Objectives. EBP: A Definition. EBP: A Definition. Evidenced-Based Practice and Research: The Fundamentals. EBP: The Definition

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1 Objectives Evidenced-Based Practice and Research: The Fundamentals March 22, 2011 EBP Boot Camp Presentation by Cynthia A. Oster, PhD, MBA, RN, CNS-BC, ANP Upon completion of this educational activity, the participant will be able to: Define EBP Name four components of EBP Name the steps of EBP Discuss fundamental principles of EBP Discuss professional roles in EBP 2 EBP: A Definition Evidence-based medicine (EBM) is the integration of best research evidence with clinical expertise and patient values. Sackett, Straus, Richardson, Rosenberg & Haynes, 2000, p. 1 Best research evidence clinically relevant research Clinical expertise ability to use clinical skills and past experience Patient values unique preferences, concerns and expectations EBP: A Definition A problem solving approach to practice that involves the conscientious use of current best evidence in making decisions about patient care. EBP incorporates a systematic search for and critical appraisal of the most relevant evidence to answer a clinical question along with one s own clinical expertise and patient values and preferences. Melnyk & Fineout-Overholt, 2005, p EBP: A Definition Evidence-based practice is the conscientious integration of best research evidence with clinical expertise and patient values and needs in the delivery of highquality, cost-effective health care. Burns & Grove, 2007, p. 4 EBP: The Definition Evidence-based practice at Porter, Littleton and Parker Adventist Hospitals is a process for finding, appraising, and aggregating evidence as the basis for effective clinical practices. Evidence Based Practice Council, Porter Adventist Hospital, February

2 EBP: Guiding Principles Unbiased research EBP: Components Evidence Based Practice Consumer needs, patient preferences, community expectations Focus on outcomes significant to clinical practice Systematic dissemination Continuous process Evaluate need for practice review Monitor effects of clinical interventions, Evidence Based Practice Council, February 2008 Practice Guidelines from Reliable Systematic Professional Sources Reviews Quality Studies and Bedside Science Research Studies 7 Houser, J. & Bokovoy, J. (2006). Clinical Research in Practice: A Guide for the Bedside Scientist. Jones and Bartlett Publishers: Sudbury MA. 8 9 Practice Guidelines Cover broad array of clinical & diagnostic services Define minimum set of services appropriate to a clinical condition Reliable professional sources Find Appraise Evaluate Adapt 10 Practice Guidelines from Reliable Professional Sources Agency for Healthcare Research and Quality Bandolier Journal of Evidence Based Guidelines in Health Care Best BETS (Best Evidence Topics) Centers for Disease Control and Prevention Institute for Clinical Systems Improvement catid=29 Infectious Diseases Society of America ractice_guidelines/standards_practice_guidelines _Statements/Standards,_Practice_Guidelines,_and _Statements.htm Michigan Quality Improvement Consortium National Centers for Infectious Disease ate.htm National Guidelines Clearinghouse National Institute for Health and Clinical Excellence New Zealand Guidelines Group 4&ScreenResSet=yes&CFTOKEN PubMed Clinical Queries ical.shtml Registered Nurses Association of Ontario Society of Critical Care Medicine lines/index.asp Quality Studies and Bedside Science Method to improve systems and processes Result in nursing practice changes to improve patient outcomes Systematic Reviews Rigorous review of literature Result in bias-free nursing practice recommendations based on strength of evidence Houser, J. & Bokovoy, J. (2006). Clinical Research in Practice: A Guide for the Bedside Scientist. Jones and Bartlett Publishers: Sudbury, MA

3 Research Studies Research is a systematic process of inquiry that uses rigorous guidelines to produce unbiased, trustworthy answers to questions about nursing practice. Houser, 2008, p. 5 Result in the generation of new nursing knowledge Research Studies Quantitative Traditional approach where variables are identified and measured in a valid and reliable way Descriptive - Studies a subject of interest in a defined population or setting Correlation - Studies that search for relationships among variables p value Power ANOVA Regression t-test Sample Size Houser, J. (2008). Nursing Research: Reading, Using and Creating Evidence. Jones and Bartlett Publishers: Sudbury, MA. Experimental - Studies that compare groups for the effects of interventions on outcomes Research Studies Qualitative Naturalistic approach where the focus is understanding the meaning of an experience of the individual s perspective Phenomenological Description of an experience as it is lived by an individual Case Study Notes Participant Observation Field Notes Anthropological Material Structured and Unstructured Interviews Videos and Recordings Monitoring of VAP rates in the ICU Building Nursing Knowledge: The Three-Legged Stool* CQI Nursing Practice EBP Guideline for the Prevention of VAP Ethnographical Investigating cultures through an in-depth study of the members of the culture Historical Narrative description or analysis of events that occurred in the remote or recent past Research Is an every 2 hour oral care protocol more effective than an every 4 hour oral care protocol in reducing VAP in the ICU? *Hedges, C. (2006). Research, Evidence-based Practice, and Quality Improvement: The 3-Legged Stool. AACN Advanced Critical Care, 17(4), EBP: The Six Steps (Houser, 2008; Melnyk & Fineout-Overholt, 2005) Step 6 Step 5 Step 4 Step 3 Step 2 Step 1 18 EBP: Step 1 Construct a well developed question PICO Format Patient or problem Intervention Comparison intervention Outcome Example: In radical prostatectomy patients staying in the hospital one day after surgery, does customized preoperative teaching compared with standard preoperative teaching lead to better pain control as measured by a visual analog scale? 3

4 EBP: Step 2 Obtain the evidence Search the literature for the most appropriate evidence. Guidelines Meta-analyses Systematic reviews EBP: Step 3 Appraise the evidence Critique the evidence for both internal and external validity EBP: Step 4 Integrate the evidence Integrate the scientific evidence with clinical experience, patient preferences and patient values. EBP: Step 5 Apply the evidence Apply the evidence to management of a patient s problem EBP: Step 6 Evaluate effectiveness Evaluate patient outcomes to determine if the plan of care was effective. QI? EBP? Research? Burning Question Adequate Evidence? Yes No QI Project Research Project EBP Project Practice Change Improved Patient Care: GREAT OUTCOMES!

5 25 Questions that Spark a Spirit of Inquiry Who? Which? When? Where? How? Why am I doing what I do with my patients? Source: Titler, M. et. al. (2001). The Iowa model of evidence-based practice to promote quality care. Critical Care Clinics of North America, 13(4), Burning Question Burning Question from the Bedside Scientist* Direct Unit-Based Practice Council Cynthia A. Oster PhD, MBA, RN, CNS /ANP Chair, Evidence-Based Practice Council Office: 303/ cynthiaoster@centura.org Nursing Practice Council EBP: Fundamental Principle Evidence alone is never sufficient to make a clinical decision. Evidence-Based Practice Council *The Bedside Scientist is a healthcare practitioner, such as a staff nurse, who contributes to the body of knowledge that is the basis for clinical practice Rating Evidence Strongest Evidence Well designed research studies suitable for the question Not all studies are well designed Different study designs suit different questions Triangulated results always stronger EBP: Fundamental Principle The kind of evidence should suit the question under consideration

6 Rating Evidence Not as Strong Expert opinion (including articles by experts giving their opinion) Studies with weaknesses but compelling results EBP: Fundamental Principle A hierarchy of evidence should guide clinical decision making Level of Rating Level I: Required Level II: Recommended Level III: Recommended Type of Study Hierarchy of Evidence - Clinical Model Multiple studies reported as meta-analysis, systematic review, or integrative review, or evidence-based practice guideline Well designed studies with large sample sizes and/or large effect sizes Evidence from at least one well designed randomized trial Single randomized trials with small samples Single studies with small to moderate effect sizes IIIA: Evidence from well designed trials without randomization IIIB: Evidence from studies of intact groups Ex post facto and causal-comparative studies Case/Control or cohort studies IIIC: Evidence obtained from time series with and without an intervention Single experimental or quasi-experimental studies with dramatic effect sizes EBP: Professional Role Informed consumer of research Find Read Evaluate Level IV: Optional 33 Evidence from expert panels Systematic reviews of descriptive studies Case series and uncontrolled studies 34 EBP: Professional Role EBP: Professional Role Participate in research related activity Journal club Attend research conference Involvement in a systematic review Practice guideline

7 EBP: Professional Role Involvement with a research study Assist with data collection Serve on a research team EBP: Professional Role Produce focused research Feasible Interesting Novel Ethical Relevant Nursing Research: Professional Role ANA, 1994 Staff Nurse Identify clinical problems Data collection Use research findings in clinical practice APN Active team member Clinical expert Proposal development Data collection Data analysis Interpretation Appraise clinical relevance of research findings Create a practice climate supportive to scientific investigation of clinical nursing problems Doctorate Conduct research Design studies Collaborate with other researchers Acquire funding Dissemination A Philosophy Yesterday Let whoever is in charge keep this simple question in her head (not, how can I always do the right thing myself, but) how can I provide for this right thing to be always done. (Nightingale, F. (1859). Notes on Nursing.) Today.. Care quality should not vary from clinician to clinician or from place to place, and this requires translation of research into practice. (Melnyk, B. M. & Fineout-Overholt, E. (2005). Evidence-Based Practice in Nursing & Healthcare. Lippincott Williams and Wilkins: Philadelphia.) Leadership for integrating findings into clinical practice Questions? Resource Change is not an invitation, it is an obligation and expectation. Tim Porter-O Grady, 2008 EBP Self-Learning Program

8 Citations Burns, N. & Grove, S. K. (2007). Understanding nursing research: Building an evidence-based practice. 4 th ed. Saunders: Philadelphia, PA. Dossey, B. M., Selanders, L. C., Beck, D. & Attewell, A. (2005). Florence Nightingale today: Healing, leadership, global action. American Nurses Association, Silver Spring, MD. Hedges, C. (2006). Research, Evidence-based Practice, and Quality Improvement: The 3-Legged Stool. AACN Advanced Critical Care, 17(4), Houser, J. (2008). Nursing Research: Reading, Using and Creating Evidence. Jones and Bartlett Publishers: Sudbury, MA. Houser, J. & Bokovoy, J. (2006). Clinical research in practice: A guide for the bedside scientist. Jones and Bartlett Publishers, Sudbury, MA. Citations Melnyk, B. M. & Fineout-Overholt, E. (2005). Evidence-based practice in nursing & healthcare: A guide to best practice. Lippincott Williams & Wilkins, New York, NY. Melnyk, B. M., Fineout-Overholt, E., Stillwell, S., & Williamson,K. (2009). Igniting a spirit of inquiry: an essential foundation for evidencebased practice, American Journal of Nursing. 109(11), Nightingale, F. (1860). Notes on nursing: What it is and what it is not. Sackett, D. L, Straus, S. E., Richardson, W. S., Rosenberg, W. & Haynes, R. B. (2000). Evidence-based medicine: How to practice and teach EBM. 2 nd ed. Churchill Livingstone, London, UK. Titler, M. et. al. (2001). The Iowa model of evidence-based practice to promote quality care. Critical Care Clinics of North America, 13(4),