Assoc Prof Majda Pajnkihar, PhD

Winter School 2015
 Every day nurses perform interventions e.g.
administering medication, educating clients, provide therapeutic interventions etc;
 This should stimulate questions about the evidence supporting their use of various interventions.
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Winter School 2015
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Winter School 2015
How nurses base their nursing care?
 Pravikoff et al., 2005 surveyed 760 USA registered nurses working in clinical practice and found that:
 67% get information for practice from other nurses,
 58% do not use research reports to support their practice,
 82% never used a hospital library,
 54% were not familiar with term Evidence Based
Practice,
 67% never searched CINAHL Database,
 72% hadn’t evaluated research reports.
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Winter School 2015
 „Integration of best research evidence with
clinical expertise and patient values“
(Dave Sackett, 1996)
 “Doing the right thing in the right way for the right patient at the right time.”
(Royal College of Nursing 1996, p. 3)
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Winter School 2015
EVIDENCE
BASED
MEDICINE
EVIDENCE
BASED
NURSING
EVIDENCE
BASED
HEALTHCARE
Evidence Based Practice
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Winter School 2015
BEST RESERCH
EVIDENCE
EBN
CLINICAL
EXPERIENCE/
EXPERTISE
Context
PATIENT
VALUES
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Winter School 2015
What do you understand by the word
‘evidence’?
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Winter School 2015
 Evidence is a collection of facts that are belived to be true (Melnyk, & Fineout-
Overholt, 2011).
 Current best evidence from clinical research:
 implies hierarchy of evidence.
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Winter School 2015
Level
1
• Systematic review of RCTs
• Systematic review of nonrandomized trials
Level 2
• Single RCT
• Single nonrandomized trial
Level 3 • Systematic review of correlational / observational studies
Level 4 • Single correlational / observational study
Level 5
Level 6
Level 7
• Systematic review of descriptive / qualitative / psychologic studies
• Single descriptive / qualitative
/ psychologic studies
• Opinions of authoities, expert committees
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Winter School 2015
 Is this hierarchy of evidence suitable for grading the evidence for a question:
 What is the perception of pain in patients with multiple sclerosis?
 Clinical question determines the type of research required for searching.
 We cannot reserach experiencing pain in patients with
RCT.
 http://www.essentialevidenceplus.com/product/ ebm_loe.cfm?show=oxford
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Winter School 2015
selection performance exclusion detection intervention outcome
Patients control outcome
An experimental comparison study in which participants are allocated to treatment/intervention or control/placebo groups using a random mechanism. Best for study the effect of an intervention.
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Winter School 2015
„I had considerable freedom of clinical choice of therapy: my trouble was that I did not know which to use and when. I would gladly have sacrificed my freedom for a little knowledge. I had never heard then of 'randomised controlled trials', but I knew there was no real evidence that anything we had to offer had any effect on tuberculosis, and I was afraid that I shortened the lives of some of my friends by unnecessary intervention."
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Winter School 2015
Sum up ov the best available research on a specific question; using transparent procedures to find, evaluate synthesize relevant research.
and of
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Winter School 2015
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Winter School 2015
 Patients experience 28% better outcomes if they receive care based on the best and latest evidence from well-designed studies compared to traditional practice (Heater et al.
1988).
 Without current best evidence practice is rapidly outdated often can be the detriment of patients (Melnyk & Fineout-Overholt, 2005)
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Winter School 2015
 Main aim is to improve client outcomes;
 Ensure clinically effective health care;
 Improve people’s experience of illness & health care;
 Clients expect it;
 Improves clinician’s knowledge;
 Communicates a profession’s research base;
 Stimulates clinically relevant research;
 Accountability.
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Winter School 2015
 Failing to use available science is costly and harmful. It leads to overuse of unhelpful care, underuse of effective care and errors in execution
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Winter School 2015
 Safe, Effective Nursing Care.
 Our nursing care is only safer if we put into practice what we learn from research.
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Winter School 2015
 Higher level of satisfaction among healthcare providers who use evidencebased approach in delivering patient care than those who deliver care steeped in tradition (Dawes 1996).
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Winter School 2015
 Having two nurses check medication orders prior to dispensing medication reduces the incidence of medication errors.
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Winter School 2015
 A Group therapy programme is more effective than a self help programme in promoting smoking cessation.
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Winter School 2015
 Special toileting needs such as incontinence, urgency or diarrhoea is a factor that increases the likelihood of a patient falling in hospital.
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Winter School 2015
 Nurses need to keep up to date and offer best practice from the best evidence.
 EBN processes focus on incorporating good information seeking habits into daily routine (Melnyk & Fineout-Overholt, 2005).
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Winter School 2015
Asking the right question - ASK
Search for the best evidence - ACQUIRE
Critically appraise evidence - APPRAISE
Integrate the evidence - APPLY
(Polit, & Beck, 2012)
Evaluate the outcomes - ASSESS
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Winter School 2015
I
P
(C)
O
(T)
• Population, problem
• Intervention or issue
• Comparison
• Outcome
• Time
In patients living in a long-term care facility who are at risk for pressure ulcers (P), how does a pressure ulcer programme (I) compared to the standard of care (e.g. turning every 2 hours) (C) affect signs of emerging pressure ulcers (O)?
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Winter School 2015
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Winter School 2015
S-model
(Haynes, 2006)
Systems
Evidence Based textbooks
Summaries
Evidence Based journal abstracts
Synopses
Systems for Clinical Decision Support
Clinical Evidence, UpToDate
Other reviews in DARE-database
(Cochrane Library)
Evidence Based Journals
Systematic reviews
Syntheses
Cochrane Reviews (Cochrane Library),
Clinical Queries (Ovid, Pubmed),
Original journal articles
Studies
CENTRAL (Cochrane Library)
Clinical Queries (Ovid, Pubmed)
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Winter School 2015
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Winter School 2015
Are the results valid (validity)?
What are the results
(reliability)?
Can I apply the results in practice
(applicaiblity)?
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Winter School 2015
 Using different critical appraisal questions, checklist and tools:
 CASP
 ...
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Winter School 2015
 Research evidence alone is not sufficient to justify a change in practice.
 Implementation of EBN is highly influenced by institutional and clinical variables.
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Winter School 2015
 After implementing EBN, it’s important to monitor and evaluate any changes in outcomes so that positive effects can be supported and negative ones remedied.
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Winter School 2015
• Studies on evidence based recommendations in practice: 30-50% is not used.
• Studies on compliance: 30-50% of patients do not adhere well.
• For some clinical care and public health recommendations 50-75% of patients may not profit (enough) from evidence.
• Many best practices in quality and safety are not adopted widely in health care (Flottorp,
2015).
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Winter School 2015
Lack of EBN knowledge and skills.
Lack of belief that
EBN will result in more positive outcomes than traditional care.
Lack of time and resources to research for and appraise evidence.
Lack of EBN mentors.
Resistance to change.
Volumnous amounts of information in professional journals.
(Melnyk & Fineout-Overholt, 2011)
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Winter School 2015
Mispertceptions or negative attitudes about research and evidence based care.
Overwhelming patient loads.
Demands from patients for a certain type of treatment.
Peer pressure to continue with practices that are seeped in tradition.
Organizational contraints.
????
(Melnyk & Fineout-Overholt, 2011)
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Winter School 2015
„The application of what we know already will have a bigger impact on health and disease than any drug or technology likely to be introduced in the next decade.“
Sir Muir Gray Director UK NHS
National Knowledge Service & NHS Chief Knowledge
Officer
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Winter School 2015
 Never stop questioning! (Susan L. Hendrix)
 https://www.youtube.com/watch?v=QUW
0Q8tXVUc
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