  • Relevance of data

9
Situational Contexts
  • Factors studied
  • Time constraints
  • Role in healthcare system
  • Factors still to be studied
  • Policies
  • Procedures
  • Philosophy and theories

10
Nurse Diagnosticians
  • Factors studied
  • Education
  • Use of teaching aids
  • Nursing experience
  • Cognitive strategies
  • Cognitive abilities
  • Personality

11
Summary of Research Findings Positive
Influences on Accuracy
  • Education related to nursing diagnoses
  • Knowledge of diagnostic process and concepts
  • Teaching aids for diagnostic reasoning
  • Variety of thinking processes
  • Experience specific to diagnostic task
  • Lesser amounts and complexity of data

12
Conclusions from Knowledge Development
  • Problem Diagnostic Accuracy varies from high to
    low.
  • Solution Use an evidence-based practice approach
    to facilitate the formulation of accurate
    diagnoses.

13
Evidence-Based Practice
Clinicians Experience
Best Evidence
Patient Preference
14
Solving the Puzzle

Is it this? Or This? Or This?
15
Evidence-Based Practice to Solve the Puzzle
  • Evidence from Literature
  • Which diagnosis are indicated by the cues?
  • What differentiates similar diagnoses?
  • Which of the possible diagnoses is the best
    match?
  • Clinician perspective
  • Patient perspective

16
EBM Model
  • Asking answerable questions
  • Finding the best evidence
  • Appraising validity of evidence
  • Integrating evidence with clinician expertise and
    patient preferences
  • Evaluating ones effectiveness in above steps
  • Sackett, Straus, Richardson, Rosenberg, Haynes
    (2000)

17
Asking Answerable Diagnostic Questions in Nursing
  • PCD format
  • P Patient population
  • C Comparison cue or cue cluster
  • D Differential diagnosis
  • developed by Levin, Miller Lunney (2004)

18
Asking Answerable Diagnostic Questions in Nursing
  • Example of PCD question
  • In adult critical care patients (population) who
    exhibit angry outbursts, complaints about
    treatments that interfere with sleep/rest, and
    irritable behavior (cue cluster) what are the
    possible nursing diagnoses to consider
    (differential diagnosis)?

19
Asking Answerable Diagnostic Questions in Nursing
  • Possible diagnoses to consider
  • sleep pattern disturbance
  • ineffective coping
  • hopelessness
  • powerlessness
  • fear and/or anxiety
  • cognitive impairment
  • other?

20
Asking Answerable Diagnostic Questions in Nursing
  • Based on evidence, what is the strength of the
    cues in relation to the possible diagnoses?
  • Based on evidence, which of the possible
    diagnoses represents the best match with the
    cues?
  • Does the patient validate the clinicians
    interpretation?

21
Finding the Evidence
  • Knowledge of possible diagnoses
  • Research evidence associated with specific
    diagnoses
  • Knowledge of useful data bases
  • Access to data bases and sources

22
Appraising the Evidence
  • Assess validity of the research-based evidence
  • Type of study
  • survey of nurses?
  • Observation of patients?
  • Sample size and selection
  • Applicability to your practice

23
Integrating Evidence
  • With clinicians expertise
  • knowledge of diagnoses and diagnostic task
  • specialty focus
  • frequency of caring for patients with specific
    responses (cue clusters)
  • knowledge of related interventions

24
Integrating Evidence
  • Patients Perspective
  • Uniqueness of individual
  • Context of human response
  • Values and preferences
  • Validation of nurses interpretation

25
Evaluating Effectiveness
  • Am I looking for the research evidence about
    human responses?
  • Am I considering the highly relevant diagnoses
    associated with observed cue clusters?
  • Am I considering the individual patient and the
    specific context when applying research-based
    evidence?

26
Evidence-Based Nursing Diagnosis Anxiety
  • NANDA Nursing Diagnoses Definitions
    Classification 2003-2004
  • Refined based on research submitted to DRC
  • 1973, 1982, 1998

27
Refinement Nursing Research Validation Studies
  • Whitley (1994, 1992, 1989)
  • Levin, Krainovich-Miller et al. (1989)\
  • Krainovich (1988)
  • Fadden, Fehring Kendel-Rossi (1987)
  • Lopez Risey (1986)
  • Jones Jakob (1984)
  • Jones Jakob (1981)
  • Haag Adamski (1978)
  • Graham Conley (1971)

28
NDx Normal Anxiety
  • Nursing Research Clinical Content Validation
    Studies
  • Interdisciplinary Case Studies Research Findings

29
Differential Diagnoses
  • Anxiety
  • Fear
  • Ineffective Coping
  • Disturbed Thought Processes

30
Diagnostic Reasoning Process
  • Definition
  • Defining Characteristics
  • Related Factors

31
COMPARE
D-Differential NDxs Definition Defining
Characteristics Related Factors
P-Population Pre-Op Pts C-Cues Presenting
Objective Subjective Data
DERIVE
Evidence-based NDx Pre-Op Anxiety
PCD
32
Patient Perspective
  • Critical to Diagnostic Accuracy
  • Compare to Clinician Perspective
  • Results NDx statement that best fits the
    patients cues in context

33
Interpreting Human Responses is a Complex Task
Accuracy
Inaccuracy
Principles of Evidence Based Practice
34
Evidence-Based Nursing
  • Asking Answerable Questions
  • Finding the Best Evidence
  • Appraising Validity of Evidence
  • Integrating Evidence (clinician/patient)
  • Evaluating Effectiveness
    Sackett et al (2000)

Applied to diagnosis, interventions (treatments),
and outcomes
35
Case Study
  • Cases are stories with a message. They are not
    simply narratives for entertainment. They are
    stories to educate.
  • ... the role of students and instructor vary as
    will the case material itself.
  • (Herreid CF, 2004)

36
Case Study
Case methods or studies provide a process of
participatory learning that facilitates active
and reflective learning and results in the
development of critical thinking and effective
problem-solving skills. This develops
self-directed lifelong learners. (Tomey AM,2003)
37
Case Study
  • A Patient in Respiratory Critical Care
  • Mrs. H, 70 years old, was admitted to a
    respiratory medical unit because she presented
    with increasing shortness of breath over....
    (Handout p.1)
  • Perry, K. A patient in respiratory critical care.
    In Lunney M. (2002).
  • Critical thinking nursing diagnosis (pp.
    74-75, 140-142).
  • Philadelphia NANDA International.

38
Case Study
  • Objective
  • Participants will apply the PCD format to
    interpret patient data
  • Directions
  • Use groups of 5 to 7
  • Assign leader recorder
  • Leader Help group to stay focused conduct
    discussions in a nurturing environment
  • Recorder Document relevant aspects of the
    discussion and report group conclusions

39
Case Study
  • Directions
  • Read the text carefully (Handout p.1)
  • Imagine you are the nurse of the patient
  • Task- state NDxs that best explain the patients
    situation
  • Apply the PCD format to ask answerable questions
    to make accurate NDXs
  • developed by Levin, Miller Lunney (2004)

40
Case Study
  • PCD format
  • P Patient population
  • C Comparison
  • D Differential diagnosis

Developed by Levin, Miller Lunney (2004)
41
P-Population
  • Asking Answerable Questions
  • What are the most common nursing diagnoses (NDxs)
    in the population that this patient represents
    (critical care patients)?
  • Searching the Evidence
  • CINAHL
  • Medline

42
P-PopulationSearching the Evidence
Subject Search CINAHL MEDLINE
S1 Nursing Diagnosis 2537 1661
S2 Critical Care 2574 7252
S3 Intensive Care - 6371
S4 Critically Ill Patient / Critical Illness 2054 4825
S5 S1 and S2 4 64
S6 S1 and S3 - 15
S7 S1 and S4 / Limit research 10 / 3 4 / NA
43
P-Population Searching the Evidence
  • CINAHL
  • Wang LT, Lee C. (2002)
  • Asencio JMM. (1997) Spanish
  • Roberts BL et al. (1996)
  • Logan J Jenny J. (1991)

44
P-Population Searching the Evidence
  • MEDLINE
  • Gordon M, Hiltunen E. (1995)
  • Wieseke A et al. (1994)
  • Pasini DA et al. (1996) Portuguese
  • Alorda C et al. (1996) Spanish

45
P-Population Appraising the Validity of Evidence
Question What are the most common nursing
diagnoses (NDxs) in the population that this
patient represents (critical care patients)?
46
P-PopulationAppraising the Validity of Evidence
  • Prevalence studies (cross-sectional)
  • Population Sample
  • Is the population similar to the population
  • of the case study patient?
  • How was the sample drawn?

47
P-PopulationAppraising the Validity of Evidence
  • Prevalence studies (cross-sectional)
  • Data collection
  • Cover different domains?
  • Who were the diagnosticians?
  • How was accuracy of NDxs assured?
  • Results
  • Valid and reliable?
  • Applicable to this case study?

48
C-Comparison
  • Asking Answerable Questions
  • Which data are cues to possible NDxs (human
    responses)?
  • Which data are highly relevant to explain the
    human responses?

49
C-Comparison
  • Asking Answerable Questions
  • Which data are cues to possible NDxs (human
    responses)?
  • ? participation in care
  • ? use of the call bell
  • ? interest in providers actions
  • ? sleep
  • ? communication with daughter (who used to read
    Bible to her)
  • What else?

50
C-Comparison
  • Asking Answerable Questions
  • Which NDx (human response) best explains the
    current situation?
  • Relevant data
  • ? participation in care
  • ? use of the call bell
  • ? interest in providers actions
  • ? sleep
  • ? communication with daughter (who used to read
    Bible to her)
  • Possible Explanations
  • Fear?
  • Powerlessness?
  • Hopelessness?
  • Spiritual Distress?
  • What else?

51
C-Comparison
  • Asking Answerable Questions
  • Based on evidence, what is the strength of the
    cues in relation to possible diagnoses?
  • Searching Evidence
  • CINAHL
  • Medline
  • NANDA International

52
C-ComparisonSearching the Evidence
Subject Search CINAHL MEDLINE
S1 Fear ( and Validation Studies) 1202 (15) 4736 (0)
S2 Hopelessness ( and Validation Studies) 175 (0) (0)
S3 Hope (and Validation Studies) 870(12) (0)
S4 Powerlessness ( and Validation Studies) 251 (3) (0)
S5 Spiritual distress NANDA (and Validation Studies) 25 (7) (0)
S6 Validation Studies 4340 (0)
53
C-Comparison Searching the Evidence
  • CINAHL
  • Fear
  • Whitley GG. (1997)
  • Powerlessness
  • Bufe GM Abdul-Hamid M. (1995)
  • Hopelessness
  • Beyea SC Peters DD. (1987)
  • Spiritual Distress
  • Twibell RS et al. (1996)
  • Hensley LD. (1994)

54
C-Comparison Searching the Evidence
  • Nursing Diagnosis Classification (NANDA
    International, Handout, p.2)
  • Fear
  • Powerlessness
  • Hopelessness
  • Spiritual Distress

55
C-Comparison Appraising Validity of the Evidence
Question Based on evidence, what is the strength
of the cues in relation to possible NDxs?
56
C-ComparisonAppraising Validity of the Evidence
  • Validation studies
  • Design
  • Clinical? Control group (with x without the NDx)?
  • Content validation by experts?
  • Sample
  • Similar to the patients population?
  • Sampling methods?

57
C-ComparisonAppraising Validity of the Evidence
  • Validation studies
  • Data collection
  • Instruments
  • Wide search for defining characteristics?
  • Based on operational definitions of the defining
    characteristics?
  • Validity and reliability?
  • Results
  • Valid and reliable?
  • Applicable to the patient?

58
C-ComparisonAppraising Validity of the Evidence
  • Concept analysis/development studies
  • Purpose
  • Identification?
  • Development?
  • Clarification?
  • Method
  • Consistent?
  • Results
  • Valid and reliable?
  • Applicable to the patient?

59
D-Differential Diagnosis
  • Asking Answerable Questions
  • Which of the possible NDxs represent the best
    match with the cues?
  • Searching Evidence
  • CINAHL
  • Medline
  • NANDA Internationals Classification

Literature data base will be the same selected
for COMPARISON
60
D-Differential DiagnosisAppraising Validity of
the Evidence
  • Validation studies
  • Design
  • Compare nursing diagnoses?
  • Clinical? Control group (with x without the ND)?
  • Content validation by experts?
  • Sample, Data collection, and Results
  • Apply the same criteria of Comparison

61
Summary
62
Challenges
  • Clinical research-based literature
  • Epidemiological studies
  • Validation studies
  • Criteria to appraise evidence
  • Data base frameworks
  • Measurement tools for specific NDxs
  • Skills for searching evidence
  • Accessibility of data bases

63
Conclusion
  • The illiterate of the 21st century will not be
    those who cannot read and write, but those who
    cannot learn, unlearn and relearn.
  • Alvin Toffler
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