Evidence Based Practice -By Ritika Soni

Shimla
ShimlaAssistant Professor( Psychiatric Nursing), shimla Nursing college, Annandale, Shimla. en Shimla
Evidence Based Practice -By Ritika Soni
Evidence Based Practice -By Ritika Soni
 Evidence-based practice is the idea that
occupational practices ought to be based on
scientific evidence.
 The movement towards evidence-based practices
attempts to encourage professionals and other
decision-makers to pay more attention to
evidence to inform their decision-making.
 The goal of evidence-based practice is to
eliminate unsound or outdated practices in more
effective ones
 by shifting the basis for decision making from
tradition, intuition, and unsystematic experience to
firmly grounded scientific research.
 Evidence based practice (EBP) is the conscientious use
of current best evidence in making decisions about
patient care.
(Sackett, Straus, Richardson, Rosenberg,
& Haynes, 2000).
 It is a problem solving approach to clinical practice
and administrative issues that integrates:
A systematic search for and critical appraisal of the
most relevant evidence to answer a burning clinical
question
One's own clinical expertise
Patient preferences and values
(Melnyk & Fineout-Overholt, 2014)
Health care that is evidence-based and conducted in
a caring context leads to better clinical decisions
and patient outcomes. Gaining knowledge and skills
in the EBP process provides nurses and other
clinicians the tools needed to take ownership of their
practices and transform health care.
Evidence Based Practice -By Ritika Soni
Evidence Based Practice -By Ritika Soni
Evidence Based Practice -By Ritika Soni
 There are many examples of EBP in the daily
practice of nursing.
1. Infection Control
 The last thing a patient wants when going to a
hospital for treatment is a hospital-acquired
infection. Nurses play a key role in helping to
prevent illness before it happens by adhering to
evidence-based infection-control policies.
 This includes keeping the healthcare
environment clean, wearing personal protective
clothing, using barrier precautions and practicing
correct hand washing.
 Although nurses are busy with many
responsibilities, the time it takes to control
infection is well worth the effort.
2. Oxygen Use in Patients with COPD
 For patient health and safety, it is essential that
nurses follow evidence-based practice in nursing
when it comes to giving oxygen to patients with
COPD.
 Despite the belief by some that providing oxygen
to these patients can create serious issues such
as hypercarbia, acidosis or even death, the
evidence-based protocol is to provide oxygen to
COPD patients. This practice can help prevent
hypoxia and organ failure. Giving oxygen, which
is the correct treatment based on the evidence,
can enhance COPD patients’ quality of life and
help them live longer.
3. Measuring Blood Pressure Noninvasively in
Children
 Nurses should measure blood pressure
according to evidence-based practice
because accurate measurements are an
essential part of effective treatment.
Measuring blood pressure in children is a
different procedure than it is for adults.
Measuring children’s blood pressure involves
the auscultatory method, then comparing the
measurement against data gathered with the
oscillometric method.
4. Intravenous Catheter Size and Blood
Administration
 Nurses should follow EBP when using
intravenous catheters to administer blood for
packed red blood cell transfusions (PRBC).
The protocol indicates that nurses should use
a smaller-gauge catheter, which increases
patient comfort.
Traditions
Borrowing
Trial & Error
Personal Experience
Role Modeling
Intuition
Reasoning
Research
A.Research evidence.
B.Clinical expertise, judicious
use.
C.Patient values and
circumstances.
Research
Evidence
Patient Values,
Circumstances
 Randomized
controlled trials
Laboratory experiments
Clinical trials
Epidemiological research
Outcomes research
Qualitative research
Expert practice
knowledge, inductive
reasoning
Clinical
Expertise
Knowledge gained
from practice over
time
Inductive Reasoning
Unique preferences
Concerns
Expectations
Financial
resources
Social support
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.
 To provide the high quality and most cost-efficient
nursing care possible.
 To update knowledge & is essential for life long
learning.
 To advance quality of care provided by nurses.
 To increase satisfaction among patients.
 To focus on nursing practice away from habits and
tradition to evidence and research.
 To better patient outcomes.
 To provide clinical judgment
 To keeps practices current and relevant.
 To increase confidence in decision-making.
Problem based and within the scope of the practitioners
experience.
It brings together the best available evidence and current
practice by combining research with knowledge and theory.
So it narrows the research practice gap. It facilitates
application of research into practice by including both primary
and secondary research findings.
It concerned with quality of service and is therefore a Quality
assurance activity.
EBP projects are team projects and therefore require team
support and collaborative action.
It support research projects and outcomes that are cost
effective. EBP de- emphasizes ritual, isolated and
unsystematic clinical experiences, ungrounded opinions and
tradition as a basis of practice. It stresses the use of
research findings.
There is a gap between what we know and what we do.
Nursing practice can and must be changed from tradition -
based to science-based:
Research-practice gap: Much of what is known from
researchhas not been applied in practice. This is known as
Research-Practice Gap.
Evidence Based Practice -By Ritika Soni
Step 1: formulating a well built question
Step 2: collecting the most relevant and
best evidence to answer the clinical
question including searching for systematic
reviews/identifying articles
Step 3: Critically appraising the evidence that
has been collected for its validity, relevance
and applicability.
Step 4: Integrating the evidence with
ones clinical expertise, assessment of
patient’s condition and available
health care resources along with the
patients preferences and values to
implement the evidence.
Step 5: Evaluating the change resulting
from application of evidence in
practice.
Determine the areas for improvement.
QUESTION
With clinical areas ,there is often a barrage of
details to digest. A well built question includes
the following components :
the patients disorder or disease
the intervention or finding under review
a comparison intervention
the question should be in PICOT or PICO
format
Patient, Population or Problem
What are the characteristics of the patient or population?
What is the condition or disease you are interested in?
( i.e. age, gender, ethnicity, with a certain disorder)
Intervention or exposure
What do you want to do with this patient (e.g. treat, diagnose, observe)?
(exposure to a disease, risk behavior, prognostic factor)
Comparison
What is the alternative to the intervention (e.g. placebo, different drug,
surgery)?
(could be a placebo or "business as usual" as in no disease, absence of
risk factor, Prognostic factor B )
Outcome
What are the relevant outcomes (e.g. morbidity, death,
complications, risk of disease, accuracy of a diagnosis, rate of
occurrence of adverse outcome)
Time
What time it takes to demonstrate an outcome (e.g. the timeit
takes for the intervention to achieve an outcome or how long
participants are observed).
Patient/Population - Pregnant women with
type 2 diabetes
Intervention - Insulin pump therapy
Comparison - Conventional insulin therapy
Outcome - Improved management of glucose
levels
INFORMATION
Background information may be found in
sources such as:
reference book entries
textbooks, chapters, appendices
drug monographs, guides to diagnostic tests
the library’s Bobcat catalog
selected electronic Reference Tools for
Background information in the health science.
SEARCHING
Once a clinical practice question has been selected,
the next step is to search and assemble research
evidence on the topic. In doing a literature review as a
background for a new study, the central goal is to
discover where the gap are and how best to advance
knowledge.
The resourses falls into 3 categories:
1.General information/background resourses-
to collect the past information of a particular disease. e.g
measles has been nearly eradicated, but there has been a
fairly recent outbreak. If you need to refresh your knowledge
of the clinical presentation, diagnosis etc of measles, a
background resource would be the best place to start.
2.Filtered resourses-
If you are trying to decide on a course of action for a patient
(diagnosis, treatment etc)and want to base your decision on the
best available evidence, consult a filtered resource. clinical
experts and subject specialists pose a question and then
synthesize evidence to state conclusions based on the
available research.
Unfiltered resources- If you don’t find an
appropriate answer in the filtered resourses ,you
will need to search unfiltered resourses (the primary
literature) to locate studies that answer your question.
unfiltered resourses provide the most recent
information ,but its upto to the clinician to evaluate
each study found to determine its validity and
applicability to the patient.
 Effectvely searching and evaluating the studies
found in unfiltered resources takes more time and
skill, which is why filtered resources are the first
choice of answering clinical questions.
A. PRE-APPRAISED RESOURCES: Filtered resource
have been reviewed for quality and relevance to
clinical care.
ACP Journal Club. This Web site comprises a 10-
year archive of the cumulative electronic contents of
"ACP Journal Club", with recurrent weeding of out-of-
date articles. The content is carefully selected from over
100 clinical journals through reliable application of
explicit criteria for scientific merit, followed by
assessment of relevance to medical practice by clinical
specialists.
Clinical Evidence.
Clinical Evidence describes the best available evidence from
systematic reviews, RCTs, and observational studies when
appropriate for assessing the benefits and harms of
treatments.
DynaMed.
DynaMed is a point-of-care reference resource designed to
provide clinicians with current, evidence-based information to
support clinical decision-making.
Essential Evidence.
Essential Evidence is a one-stop reference that includes
evidence-based answers to clinical questions concerning
symptoms, diseases, and treatment.
FPIN Clinical Inquiries.
Clinical Inquiries provides answers to clinical
questions by using a structured search,
critical appraisal, clinical perspective, and
rigorous peer review. FPIN Clinical Inquiries
deliver evidence for point of care use.
UpToDate.
UpToDate is an evidence-based, peer
reviewed information resource available via
the Web, desktop/laptop computer, and
PDA/mobile device.
DATABASES:
PubMed. PubMed comprises more than 22 million
citations for biomedical articles from MEDLINE and life
science journals. Citations may include links to full-text
articles from PubMed Central or publisher web sites.
Cochrane Library. The Cochrane Library contains high-
quality, independent evidence to inform healthcare
decision-making. It includes reliable evidence from
Cochrane systematic reviews and a registry of published
clinical trials. The methodology used to create the Cochrane
reviews is recognized as the gold standard for developing
systematic reviews.
Center for Reviews and Dissemination website : The
databases DARE (database of abstracts of reviews
of effects), NHS, EED(economic evaluation
database) and HTA(health technology assessment)
assist decision- makers by identifying and describing
systematic reviews and economic evaluations,
appraising their quality, and highlighting their relative
strengths and weaknesses.
AccessMedicine: Access Medicine is an online resource
that provides students, residents, clinicians, researchers, and
other health professionals with access to "Harrisons Online"
etc.
Scientific American Medicine. Formerly known asACP
Medicine, Scientific American Medicine includes science,
medicine, health and technology information. It is also
available from Stat!Ref.(e-resource)
ACP Smart Medicine. Formerly known as ACP PIER
(physicians information & education resource).
ACP Smart Medicine is an online clinical tool that provides
evidence-based clinical guidance to improve clinical care. It is
free to ACP members or can be purchased as asubscription.
Stat!Ref. STAT!Ref is a collection of online electronic
textbooks for healthcare professionals.
META-SEARCH ENGINES:
Trip: (Turning research in to practice)
The TRIP Database searches across
multiple internet sites for evidence-based
content. It covers key medical journals,
Cochrane Systematic reviews, clinical
quidelines, and other highly relevant websites
to help health professionals find high quality
clinical evidence for clinical practice.
ARTICLE
The assessment of evidence by systematically
reviewing its relevance, validity and results of
specific situations.
In determining the implementation potential of an innovation
in a particular setting, several issues should be considered,
particularly the transferability of the innovation, the
feasibility of implementing it and its cost benefit ratio.
For example, the traditional method for verifying the
placement of a nasogastric tube was air insufflation.
However, according to current nursing research, the
accurate method for verifying placement is radiologic
examination (Metheny & Titler, 2001).
If the implementation assessment suggests that there might
be problems in testing the innovation in that particular
practice setting, then the team can either identify a new
problem and begin the process a new or consider adopting
the plan to improve the implementation potential (e.g.
seeking external resources if cost were the inhibiting factors)
WITH ONES CLINICAL EXPERTISE
EXPERTISE
If the implementation criteria are met, the team can design and
plot the innovation. To reach your conclusion you may consult
questions related to diagnosis ,therapy, harm and prognosis keep
in mind that you must interpret the information based on a number
of criteria and depending on your skill and experience ,you may
need to confer with a peer.
example- Sample evidence practice e.g. consider a nine year
old girl present in the ER with abdominal pain and you
suspect appendicitis. which imaging modality is best for
making the diagnosis CT or ultrasound.
The fifth step of the process, outcome evaluation, attempts to
interpret the results and evaluate the outcomes of the applied
evidence (intervention). Outcome measures may be psychosocial
(quality of life, improved patient perception of care, reduction in
depressive and anxiety symptoms),
Physiologic: (improved health, reduced complications), or functional
improvement.
Evaluation of the process and the results may occur through peer
assessment, audit, or even self reflection. Depending on the type
of outcomes achieved, it may be possible to compare the
outcomes of a study with similar outcomes on a local, regional,
national, or international level.
Evidence Based Practice -By Ritika Soni
Stelter Model
Lowa Model of Evidence Based Practice
John Hopkins Model
CURN
The stelter model was designed with the
assumption that Research Utilization could be
undertaken:
not only by organizations but by individual
clinicians and managers. It was a model
designed to promote and facilititate critical
thinking about the application of research
findings in practice.
The current model presented graphically
involves five sequential phases:
Evidence Based Practice -By Ritika Soni
Preparation
In this phase, the nursing officer define the underlying purpose and
outcomes of the project, search, sort and select sources of research
evidence.
She considers external factors that can influence potential application
and internal factors that can diminish objectivity and affirm the priority
of perceived problem.
Validation
This phase involves a utilization of focused critique of each source of
evidence, focusing in particular on whether it is sufficiently sound for
potential application in practice.
Comparative evaluation and decision- making
This phase involves a synthesis of findings and application of criteria
that taken together are used to determine the desirability and
feasibility of applying findings from validated source to nursing
practice. The end result of the comparative evaluation is to make a
decision about using the study findings.
Translation/application
This phase involves activities to confirm how the
findings will be used (e.g. formally or informally)
and spell out the operational details of the
application and implement them.
Evaluation
In the final phase, the application is evaluated.
Informal use of the innovation versus formal
use would lead to different evaluative
strategies.
 Lowa model was developed at the university of
Lowa hospitals and clinics in 1990s to serve as a
guide for nurses to use research findings to improve
patient care /quality of care.
 The model was developed as a pathway / method
to EBP – a method to guide the steps to help
identify issues, research solutions and implement
changes.
 It is an application – oriented guide for the EBP
process.
1. Identify the trigger where an EBP change is
warranted. Either a knowledge focus
trigger or a problem focus trigger.
2. Determine if the problem at the hand is a
priority for the organization, practice,
department or unit.
3. Form a team that will develop, evaluate &
implement the EBP change. The team
should be made up of representative both
in and out of nursing unit. This helps in
better evaluation and implementation of
the change.
4. Gather and analyze the research related to the
desired practice change. This includes
formulating a good research question using the
PICO (T) method and conducting a literature
search looking for related research studies.
5. Critique and synthesize the research discovered
during the literature search. This includes
reviewing the research to determine if the
change is scientifically sound.
6. STOP & DECIDE if there is sufficient research to
implement a practice change:
 No – review the research
 Yes- move to step 7
7. Implement change into Pilot program.
Change one or two smaller areas / units first
for evaluation.
8. Evaluate results. Is the change feasible and
does it result in improved outcomes?
 NO- Continue to evaluate the care and new
research to be able to revisit the issue in the
future with new information.
 YES- introduce the change across the
department/ unit/ practice/ organization. After
the introduction of the change, continue to
observe, evaluate, and analyze the results.
Evidence Based Practice -By Ritika Soni
Evidence Based Practice -By Ritika Soni
Evidence Based Practice -By Ritika Soni
 The conduct and utilization of research in
nursing (CURN) project. The CURN project
was designed to develop and test a model for
using research- based knowledge in clinical
practice settings.
 Research utilization is viewed as an
organizational process. Planned change is
integrated throughout the research
utilization process.
 System change is essential to establishing
research based practice on a large scale.
The best evidence for interventions comes from
following a evidence hierarchy.
Systematic review
Randomized controlled trial
Cohort study
Case control study
Cross-section analytical study
Descriptive/narrative study
Evidence Based Practice -By Ritika Soni
Evidence Based Practice -By Ritika Soni
Resistant to changes in nursing
practice.
I n ability to critically appraise
research findings.
Time, workload pressures, and
competing priorities.
Lack of continuing education
programs.
Fearof "stepping on one'stoes“
Poor administrative support.
Evidence Based Practice -By Ritika Soni
Many Nurses have not received any formal
instruction in research and they lack skill to
judge the merits of a study.
Nurses attitude toward research and their motivation
to engage in EBP have been identified a potential
barrier. People are often resistant to change. Change
requires effort, retraining and restructuring of work
habits. Thus there is likely to be some opposition to
introducing innovations in practice setting.
ADVICE
Read widely and critically. Professionally
accountable nurses should read journals relating to
their specialty, including research reports in them.
Attend professional conference. Conference attending
give opportunities to meet researchers and to explore
practice implications.
Learn to expect evidence that a procedure is effective.
Nurses need to develop expectations that the decisions
they make in their clinical practice are based on sound
rationales.
Become involved in a journal club. Many
organizations that employ nurses sponsor journal
clubs that meet to review research articles that have
potential relevance to practice.
Pursue and participate in EBP projects. Nurses who
are involved in research related activities develop
more positive attitudes toward research and better
research skills.
Many of the major impediments to using research in practice
stem from the organizations that train and employ nurses.
Organizations have failed to motivate or reward nurses to seek
ways to implement appropriate findings in their practice. In
several studies of barriers to RU, one of the greatest
reported Barrier was “insufficient time on the job to implement new
ideas”. Organizations may be reluctant to expand resources for
RU, EBP activities or for changing organizational policy.
ADVICE: To promote the use of research evidence,
administrators can adopt the following strategies:
Foster a climate of intellectual curiosity. Open communication is
important in persuading staff nurses that their experiences and
problem are important and that the administration is willing to
consider innovative solutions.
Reward efforts for using research. RU should not
be the primary criterion for evaluating nurses
performance but its inclusion is an important
criteria to affect their behavior.
Seek opportunities for institutional RU/EBP projects.
Organizational efforts and commitment are
essential for the type of projects. ·
Offer emotional or moral support. Administrators
need to make their support visible by informing staff
by establishing EBP committees, by helping to
develop journal clubs and by serving as role models
for staff nurses.
Offer financial or research support for utilization.
There is a shortage of appropriate role
models- nurses who can be emulated for
their success in using or promoting the use
of research in clinical practice. The nurses
feel that he or she didn’t have “enough
authority to change patient careprocedures”
ADVICE:
Educators could help to promote the use
of research evidence through the
following strategies:
Incorporate research findings into curriculum.
Research findings should be integrated
throughout the curriculum and when possible,
the efficacy of specific procedures should be
documented by referring to relevant studies.
Encouraging research and research use. Either
by acting as role models to students or by
demonstrating positive attitudes towards
research and its use in nursing.
Place demands on researchers. Faculty review
of research proposals should demand that
researchers demonstrate the proposed studies
potential for clinical use; they can also demand
that the researchers include a specific plan for
dissemination or utilization.
1.A nurse can be a decision maker and coordinator of care.
2. As a scientist: A nurse ensures his or her practice is evidence-
based and that institution approved protocols are utilized.
3. As a transferor of knowledge: This important role is invoked
when discussing the plan of care with patients, their loved
ones, and with other members of the healthcare team.
4. Manage resources and facilitate the success of unit-based EBP
workgroups
5. Support EBP by communicating with unit staff the
expectations for participation and available resources
Encourage broad staff participation to promote collaborative
teamwork
6. Become a primary vehicle for recognition of
staff nurses' success
7) Encourage research and research uses.
8) Offer emotional and moral support to senior
staffs for evidence based practice.
9) Foster a climate of intellectual curiosity.
10) Attend and encourage junior staffs to
conference
11).The registered nurses participates as
appropriate to education level and position in the
formulation of evidence-based practice
through research.”
12. The registered nurses utilizes current
evidence- based nursing knowledge,
including research findings, to guide
practice.
13. Expect that evidence is the foundation of
practice
14.Participate in EBP projects
15.Disseminate project findings in
various forums
16.Collaborate with the healthcare team
to provide quality care
Evidence Based Practice -By Ritika Soni
Evidence Based Practice -By Ritika Soni
Evidence Based Practice -By Ritika Soni
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Evidence Based Practice -By Ritika Soni

  • 3.  Evidence-based practice is the idea that occupational practices ought to be based on scientific evidence.  The movement towards evidence-based practices attempts to encourage professionals and other decision-makers to pay more attention to evidence to inform their decision-making.  The goal of evidence-based practice is to eliminate unsound or outdated practices in more effective ones  by shifting the basis for decision making from tradition, intuition, and unsystematic experience to firmly grounded scientific research.
  • 4.  Evidence based practice (EBP) is the conscientious use of current best evidence in making decisions about patient care. (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000).  It is a problem solving approach to clinical practice and administrative issues that integrates: A systematic search for and critical appraisal of the most relevant evidence to answer a burning clinical question One's own clinical expertise Patient preferences and values (Melnyk & Fineout-Overholt, 2014)
  • 5. Health care that is evidence-based and conducted in a caring context leads to better clinical decisions and patient outcomes. Gaining knowledge and skills in the EBP process provides nurses and other clinicians the tools needed to take ownership of their practices and transform health care.
  • 9.  There are many examples of EBP in the daily practice of nursing. 1. Infection Control  The last thing a patient wants when going to a hospital for treatment is a hospital-acquired infection. Nurses play a key role in helping to prevent illness before it happens by adhering to evidence-based infection-control policies.  This includes keeping the healthcare environment clean, wearing personal protective clothing, using barrier precautions and practicing correct hand washing.  Although nurses are busy with many responsibilities, the time it takes to control infection is well worth the effort.
  • 10. 2. Oxygen Use in Patients with COPD  For patient health and safety, it is essential that nurses follow evidence-based practice in nursing when it comes to giving oxygen to patients with COPD.  Despite the belief by some that providing oxygen to these patients can create serious issues such as hypercarbia, acidosis or even death, the evidence-based protocol is to provide oxygen to COPD patients. This practice can help prevent hypoxia and organ failure. Giving oxygen, which is the correct treatment based on the evidence, can enhance COPD patients’ quality of life and help them live longer.
  • 11. 3. Measuring Blood Pressure Noninvasively in Children  Nurses should measure blood pressure according to evidence-based practice because accurate measurements are an essential part of effective treatment. Measuring blood pressure in children is a different procedure than it is for adults. Measuring children’s blood pressure involves the auscultatory method, then comparing the measurement against data gathered with the oscillometric method.
  • 12. 4. Intravenous Catheter Size and Blood Administration  Nurses should follow EBP when using intravenous catheters to administer blood for packed red blood cell transfusions (PRBC). The protocol indicates that nurses should use a smaller-gauge catheter, which increases patient comfort.
  • 13. Traditions Borrowing Trial & Error Personal Experience Role Modeling Intuition Reasoning Research
  • 14. A.Research evidence. B.Clinical expertise, judicious use. C.Patient values and circumstances.
  • 15. Research Evidence Patient Values, Circumstances  Randomized controlled trials Laboratory experiments Clinical trials Epidemiological research Outcomes research Qualitative research Expert practice knowledge, inductive reasoning Clinical Expertise Knowledge gained from practice over time Inductive Reasoning Unique preferences Concerns Expectations Financial resources Social support
  • 16. 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.
  • 17.  To provide the high quality and most cost-efficient nursing care possible.  To update knowledge & is essential for life long learning.  To advance quality of care provided by nurses.  To increase satisfaction among patients.  To focus on nursing practice away from habits and tradition to evidence and research.  To better patient outcomes.  To provide clinical judgment  To keeps practices current and relevant.  To increase confidence in decision-making.
  • 18. Problem based and within the scope of the practitioners experience. It brings together the best available evidence and current practice by combining research with knowledge and theory. So it narrows the research practice gap. It facilitates application of research into practice by including both primary and secondary research findings. It concerned with quality of service and is therefore a Quality assurance activity. EBP projects are team projects and therefore require team support and collaborative action. It support research projects and outcomes that are cost effective. EBP de- emphasizes ritual, isolated and unsystematic clinical experiences, ungrounded opinions and tradition as a basis of practice. It stresses the use of research findings.
  • 19. There is a gap between what we know and what we do. Nursing practice can and must be changed from tradition - based to science-based: Research-practice gap: Much of what is known from researchhas not been applied in practice. This is known as Research-Practice Gap.
  • 21. Step 1: formulating a well built question Step 2: collecting the most relevant and best evidence to answer the clinical question including searching for systematic reviews/identifying articles Step 3: Critically appraising the evidence that has been collected for its validity, relevance and applicability.
  • 22. Step 4: Integrating the evidence with ones clinical expertise, assessment of patient’s condition and available health care resources along with the patients preferences and values to implement the evidence. Step 5: Evaluating the change resulting from application of evidence in practice. Determine the areas for improvement.
  • 23. QUESTION With clinical areas ,there is often a barrage of details to digest. A well built question includes the following components : the patients disorder or disease the intervention or finding under review a comparison intervention the question should be in PICOT or PICO format
  • 24. Patient, Population or Problem What are the characteristics of the patient or population? What is the condition or disease you are interested in? ( i.e. age, gender, ethnicity, with a certain disorder) Intervention or exposure What do you want to do with this patient (e.g. treat, diagnose, observe)? (exposure to a disease, risk behavior, prognostic factor) Comparison What is the alternative to the intervention (e.g. placebo, different drug, surgery)? (could be a placebo or "business as usual" as in no disease, absence of risk factor, Prognostic factor B )
  • 25. Outcome What are the relevant outcomes (e.g. morbidity, death, complications, risk of disease, accuracy of a diagnosis, rate of occurrence of adverse outcome) Time What time it takes to demonstrate an outcome (e.g. the timeit takes for the intervention to achieve an outcome or how long participants are observed).
  • 26. Patient/Population - Pregnant women with type 2 diabetes Intervention - Insulin pump therapy Comparison - Conventional insulin therapy Outcome - Improved management of glucose levels
  • 27. INFORMATION Background information may be found in sources such as: reference book entries textbooks, chapters, appendices drug monographs, guides to diagnostic tests the library’s Bobcat catalog selected electronic Reference Tools for Background information in the health science.
  • 28. SEARCHING Once a clinical practice question has been selected, the next step is to search and assemble research evidence on the topic. In doing a literature review as a background for a new study, the central goal is to discover where the gap are and how best to advance knowledge. The resourses falls into 3 categories:
  • 29. 1.General information/background resourses- to collect the past information of a particular disease. e.g measles has been nearly eradicated, but there has been a fairly recent outbreak. If you need to refresh your knowledge of the clinical presentation, diagnosis etc of measles, a background resource would be the best place to start. 2.Filtered resourses- If you are trying to decide on a course of action for a patient (diagnosis, treatment etc)and want to base your decision on the best available evidence, consult a filtered resource. clinical experts and subject specialists pose a question and then synthesize evidence to state conclusions based on the available research.
  • 30. Unfiltered resources- If you don’t find an appropriate answer in the filtered resourses ,you will need to search unfiltered resourses (the primary literature) to locate studies that answer your question. unfiltered resourses provide the most recent information ,but its upto to the clinician to evaluate each study found to determine its validity and applicability to the patient.  Effectvely searching and evaluating the studies found in unfiltered resources takes more time and skill, which is why filtered resources are the first choice of answering clinical questions.
  • 31. A. PRE-APPRAISED RESOURCES: Filtered resource have been reviewed for quality and relevance to clinical care. ACP Journal Club. This Web site comprises a 10- year archive of the cumulative electronic contents of "ACP Journal Club", with recurrent weeding of out-of- date articles. The content is carefully selected from over 100 clinical journals through reliable application of explicit criteria for scientific merit, followed by assessment of relevance to medical practice by clinical specialists.
  • 32. Clinical Evidence. Clinical Evidence describes the best available evidence from systematic reviews, RCTs, and observational studies when appropriate for assessing the benefits and harms of treatments. DynaMed. DynaMed is a point-of-care reference resource designed to provide clinicians with current, evidence-based information to support clinical decision-making. Essential Evidence. Essential Evidence is a one-stop reference that includes evidence-based answers to clinical questions concerning symptoms, diseases, and treatment.
  • 33. FPIN Clinical Inquiries. Clinical Inquiries provides answers to clinical questions by using a structured search, critical appraisal, clinical perspective, and rigorous peer review. FPIN Clinical Inquiries deliver evidence for point of care use. UpToDate. UpToDate is an evidence-based, peer reviewed information resource available via the Web, desktop/laptop computer, and PDA/mobile device.
  • 34. DATABASES: PubMed. PubMed comprises more than 22 million citations for biomedical articles from MEDLINE and life science journals. Citations may include links to full-text articles from PubMed Central or publisher web sites. Cochrane Library. The Cochrane Library contains high- quality, independent evidence to inform healthcare decision-making. It includes reliable evidence from Cochrane systematic reviews and a registry of published clinical trials. The methodology used to create the Cochrane reviews is recognized as the gold standard for developing systematic reviews. Center for Reviews and Dissemination website : The databases DARE (database of abstracts of reviews of effects), NHS, EED(economic evaluation database) and HTA(health technology assessment) assist decision- makers by identifying and describing systematic reviews and economic evaluations, appraising their quality, and highlighting their relative strengths and weaknesses.
  • 35. AccessMedicine: Access Medicine is an online resource that provides students, residents, clinicians, researchers, and other health professionals with access to "Harrisons Online" etc. Scientific American Medicine. Formerly known asACP Medicine, Scientific American Medicine includes science, medicine, health and technology information. It is also available from Stat!Ref.(e-resource) ACP Smart Medicine. Formerly known as ACP PIER (physicians information & education resource). ACP Smart Medicine is an online clinical tool that provides evidence-based clinical guidance to improve clinical care. It is free to ACP members or can be purchased as asubscription. Stat!Ref. STAT!Ref is a collection of online electronic textbooks for healthcare professionals.
  • 36. META-SEARCH ENGINES: Trip: (Turning research in to practice) The TRIP Database searches across multiple internet sites for evidence-based content. It covers key medical journals, Cochrane Systematic reviews, clinical quidelines, and other highly relevant websites to help health professionals find high quality clinical evidence for clinical practice.
  • 37. ARTICLE The assessment of evidence by systematically reviewing its relevance, validity and results of specific situations. In determining the implementation potential of an innovation in a particular setting, several issues should be considered, particularly the transferability of the innovation, the feasibility of implementing it and its cost benefit ratio. For example, the traditional method for verifying the placement of a nasogastric tube was air insufflation. However, according to current nursing research, the accurate method for verifying placement is radiologic examination (Metheny & Titler, 2001).
  • 38. If the implementation assessment suggests that there might be problems in testing the innovation in that particular practice setting, then the team can either identify a new problem and begin the process a new or consider adopting the plan to improve the implementation potential (e.g. seeking external resources if cost were the inhibiting factors)
  • 39. WITH ONES CLINICAL EXPERTISE EXPERTISE If the implementation criteria are met, the team can design and plot the innovation. To reach your conclusion you may consult questions related to diagnosis ,therapy, harm and prognosis keep in mind that you must interpret the information based on a number of criteria and depending on your skill and experience ,you may need to confer with a peer. example- Sample evidence practice e.g. consider a nine year old girl present in the ER with abdominal pain and you suspect appendicitis. which imaging modality is best for making the diagnosis CT or ultrasound.
  • 40. The fifth step of the process, outcome evaluation, attempts to interpret the results and evaluate the outcomes of the applied evidence (intervention). Outcome measures may be psychosocial (quality of life, improved patient perception of care, reduction in depressive and anxiety symptoms), Physiologic: (improved health, reduced complications), or functional improvement. Evaluation of the process and the results may occur through peer assessment, audit, or even self reflection. Depending on the type of outcomes achieved, it may be possible to compare the outcomes of a study with similar outcomes on a local, regional, national, or international level.
  • 42. Stelter Model Lowa Model of Evidence Based Practice John Hopkins Model CURN
  • 43. The stelter model was designed with the assumption that Research Utilization could be undertaken: not only by organizations but by individual clinicians and managers. It was a model designed to promote and facilititate critical thinking about the application of research findings in practice. The current model presented graphically involves five sequential phases:
  • 45. Preparation In this phase, the nursing officer define the underlying purpose and outcomes of the project, search, sort and select sources of research evidence. She considers external factors that can influence potential application and internal factors that can diminish objectivity and affirm the priority of perceived problem. Validation This phase involves a utilization of focused critique of each source of evidence, focusing in particular on whether it is sufficiently sound for potential application in practice. Comparative evaluation and decision- making This phase involves a synthesis of findings and application of criteria that taken together are used to determine the desirability and feasibility of applying findings from validated source to nursing practice. The end result of the comparative evaluation is to make a decision about using the study findings.
  • 46. Translation/application This phase involves activities to confirm how the findings will be used (e.g. formally or informally) and spell out the operational details of the application and implement them. Evaluation In the final phase, the application is evaluated. Informal use of the innovation versus formal use would lead to different evaluative strategies.
  • 47.  Lowa model was developed at the university of Lowa hospitals and clinics in 1990s to serve as a guide for nurses to use research findings to improve patient care /quality of care.  The model was developed as a pathway / method to EBP – a method to guide the steps to help identify issues, research solutions and implement changes.  It is an application – oriented guide for the EBP process.
  • 48. 1. Identify the trigger where an EBP change is warranted. Either a knowledge focus trigger or a problem focus trigger. 2. Determine if the problem at the hand is a priority for the organization, practice, department or unit. 3. Form a team that will develop, evaluate & implement the EBP change. The team should be made up of representative both in and out of nursing unit. This helps in better evaluation and implementation of the change.
  • 49. 4. Gather and analyze the research related to the desired practice change. This includes formulating a good research question using the PICO (T) method and conducting a literature search looking for related research studies. 5. Critique and synthesize the research discovered during the literature search. This includes reviewing the research to determine if the change is scientifically sound. 6. STOP & DECIDE if there is sufficient research to implement a practice change:  No – review the research  Yes- move to step 7
  • 50. 7. Implement change into Pilot program. Change one or two smaller areas / units first for evaluation. 8. Evaluate results. Is the change feasible and does it result in improved outcomes?  NO- Continue to evaluate the care and new research to be able to revisit the issue in the future with new information.  YES- introduce the change across the department/ unit/ practice/ organization. After the introduction of the change, continue to observe, evaluate, and analyze the results.
  • 54.  The conduct and utilization of research in nursing (CURN) project. The CURN project was designed to develop and test a model for using research- based knowledge in clinical practice settings.  Research utilization is viewed as an organizational process. Planned change is integrated throughout the research utilization process.  System change is essential to establishing research based practice on a large scale.
  • 55. The best evidence for interventions comes from following a evidence hierarchy. Systematic review Randomized controlled trial Cohort study Case control study Cross-section analytical study Descriptive/narrative study
  • 58. Resistant to changes in nursing practice. I n ability to critically appraise research findings. Time, workload pressures, and competing priorities. Lack of continuing education programs. Fearof "stepping on one'stoes“ Poor administrative support.
  • 60. Many Nurses have not received any formal instruction in research and they lack skill to judge the merits of a study. Nurses attitude toward research and their motivation to engage in EBP have been identified a potential barrier. People are often resistant to change. Change requires effort, retraining and restructuring of work habits. Thus there is likely to be some opposition to introducing innovations in practice setting. ADVICE Read widely and critically. Professionally accountable nurses should read journals relating to their specialty, including research reports in them.
  • 61. Attend professional conference. Conference attending give opportunities to meet researchers and to explore practice implications. Learn to expect evidence that a procedure is effective. Nurses need to develop expectations that the decisions they make in their clinical practice are based on sound rationales. Become involved in a journal club. Many organizations that employ nurses sponsor journal clubs that meet to review research articles that have potential relevance to practice. Pursue and participate in EBP projects. Nurses who are involved in research related activities develop more positive attitudes toward research and better research skills.
  • 62. Many of the major impediments to using research in practice stem from the organizations that train and employ nurses. Organizations have failed to motivate or reward nurses to seek ways to implement appropriate findings in their practice. In several studies of barriers to RU, one of the greatest reported Barrier was “insufficient time on the job to implement new ideas”. Organizations may be reluctant to expand resources for RU, EBP activities or for changing organizational policy. ADVICE: To promote the use of research evidence, administrators can adopt the following strategies: Foster a climate of intellectual curiosity. Open communication is important in persuading staff nurses that their experiences and problem are important and that the administration is willing to consider innovative solutions.
  • 63. Reward efforts for using research. RU should not be the primary criterion for evaluating nurses performance but its inclusion is an important criteria to affect their behavior. Seek opportunities for institutional RU/EBP projects. Organizational efforts and commitment are essential for the type of projects. · Offer emotional or moral support. Administrators need to make their support visible by informing staff by establishing EBP committees, by helping to develop journal clubs and by serving as role models for staff nurses. Offer financial or research support for utilization.
  • 64. There is a shortage of appropriate role models- nurses who can be emulated for their success in using or promoting the use of research in clinical practice. The nurses feel that he or she didn’t have “enough authority to change patient careprocedures” ADVICE: Educators could help to promote the use of research evidence through the following strategies:
  • 65. Incorporate research findings into curriculum. Research findings should be integrated throughout the curriculum and when possible, the efficacy of specific procedures should be documented by referring to relevant studies. Encouraging research and research use. Either by acting as role models to students or by demonstrating positive attitudes towards research and its use in nursing. Place demands on researchers. Faculty review of research proposals should demand that researchers demonstrate the proposed studies potential for clinical use; they can also demand that the researchers include a specific plan for dissemination or utilization.
  • 66. 1.A nurse can be a decision maker and coordinator of care. 2. As a scientist: A nurse ensures his or her practice is evidence- based and that institution approved protocols are utilized. 3. As a transferor of knowledge: This important role is invoked when discussing the plan of care with patients, their loved ones, and with other members of the healthcare team. 4. Manage resources and facilitate the success of unit-based EBP workgroups 5. Support EBP by communicating with unit staff the expectations for participation and available resources Encourage broad staff participation to promote collaborative teamwork
  • 67. 6. Become a primary vehicle for recognition of staff nurses' success 7) Encourage research and research uses. 8) Offer emotional and moral support to senior staffs for evidence based practice. 9) Foster a climate of intellectual curiosity. 10) Attend and encourage junior staffs to conference 11).The registered nurses participates as appropriate to education level and position in the formulation of evidence-based practice through research.”
  • 68. 12. The registered nurses utilizes current evidence- based nursing knowledge, including research findings, to guide practice. 13. Expect that evidence is the foundation of practice 14.Participate in EBP projects 15.Disseminate project findings in various forums 16.Collaborate with the healthcare team to provide quality care