EVIDENCE-BASED PRACTICE:

WHAT’S IN IT FOR YOU?

OBJECTIVES

 Describe evidence based practice from a nursing

perspective
 Identify challenges to using evidence based
practice in nursing
 Identify resources necessary for evidence based
practice relevant to nursing
EVIDENCE-BASED PRACTICE (EBP)
 Process by which health care providers know how
to find, critically appraise, and use the best
evidence
WHAT IS EVIDENCE-BASED NURSING
PRACTICE

 Builds on process of research use, but

more encompassing
 Does not foster rigid adherence to
standardized guidelines
 Recognizes the role of clinical expertise
 EB nursing practice is a state of mind!
WHY EVIDENCE-BASED PRACTICE IN
NURSING

 Fueled by accrediting bodies, professional

organizations, third party payers
 Focus on practices that result in best
possible outcomes at possibly lower cost
WHY EVIDENCE-BASED PRACTICE IN
NURSING
 Potential to narrow the ‘research-practice gap’:
adoption of research findings into practice can
take as long as 17 years (Balas & Boren)
 Impacted by perception that published research
is not relevant to practice
 Bedside nurse as conduit!!
WHY EVIDENCE-BASED PRACTICE (EBP)
??
Health care delivery is filled with uncertainty and
many questions arise in every day practice…
COMMON QUESTIONS THAT ARISE
IN EVERYDAY PRACTICE:
 Which combination and sequence of treatments is
most effective?
 Which patient symptoms predict better or worse
outcomes?
 What is the experience of illness for a patient
with this diagnosis?
 Which treatment is most effective and will
produce the best patient outcome?
 If a diagnosis is left untreated, what might be the
outcome?
EVIDENCE TO SUPPORT BEST PRACTICES IS
CONSTANTLY CHANGING
CORE COMPETENCIES

 Ask: why are we doing this..

what is the evidence?
 Think critically!
 Think out of the box!
EBP IN NURSING
CORE COMPETENCIES (CONT.)

 Search for evidence

• Evaluate the evidence

CLINICAL VERSUS STATISTICAL SIGNIFICANCE

 Clinical significance has little to do with

statistics and is a matter of judgment.
Clinical significance often depends on
the magnitude of the effect being
studied.
 It answers the question "Is the
difference between groups large enough
to be worth achieving?" Studies can be
statistically significant yet clinically
insignificant.
Guyatt, G. Rennie, D. Meade, MO, Cook, DJ. Users' Guide to Medical Literature: A
Manual for Evidence-Based Clinical Practice, 2nd Edition 2008.
 SAMPLE:
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?
 COMMONALITIES – IMPROVE CARE
DELIVERY!
 Involve teamwork – not done in isolation
 Call for critical thinking and creativity
 Commitment to improve care
 One informs the other
 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
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
FORMULATING THE CLINICAL
QUESTION
 The “PICO” format is used to construct the
clinical question specifically
 Using PICO format helps you find a needle in a
hay stack of research information
PICO FORMAT
 Patient Population
 Intervention of Interest

 Comparison intervention or status

 Outcome
PATIENT POPULATION
 Consideration of the patient and population of
interest
 Limit to age group or subgroup if possible
INTERVENTION
 Exposure
 Treatment

 Patient perception

 Diagnostic test
COMPARISON
 Could be true control, such as placebo or doing
nothing
 Could be another treatment

 Sometimes it is the usual standard of care

OUTCOME
 Outcome may be very specific, e.g. death
 Outcome may be something that has a variety of
measures, e.g. dehydration could be a measure,
also tachycardia, dry mouth, fever, restlessness
and irritability
PICO FORMAT EXAMPLE
 Are 35 to 55 year-old women (p) who have high
blood pressure (I) at increased risk for acute
myocardial infarction (O) compared with women
without hypertension (C)
EBP PROCESS
(1) formulating an appropriate question,

(2) Performing an efficient literature search,

(3) Critically appraising the best available evidence,

(4) applying the best evidence to clinical practice, and

(5) assessing outcomes of care (Noteboom, 2008).

 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 (www.acestar.uthscsa.edu)
 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

 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
 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
 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

 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?
 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?
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!
A RATING SYSTEM FOR LOOKING
AT EVIDENCE IN INDIVIDUAL
STUDIES

65, 251-258.
Siwek, J. et al. (2002). Am Fam Physician
 Level A: Randomized control trial (RCT)
 Level B: (other evidence)
 Well-designed, nonrandomized trial
 Non-quantitative systematic review
 Lower quality RCT’s, clinical cohort studies, case-
control studies
 High-quality historical, less controlled studies, well-
designed epidemiological studies
 Level C: consensus/expert opinion
SEARCHING FOR THE BEST
EVIDENCE: SEARCHABLE
DATABASES
 CINAHL
 MEDLINE: (PubMed)

 National Guidelines Clearinghouse:

http://www.guideline.gov
 Agency for Healthcare Research and Quality:
www.ahrq.gov/clinic/cpgsix.htm
 National Institute of Nursing:
http://ninr.nih.gov/ninr
CONCLUSION
 Practices that are unnecessary are
eliminated; ineffective practices are
replaced with practices that result
in desired outcomes (Houser, 2010,
p.8).
 Potential outcomes of the
participation of staff nurses in and
EBP include increase confidence in
using research finding, peer
leadership, increased critical
thinking skills in making clinical
decisions and validation of nursing
practice.
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: http://www.acestar.uthscsa.edu/Learn_model.htm
 Deming Model:
http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/