1. INTRODUCTION TO EVIDENCE BASED NURSING
Assoc Prof Majda Pajnkihar, PhD

2. Winter School 2015 
Introduction
Every day nurses perform interventions e.g. administering medication, educating clients, provide therapeutic interventions etc;
This should stimulate questions about the evidence supporting their use of various interventions.

3. What do we base our decision on?
Winter School 2015 
What do we base our decision on?

4. How nurses base their nursing care?
Winter School 2015 
How nurses base their nursing care?
Pravikoff et al., 2005 surveyed 760 USA registered nurses working in clinical practice and 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 Evidence Based Practice,
67% never searched CINAHL Database,
72% hadn’t evaluated research reports.

5. Evidence Based Practice
Winter School 2015 
Evidence Based Practice
„Integration of best research evidence with clinical expertise and patient values“
(Dave Sackett, 1996)
“Doing the right thing in the right way for the right patient at the right time.”
(Royal College of Nursing 1996, p. 3)

6. Evidence Based Practice
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Evidence Based Practice
Evidence Based Practice
EVIDENCE BASED HEALTHCARE
EVIDENCE BASED MEDICINE
EVIDENCE BASED NURSING

7. Evidence Based Nursing
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Evidence Based Nursing
Context
BEST RESERCH EVIDENCE
CLINICAL EXPERIENCE/ EXPERTISE
EBN
PATIENT VALUES

8. What do you understand by the word ‘evidence’?
Winter School 2015 
What do you understand by the word ‘evidence’?

9. Winter School 2015 
Evidence
Evidence is a collection of facts that are belived to be true (Melnyk, & Fineout-Overholt, 2011).
Current best evidence from clinical research:
implies hierarchy of evidence.

10. Hierarchy of Evidence Winter School 2015 Level 1
Systematic review of RCTs
Systematic review of nonrandomized trials
Level 2
Single RCT
Single nonrandomized trial
Level 3
Systematic review of correlational / observational studies
Level 4
Single correlational / observational study
Level 5
Systematic review of descriptive / qualitative / psychologic studies
Level 6
Single descriptive / qualitative / psychologic studies
Level 7
Opinions of authoities, expert committees

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Hierarchy of Evidence
Is this hierarchy of evidence suitable for grading the evidence for a question:
What is the perception of pain in patients with multiple sclerosis?
Clinical question determines the type of research required for searching.
We cannot reserach experiencing pain in patients with RCT.

12. Randomized controlled trial
Winter School 2015 
Randomized controlled trial
selection
performance
outcome
exclusion
detection
intervention
Patients
control
outcome
An experimental comparison study in which participants are allocated to treatment/intervention or control/placebo groups using a random mechanism. Best for study the effect of an intervention.

13. Archie Cochrane – supporter of RCT
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Archie Cochrane – supporter of RCT
„I had considerable freedom of clinical choice of therapy: my trouble was that I did not know which to use and when. I would gladly have sacrificed my freedom for a little knowledge. I had never heard then of 'randomised controlled trials', but I knew there was no real evidence that anything we had to offer had any effect on tuberculosis, and I was afraid that I shortened the lives of some of my friends by unnecessary intervention."

14. Systematic review Winter School 2015
Sum up ov the best available research on a specific question; using transparent procedures to find, evaluate and synthesize of relevant research.

15. Winter School 2015 

16. Winter School 2015 
Why EBN?
Patients experience 28% better outcomes if they receive care based on the best and latest evidence from well-designed studies compared to traditional practice (Heater et al. 1988).
Without current best evidence practice is rapidly outdated often can be the detriment of patients (Melnyk & Fineout-Overholt, 2005)

17. Why is EBN important? Main aim is to improve client outcomes;
Winter School 2015 
Why is EBN important?
Main aim is to improve client outcomes;
Ensure clinically effective health care;
Improve people’s experience of illness & health care;
Clients expect it;
Improves clinician’s knowledge;
Communicates a profession’s research base;
Stimulates clinically relevant research;
Accountability.

18. Winter School 2015 
Why is EBN important?
Failing to use available science is costly and harmful. It leads to overuse of unhelpful care, underuse of effective care and errors in execution

19. Overarcing Goal Safe, Effective Nursing Care.
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Overarcing Goal
Safe, Effective Nursing Care.
Our nursing care is only safer if we put into practice what we learn from research.

20. Winter School 2015 
Why EBP 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 1996).

21. Show me the Evidence I wonder…
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I wonder…
Having two nurses check medication orders prior to dispensing medication reduces the incidence of medication errors.
Is that really the case?
Show me the Evidence

22. Show me the Evidence I wonder…
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I wonder…
A Group therapy programme is more effective than a self help programme in promoting smoking cessation.
How so?
Show me the Evidence

23. GOSH, should we do someting about this?
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I wonder…
Special toileting needs such as incontinence, urgency or diarrhoea is a factor that increases the likelihood of a patient falling in hospital.
GOSH, should we do someting about this?
Show me the Evidence

24. Winter School 2015 
Keeping up to date
Nurses need to keep up to date and offer best practice from the best evidence.
EBN processes focus on incorporating good information seeking habits into daily routine (Melnyk & Fineout-Overholt, 2005).

25. EBN process Winter School 2015 (Polit, & Beck, 2012)
Asking the right question - ASK
Search for the best evidence - ACQUIRE
Critically appraise evidence - APPRAISE
Integrate the evidence - APPLY
Evaluate the outcomes - ASSESS
(Polit, & Beck, 2012)

26. Asking the right question
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Asking the right question P
Population, problem I
Intervention or issue
(C)
Comparison O
Outcome
(T)
Time
In patients living in a long-term care facility who are at risk for pressure ulcers (P), how does a pressure ulcer programme (I) compared to the standard of care (e.g. turning every 2 hours) (C) affect signs of emerging pressure ulcers (O)?

27. Asking the right question
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Asking the right question

28. Search for the best evidence
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Search for the best evidence
Systems
Summaries
Synopses
Syntheses
Studies
Systems for Clinical Decision Support
S-model
Evidence Based
textbooks
Clinical Evidence, UpToDate
(Haynes, 2006)
Other reviews in DARE-database (Cochrane Library)
Evidence Based Journals
Evidence Based
journal abstracts
Cochrane Reviews (Cochrane Library),
Clinical Queries (Ovid, Pubmed),
Systematic reviews
CENTRAL (Cochrane Library)
Clinical Queries (Ovid, Pubmed)
Original journal articles

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Cochrane Library

30. Critically appraise evidence
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Critically appraise evidence
Are the results valid (validity)?
What are the results (reliability)?
Can I apply the results in practice (applicaiblity)?

31. Critically appraise evidence
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Critically appraise evidence
Using different critical appraisal questions, checklist and tools:
CASP
...

32. Integrate the evidence
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Integrate the evidence
Research evidence alone is not sufficient to justify a change in practice.
Implementation of EBN is highly influenced by institutional and clinical variables.

33. Winter School 2015 
Evaluate the evidence
After implementing EBN, it’s important to monitor and evaluate any changes in outcomes so that positive effects can be supported and negative ones remedied.

34. Evidence lost in translation
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Evidence lost in translation
Studies on evidence based recommendations in practice: 30-50% is not used.
Studies on compliance: 30-50% of patients do not adhere well.
For some clinical care and public health recommendations 50-75% of patients may not profit (enough) from evidence.
Many best practices in quality and safety are not adopted widely in health care (Flottorp, 2015).

35. Barriers of EBN Winter School 2015 (Melnyk & Fineout-Overholt, 2011)
Lack of EBN knowledge and skills.
Lack of belief that EBN will result in more positive outcomes than traditional care.
Lack of time and resources to research for and appraise evidence.
Lack of EBN mentors.
Resistance to change.
Volumnous amounts of information in professional journals.
(Melnyk & Fineout-Overholt, 2011)

36. Barriers of EBN Winter School 2015 (Melnyk & Fineout-Overholt, 2011)
Mispertceptions or negative attitudes about research and evidence based care.
Overwhelming patient loads.
Organizational contraints.
Demands from patients for a certain type of treatment.
Peer pressure to continue with practices that are seeped in tradition.
????
(Melnyk & Fineout-Overholt, 2011)

37. Knowledge: the enemy of disease
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Knowledge: the enemy of disease
„The application of what we know already will have a bigger impact on health and disease than any drug or technology likely to be introduced in the next decade.“
Sir Muir Gray Director UK NHS
National Knowledge Service & NHS Chief Knowledge Officer

38. Viva La Evidence Never stop questioning! (Susan L. Hendrix)
Winter School 2015 
Viva La Evidence
Never stop questioning! (Susan L. Hendrix)

39. Go find the evidence.