1. Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 10 Evidence-Based Practice Sharon E. Lock

2. Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 2 Introduction  Research evidence provides a scientific basis for practice; thus using research to support practice will result in better client outcomes and more efficient practice  Research evidence is not always available to use for decision making; when that is the case, other sources of evidence are used to make clinical decisions

3. Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 3 Definitions Related to Evidence-Based Practice  Evidence-based medicine: being aware of the evidence on which one’s practice is based, the soundness of the evidence, and the strength of inference the evidence permits  Evidence-based public health: a public health endeavor in which there is an informed, explicit, and judicious use of evidence that has been derived from any of a variety of science and social science research and evaluation methods  Evidence-based nursing: an integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families, and communities who are served  Evidence-based practice: includes the best available evidence from a variety of sources, including research studies, evidence from nursing experience and expertise, and evidence from community leaders

4. Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 4 History of Evidence-Based Practice  Mid- to late 1970s  Growing consensus among nursing leaders that scientific knowledge should be used as a basis for nursing practice  Medicine also began to call for physicians to increase their use of scientific evidence to make clinical decisions  Division of nursing began funding research utilization projects  1990s  Paradigm shift – need to be able to critically appraise the research literature in order to appropriately apply research findings in practice

5. Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 5 Types of Evidence  Systematic review: a summary of the research evidence that relates to a specific question and to the effects of an intervention  Meta-analysis: a specific method of statistical synthesis used in some systematic reviews, where the “results from several studies are quantitatively combined and summarized”  Randomized control trial (RCT): generally ranks as the highest level of evidence followed by other RCTs, nonrandomized clinical trials, prospective cohort studies, case-control studies, case reports, and expert opinion

6. Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 6 Evaluating Evidence  Sample selection  Randomization  Blinding  Sample size  Description of intervention  Outcomes  Length of follow-up  Attrition  Confounding variables  Statistical analysis

7. Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 7 Grading the Strength of Evidence  The evidence is assigned a “grade” based on:  The quality of the evidence  The number of well-designed studies  The presence of similar findings in all of the studies  Three domains for evaluation systems  Quality  Quantity  Consistency

8. Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 8 Implementation  Recognizing the current status of one’s own practice and believing that care based on the best evidence will lead to improved client outcomes  Steps for EBP  Ask a clinical question  Collect the most relevant and best evidence  Critically appraise the evidence  Make a clinical decision or change by integrating all the evidence with clinical expertise, client preferences, and values  Evaluate the clinical decision or change

9. Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 9 Barriers to Implementation  Misunderstood communication between nursing leaders about the process involved  Inferior quality of available research evidence  Inability to assess and use research evidence  Unwillingness of organizations to fund research and make decisions based on evidence  Concern that EBP will lead to a “cookbook” approach to nursing while ignoring individual client needs and the nurse’s ability to make clinical decisions  Community-focused nursing agencies may lack the resources needed for EBP implementation

10. Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 10 Current Perspectives  Cost versus quality  Individual differences  Appropriate EBP methods for community- oriented nursing practice

11. Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 11 Future Perspectives  Rising costs of health care = continued challenge of finding resources to implement EBP  Emphasis on quality care, equal distribution of health care resources, and cost control will continue  Use of Internet for evidence data

12. Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 12 Healthy People 2010 Objectives  Offer a systematic approach to health improvement  Provide general direction and focus for measuring progress of improving health status within a specific amount of time  CDC data system tracks all 467 objectives  Partners in Information Access for the Public Health Workforce makes information and evidence-based strategies related to HP 2010 objectives easier to find

13. Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 13 Nursing Interventions Related to the Core Public Health Functions  Assessment  Monitoring health  Diagnosis  Investigation  Policy development  Informing and educating the public  Mobilizing the community  Assurance  Linking or providing care to the community  Ensuring a competent workforce  Evaluation

14. Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 14 The Minnesota Model  1994: the Minnesota Department of Health nursing staff aimed to develop a model of public health nursing interventions  The model received input from public health nurses, clinicians and educators, and a national expert panel  Final model defines the scope of public health nursing practice by type of intervention and the client level of practice  17 interventions were identified

15. Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 15 Minnesota Model: 17 Interventions 1. Surveillance 10. Counseling 2. Disease and health event investigation 11. Consultation 3. Outreach 12. Collaboration 4. Screening 13. Coalition building 5. Case finding 14. Community organizing 6. Referral and follow-up 15. Advocacy 7. Case management 16. Social marketing 8. Delegated functions 17. Policy development and enforcement enforcement 9. Health teaching

16. Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc. 16 Minnesota Model: Actions  For each intervention listed on the previous slide, the following actions are taken:  The intervention is defined  Assumptions about the intervention are given  Practice examples are given for type of client  How the intervention relates to other interventions is explained  Basic steps are given for implementing the intervention.  Best practices are explained  The evidence used to develop the intervention is given