Julia Wetmore, RN, PhD Evidence Based Nursing Practice

What is EBP? The conscious and intentful use of research and theory based information to make decisions about patient care delivery (Macnee, 2004).

EBP is a problem-solving approach integrating:  The most relevant evidence from literature to answer the clinical question.  One’s own clinical expertise.  Patient preferences and values.

EBP originated in medicine. Dr. Archie Cochrane, Epidemiologist Crossing the Quality Chasm (IOM, 2001) Studies in medicine and nursing indicating that interventions based on evidence have better outcomes.

How do we establish which evidence is “best”?

Five Key Steps of EBP Step 1. Formulate the question (PICO). Step 2. Search for the best evidence. Step 3. Critically appraise the evidence. Step 4. Integrate the evidence. Step 5. Evaluate its effectiveness.

The “PICO” format P Population I Intervention or Interest C Comparison intervention or status O Outcome

What are the types of evidence we are likely to find?  Clinical Guidelines  Systematic Reviews or Meta-analyses  RCTs  Quasi-experimental Studies  Descriptive or Qualitative Studies

Handy links to library web pages At WCU, a link takes our students directly to the EBP web page, designed by the university librarian. It is placed on the content page of every online nursing course.

Definitions of different types of evidence syntheses (Melnyk & Overholt, 2005) Systematic review: A compilation of like studies to address a specific clinical question using a detailed, comprehensive search strategy and rigorous appraisal methods for the purpose of summarizing and communicating the results and implications of contradictory results or otherwise unmanageable quantities of research.

Definitions of different types of evidence syntheses (continued) Meta-analysis: A statistical approach to synthesizing the results of a number of studies that produces a larger sample size and thus a greater power to determine the true magnitude of an effect. Used to obtain a single-effect measure (i.e. a summary statistic) of the summarized results of all studies included in a review.

Definitions of different types of evidence syntheses (continued) Integrative review: A systematic review that does not have a summary statistic because sample sizes cannot be summarized in an integrative review (usually due to heterogeneous studies/samples). Narrative review: A review that includes published papers that support an author’s particular point of view; serves as a general background discussion of a particular issue.

Example of an Integrative Review Armstrong, D. & Bortz., P. (2001). An integrative review of pressure relief in surgical patients. AORN Journal, 73(3), 645, (copy of article available upon request). Many good examples of SRs, meta-analyses and integrative reviews in Evidence-Based Nursing.

How do we critically appraise the evidence? Rate the evidence based on a hierarchy. Rate the evidence based on a hierarchy. Ask three questions: Ask three questions: 1. Are the results valid? 2. Are the results significant? 3. Can I generalize the results? Use a review team to appraise the literature. Use a review team to appraise the literature.

Rating System for the Hierarchy of Evidence (Melnyk, 2006) Level I. Evidence obtained from a systematic review or meta-analysis of all relevant, randomized clinical trials (RCTs), or 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 (quasi- experimental).

Rating system (continued): Level IV. Evidence from well designed case-control and cohort studies. Level V. Evidence from SRs of descriptive and qualitative studies. Level VI. Evidence from a single descriptive or qualitative study. Level VII. Evidence from opinion of authorities and/or reports of expert committees.

The Ace Star Model (Stevens, 2005)  Discovery  Summary  Translation  Integration  Evaluation

Other models of EBP include: Iowa Model. Rosswurm and Larrabee Model. Stetler Model.

What needs to be taught to the student of nursing? oEssential competencies from ACE (Stevens, 2005). oAACN competencies identified in Essentials of baccalaureate education (AACN, 1998).

Stevens (2005) Essential Competencies From: Stevens, K. (2005). Essential competencies for evidence-based practice in nursing. (1 st ed.). San Antonio, TX: ACE, UTHSCSA. Define EBP in terms of evidence, expertise, and patient values. Critically appraise original research reports for practice implications. Classify clinical knowledge as primary research, evidence summary, or practice guideline. Recognize ratings of strength of evidence when reading literature.

Essential competencies (cont.) Use evidence summary databases to locate systematic reviews and evidence summaries on clinical topics. Participate on a team to develop agency-specific evidence-based clinical guidelines. Deliver care using evidence-based clinical practice guidelines. Choose evidence-based approaches over routine as basis for own clinical decision-making.

AACN Essential Competencies (1998) Related to Critical Thinking o Apply research-based knowledge from nursing and sciences as the basis for practice. o Evaluate nursing care outcomes through the acquisition of data and questioning of inconsistencies.

AACN essentials (cont.) Related to Provider of Care o Integrate theory and research-based knowledge from the arts, humanities and sciences to develop a foundation for practice. o Participate in research that focuses on the effectiveness of nursing interventions. o Utilize outcome measures to evaluate effectiveness of care.

Teaching principles of EBP to students What? When? How?  Components of EBP.  EBP versus RU.  EBP versus “best practice.”  EBP applied to patient care.  EBP assignment in NSG 470.

Barriers to EBP in Clinical Settings from Pravikoff et al., (2005). Readiness of US Nurses for Evidence-Based Practice. AJN, 105.  Lack of knowledge about EBP.  Lack of knowledge about library and online resources.  Inconvenient/inaccessible library/internet.  Misperceptions or negative views of research.  Devotion to traditional care.

Barriers (continued)  Overwhelming patient care load.  Voluminous amounts of literature.  Difficult patient care situations.  Organizational constraints.  Inadequate information in prelicensure nursing program.  Laziness/lack of motivation/ burnout.

EBP Facilitators  Educational emphasis in nursing schools and hospitals.  Administrative support and encouragement.  Time to think through patient care situations.  Time to critically appraise studies and implement findings.  Clearly written, well-done research reports.  Library and internet access in the clinical area.

EBP Controversies  Is it just a new term for RU?  Is it too “cookbook” to be realistic?  Patient care realities are too varied and complex…how can guidelines be practical?  Few guidelines, hard to find.  It requires RCTs which are impossible in health care settings.

References American Association of Colleges of Nursing. (1998). The essentials of baccalaureate education for professional nursing practice. Washington, DC: AACN. Burns, N. & Grove, S. (2007). Understanding nursing research. Building an evidence-based practice. (4th ed.). St. Louis, Missouri: Saunders/Elsevier. Institute of Medicine. (2001). Crossing the quality chasm. Washington, DC: National Academy Press. Heater, B., Becker, A. & Olson, R. (1988). Nursing interventions and patient outcomes. A meta-analysis of studies. Nursing research, 37, Macnee, C.L. (2004). Understanding nursing research: Reading and using research in practice. Philadelphia: Lippincott, Williams, & Wilkins. Melnyk, B. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & healthcare. Philadelphia: Lippincott, Williams & Wilkins. Pravikoff, D.S., Tanner, A.B. & Pierce, S.T. (2005). Readiness of U.S. Nurses for Evidence-Based Practice. American Journal of Nursing, 105, Stevens, K.R. (2005). Essential competencies for evidence-based practice in nursing. (1st ed.). San Antonio, TX: Academic Center for Evidence-Based Practice, UTHSCSA.