Introduction and Overview of Evidence Based Practice Dr Helen Noble Queens University Belfast, Lecturer, Health Services Research. Associate Editor, Evidence Based Nursing School of Nursing & Midwifery
AIMS OF PRESENTATION Biography Discuss Evidence Based Practice (EBP) Examples of EBP Evidence Based Renal Care - The PACKS study Importance to Nursing Barriers to EBP
BIOGRAPHY
BIOGRAPHY
CAREER CHANGE Senior Clinical Nurse Specialist - 2005 Established Renal Supportive and Palliative care Service No evidence base PhD Opting not to Dialyse: A Practitioner Research Study to Explore Patient Experience Symptoms Impact on carers Trajectories of dying Added to theoretical knowledge of death and dying..city University
THE LADS!
QUEENS UNIVERSITY BELFAST
WHAT IS EVIDENCE BASED PRACTICE The conscious use of current best evidence in making decisions about patient care ( S a c ket t et a l 2 0 0 0 Eviden ce-based M edicine: H ow to Practice a n d Teach E B M ). Definitions of EBP have broadened in scope. Now defined as a lifelong problem-solving approach to clinical care that integrates: A systematic search for and critical appraisal of the most relevant and best research to answer clinical questions One s own clinical expertise (the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice) Patients preferences and values (Melnyk BM, Fineout-Overholt E 2005) Transforming healthcare from the inside out: advancing evidence based practice in the 21 st century. Journal of Professional Nursing; 21: 6, 335-344)
TRIAD OF EVIDENCE BASED PRACTICE Best Available Evidence Individual Clinical Expertise EBP Patient values & Expectations
EBP Integrates best available external clinical evidence from systematic research with Individual clinical expertise..while Taking into account patient preferences/values to achieve Improved patient outcomes
LEVELS OF EVIDENCE I Evidence - Systematic reviews, meta-analysis RCTs, EB clinical practice guidelines based on RCTs II Evidence - One well designed RCT III Evidence - CTs without randomization IV Evidence - Well-designed case control or cohort studies V Evidence - Systematic reviews of descriptive or qualitative studies VI Evidence - Single descriptive or qualitative study VII Evidence Opinions of authorities, reports of experts
RCTS One of the simplest but most powerful tools of research. People are allocated at random to receive one of several clinical interventions. Used to examine the effect of interventions on particular outcomes such as death or the recurrence of disease. Some consider randomized controlled trials to be the best of all research designs, or the most powerful tool in modern clinical research. N y s t r o m L, R u t q v i s t L E, W a l l S, e t a l. B r e a s t c a n c e r s c r e e n i n g w i t h m a m m o g r a p h y : o v e r v i e w o f S w e d i s h r a n d o m i s e d t r i a l s. L a n c e t 1 9 9 3 ; 3 4 1 : 9 7 3 978 KEY: the act of randomizing patients to receive or not receive the intervention ensures that, on average, all other possible causes are equal between the two groups. C o c h r a n e L i b r a r y W e b s i t e. A v a i l a b l e a t : w w w. u pdate-software.com / a b s t r a c t s / a b 0 0 1 8 7 7. h t m
FORMS OF EVIDENCE External evidence Systematic reviews Randomised controlled trials Clinical practice guidelines Internal evidence Health care professionals expertise Quality improvement projects Patient evidence Preferences what does the patient want when given different options Values quality of life
STEPS IN THE EBP PROCESS ASSESS the patient ASK the question ACQUIRE the evidence APPRAISE the evidence APPLY: talk with the patient Selfevaluation 1. Start with the patient -- a clinical problem or question arises from the care of the patient 2. Construct a well built clinical question derived from the case 3. Select the appropriate resource(s) and conduct a search 4. Appraise that evidence for its validity (closeness to the truth) and applicability (usefulness in clinical practice) 5. Return to the patient -- integrate that evidence with clinical expertise, patient preferences and apply it to practice 6. Evaluate your performance with this patient
WHY DO NURSES NEED TO DELIVER EVIDENCE BASED PRACTICE Environments constantly changing and evolving Nursing has evolved from a series of dictated tasks to a holistic care approach = requires evidence and guidelines. Guidelines support nurses to promote an individualised approach to holistic care, moving away from ritualistic practice. Globally recognised that evidence based practice is the key to delivering the highest quality healthcare and ensuring best patient outcomes at the lowest costs. An evidence based approach to providing health care versus the implementation of clinical care that is steeped in tradition or based on outdated policies, results in improved health, safety and cost outcomes, including a decrease in patient deaths
SO MANY QUESTIONS... Evidence-Based Practice (EBP): What is the best approach for managing neuropathic pain in the terminally ill patient? What research has been done that could provide clinical practice guidelines? Quality Improvement (QI): Are we doing the right things to appropriately manage patients neuropathic pain? How do we know? How are we measuring patient outcomes? Research (R): What is it like to live with neuropathic pain? Does drug A work better than drug B? What s been studied? Where are the gaps?
SCOPE OF NURSING AND MIDWIFERY PRACTICE FRAMEWORK 4.2 Responsibility, Accountability and Autonomy Accountability. being able. to justify their (nurses) decisions in the context of legislation, professional standards and guidelines, evidence-based practice and professional and ethical conduct.
A NURSE-LED EVIDENCE BASED PRACTICE PROJECT MONITORING & IMPROVING MANAGEMENT OF CHEMOTHERAPY-INDUCED NAU Chemotherapy-induced nausea and vomiting (CINV) Common Severe symptoms experienced by patients undergoing cancer treatment Identification of risk factors for CINV Structured, nurse-led telephone follow-up Evidence-based methods to support patients undergoing cancer treatment. The authors successfully implemented a structured, nurse -led CINV intervention to improve assessment, follow -up, and support patients undergoing chemotherapy Underhill et al (2015) Clinical Journal of Oncology Nursing 19(1); 38-40
EXAMPLE OF EVIDENCE BASED PRACTICE https://www.youtube.com/w atch?v=q7odsqrjb88
PALLIATIVE CARE IN CHRONIC KIDNEY DISEASE (PACKS) QUALIT Y OF LIFE, DECISION-MAKING, COSTS AND THE IMPACT ON CARERS IN PEOPLE MANAGED WITHOUT DIALYSIS: A STUDY PROTOCOL http://bmcnephrol.biomedcentral.com/articles/10.1186/s12882-015-0084-7
AIM OF STUDY Measure and describe QOL, Satisfaction with decision-making, Costs, Cognition, frailty and performance in patients with advanced chronic kidney disease managed without dialysis. Impact on Carers 10 UK sites
QUALITATIVE ARM Understanding of the decision making process that precedes referral to CKM Qualitative interviews with staff Drs and nurses Transcribed data Line by line coding Early themes Fractured decision making changing mind Adequate support and input staff opinion Staff know what's best for patients Paternalistic approach Publication and sharing of knowledge Prepare for new study Inform practice based guidelines
POTENTIAL PROBLEMS AFFECTING NURSES DELIVERING EVIDENCE BASED CARE Lack of time Lack of experience and little confidence in using computers Poor access to facilities and information Lack of educational skills in critiquing research The quality of the resources that nurses access remains contentious
SUMMARY Evidence based practice is a natural, expected part of the nursing role Not an easy process and takes planning and interdisciplinary collaboration Improves patient care and outcomes Requires evidence developed into guidelines: Individualised care Holistic care Rigorous and robust Stops ritualistic care how it s always been done