Evidence-Based Practice
01/29/2014
Evidence-Based Practice
Karen N. Drenkard, PhD, RN, NEA-BC, FAAN
Chief Clinical/Nursing Officer
GetWellNetwork, Inc.
This program generously funded by the Robert Wood Johnson Foundation
American Association of Colleges of Nursing. © 2014 - All Rights Reserved.
Learner Objectives
By the end of this module, the learner will be
able to:
1.
2.
3.
4.
Define Evidence-Based Practice - the
content.
Define the requirements for graduate level
competencies
Describe the barriers to implementation of
Evidence Based Practice
Describe teaching strategies for graduate
level when teaching evidence based
practice
American Association of Colleges of Nursing. © 2014 - All Rights Reserved.
Evidence-Based Practice:
Practice based on the best
available evidence that also
incorporates:
-patient values and preferences
- clinician judgment and
expertise (Sherwood and
Barnsteiner)
Using evidence to guide nursing
practice
American Association of Colleges of Nursing. © 2014 - All Rights Reserved.
Karen N. Drenkard, PhD, RN, NEA-BC, FAAN
1
Evidence-Based Practice
01/29/2014
Key Terms
Research
Evidence Based Practice
Quality Improvement
Provide your students with resources
- Enclosed selected reference list
Be clear on definitions
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Link to Safety and Quality
Safe, effective delivery of patient care
requires the use of nursing practices
consistent with the best available knowledge.
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Evidence-Based Practice –
the content
Karen N. Drenkard, PhD, RN, NEA-BC, FAAN
2
Evidence-Based Practice
01/29/2014
Steps in EBP
1. Develop a researchable question
2. Search for best evidence available and assess the strength
of that evidence
3. Complete a critical analysis and synthesis of the evidence
4. Develop recommendations for practice
5. Evaluate the outcome of evidence based practice changes.
Numerous models have been published to guide nurses in
moving to EBP. Commonly used nursing models include the
Iowa, STAR, Hopkins and University of Arizona models.
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1. Develop a researchable question
The PICO model is often used to
define a problem and formulate
a specific question:
Population
Intervention
Comparison
Outcome
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Develop a researchable question
An example of the PICO is as follows:
In homebound patients over 60 years of age, how
effective is a falls-prevention program in
comparison to the normal standard of care in
decreasing falls and falls injury rates by 50%?
The question guides the search for evidence so the more
explicit the question, the easier it is to develop the search
strategies.
American Association of Colleges of Nursing. © 2014 - All Rights Reserved.
Karen N. Drenkard, PhD, RN, NEA-BC, FAAN
3
Evidence-Based Practice
01/29/2014
Teaching Strategy #1
Sacred Cows Contest:
1. What is the most traditional nursing practice
2.
3.
done in this clinical area?
What is the least logical nursing practice
happening in your area?
What is the most time consuming practice in
your area?
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2. Search for the best evidence available
• Searching for evidence difficult and complex.
• Numerous templates for conducting systematic
reviews.
• Information is gathered from several sources including:
systematic reviews,
clinical practice guidelines, and
searching journal publications for pertinent
research articles.
American Association of Colleges of Nursing. © 2014 - All Rights Reserved.
Sources of Synthesized Knowledge
Sources of synthesized knowledge include:
National Guidelines Clearing House
Sigma Theta Tau International
Evidence-Based Nursing
Worldviews on Evidence-Based Nursing
The Johanna Briggs Institute
Cochrane Collaborative
Health Information Resources
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Karen N. Drenkard, PhD, RN, NEA-BC, FAAN
4
Evidence-Based Practice
01/29/2014
EB Summaries of Systematic Reviews
Evidence summaries or systematic
reviews provide a foundation for
EBP activities. Clinicians often do
not have the time to summarize the
total evidence for a question.
Systematic reviews may be
published and indexed in large
databases such as Medline and
CINAHL.
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Clinical Practice Guidelines
EB clinical practice guidelines are systematically
developed statements that help clinicians and patients
make decisions about health care for specific clinical
circumstances. They often are developed by a
multidisciplinary group, followed by external review prior to
publication.
The National Guidelines Clearinghouse has guidelines
developed in the US as well as internationally.
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3. Complete a critical analysis and
synthesis of the evidence
Assess the strength of the evidence:
Systematic and metaanalysis reviews
Randomized control trials
Cohort studies
Level of
Evidence
Review
Case Control studies
Case Reports
Expert opinion
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Karen N. Drenkard, PhD, RN, NEA-BC, FAAN
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Evidence-Based Practice
01/29/2014
4. Develop recommendations for
practice
A comprehensive and detailed plan including communication
of the change to all those affected, training requirements,
development of detailed protocols, and notifying other
departments and individuals who may be affected by the
change is included in the dissemination plan. Active
interventions such as self-study, learning labs, reminders,
and decision supports are more likely to induce change than
passive education.
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Patient Values and Clinical Expertise
Join in the Equation
Little has been written regarding patient/family preferences
and values related to EBP as well as the role of clinical
expertise. Generally EBP has focused on the translation of
research into practice.
However, research evidence alone is not sufficient to
ensure sound clinical decisions necessary for effective
health care.
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Incorporating Patient / Family Preferences
• Question prompts for patients, and coaching to develop
skills in questioning clinicians and deliberating about
options improve patient/family member decision-making
abilities.
• Kleinman’s questions for ascertaining patients’ beliefs
and values may serve as a useful reference.
• Patient-centered care may at times conflict with
evidence-driven care and that patient preferences have
priority over evidence-based recommendations.
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Karen N. Drenkard, PhD, RN, NEA-BC, FAAN
6
Evidence-Based Practice
01/29/2014
Clinical Expertise
• Clinical decision making complex process
• Requires more than research to guide practice.
• Proficiency and judgment that individual clinicians acquire
through clinical experience and clinical practice.
• Experienced clinicians use both individual clinical
expertise and the best available external evidence.
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5. Evaluate the outcome of evidence
based practice changes
Determine how the practice change is used. Audit and
feedback demonstrates the gap between actual and
desired results and address questions such as did the
clinicians receive the information about a practice change
and did they adhere to the practice change.
How difficult or smooth was it to use the new way?
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Barriers to EBP
Karen N. Drenkard, PhD, RN, NEA-BC, FAAN
7
Evidence-Based Practice
01/29/2014
Assess the Barriers to Using
the Knowledge
Consideration of barriers that may be
encountered and resolving them prior to
dissemination will help to ensure the
success of the EBP.
This includes identifying and obtaining
resources that may be necessary.
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Barriers to EBP
Barriers identified include:
Lack of time to locate and synthesize knowledge
Negative attitudes towards research and EBP
Lack of skill to search the literature and to interpret evidence
Access to the internet and computerized resources in clinical
settings
The perception of lack of authority to change practice
These barriers need to be kept in mind even as one moves
through the steps in the process.
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Teaching Strategy #2
Improving Evidence Based Practice in Systems:
Assess a system to identify barriers to
implementing evidence based practice
Design an evidence based structure
Choose strategies to improve use of evidence
based practice and develop a plan
American Association of Colleges of Nursing. © 2014 - All Rights Reserved.
Karen N. Drenkard, PhD, RN, NEA-BC, FAAN
8
Evidence-Based Practice
01/29/2014
Graduate Level
Competencies
• Differentiate
between research,
EBP, and QI
• Role model clinical
decision making
• Promote a
research agenda
• Lead and marshal
resources for EBP
• Design
organizational
systems that
support EBP
Attitudes
• Understand
the content –
methods and
processes
• Determine the
evidence gaps
• Address the
gaps
• Evaluation of
organizational
structures and
cultures that
promote EBP
Skills
Knowledge
Graduate Level Competencies
• Value the
process
• Champion the
changes
• Value the
scientific
process
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Graduate Level Teaching
Strategies
Karen N. Drenkard, PhD, RN, NEA-BC, FAAN
9
Evidence-Based Practice
01/29/2014
Teaching Tips
• Enthusiasm is contagious. Approach the content in a
positive and upbeat way.
• Role model the use of evidence based practice.
Share
examples from your own practice during lectures and small
group report out.
• Millenial students want pedagogy of engagement – Don’t
lecture at them – engage them in the work.
• Whenever possible, the work should be interactive.
Have the class work in small groups as much as possible.
• Consider experiential approaches. This will require
a practice partner / clinical service partnership.
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Teaching Tips
• Cite examples of clinical research in class.
• Allow the students whenever possible to choose their clinical interest
area to conduct evidence analysis.
• Teach them how to critique a nursing research study using any of the
research guides available.
Invite a guest speaker to share a case study of an experience where
research was incorporated into clinical practice. Have the students
review the 5 steps in the EBP process – did the case study touch on
all of the steps?
• Develop researchable questions in a fun way – consider a contest, or
a game show format for generating ideas for questions
that they want answered or want to know more about.
•
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Teaching Strategy #3
Development and Implementation of a Practice Change
Based on Evidence
Develop practice recommendations based on the EBP
process steps
Prepare an environment for change
Implement a practice change
American Association of Colleges of Nursing. © 2014 - All Rights Reserved.
Karen N. Drenkard, PhD, RN, NEA-BC, FAAN
10