1. EVIDENCE-BASED PRACTICE: WHAT’S IN IT FOR YOU?
Sharon Bond, PhD, CNM
Associate Professor
Special Thanks to:
Barbara J. Edlund RN, PhD, ANP, BC
Professor
College of Nursing, MUSC

2. SO MANY QUESTIONS . . .
Evidence-Based Practice (EBP): What is the best approach for managing neuropathic pain in the terminally ill patient? What research has been done that could provide clinical practice guidelines? Quality Improvement (QI): Are we doing the right things to appropriately manage patients’ neuropathic pain? How do we know? How are we measuring patient outcomes? Research (R): What is it like to live with neuropathic pain?Does drug “A” work better than drug “B?” What’s been studied? Where are the gaps?

3. COMMONALITIES – PROVIDE STRUCTURE!
Evidence-based practice (EBP) – utilizes the best clinical evidence in making patient care decisions typically from research. EBP translates knowledge into practice
Quality improvement (QI) - utilizes a system to monitor and evaluate the quality and appropriateness of care (outcomes) based on EBP and research
Research (R) - applies a methodology whether quantitative or qualitative to develop, uncover, create, find, add new nursing knowledge

4. COMMONALITIES – IMPROVE CARE DELIVERY!
Involve teamwork – not done in isolation
Call for critical thinking and creativity
Commitment to improve care
One informs the other
Nurses base their practice on emerging evidence from research (EBP)
Research starts in practice and ends in practice
Quality improvement evaluates and monitors care, and identifies opportunities to improve care as the processes and outcomes of care are measured, continuously evaluated and improved

5. WHAT IS EVIDENCE-BASED PRACTICE?
Conscientious use of current best evidence to make decisions about patient care
A problem-solving approach to clinical practice
Based on:
1. systematic search for and appraisal of most relevant evidence to answer questions
2. one’s clinical experience and expertise
3. patient preference and values

6. Levels of Evidence I Evidence - Systematic reviews, meta-analysis
RCTs, EB clinical practice guidelines based on RCTs
II Evidence - One well designed RCT
III Evidence - CTs without randomization
IV Evidence - Well-designed case control or cohort
studies
V Evidence - Systematic reviews of descriptive or
qualitative studies
VI Evidence - Single descriptive or qualitative study
VII Evidence – Opinions of authorities, reports of
experts

7. EVIDENCE-BASED PRACTICE
The process of doing the “right thing”
Standards of care
Baseline description of quality- may be
discipline focused AANP standards of NP practice
Clinical guidelines
Broad-based recommendations
Critical pathways
Identify key/critical activities that must occur in
predictable fashion
Protocols
Detailed procedures on how to proceed with
evaluation and treatment
NONPF

8. FIVE STEPS OF EVIDENCE-BASED PRACTICE
Ask the burning clinical question (Picot format)
Search for and collect the most relevant and best evidence
Critically appraise the evidence
Integrate all evidence with one’s clinical expertise, patient preferences and values in making a practice decision or change
Evaluate the practice decision or change
(Disseminate)
Unlike research utilization (info from a single study), EBP - takes into account expertise of the practitioner and patient preferences / values
Melnyk & Fineout-Overholt 2005

10. STAR MODEL – FIVE STAGES: EBP
Depicts 5 major stages of knowledge in a relative sequence as research evidence is moved through several cycles, combined with other knowledge and integrated into practice
Converting knowledge into practice
Provides a framework for systematically putting evidence- based practice processes into operation
Stevens 2004 (

11. Reference: Haynes (1998). Barriers and bridges to evidence-based clinical practice. BMJ, 317:

12. QUALITY IMPROVEMENT
Process that utilizes a system to monitor and evaluate the quality and appropriateness of care based on evidence-based practice and research

13. ASPECTS OF QUALITY IMPROVEMENT
On-going process to improve quality of care
Whole team collaborates across departments and systems…team with clear aims, clear outcome measures of results to be achieved…process for implementing change and institutional or organizational support
Information systems…show me the data
System focused (not individual)
Practice process changes to meet guidelines (EBP) and to see if changes are working
NONPF

14. QUALITY IMPROVEMENT: FOCUS
Questions (3)
1. What are we trying to accomplish?
2. How will we know a change is an
improvement?
3. What changes can we make that will
result in improvement?
Rapid Improvement or PDSA cycles

15. PDSA: THE DEMING MODEL Plan - Test objectives - Who will do what
- Predict outcomes Do
- What happened
- Did it work
Study
- Analyze outcomes in context of predicted
- Summarize lessons learned
Act
- What modification needs to be made
- Statement of new plan ….. PDSA cycle repeats

16. NATIONAL GUIDELINES OR BENCHMARKS
Need quantifiable measures
Need to know the difference between your practice and national benchmarks
National Guidelines Clearing House
Guidelines.gov
National benchmarks or quality goals…AHRQ
NONPF

17. BARRIERS TO EVIDENCE-BASED PRACTICE
Overwhelming patient workloads
Misperceptions about EBP and research
Lack of time and resources to search for and appraise evidence
Organizational constraints – lack of support
Peer pressure to continue with practices that are steeped in tradition – “we’ve always done it this way and we are not changing now”
Melnyk & Fineout-Overholt 2005

18. BARRIERS TO EVIDENCE-BASED PRACTICE
Knowledge… lack of knowledge/awareness .… unfamiliar with guidelines and guideline accessibility
Attitudes …. lack of confidence in the guideline developer, lack of motivation to perform the guideline recommendations
Behaviors …. inability to incorporate patient preferences into the clinical decision making process
Melnyk & Fineout-Overholt 2005

19. WHAT ARE YOUR EXPERIENCES WITH CHANGE?
Have you ever tried to change a practice at your work site?
What worked?
What didn’t?
What was the final outcome?
What would you do differently?
Do facts (evidence) change behavior?

20. Research: When Evidence is Not There/Not Sufficient
Conduct a research study to determine the “what is it we want to know”
Nature of the question will determine the level of the research study
1 - What is the nature of the phenomenon?
2 - Who, what, how many, how much?
3 - What are the relationships among the variables?
4 - Does one variable cause the other?

21. RESEARCH QUESTIONS…..
First three questions - reflect levels of research seeking descriptive knowledge of the variables under study…non-experimental design
Fourth question reflects a level of research that examines cause and effect…experimental design
Before one conducts an experimental research study, one must have data from the three previous levels to support such a study…the preliminary work!
Value of research…adds new knowledge…to guide and improve nursing practice

22. QI VS. RESEARCH
Intervention may be multifactorial represents best practices
Rapid improvement cycles
No risk to patients
Audience is organization
Data source: organization
Design - no controls
Not generalizable
NONPF
Untried intervention being tested
Risk may be present
Complex protocol
Audience is scientific community
Data source –randomized population, multiple sites
Design – focus on controls
Generalizable

23. HOW DOES FOCUS OF DNP DIFFER FROM PHD?
DNP: Experts in EBP
PhD: Experts in Research
Eating during labor
Identify the problem
Find the evidence
Appraise the evidence
Integrate evidence with clinical expertise, patient values
Evaluate outcomes
Disseminate
Eating during labor
Explore, compare cultural differences
Compare differences in practice by geographic region, type of hospital, birth center
Physiologic effects of restriction

24. Quality Improvement (QI) vs. Performance Improvement (PI)
Often used interchangeably
Useful to think of PI as a “drill down process” to look at a specific problem that occurs with the implementation of EBP

25. OTHER THOUGHTS….
Research, quality improvement and evidence based practice are integral to the delivery of quality patient care
Each informs the other and improves upon the other
Each requires commitment, team work, vision, critical thinking, creativity, leadership, energy and endurance
“Doing the right thing” in each of these areas contributes to an environment of excellence, quality patient care and clinician satisfaction…and sets you apart as an organization!

26. YOUR DNP PRACTICE INQUIRY PROJECTS
What are your burning issues in health care, in your advanced nursing practice (why are you here)?
Implement innovations
Apply evidence-based interventions
Propose changes to care delivery models
Implement quality improvement projects
Develop and implement health policy
You are a Change Agent !

27. REFERENCES
Burns & Grove (2005). The Practice of Nursing Research (5th ed).St. Louis: Elsevier Saunders
Polit & Beck (2008). Nursing Research: Generating and Assessing Evidence for Nursing Practice. Philadelphia : Lippincott Williams & Wilkins
Melnyk & Fine-Overholt (2005). Evidence-Based Practice in Nursing & Health Care.
Philadelphia: Lippincott Williams & Wilkins
Roberts & Bourke (1989). Nursing Research: A Quantitative and Qualitative Approach. Boston: Jones & Bartlett
NONPF
ACE Star Model:
Deming Model: