What is evidence?
Professor Lisbeth Fagerström
Høgskolen i Buskerud, Drammen, Norway.
Associate Professor, Åbo Akademi, Vasa Finland and
Örebro Universitet, Sverige
Email: lisbeth.fagerstrom@hibu.no
Evidens – naturens hälsoeffekt
Varför evidens baserad vård?
Fel behandling och vård
Utebliven vård –’Icke vård’
• 20% av alla patienter
upplever att de får
felbehandling i alla land
som är undersøkt
• 30-40 prosent av
patienterna får inte
behandling i linje med
vetenskapliga resultat
• 20-25 prosent av all
behandling är
onödvändig, eller kan
vara skadlig
• Situationen i Norge:
Ca 1000-2000 dödsfall
Ca 15.000 långvariga
skador
Schuster, McGlynn, Brook (1998). Grol R (2001).
Evidence Based Practice
• Evidence-based medicine has been described as ‘the
conscientious, explicit and judicious use of current
best evidence in making decisions about the care of
individual patients.’
• The practice of evidence-based medicine means
integrating individual clinical expertise with the best
available external clinical evidence from systematic
research’ (Sackett et al. 2000).
EB Nursing expands the above definition to include
patient preferences and clincial expertise as sources
of evidence.
Vad räknas som evidens?
• what constitutes a sufficient source of
evidence and do different knowledge
sources for evidence exist?
• What should be considered evidence
and in what circumstances?
Källor för evidens
• Various knowledge sources for evidence exist,
including research, clinical experience, life
experiences, patients/clients/carers, local context and
environment.
• In the delivery of evidence-based health care,
research evidence has been prioritized.
• As interest in person-centred care has been
emphasized, clinical experience and life experiences
have gained more attention.
• Even the context of care has been defined as a
knowledge source for evidence. Locally collected
data may also have an important role to play in the
development of evidence-based care.
• A rather new trend is participatory research: when
end-users (patients) are given the opportunity to
collaborate in research projects.
Nierse CJ et al (2011). Collaboration and co-ownership in researc:
dynamics and dialogues between patient research partners and
professional researchers in a rsearch team. Health Expect. 17, Online
published.
• According to Pearson (2002) and the
Joanna Briggs Institute, evidence-based
nursing leads to fewer variations in
practice, cost savings that flow from
appropriate product use and best health
outcomes, and improvements in health
outcomes in general.
• A rather new trend is participatory
research: when end-users (patients) are
given the opportunity to collaborate in
research projects. Even the context of
care has been defined as a knowledge
source for evidence. Locally collected
data may also have an important role to
play in the development of evidencebased care.
• The FAME Scale can be used to evaluate
evidence for practice; evidence should extend
to issues relating to the feasibility,
appropriateness, meaningfulness and
effectiveness of interventions and activities.
• Defined so, qualitative research constitutes
legitimate evidence. Still, best practice should
reflect the whole range of evidence available
– both quantitative and qualitative.
Användbarhet-LämplighetMeningsfull-Effektiv
Pearson A. 2002. Nursong takes the lead. Reflections on
Nuring Leadership, Fourth Quarter, 17-20.
Kunskapsbaserad praxis
Å utøve kunnskapsbasert praksis er å ta
faglige avgjørelser basert på
systematisk innhentet forskningsbasert
kunnskap, erfaringsbasert kunnskap og
pasientens ønsker og behov i den gitte
situasjonen.
Nortvedt MW, Jamtvedt G, Graverholdt B, Reinar LM, 2007
Forskningsbasert
kunnskap
Erfaringsbasert
kunnskap
Kunnskapsbasert
praksis
Kontekst
Brukerkunnskap og
brukermedvirkning
Jamtvedt, kunnskapssenteret.no
Tredimensionell kunskapssyn
Fagerström L. (2011). Den tredimensionella kunskapssynen som epistemologisk
grundsyn. I: Fagerström L. (red). Avancerad klinisk sjuksköterska. Avancerad
omvårdnad i teori och proxis., s. 60. Studnetlitteratur, Lund.
Barriers and facilitators in regard to the
utilization of research in nursing practice.
• In developing health care, evidencebased management is also needed.
• Organizational support is an important
factor when using research evidence in
practice.
• Leaders are responsible for creating a
culture that promotes evidence-based
practice and the continuous
improvement of competence.
Barriers to using research
evdience in nursing practice
• Accessibility (tillgänglighet) of research
findings
• Anticipated (förväntad) outcomes of using
research
• Organizational support to use research
• Suuport from others to use research
(organizational support most important)
Retseas A. 2000. Barriers to using research evdience in nursing
practice Journal of Advanced Nursing, 31, 599-606
Individual determinants of
reserach utilization
The aim of the review: to examine individual
characterstics of nurses and how they influences
reserach use.
Results:
• Beliefs and attitudes
• Involvemenet in reserach activities
• Information seeking
• Professional characterstics
• Education and oterh socio-economic factors
Estabrooks et al. 2003. Individual determinants of reserach
utilization: a systematic review. Journal of Advanced Nursing 43,
506-520.
Sjuksköterskeresursser og
patient outcome/resultat
• Internationell forskning har påvisat att
sjuksköterskeresurser har ett klart samband med
kvalitetsindikatorer, resultat och mortalitet.
• För få sjuksköterskor leder till en ökning av
omvårdnadssensitiva (nursing sensitive quality
indicators) kvalitetsproblem så som trycksår,
sårinfektioner, fall, läkemedelsavvikelser samt ökad
mortalitet.
• Att utgå ifrån standardiserade nurse/patient ration (ex
0,8 Nurse/Patient) är inte förenligt med en vårdsyn
där patientens tillfredsställelse med vården är central
samt att varje patients behandling når uppställda
resultatmål.
19
Workload and care quality
problems
•
•
Aiken, Clarke, et al. (2002)
– Journal of the American Medical Association (2002)
• Surveyed nurses about staffing and work environment in
Pennsylvania, linked surveys to discharge data
• Poor nurse staffing associated with higher: 30-day
mortality, failure to rescue
Needleman, Bauerhaus, et al. (2001)
– Report for Health Resources and Services Administration
– Companion article in New England Journal of Medicine (2002)
– Use of administrative hospital data from states
– Key outcomes associated with nurse staffing:
• Urinary tract infections, pneumonia
• Length of stay
• Upper gastrointestinal bleeding
• Shock, failure to rescue
20
Sykepleieresursser og patient
outcome/resultat
• I tidigare forskning har dessa samband
påvisats genom att utgå ifrån personår
relaterat till antal patienter och
kvalitetsproblem.
• Ingen internationell forskning finns där
personalbehovet utgår ifrån den enskilda
patientens dagliga vårdbehov och behov av
omvårdnadsinsatser.
Needleman J. et al (2011). Nurse Staffing and Inpatient Hospital Mortality. The New
England Journal of Medicine 364;11, 1037-1045.
Aiken et al (2010). Implications of the California Nurse Staffing Mandate for Other
States. Health Services Research, 45 (4), p. 904–921.
21
RAFAELA-systemets
uppbyggnad
OPC
= pat:s pleietyngd
6-24 p/pat
Personalresurser
= antal sköt som
vårdat pat
PAONCIL
Bedömning av personalresurser i
relation
till det optimala
Pleietyngd/nurse
Optimala
pleietyngdsnivån
Regressionsanalys
22
HVORFOR TRENGER VI MÅLNING AV
SYKEPLEIEINTESITET?
A. For å sikre behandlingsresultat/outcome
• for systematisering av sykepleiens innehold
• for analys og kvalitetsutvikling av sykepleie
• For å garantere pasientsikkerhet/patient
safety
• Utvikler sykepleiedokumentasjon
• For evaluering av pleie og omsorg til pas.
• En del av verksamhetsuppföljningen
Aiken et al (2010). Implications of the California Nurse Staffing Mandate for Other
States. Health Services Research, 45 (4), p. 904–921.
23
HVORFOR TRENGER VI MÅLNING
AV SYKEPLEIEINTESITET?
B. For optimal resurshåndtering
C. Metode for kunskapsbasert ledelse
• Sykepleieintensitet en sentral del virksomheten som
helhet
• bakgrunnsdata for analyse av virksomheten og for
beslutt
• bakgrunnsdata for kommunikasjon med ansvarlige
beslutningstagare
• for å garantere en balanse mellom pasientenes
helsebehov og personalresurser
Fagerström L. 2009. Evidence-based human resource management:
a study of nurse leaders' resource allocation. Journal of Nursing
Management, 17, 415–425.
Ledarskapets betydelse
’Change management and clinical
leadership are cruicial for Evidence
Based Practice.’
Source: Foundation of Nursing Studies. 2001. Taking Action:
Moving Towards Evidence Based Practice – exectuive
summary.
Organisational infrastructures to promote evidence based nursing
practice.
Results: Organizational infrastructures may be important in the
development of evidence based nursing practice.
The Cochrane Collaboration. Foxcroft. D & Cole N. Organisational infrastructures to promote
evidence based nursing practice. Cochrane database of Systematic Reviews 2003, Issue 4.
Avancerad klinisk sjuksköterska
ICNs definition av Advanced Practice
Nurse:
A registered nurse who has acquired the
expert knowledge base, complex
decision-making skills and clinical
competencies for expanded practice,
the characteristics of which are shaped
by the context and/or country in which
s/he is credentialed to practice’.
En nordisk modell för Avancerad
Klinisk Omvårdnad
Fagerström L. (2011).En nordisk
modell för Avancerad klinisk
omvårdnad. I: Fagerström L.
(red). Avancerad klinisk
sjuksköterska. Avancerad
omvårdnad i teori och proxis., s.
99. Studnetlitteratur, Lund.
Hygiensjuksköterskan som AKS
• God och säker vård
• Expertroll, konsult, samarbete, etiskt
beslutsfattande
• Ledaruppgift
• Forskning och utveckling
• Direkt klinisk praxis?
• Rätt att ordniera ordinera mediciner, ge
vård och behandlingsföreskrifter?
Tack och Lycka till!