What is Evidence-Based Practice?

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What is Evidence-Based Practice?

• Evidence-Based Practice from a Nursing
  Perspective
• Cynthia Padula, PhD, RN
• Nurse Researcher, The Miriam Hospital
• Masters Program Director, Rhode Island College

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Objectives

• Describe evidence based practice from a nursing
  perspective
• Identify challenges to using evidence based
  practice in nursing
• Compare and contrast evidence based nursing and
  medicine
• Recognize the impact of the Magnet movement on
  evidence based nursing practice
• Identify resources relevant to nursing

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Definition

• Process by which nurses make clinical
  decisions using best available evidence, clinical
  expertise, patient preferences in the context
  of available resources (DiCenso, 1998)

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Evidence Based Practice
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What is Evidence-Based Nursing Practice

• Builds on process of research use, but more
  encompassing
• More specific than term best practices
• Does not foster rigid adherence to standardized
  guidelines
• Recognizes the role of clinical expertise
• EB nursing practice is a state of mind!

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Why Evidence-Based Practice in Nursing

• Fueled by accrediting bodies, professional
  organizations, third party payers
• Potential to improve quality, reduce variations
  in care
• Focus on practices that result in best possible
  outcomes at possibly lower cost
• Provides a way to keep pace with advances

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Why Evidence-Based Practice in Nursing

• Potential to narrow the research-practice gap
• adoption of research findings into
  practice can
• take as long as 17 years (Balas Boren)
• Impacted by perception that published research is
  not
• relevant to practice
• Provides a means to answer problematic clinical
• practice issues
• Potential to improve individual bedside practice
  
• supports/improves clinical decision-making
  skills
• Bedside nurse as conduit!!

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Traditional Basis for Nursing Practice
(Stetler)

• Rituals, unverified rules
• Anecdotes, isolated experiences
• Customs, opinions, unit cultures
• Physicians authority

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Bases for Practice in Nursing (Stetler, 1998)

• Philosophical/conceptual basis mission values
  professional practice models conceptual
  frameworks professional codes
• Regulatory basis state practice act JCAHO
  regulatory agencies
• Traditional basis
• Evidence-based practice

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Alternative Approach

• Clinical expertise as necessary but not
  sufficient to provide best possible care
• Emphasis is on systematic, reproducible, unbiased
  evidence
• Focus on evidence authority in combination with
  clinical expertise

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Core Competencies

• Ask why are we doing this..
• what is the evidence?
• Think critically!
• Think out of the box!

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Core Competencies (cont.)

• Prioritize and clearly articulate answerable
• clinical questions with a focus on outcomes
• Appreciate role of quality improvement activities
• Evaluate practice outcomes
• Work effectively with others

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Core Competencies (cont.)

• Search for evidence

• Evaluate the evidence

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Core Competencies (cont.)

• Read and understand research

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Levels of Evidence Hierarchy(Stetler et al.)

• Level I Meta-analysis of multiple RCTs
• (gold standard)
• Level II Individual RCTs
• Level III Quasi-experimental
• Level IV Non-experimental qualitative
• Level V Program evaluation QI RU case
  reports
• Level VI Opinion of respected authorities
• modified slightly by Padula

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Levels of Evidence Pyramid
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Evidence Based Practice Process

• Identify a practice issue
• Formulate an answerable question
• Search for best evidence
• Critically evaluate the evidence and clinical
  relevance
• Make recommendations
• Apply to clinical practice
• Evaluate impact/effectiveness/ outcomes

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EBP in Nursing
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Readiness of US Nurses for EBP (Pravikoff et al.,
2005)

• Purpose to examine nurses perceptions of their
  skills in obtaining evidence and their access to
  tools with which to do so.
• Sample stratified random sample of 3,000 RNs
  across the US 1,097 responded
• Measurement 93 item measure content validity
  established varying response format

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Sample Characteristics (Pravikoff et al.)

• 91 female
• 79 between gt40 years of age
• Educational preparation
• Diploma 17
• AD 34
• BSN 39
• MS 9
• Employment 60 in hospitals

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Subscale Information Need/Seeking

• How often do you need
• information to support nursing role?
• 61 once or twice a week
• How do you find the information
• needed?
• 67 always or freq sought a colleague
• 58 didnt use research reports at all
• 82 had never used a hospital library

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Subscale Resource Availability and Use

• 83 at least somewhat successful when searching
  the Internet
• 19 somewhat confident in ability to search
  CINAHL 76 never search CINAHL
• 36 somewhat confident in ability to search
  MEDLINE
• 83 rarely or never sought librarian assistance
  82 didnt use hospital library

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Resource Use/Availability (cont.)

• 77 had never received instruction re electronic
  resources
• 36 reported had access to electronic databases
  29 did not know if access was available
• 26 had access to electronic databases on nursing
  units
• 49 had access to the Internet on units

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Subscale Individual Barriers (other than time)

• Lack of value for research in practice
• Lack of understanding of electronic databases
• Difficulty accessing materials
• Lack of computer skills
• Difficulty understanding articles
• Lack of access to computer library access
  search skills research knowledge critiquing
  skills

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Differing ChallengesNursing
Medicine

• Varying entry levels
• Rapid indoctrination
• Off unit access difficult
• Clinical reality more subjective/human
  response
• Most quasi or below qualitative

• MD degree
• Internship/residency
• Easier access off unit
• Focus on objective reality/ treatment
  effectiveness research
• More RCTs

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Using the Magnet Influence

• Administered by the American
• Nurses Credentialing Center
• http//nursingworld.org.ancc
• Magnet designation recognized
• and rewards nursing excellence
• Forces of Magnetism (14) identified via a
  landmark study (McClure Hindshaw)

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Selected Forces

• Professional models of care
• -must designate a nursing theory
• Quality of care
• -support of research/evidence based practice
• Quality improvement
• -nurse driven, evidence based quality
  initiatives

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Selected Forces (cont.)

• Professional development
• -training, mentoring
• Interdisciplinary relationships
• -opportunities for collaboration consultation

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Collaboration is Key

• Library can serve as archive for nursing
  publications/Magnet applications (Rourke)
• Committee participation
• Heightened visibility
• Facilitation is key
• Write library services and
• librarians into grants

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Take the Magnet Journey!!
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Resources

• Evidence Based Nursing Journal
• Online Journal of Knowledge Synthesis for
  Nursing, Sigma Theta Tau
• http//www.nursingsociety.org
• US Preventive Services Task Force
• http//www.ahrq.gov/clinic/uspsfact.htm

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Selected Lifespan Resources

• Direct links to PubMed and Ovid
• Micromedex
• gt 3000 journals
• DXplain
• MD consult

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References

• Baras, E., Boren, S. (2000). Managing clinical
  knowledge for
• healthcare improvement (pp. 65-70). Germany
  Schattauer
• Publishing.
• Dee, C., Stanley, e. (2005). Nurses
  information needs nurses and
• hospital librarians perspective. J Hosp
  Librar, 5(2), 1-13.
• Hallyburton, A., St. John, B. (2009).
  Partnering with your library to
• strengthen nursing research. J Nsg Educ,
  49(3), 164-167.
• McClure, M., Hinshaw, A. (2002). Magnet
  hospital revisited.
• Washington DC ANA.
• Pravikoff, D., Tanner, A., Pierce, S. (2005).
  Readiness of US nurses
• for evidence-based practice. AJN, 105(9),
  40-51.

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References (cont.)

• Rourke, D. (2007). The hospital library as a
  Magnet ForceMed Ref
• Svcs Quar, 26(3), 47-54.
• Sherwill-Navarro, P., Roth, K. (2007).
  Magnet hospital/magnetic
• libraries. J Hosp Librar, 7(3), 21-31
• Stetler C. et al. (1998). Evidence-based
  practice and the role of nursing
• leadership. JONA, 28(7/8), 45-53.
• Stetler, C. et al. (1998). Utilization-focused
  integrative reviews. Appl
• Nurs Res, 11(4).