Evidence Based Practice In Nursing Dr Abdul-Monim Batiha

Evidence Based Practice In Nursing Dr. Abdul-Monim Batiha Assistant Professor Critical Care Nursing Philadelphia university

Today’s health care system has become increasingly more Consequently, in this costly and market-driven complex. delivery system, there is a greater emphasis on outcomes, cost-effectiveness, and consumer satisfaction.

t These pressures operate in an environment of rapid information exchange, technological advancements, and an increasing nursing workload t Nurses are challenged to maintain clinical competence, to demonstrate how their care positively affects patient outcomes, & to participate actively in clinical decision-making & practice improvements

u Nurses are now mandated to demonstrate costeffectiveness and efficiency with the use of time and resources, while continuing to demonstrate their value added impact on outcomes. These mandates provide a strong rationale for adopting an evidencebased model of practice

What Is Evidence- Based Nursing?

Evidence – Based Nursing (EBN) u Process by which nurses make clinical decisions using the best available research evidence, their clinical expertise & patient preferences" Clinical expertise u Ability to use our clinical skills & experience to rapidly identify each patient's unique health state &diagnosis, their individual risks & benefits of potential interventions, & their personal values & expectations

Patient values & preference u Unique preferences, concerns & expectations each patient brings to a clinical encounter & which must be integrated into clinical decisions if they are to serve the patient

u Goals of EBN are to apply valid & reliable nursing research to clinical practice "Research utilization" & to bring the most current knowledge to clinicians. This is particularly important due to the knowledge explosion in nursing and health care

Steps to Evidence-Based Critical Care Nursing Practice u Accept the fact that health care is evolving, with the consequent need to base nursing care on evidence, rather than on tradition or previous education u Identify a need for change in practice by examining less than favorable patient outcomes; causes of patient, family/significant other, or staff dissatisfaction; or situations in which compelling new evidence exists in an aspect of care

u Frame a clinical question and search the literature for evidence regarding the topic u Once current research data and evidence have been collected, evaluate the evidence for scientific merit, quality, and applicability

u Synthesize to determine the strength of the evidence to support a change in practice u Conduct a comparison between current practice recommendations and current research

u If there is sufficient evidence to suggest a change in practice and the change in practice is practical in respect to costs, staff skill, and resources required, application of the evidence into practice can occur Implicit in the implementation of evidence are the issues associated with change, including fear of change & the need for information, staff training, leadership, & ongoing evaluation of the change

u Continue to evaluate the evidence through an ongoing and systematic review to promote state of the science nursing care

Converting information needs into clear questions

Art to Phrasing Questions u An art to phrasing questions in such a way as to elicit a meaningful answer, there are three key reasons for focusing questions:

u Facilitating the search for relevant evidence. The more explicit the question, the easier it is to run searches on electronic databases such as those contained within the Library shelves, CINAHL (Cumulative Index of Allied Health and Nursing Literature, or MEDLINE A non focused question is more likely to yield larger numbers of non relevant studies than a focused question, and valuable search time will be wasted trying to sift through the long list of retrieved references for relevant studies

u Sorting best evidence from weaker, less valid evidence u Deciding whether the evidence is applicable to our patients u The PICO (population, intervention, comparison intervention, out come)framework, devised by Saekett et al (1997), is a useful method for making questions more focused. The question is built in four (or three) parts

PICO Frame u Population or Problem, it may be necessary to specify age, gender, disease type, disease severity or comorbidity. This will depend on whether the results of a very broad, inclusive population could be applied to your specific patient group Define who or what the question is about

PICO Frame u Intervention: Define which intervention, test or exposure you are interested in. An intervention is a planned course of action. An exposure is something that happens such as a fall, anxiety. The intervention (or test or exposure) may need to be described in some detail to ensure clarity Describe what it is you are considering doing or what it is that has happened to the patient

PICO Frame u Comparison intervention: alternate intervention Define the Describe the alternative that can be compared with the intervention Outcomes: Define the important outcomes, beneficial or harmful Define what you are hoping to achieve or avoid

PICO Frame u Outcomes: very general outcomes may be difficult to measure, and details of how outcomes can be objectively measured may need to be specified

Searching Literature

Basic search principles u Analyzing the question u Generating u Linking a word lists( Boolean logic: AND, OR, NOT)

Boolean Operator

Types Of Evidence Used

u Health Care Indexes u Research u Retrospective or Concurrent Chart Review u Quality Improvement & Risk Data & Benchmarking u International, National, & Local Standards u Infection Control Data u Pathophysiology u Cost effectiveness Analysis u Patient Preferences u Clinical Expertise

Health care indexes u Two of the most common indexes used by nurses are MEDLINE, produced by the National Library of Medicine (NLM) u CINAHL (Cumulative Index for Nursing & Allied Health Literature) produced by the C 1 NAHL corporation. Both of these are available in print & computerized forms

u The International Nursing Index, Hospital Literature Index, Psych Index, and Social Sciences Index are other common used indexes that would reference articles and books pertinent to nursing practice u Many libraries subscribe to computerized databases such as Ebsco and Proquest, which provide citations, abstracts, and some whole articles

u The Cochrane library Collaboration prepares maintains and disseminates systematic reviews of health care interventions focusing primarily on systematic reviews of controlled trials of therapeutic interventions (the gold standard for experimental research design)

Research u Most experts consider the well designed double blind experiment (often referred to as the randomized control trial) the best type of evidence u Another type of evidence is found in research studies that have fewer controls. Some of these types of studies are included in the discussion of reading research. The Centers for Disease Control and Prevention identify these types of research evidence as the most important in demising their guidelines for disease and injury prevention and control

Retrospective or concurrent chart reviews, Quality improvement and risk data u Aggregating data across an institution or several institutions provides an opportunity to assess how well current practices are working u Determining patient outcomes for large groups provides a firm foundation of data that, although not part of a research study, can guide practice u Individual health care institutions and health plans are compiling information for statistical analysis & making decisions about health care based on these statistical measures

International, and local standards u Bring together the opinions & expertise of many health care providers u The standards are based on the collective experience & goals of individuals who are intimately involved with health care practice u Individuals who have worked with many patients, seen the results of multiple trials, & identified at first hand the complexity of the care have a special insight into effective practice. Because of this involvement & knowledge, the standards provide guidance and support for practice

Infection control data u Because infection remains a major complicating factor in health care, infection control data assume major importance as guide for practice u The incidence of infection is of critical importance to both the patient and the entire system in terms of its impact on overall health outcomes u Practices that decrease the potential for infection have high priority

Modern understanding of pathophysiology u Modern understanding of pathophysiology at even the cellular level has changed thinking about many health care practices

Information regarding costeffectiveness analysis u Helps an institution weigh possible benefits against costs u It compares how much improvement a certain practice makes versus how much that practice costs

Patient preferences u the importance of self care in managing health and illness, practices to which patients will adhere and ones that make their lives simpler are more likely to be incorporated u Failure to take into consideration patient preferences may make the best designed therapy ineffective

Opinions of clinical experts u Remain an important aspect of evidence. Individuals who have worked with many patients, seen the results of multiple trials, and identified at first hand the complexity of the care have a special insight into effective practice

Systematic Analysis of Information &Evidence

u Not all published research evidence can be used for making decisions about patient care u Deficiencies in research design can make an intervention look better than it really is u The location and subjects of a particular research study may affect the results in a unique way u Assess the quality, importance and applicability of any research evidence that is being consulted to answer a specific clinical question critical appraisal

Critical Appraisal u The purpose of the critical appraisal for evidence based practice is to decide whether the quality of a research study is good enough for the results it provides to be used to answer a question posed by a health care practitioner or patient u Critical appraisal can be broken down into three distinct but related parts:

u Is the quality of the study good enough to use the results? u Are the findings applicable in my setting? u What do the results mean for my patients?

Criteria & questions for use in assessing the quality of research studies Question about the effectiveness of a therapy or intervention Question about whether a particular diagnostic test or method of assessment works Question about finding out the likely pattern and/or outcome of a particular health problem/ disease Design Comparative / prospective, ideally randomized, controlled trial. Cross sectional/ comparative study (longitudinal) cohort or case control study Sample Random allocation to intervention or control group. Baseline group comparability Appropriate spectrum of subjects Defined, representative sample. Assembled at a common (usually | early} point Intervention clearly described. Appropriate outcome measures New test compared against a reference standard Appropriate end points Clinician/assessor/ patient masked (blinded) as to which group the patient has been allocated to Clinician/assessor masked (blinded) as to the results of the reference standard No dependent relationship between subject & investigator All entrants adequately accounted for at the end of the study All entrants given both new and reference standard test Follow up of adequate duration & completeness Analysis carried out on an intention to treat basis Reliability reported Effect of time confounders explored Question Measures Researcher Data collection Data analysis

Matching study design to questions Type of question Example question Research design The effectiveness of a therapy or intervention Does a nurse led discharge package for children admitted with acute asthma reduce readmission rates? Comparative/prospective randomized controlled trial Finding out the likely pattern and/ or outcome of a particular health problem or disease (i. e. prognosis) Are women oral contraceptive users who smoke at greater risk of myocardial infarction (Ml Cohort study: participants exposed to an agent (contraceptive pill) are followed forward in time to see if they develop an outcome (Ml) Case control study: participants with the condition (Ml) are matched with controls (no Ml), study looks back in time to identify exposure to an agent (contraceptive pill) Whether a particular diagnostic test or method of assessment works In primary care, does asking patients about feeling depressed and loss of interest accurately identify those who are clinically depressed? Cross sectional study where the 'new' test (or method of assessment) is compared with a reference standard test

Factors to consider when assessing the quality of a study u Randomization u The group to which the patient has been allocated must be concealed from the clinician/researcher until the patient has been accepted into the trial u Demographic and health status details for the two groups are of interest u It is helpful if the intervention is described in sufficient detail to allow clinicians to reproduce it in their own setting

u Keeping patients, clinicians and researchers blinded as to whether a patient is in the treatment or control group is a useful way of minimizing bias u People drop out of studies for all sorts of reasons: death, relocation to another geographical area, treatment found to be too unpleasant, etc. It is important that the researcher tries to identify whether the reasons relate to the outcomes of interest

Factors to consider when assessing applicability u The characteristics of the participants in the study u Is it feasible to introduce the intervention or test described in the study? u When thinking of the costs and benefits of the intervention or test, think beyond purely financial terms

Questions for assessing & screening applicability u Is it clear what the study about? u Is the sample adequately considered? u Are my patients / context sufficiently different that results will not apply? u Is the action indicated, or the intervention available, or the change possible in my setting? u Do the benefits of any change for my patients / context outweigh the like costs? u Are the patient’s values and preferences satisfied by change? Are my colleagues and mine?

Questions that must be included in deliberations for evaluating information u Is the source identified? u Is the source reliable? u Is the source biased? u How timely is the information relative to the need? u How does the information fit with the purpose for which it will be used? u How does the setting that originated the information compare with your setting?

Evaluation the studies results using the Meta analysis test

Meta Analysis Test u Like all quantitative studies, systematic reviews often include a statistical analysis u. A meta-analysis combines the results of several studies that address a set of related research hypotheses, in an attempt to overcome the problem of reduced statistical power in studies with small sample sizes; analyzing the results from a group of studies can allow more accurate estimation of effects

u Meta analysis is a collection of systematic techniques for resolving apparent contradictions in research findings u Meta analysis translates results from different studies to a common u Metric and statistically explore relations between study characteristics and findings u Modern meta analysis does more than just combine the effect sizes of a set of studies. It tests if the studies outcomes show more variation than the variation that is expected because of sampling different research participants

Steps in performing meta-analysis u Meta analysis should be viewed as an observational study of the evidence. The steps involved are similar to any other research undertaking: u Formulation of the problem to be addressed u Collection and analysis of the data u Reporting of the results

u Researchers should write in advance a detailed research protocol that clearly states the objectives, the hypotheses to be tested, the subgroups of interest, and the proposed methods and criteria for identifying and selecting relevant studies and extracting & analyzing information u As with criteria for including and excluding patients in clinical studies, eligibility criteria have to be defined for the data to be included u Criteria relate to the quality of trials and to the combinability of treatments, patients, outcomes, and lengths of follow up u Quality and design features of a study can influence the results. Ideally, researchers should consider including only controlled trials with proper randomization

u The strategy for identifying the relevant studies should be clearly delineated. In particular, it has to be decided whether the search will be extended to include unpublished studies, as their results may systematically differ from published trials u A standardized record form is needed for data collection. It is useful if two independent observers extract the data, to avoid errors. At this stage the quality of the studies may be rated, with one of several specially designed scales

u Blinding observers to the names of the authors and their institutions, the names of the journals, sources of funding, and acknowledgments leads to more consistent scores u This entails photocopying papers, removing the title page, and concealing journal identifications and other characteristics with a black marker, or scanning the text of papers into a computer and preparing standardized formats

Levels of evidence 1++ High quality meta analyses, systematic reviews of randomized controlled trials (RCTs) or RCTs with a very low risk of bias I+ 1 Well conducted meta analyses, systematic reviews of RCTs, or RCTs with a low risk of bias Meta analyses, systematic reviews of RCTs, or RCTs with a high risk of bias 2++ High quality systematic reviews of case control or cohort studies. High quality case control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal

Levels of evidence 2+ Well conducted case control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal 2 3 Case control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal Non analytic studies, e. g. case reports, case series 4 Expert opinion

The process of changing practice Evidence- based guidelines

u Clinical guidelines are systemically developed statement to assist practitioner decisions about appropriate health care for specific clinical circumstances

Prioritizing topic areas for guideline development u Situations where there is evidence of excessive morbidity, disability or mortality u Conditions for which available treatment offers the potential for improvement in any of the above u Those where there is evidence of wide variation in practice u Conditions that are resource intensive either because they are high cost or high volume u Situations involving cross boundary issues, e. g. , interprofessional working or the need for joint working between primary and secondary care

How are guidelines developed? u u u u u Selection of guideline topic Composition of the guideline development group Defining the scope of the guideline Systematic literature review Formation of recommendations Consultation and peer review Presentation and dissemination Local implementation Audit and review

skills are required in guideline development group u Clinical expertise u Other specialist expertise (e. g. Health economics, research methods) u Practical understanding of the problems faced in the delivery of care u Critical appraisal skills

Characteristics of effective guidelines u u u u u Attribute Validity Cost effectiveness Reproducibility Reliability Representative development Clinical applicability Clinical flexibility Clarity Scheduled review

Benefits of clinical guidelines u u u u Ensure safe practice Improve consistency of care in different parts of the country/settings patients receive correct treatment Build parity of knowledge amongst staff Bring the expert opinion to everyday clinical care Allow for individual patient variation non application is not disallowed, it simply has to be justified Provide more information for patients about what they should expect from the health care system Distill the vast array of knowledge relating to individual clinical conditions into a manageable guide for busy clinicians

disbenefits of clinical guidelines u Stifle individual clinical judgment u De skill professionals by reducing their capacity to think for themselves u Limit quality of care by restricting care/treatment options u Introduce practice which could be ineffective or dangerous u Encourage the illusion that there is clear cut direction to be taken in every clinical situation u Be very resource intensive in relation to their development and implementation

Introducing guidelines into practice u Dissemination u Implementation

Diagnosing the challenges to changing practice u Identifying all the groups involved in, affected by, or influencing the proposed change (s) in practice u Assessing the characteristics of the proposed change that might influence its adoption u Assessing the preparedness of the health professionals to change and other potentially relevant internal factors within the target group u Identifying the potential external barriers to change u Identifying the likely enabling factors, including resources and skills

Methods exists for gaining a purchase u Surveying key groups of stakeholders (such as senior staff, managers, and patient representatives u Adapting ward meetings or clinical supervision sessions so that potential problems can be identified, recorded and fed into the strategic planning process u Establishing a focus group of professionals, managers and, where appropriate, patient representatives, to identify pertinent barriers and drivers u Isolating some of the barriers to research uptake in clinical practice

Common complexities associated with nursing and research use u u Professional culture Clinical information Environment Individual decision – maker Knowledge and educational attainment Valuing research Valuing change

Forces working for and against an evidence-based organizational culture

Planning for and managing resistance and change

Social marketing mode The model has six stages: u u u Research the group(s) you wish to target and identify the resources you have available to help you achieve the change Select the 'raw materials' for the change you want to introduce Develop and pilot the materials used to facilitate the change u Implement the change u Evaluation Feedback u

Precede—proceed mode u Its name is derived from the fact that it specifies the steps that should precede any change and the ways in which organizations should proceed with the change u The first stage of the precede proceed model is concerned with specifying the problem to be addressed and isolating those factors which contribute to the presence of the problem

u This stage recognizes that problems will have different priorities for different organizational stakeholders & so it is important to try to reach some form of consensus regarding the factors which predispose & contribute to the problem, the importance of these factors and their susceptibility to change

u Commonly, this takes the form of a ranking or rating approach. Common factors include: Predisposing: the perceptions, attitudes, motivations and beliefs of stakeholders involved with the change Enabling: resources such as skills, knowledge (& funds) Reinforcing: rewards or incentives even if only in the form of positive feedback

Strategic approaches for bridging the gap between the research and practice

General u Continuing u Clinical u Other education guidelines broad approaches

Specific interventions classified according to the degree of effect on clinical practice u Educational outreach / detailing u Reminder u Multifaceted interventions

Mixed effects u Audit and feedback u Local opinion leaders u Local consensus approaches Little or no effect

Strategies to Overcome Challenges u Lack of knowledge or skill u Identify resources u Staff development plans u Supervision and mentoring u Collaborative training and technical assistance u Developing shared vision and commitment

Strategies to Overcome Challenges u Beliefs and Attitudes u Articulate existing beliefs and attitudes u Hold frequent meetings to discuss change u Utilize motivational strategies to move staff ambivalence toward positive change u Ensure a clear understanding of terms u Enlist a neutral facilitator u Affect beliefs through information u u Provide opportunities to speak with people who have done it Provide incentives and recognition

Strategies to Overcome Challenges u Lack of Adequate Resources u Resource sharing with other providers u Cross site training and technical assistance u Community wide collaboration

Strategies to Overcome Challenges u Lack of collaboration u Implement a collaborative planning model u u u Use stakeholder teams to make decisions Partner with other agencies implementing the same intervention Develop a community wide system of care where the evidence based practice is essential to producing desired outcomes