DEVELOPING AN EVIDENCE-BASED PRACTICE

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Developing an

Evidence-Based Practice

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Conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions

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Evidence-based practice is the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions.

Research utilization

Evidence-based practice encompasses research utilization but also case reports and expert opinion

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Research utilization is a subset of EBP that focuses on the application of research findings.

Evidence-based practice is a broader term that encompasses research utilization but also case reports and expert opinion.

Multifaceted, systemic process of promoting adoption of evidence-based practices in delivery of health care services that goes beyond dissemination of evidence-based guideline

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Evidence-based practice is the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions.

Dissemination: publications, conferences, consultations, and training programs

Conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions

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Evidence-based practice is the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions.

Validates current practice, changes in practice, cost-effectiveness, and quality of care

High-quality

Cost-effective

Outcomes

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Research

Conduct

Research

Utilization

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Questions about current nursing practice

Literature review

Need for investigation

Clinical research

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  • Knowledge and problem-focused “trigger(s)” lead to questions about current nursing practice.
  • A literature review and critique of studies finds that there is not a sufficient number of scientifically sound studies to use as a base for practice.
  • Need for investigation.
  • Nurses in practice collaborate with scientists in nursing and other disciplines conducting clinical research.

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  • Knowledge and problem-focused “trigger(s)” lead to questions about current nursing practice.
  • A literature review and critique of studies finds that there is not a sufficient number of scientifically sound studies to use as a base for practice.
  • Need for investigation.
  • Nurses in practice collaborate with scientists in nursing and other disciplines conducting clinical research.

Develop and implement improved practice

Other types of evidence

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Findings are then combined with evidence from existing scientific knowledge to develop and implement improved practice.

If there is insufficient research to guide practice, and conducting a study is not feasible, other types of evidence (e.g., case reports, expert opinion, scientific principles, theory) are used and/or combined with available research evidence.

Priority is given to projects in which a high proportion of practice is guided by research evidence.

If a practice change is warranted, changes are implemented using a process of planned change.

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Priority is given to projects in which a high proportion of practice is guided by research evidence. Practice guidelines usually reflect research and nonresearch evidence and therefore are called EBP guidelines.

If a practice change is warranted, changes are implemented using a process of planned change. The practice is first implemented with a small group of patients, and an evaluation is carried out.

EBP is refined based on evaluation data.

Outcomes are monitored.

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The EBP is then refined based on evaluation data, and the change is implemented with additional patient populations for which it is appropriate.

Patient/family, staff, and fiscal outcomes are monitored.

Selecting a topic

Problem-focused triggers

Quality improvement data

Risk-surveillance data

Benchmarking data

Financial data

Recurrent clinical problems

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Selecting a topic

Knowledge-focused triggers

Reading research

Listening to scientific papers at research conferences

Reviewing EBP guidelines published by federal agencies or specialty organizations

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Critical that staff members:

Be involved in selecting the topic

View the potential practice as contributing significantly to patient care

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No matter what method is used to select an EBP topic, it is critical that the staff members who will implement the potential practice changes are:

  • Involved in selecting the topic
  • View it as contributing significantly to the quality of care

Forming a team

Composition of the team

Key stakeholders identified

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Forming a team

  • The composition of the team is directed by the topic selected and should include interested stakeholders in the delivery of care.
  • Key stakeholders who can facilitate the EBP project or put up barriers against successful implementation should be identified.
  • A stakeholder is a key individual or group of individuals who will be directly or indirectly affected by the implementation of the EBP.

Identification of key stakeholders:

How are decisions made?

What types of changes will be needed?

Who is involved in decision-making?

Who is likely to lead and champion implementation?

Who can influence the decisions?

What type of cooperation is needed?

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Questions to consider in identification of key stakeholders include:

  • How are decisions made in the practice areas where the EBP will be implemented?
  • What types of system changes will be needed?
  • Who is involved in decision-making?
  • Who is likely to lead and champion implementation of the EBP?
  • Who can influence the decision to proceed with implementation of an EBP?
  • What type of cooperation do you need from which stakeholders to be successful?

Failure to involve or keep supportive stakeholders informed may place the success of the EBP project at risk because they are unable to anticipate and/or defend the rationale for changing practice, particularly with resistors (non-supportive stakeholders) who have a great deal of influence among their peer group.

Question clearly defined:

Types of people and patients

Interventions or exposures

Outcomes

Relevant study designs

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A clearly defined question should specify

Types of people/patients

  • Diseases or conditions of interest
  • Patient population (e.g., age, gender, educational status)
  • Setting

Interventions or exposures

  • Types of interventions of interest to the project
  • Comparison interventions (e.g. standard care, alternative treatments)

Outcomes

Outcomes of primary importance

  • Type of outcome data that will be needed for decision-making (e.g. benefits, harm, cost)
  • Avoid including outcomes that may be interesting but of little importance to the project

Relevant study designs

  • Provide reliable data
  • Search for the highest level of evidence available

Consider using PICO

Patient, population, or problem

Intervention or treatment

Comparison intervention or treatment

Outcomes

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Evidence examined should include:

Clinical studies, meta-analyses, integrative literature reviews, and existing EBP guidelines

Identify key search terms

Use the expertise of health science librarians

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It is helpful to categorize articles and read in this order:

Clinical (nonresearch)

Theory articles

Integrative and systematic reviews

Synthesis reports

EBP guidelines

Research articles

Meta-analyses

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There are many grading schemas available but all address:

Quality of the individual research

Strength of the body of evidence

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Before reviewing the literature, it is imperative that the team agree on:

Methods for categorizing the type of research

Rating the quality of individual articles

Grading the strength of the body of evidence

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Date of publication or release

Authors of the guideline

Endorsement of the guideline

Clear purpose of what the guideline covers and the patient groups for which it was designed

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Types of evidence (research, nonresearch) used in formulating the guideline

Types of research included in formulating the guideline

Description of the methods used in grading the evidence

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Search terms and retrieval methods used to acquire research and nonresearch evidence used in the guideline

Well-referenced statements regarding practice

Comprehensive reference list

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Review of the guideline by experts

Whether the guideline has been used or tested in practice and, if so, with what types of patients and in what types of settings

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Best as a group project

Journal club

Novice and expert

Assistance from students

Use graduate students

Class project

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Best as a group project

  • Use a journal club to discuss critiques done by each member of the group.
  • Pair a novice and expert to do critiques.
  • Get assistance from students who may be interested in the topic and want experience doing critiques.
  • Assign the critique process to graduate students interested in the topic.
  • Make a class project of critique and synthesis of research for a given topic.

Use summary tables to synthesize information and include:

Study purpose

Research questions and hypotheses

Variables studied

Description of sample and setting

Research design

Methods used to measure each variable

Description of the intervention tested

Findings

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Use summary tables to synthesize information. Include:

  • Study purpose
  • Research questions/hypotheses
  • The variables studied
  • A description of the study sample and setting
  • The type of research design
  • The methods used to measure each variable
  • Detailed description of the independent variable/intervention tested
  • The study findings

Practice changes based on evidence

Consider:

Relevance

Consistency

Sample characteristics

Feasibility

Risk-benefit ratio

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Practice changes should be based on evidence derived from several sources demonstrating consistent findings.

Consider:

  • Relevance for practice
  • Consistency in findings across studies/guidelines
  • A significant number of studies/guidelines with sample characteristics similar to those to which the findings will be used
  • Consistency between research and nonresearch evidence
  • Feasibility for use in practice
  • The risk/benefit ratio

Put in writing the evidence base of the practice.

Clinicians need to know:

That recommended practices are based on evidence

The type of evidence (e.g., randomized clinical trial, expert opinion) used in developing the EBP standard

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Implementing the practice change

Rogers’ model on diffusion of innovations

  • Nature of the innovation
  • Manner in which it is communicated

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Implementing the practice change

Rogers’ model on diffusion of innovations theorizes that adoption of innovations, such as EBPs are influenced by:

  • The nature of the innovation (e.g. the type and strength of evidence; the clinical topic)
  • The manner in which it is communicated (disseminated) to members (nurses) of a social system (organization, nursing profession)

Characteristics of innovations that influence adoption:

Advantage

Compatibility

Complexity

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Characteristics of innovations that influence adoption:

  • The relative advantage of the EBP (e.g. effectiveness, relevance to the task, social prestige)
  • The compatibility with values, norms, work, and perceived needs of users
  • The complexity of the EBP topic

Strategies to promote adoption:

Reinvention of the EBP guideline to fit the local context

Use of quick reference guides and decision aids

Use of clinical reminders

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Methods of communicating change:

Mass media

Educational strategies

Opinion leaders

Change champions

Core groups

Educational outreach

Performance gap assessment

Audit and feedback

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Methods of communicating change:

Mass media

Educational strategies

  • Posters
  • Train-the-trainer programs
  • Computer assisted training
  • Competency testing

Opinion leaders

  • Members of the local peer group
  • Viewed as a respected source of influence
  • Considered by associates as technically competent
  • Trusted to judge the fit between the innovation and the local setting

Change champions

  • Practitioners within the local group setting
  • Expert clinicians
  • Passionate about the innovation
  • Committed to improving quality of care
  • Have a positive working relationships
  • They are encouraging and persistent
  • Particularly effective with nurses

Core groups

  • A select group of practitioners who disseminate information and facilitate change
  • Members represent various shifts and days of the week
  • Members knowledgeable about the scientific basis for the practice
  • Members take the responsibility educating and effecting practice change with several peers
  • They reinforce the practice change on a daily basis and provide positive feedback

Educational outreach/academic detailing

  • Done by a topic expert who may be external to the practice setting
  • Meets one-on-one with practitioners
  • These experts are able to explain the research base for the EBPs to others and are able to respond convincingly to challenges and debates
  • Advanced practice nurses often fill this role

Performance gap assessment

  • Informs members, at the beginning of change, about a practice performance and opportunities for improvement
  • Specific practice indicators selected

Audit and feedback

  • Ongoing auditing of performance indicators
  • Aggregating data into reports
  • Discussing the findings with practitioners
  • Occurs during the practice change

Social context and change

Strong leadership

Clear strategic vision

Good managerial relations

Visionary staff in key positions

A climate conducive to experimentation and risk taking

Effective data capture systems

Available resources to support change

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Goal is to collect and analyze data with regard to use of a new EBP and then to modify the practice as necessary.

Evaluation should include both:

Process measures

Outcome evaluation

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Goal is to collect and analyze data with regard to use of a new EBP and then to modify the practice as necessary

Evaluation should include both process and outcome measures

Process measures

  • Focus on how the EBP change is being implemented.
  • Is staff using the practice in care delivery and implementing the practice as noted in the written EBP standard?

Outcome evaluation

  • Assess whether the patient, staff, and/or fiscal outcomes expected are achieved
  • Baseline data needed for a pre/post comparison

Process measures should evaluate

  • Barriers that staff encounter in carrying out the practice
  • Differences in opinions among health care providers
  • Difficulty in carrying out the steps of the practice as originally designed
  • Data can be collected from staff and/or patient self-reports, medical record audits, or observation of clinical practice

Outcome measures should evaluate

  • The practices that are projected to change
  • Practice before the change in practice is implemented, after implementation, and every 6 to 12 months

Findings must be provided to clinicians to:

Reinforce the impact of the change in practice

Ensure that they are incorporated into quality improvement programs

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Education must include knowledge and skills in the use of research evidence in practice.

Communicate and integrate EBP into nursing profession.

Professional responsibility of all nurses to read and use research in their practice and to communicate with nurse scientists the many and varied clinical problems for which we do not yet have a scientific base.

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The researcher

A direct care provider

The hospital administrator or CEO

The head nurse or CNO

A mixture of management and direct care providers

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ANSWER: E

RATIONALE: A group of people--and they should be key stakeholders in the decision-making process--would be most effective in implementing EBP changes.

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Education specialist

Information technologist

Opinion leader

Risk manager

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ANSWER: C

RATIONALE: Of course, all of these help, but opinion leadership is multifaceted and complex, with role functions varying by the circumstances. Few successful projects to implement innovations in organizations have managed without the input of identifiable opinion leaders. They champion the cause.

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Strong leadership

Clear strategic vision

Visionary staff in key positions

A climate conducive to experimentation and risk taking

All of the above

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ANSWER: E

Rationale: All answers are correct.

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Patient outcomes

Cost savings

Who is successfully using it

Barriers overcome

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ANSWER: A

RATIONALE: Patient outcomes is slightly ahead of cost savings. Both are important. Evaluation should include both process and outcome measures. The process component focuses on how the EBP change is being implemented. It is important to know whether staff are using the practice in care delivery and whether they are implementing the practice as noted in the written EBP standard. Evaluation of the process also should note (1) barriers that staff encounter in carrying out the practice (e.g., lack of information, skills, or necessary equipment), (2) differences in opinions among health care providers, and (3) difficulty in carrying out the steps of the practice as originally designed.

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