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EEWR
Mentoring & Assessing in Healthcare Settings (module 308CPD) – E-Learning
programme
SUPPORTING AND DEVELOPING
PROFESSIONAL PRACTICE - I
Evidence-Based Practice
Research Implementation
Practice Development
Presenter: Neil Gopee
Identifying the NMC (2008) outcomes for mentor that address EBP
i) Comes under NMC (2008) domain: Evidence-based
practice
Competence:
Apply evidence-based practice to their own work and
contribute to the further development of such a knowledge
and practice evidence base.
Outcomes
• Identify and apply research findings and evidencebased practice to their area of practice.
• Contribute to strategies to increase or review the
evidence-base used to support practice.
• Support students in applying an evidence base to their
own practice.
Activity 1: If working in pairs or 3s, take 3-5 mins
Do a brainstorm / ideas generation exercise and
identify all the reasons you can think of, for
EBP in nursing, midwifery or in your allied
health profession.
WHY EBP, clinical practice development , ……?
Under Stage 1 ‘Nurses & Midwives’ outcomes (NMC, 2008)
Evidence-based practice
Further develop their evidence base for practice to
support their own personal and professional
development and to contribute to the development of
others.
Context of practice
Whilst enhancing their own practice and proficiency, as a
registered nurse or midwife, (the RN must) act as a role
model to others to enable them to learn their unique
professional role.
WHY …. Benefits of EBP
Kopp (2001) - through EBP, healthcare professionals can:
• Instigate appropriate and up-to-date interventions.
• Inform or advise patients more accurately.
• Make better use of limited resources.
• Measure practice against appropriate guidelines or
standards.
• Provide a more informed decision-making process to
previously untreatable or more expensive treatments.
… practice risks becoming tyrannised by evidence, but
without available evidence, practice risks becoming
rapidly out of date to the detriment of patients’ (Sackett
et al, 1996 p71).
EVIDENCE-BASED PRACTICE - definitions
Evidence-based practice (EBP) is a problem-solving approach
to clinical practice 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 and Fineout-Overholt, 2005).
WHAT is EVIDENCE-BASED PRACTICE (EBP), EBHC,
EBM, ….
• EBP refers to single clinical interventions (by nurse /
midwife / doctor / AHP)
• Evidence-based healthcare (EBHC) tends to refer to
groups of patients, a health problem / an illness that
affects many
• Evidence-based medicine (EBM)
• Evidence-based nursing (EBN)
• Evidence-based management
• Evidence-based education
• Evidence-based assessment
• ….
Definitions of EBHC, EBN
• Evidence-based healthcare (EBHC) is an approach to
decision-making in which the clinician uses the ‘best
evidence’ available (Gray, 2001).
• Evidence-based nursing (EBN) is ‘an ongoing process
by which evidence, nursing theory and the
practitioners’ expertise are critically evaluated and
considered, in conjunction with patient involvement, to
provide delivery of optimum nursing care for the
individual’ (Scott and McSherry, 2009 p1089).
• EBN refers to holistic clinical interventions that are
based on information that is available from valid and
reliable relevant research, national clinical guidelines,
and expert healthcare professionals (Gopee, 2010 p73)
Classification of evidence (in EBP) as grades, levels or types
of evidence e.g. Bandolier’s (2001 p6) hierarchy of evidence
I–1: Systematic review of several double-blind randomised
control trials (RCT)
I–2: One or more large double-blind randomised control
trials
II–1: One or more well-conducted cohort studies
II–2: One or more well-conducted case-control studies
II–3: A dramatic uncontrolled experiment
III: Expert committee sitting in review; peer leader opinion
IV: Personal experience
Systematic
review of several
double-blind
randomised
control trials
One or more large double-blind
randomised control trials
One or more well-conducted cohort
studies.
One or more well-conducted case-control studies
A dramatic uncontrolled experiment
Expert committee sitting in review; peer leader
opinion
Personal experience
Bandolier’s (2001 p6) hierarchy of evidence
See also: Joanna Briggs Institute
(2008) JBI Levels of Evidence.
Why identify and apply research findings
NMC (2008) outcomes for mentors – under ‘Evidence-based practice’:
‘Identify and apply research and evidence based practice to their
area of practice’.
NMC (2004) ‘Standards of proficiency’ for pre-registration nursing
course under ‘care delivery’
CFP
• access and discuss research and other evidence in nursing and
related disciplines
• identify examples of the use of evidence in planned nursing
interventions
Branch
• ensure that current research findings and other evidence are
incorporated in practice
• engage with, and evaluate, the evidence base that underpins safe
nursing practice.
How identify and apply research
By:
• Critical appraisal or systematic reviews
• Dissemination
• Management of change
• …
Activity 2: Examples of EBP in your workplace
Examples of EBP in your workplace
1
2
3
4
5
Activity 3
Make a list of different sources of critically appraised
/ systematically reviewed evidence.
Different sources of research evidence
 Reports held locally
 Published papers
 Dissertations held in universities
 Local presentation
 National presentation
 International presentation
 Unfinished / ongoing research
…
EVIDENCE-BASED HEALTHCARE
Possible sources of evidence that can be used to inform
clinical practice
•
•
•
•
Randomised controlled trials (RCT)
Qualitative studies
Personal intuition
Policy directives (from local
sources/central/ local govt legislation)
• Textbooks
• Own professional education
Different sources of evidence
• Cochrane library
• Bandolier (based in Oxford), JBI,
• MEDLINE, CINAHL, PUBMED, …
• …
Q7: HOW …. -Typical headings for critiquing a research study are
(Gopee, 2011 p145):
•
How clear and specific is the research question?
•
Was the research funded by a particular organisation and, if so, does the
researcher hold any allegiance to them?
•
Is the research design the most appropriate to answer the research question?
•
Are the sampling strategies the most appropriate?
•
Precisely what was measured?
•
Precise details and relevance of how the data was collected.
•
How researcher effects and other intervening variables were controlled.
•
Was the framework or method used for analysing the data the most appropriate?
•
Are the statistical tests used appropriate and accurately documented?
•
Are the conclusions drawn logically argued and is the generalisability statement
justifiable?
•
To what extent is the study relevant to clinical practice in the particular practice
setting?
•
Does the dissemination of the study indicate frameworks for implementation,
including resources required such as costs?
What is a systematic review?
A systematic review comprises finding all relevant
studies, published and unpublished, assessing each
study, synthesising the findings from individual studies
in an unbiased way, and presenting a balanced and
impartial summary of the findings with due
consideration of any flaws in the evidence (Bandolier,
2001 p1).
Such systematic reviews usually provide a quantitative
estimate … also termed meta-analysis.
[see Gopee 2010]
EVIDENCE-BASED PRACTICE – However, what are the
problems you encounter with implementing EBP?
Randomised controlled trials (RCTs) should not be seen as the
'gold standard' for all evidence. Best evidence should be
judged by that which helps the individual patient / client, not
just scientific evidence (Clarke, 1999).
Barriers to implementation of EBP (Kopp, 2001): … are similar
to those that present as obstacles to implementation of
research findings, e.g. a lack of:
• Awareness of evidence
• Self-confidence
• Peer support
• Resources.
Main barriers to using and developing EBP skills (Morris &
Maynard, 2007; Palfreyman, et al 2003): Time and the practice
setting’s culture.
Identify the NMC (2008) outcomes for mentor that address PD
i) Under NMC (2008) domain: Context of practice Competence:
Support learning within a context of practice that reflects
healthcare and educational policies, managing change
to ensure that particular professional needs are met
within a learning environment that also supports
practice development.
Outcomes:
• Contribute to the development of an environment in
which effective practice is fostered, implemented,
evaluated and disseminated.
• Set and maintain professional boundaries that are
sufficiently flexible for providing inter-professional
care.
• Initiate and respond to practice developments to
ensure safe and effective care is achieved and an
effective learning environment is maintained.
CLINICAL PRACTICE DEVELOPMENT
What is PD? – definitions
Clinical practice development is to do with developing clinical
practice, i.e. hands-on patient care for particular components of
nursing or midwifery?
Practice development is taken to mean a broad range of innovations
that are initiated to improve practice and the services in which that
practice takes place (Bryar & Griffiths 2003).
Practice development is a continuous process of improvement
towards increased effectiveness in person-centred care, through
the enabling of nurses and healthcare teams to transform the
culture and context of care. It is enabled and supported by
facilitators committed to a systematic, rigorous and continuous
process of emancipatory change (McCormack et al 1999 p256).
Activity 4
Think of care and treatment in general, and
then within your own specialism, and try and
identify specific changes in hands-on patients
and service user care that have occurred
recently or over the last 2 to 3 years.
Examples of changes in - HANDS-ON CLINICAL PRACTICE,
PATIENT TEACHING & ORGANISING / MANAGING CARE
CLINICAL PRACTICE
• No lift policy
• Cognitive behaviour therapy
• Using tympanic thermometers rather than glass thermometers.
• Bedside handover
• Treatment of leg ulcers – using Doppler machine
• Red tray/green tray
• Single Assessment Process (SAP)
• MEWS – modified early warning score
• Cardio-pulmonary resuscitation techniques
• … [add your own]
‘How’ to develop practice
Unsworth’s (2000) - critical attributes of practice development:
• New ways of working which lead to a direct measurable
improvement in the care or service to the client.
• Changes which occur as a response to a specific client need or
problem.
• Changes which lead to the development of effective services.
• The maintenance or expansion of business/work.
Titchen (2003) - 3 overarching themes for effective practice
development:
(i) changing the practice philosophy,
(ii) the process of change in practice, and
(iii) investing in professional development.
CHANGE STRATEGIES – How to introduce change
MANAGEMENT OF CHANGE - If not ‘Management
of change’, then what is it?
• Imposed change
• Unplanned change
• Change of lifestyle / behaviour as in health
education (role of the nurse) – Prochaska &
Diclemente (1983) ‘Stages of Change model’:
Pre-contemplation – aware of the change >>Thinking
about the change >>Preparing to change >>Making
changes >>Maintaining change >>Possible relapsing
Recognition
Analysis
Preparation
Strategies
Implementation
Evaluation
Sustaining
The 7-step RAPSIES framework for managing change effectively (Figure 4.2 of
Gopee and Galloway, 2009)
The RAPSIES framework for effective change management
(Gopee & Galloway, 2009)
RECOGNITION of the need for change to solve a
problem, or to improve an element of practice.
ANALYSIS of the available options related to the
contemplated change.
PREPARATION for the change, e.g. identifying a change
agent, education, & involving relevant colleagues.
STRATEGIES for implementing the change.
IMPLEMENTATION of the change including piloting the
change, and timing of implementation.
EVALUATION of the impact of the change.
SUSTAINING the change, i.e. how to ensure the change
endures and is mainstreamed.
CHANGE STRATEGIES
a) Empirical-rational
b) Power-coercive
c) Normative-re-educative
d) Combined
e) Lewin’s 3-stage process of
change
e) Lewin's 3-stage process of change (in Mullins 2010
p912):
Lewin's 3-stage
process
• Unfreezing
• Movement
• Refreezing
Barriers to implementing research findings
Activity 5
• What are the barriers to implementation of change in
your clinical setting?
• What mechanisms [levers] are available to overcome
some of these barriers?
Implementation, evaluation and sustaining
change.
Summary
In summary, this presentation on Supporting and
Developing Professional Practice as a mentor competence
area entailed exploring Evidence-Based Practice,
Research Implementation and Practice Development.
FURTHER READING
Gopee N, Galloway J (2009) Leadership and Management in
Healthcare. London, SAGE Publications
Gopee N (2010) Practice Teaching in Healthcare. London,
SAGE Publications
Gopee N (2011) Mentoring and Supervision in Healthcare (2nd
edn). London, SAGE Publications
Joanna Briggs Institute (2008) JBI Levels of Evidence.
Available from:
http://www.joannabriggs.edu.au/About%20Us/JBI%20Appr
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29th August 2011).
Morris J, Maynard V (2007) The value of an evidence-based practice
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professional practice
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