Ever Wonder? DO YOU DO EBP? Does not have to be new knowledge!

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1 Evidenced based practice Berdette Reuer, MSN, RN Ever Wonder? Have questions about what you do? Wonder if there is a better way to do it? Notice a policy/procedure that needs updating? This is how we do it- so no need to question If EBP is a big project? If EBP is extra work? Do you have time for EBP? 1 2 DO YOU DO EBP? Does not have to be new knowledge! Evidence-Based PRACTICE Examine nursing practice Analyze alternative and contradictory data Make sound nursing care decision supported by best evidence Systematic approach to nursing practice enhances likelihood that patient will receive the best care possible Evidence-Based PROJECT Education of others Translation of practice Re-evaluate results Your car has just died & cannot be resuscitated! A family member has offered to loan you the money to get a new car. What do you do next? A. Check Consumer Reports B. Ask friends/coworkers for a recommendation C. Buy the brand you always get D. Go out & try a few on the road Self ownership VS Unit department influence toward transformation 3 When you need information for a clinical problem, where do you usually go to find information? A. Ask a colleague B. Look for a policy/procedure C. Search the internet D. Ask the librarian How do you find information when you need it? Librarian: 56.3% never; 26.7% rarely; 81% never use workplace library Search Databases: 42.2% never; 26.8% rarely 36%said facility provided access to electronic databases, 29% didn t know; 26% had access to electronic databases on their nursing units 1

2 How do you find information when you need it? Read journals or books: 45.2% = never, rarely, or sometimes (17.4% never); 40% had access to journals on their nursing unit Research reports: 58.2% never seek information from this source; 71.8% had not evaluated a research report in the past year; 66.5% had not participated in research; 58.7% had not identified researchable problems How do you find information when you need it? Colleague or peer: 15.5% always; 78.6% frequently or sometimes Peer response is the greatest resource. What is Evidence Based Practice? Evidence-based practice has been defined as a problemsolving approach to the delivery of healthcare that incorporates the best available evidence, clinician s expertise and patient values and preferences (Melnyk, Gallagher-Ford, Long, & Fineout-Overholt, 2014). Other Definitions The process of shared decision-making between the practitioner, patient, and others significant to them based on the best available evidence, the patient s experience and preference. (Sigma Theta Tau, 2008) EBP is traditionally defined in terms of a "three legged stool" integrating three basic principles: (1) the best available research evidence bearing on whether and why a treatment works, (2) clinical expertise (clinical judgment and experience) to rapidly identify each patient's unique health state and diagnosis, their individual risks and benefits of potential interventions, and (3) client preferences and values. (Spring, 2007; Lilenfield, et al, 2013). 10 What do we mean by practice? EBP Nurses engage in professional nursing practice Practice is the mental, physical, emotional, and spiritual work that we do Practice implies an interaction INTEGRATION OF: BEST EVIDENCE CLINICAL EXPERTISE PATIENT PREFERENCES 2

3 Best evidence Clinical expertise Clinical judgment that accumulates with experience Reality filter for evidence Patient preference EBP Personal, spiritual, cultural beliefs and values Freedom to choose NO THANKS The patient trumps evidence and clinical expertise CORE: Evidence based Practice + + Your clinical expertise Best available clinical evidence from systematic research Preferences & values of individuals, families, communities 18 3

4 Why Is EBP Important? Organizational readiness Internal Factors Improve quality of care Patient safety ANA professional standards of practice & professional performance Informed clinical & administrative decisions Cost savings Stay abreast of knowledge explosion External factors Accreditation Legislation Regulations Standards Magnet Internal and external influences Culture Vision vs. Clinical Staff vs. Management 20 Translate Knowledge Into Action Staff Readiness Personal interest Avoid risk of negative consequences Personal value Decrease work stress Someone says to do it Regulatory guidelines Going for magnet status Leadership Clinical education Managers ACE Star model of knowledge translation Organizational Readiness Desired Vision What Is Practical Culture of inquiry/openness Nurse skills to locate info Translate research findings Present evidence & proposed practice change Champion changes Staff and Managers Attitude on EBP Readiness Agree Regulatory agency requirements were a negative motivator Institution history had difficulty sustaining practice changes Too many changes at one time Disagree +staff/-manager Support of clinical educator EBP does not take into account limitations of the practice setting -staff/+managers Availability of information Support for bedside staff Lack of resources as a major barrier to success of implementation 24 4

5 Organizational Readiness Supporting Infrastructure Barriers Individual characteristics Lack skill to locate, interpret research Insufficient time Attitude: not interested Organizational Insufficient time Lack of staff Insufficient administrative support Limited access to info (library/articles) Not having right equipment, supplies, technology 25 Professional Practice Model with Shared Governance 1. Professional development (e.g. journal/book club) 2. Nurse Practice Council 3. Performance Improvement Council 4. Nursing Peer Review 5. Evidence-Based Practice Committee Organizational culture Commitment to EBP & professional nursing EBP is a priority Skill development Provide resources Participative leadership style What does the evidence show? ANA Standards of Professional Practice (2004) History Lesson The RN utilizes the best available evidence, including research findings, to guide practice decisions. 27 a2 Is EBP = research utilization? What s the difference? EBP Research utilization (RU) Broad A part of EBP Critical appraisal of all evidence Critical appraisal of research reports Evidence includes many types of credible info: Only EVIDENCE is research: experimental Clinical Guidelines Lit Reviews quasi-experimental Recommendations Of Prof. Organizations Expert Opinion/Consensus non-experimental qualitative Regulations QI Data Program Evaluations Theories * Depends on availability, usually publication Case Reports Organizational Data Evaluative Data Clinical Judgment/Experience Patient Experience, Preferences, Values When applying, integrate clinician s expertise & client preference Answers a specific question under specific conditions a1 How Now Sacred Cow? Nursing as a profession has accepted many practices as "truth"; traditional practices so revered that they are not questioned. As nursing shifts into a culture of evidencebased practice, the time has come to examine the sacred cows. We need to ask the question: Why do we do it this way? 5

6 Traditions or Science? Use of Trendelenburg position for hypotension or Head down position worsens shock, increases ICP, restricts ventilation, displaces only 1.8% of total blood volume Hartshorn et al, 1997; Bridges & Jarquin-Valdivia, 2005 Restricted visiting of patients in ICU - every 2 hours; 10 minute visits; immediate family members; no children Flexible visiting practices (Cohen et al, 1998; Cullen, Titler & Drahozal, 2003; Halm et al, 1990; Titler, 1999; Titler et al, 1995; Titler 1995; Titler & Walsh, 1992; Titler et al, 1991) Auscultation during air insufflation for verification of NG tube placement Auscultation of air insufflation is not reliable in differentiating tube location; the only reliable method to verify tube placement is X-ray Other bedside methods provide acceptable alternatives (e.g., aspirate color, aspirate ph, marking and securing the tube at the nares, etc.) Burns, et al., 2001; Farrington, et al., under review; Ghahremani & Gould, 1986; Gabriel, et al., 1997; Huffman, et al., 2004; Kearns, 1997; McWey, et al., 1988; Methany, 1988; Methany et al., 1988; Methany, et al., 1993; Methany et al., 1994; Methany et al., 1999; Methany & Titler, 2001; Methany & Stewart, 2002; Rakel, et al., 1994; Swiech, et al., 1994; Westhus, 2004 EBP Model Johns Hopkins Johns Hopkins Nursing EB Process steps Practice Question 1. ID an EBP question 2. Define scope of practice 3. Assign responsibility for leadership 4. Recruit multidisc. Team 5. Schedule tm conference Evidence steps 6. Conduct internal & external search for evidence 7. Critique all types of evidence 8. Summarize evidence 9. Develop recommendations for change in processes or systems of care based on strength of evidence Translation steps 11. Determine if appropriate & feasible to translate recommendations into practice setting 12. Create action plan 13. Implement change 14. Evaluate outcomes 15. Report prelim results to decision makers 16. Secure support to implement change 17. Identify next steps 18. Communicate findings 35 6

7 Ask a burning question Collect the most relevant and best evidence Critically appraise the evidence Integrate all evidence to make a practice decision or change Evaluate the practice decision or change Ask a burning question Collect the most relevant and best evidence Critically appraise the evidence Integrate all evidence to make a practice decision or change Evaluate the practice decision or change 38 Questions about our practice occur daily. Ask a burning question Why do we perform an assessment or intervention in a particular way? Why does the medical floor perform a procedure one way and the surgical floor another way? Triggers for EBP Problem-focused Clinical problems Procedures Risk management Process improvement Benchmarks Need for cost reduction Knowledge-focused New standards/guidelines New research/literature Integrating philosophy of care/theoretical framework what is the best way to Is more effective than What is the best way to Is more effective than Jot down 5-7 clinical problems, practice dilemmas, or questions that you experienced in the past 3 weeks. The one that is most important to you. 42 7

8 We have lots of ideas. Why Does Your Question Matter? Which questions have best chance of being selected/ supported? Priority for department/organization? (Strategic Goals, Key Project Improvement Plans) Magnitude of the problem? Likelihood of a) improving outcomes &/or b) saving money? Staff interest/commitment? Nursing only vs. multidisciplinary? Anticipate any strong opposition? Background The foundation of current practice Rational of current practice Internal design External design Significant of the problem Foreground Vision for change Goals or direction Outcomes or results 44 Background Foreground Frame a Question: PICO P Patient, population, or problem Research Subjects/sample 45 I Intervention C Comparison with other treatment, if applicable (There may not be a comparison.) O Outcomes Independent variable Control Dependent variables Confounding variables Limitations Population PICO Patients with heart failure Intervention Comparison Standardized discharge education including 5 elements: activity, diet, medications, upcoming appointments, and what to do if symptoms worsen No comparison due to Joint Commission standards P I C O Outcomes Decreased hospital admissions, increased disease management at home

9 Collect the most relevant and best evidence Start with the Advanced Search Tool Use the right language Search engine Database Synonyms, related terms Start broad (nouns of your PICO) narrow or expand Limiters/refine the search Evidence-based systematic review Evidence based synopsis EBP synthesis Practice alerts Guidelines meta-analysis or meta-synthesis Question??? Search Strategy Identify search terms Correct terminology is crucial Lateral thinking Awareness of terminology that reflects topic interest Ex=Pressure ulcer wound management tissue viability Combine relevant topics And - Or - Select relevant materials Key words Search Databases Major databases Cost: free vs. subscription How much can you get? citations vs. abstracts vs. full text The Big 4: 1. Cochrane Database of Systematic reviews ($) 2. PubMed/MEDLINE (free) 3. CINAHL ($) 4. OVID ($) 53 9

10 More Professional organizations Benchmarking data Standards (Joint Commission) Guidelines (AHRQ, CPG) Practice alerts Expert opinions Conferences (live, abstracts, presentations) Newsletters Google advanced search Joanna Briggs Institute Internal resources Continuous Improvement Department Infectious Disease Department Leadership Finance Department Supply Department 56 Critically appraise the evidence Find the best evidence There are several types of evidence Not all evidence is equal Systematically search for evidence Design and Implementation Map out a plan and/or time line Project manager Accountability of task Include all the disciplines and/or areas that will be effected by the change Remember to include all processes that may be necessary for facility processes Integrate all evidence to make a practice decision or change =detail&mid=57819eb a51e eb a51 E92&rvsmid=D7C61936B35C347DE6F3D7C61936B35C347D E6F3&fsscr=

11 Measure Outcomes Evaluate the practice decision or change Clinical expertise Evidence Practice Patient value Clinical Decision Making What Patients Staff Satisfaction Compliance Patient Outcomes How Data collection tools o Design your own o Established tools Reliability and validity 62 What is EBP? Essential resources Clinical Decision Making Patient Outcomes 1. Availability of nurse researcher who is adept at methodological design MENTOR 2. Full service library with subscriptions to databases that contain high-level EBP resources 3. Experts (quality or clinical specialists or nurse educators) to bridge the gap between how to access, interpret, implement, & evaluate EB decisions 4. Active participation by RN staff 5. Coordination of administrative details Ask a burning question Collect the most relevant and best evidence Critically appraise the evidence Integrate all evidence to make a practice decision or change Evaluate the practice decision or change 63 11