Evidence-Based Practice R O S E L. H O F F M A N N P H D, R N A S S I S T A N T P R O F E S S O R U N I V E R S I T Y O F P I T T S B U R G H S C H O O L O F N U R S I N G S E P T E M B E R 2 1, 2 0 1 0
Evidence Based Nursing Process by which nurses make clinical decisions, using the best available research evidence, their clinical expertise and patient preference (Sackett, 2000) EBN does not equal research EBN means continual re-evaluation of your practice
Research vs. Quality Improvement Research: a systematic search for knowledge about issues of importance to nursing Polit & Hungler Quality Improvement: ongoing process of innovation, prevention of errors and staff development Yoder-Wise, 2003
I will do all in my power to maintain and elevate the standard of my profession Nightingale Pledge
Why is EBP Important Abundance of literature Lots of information published at rates too fast for clinicians to read and synthesize 61 journals with nursing in title EBP resources make evidence-based decisions about patient care in a focused and time efficient manner Unmet information needs Unanswered question with every patient encounter EBP resources easy to use and help connect practitioners to EBP answers to clinical questions Implementation delays Research findings take years to be implemented into practice EBP resources take into account many fields and allows clinicians greater exposure to evidence
Misconceptions EBN ignores patient preferences and values EBN is a theoretical EBN is only about quantitative research EBN overemphasizes randomized controlled trials and systematic reviews
Think about a specific patient population you work with often. Choose a problem or condition that you encounter in that population for which you do not know what therapy the evidence suggests (i.e. what the literature recommends for effective treatment)
Model Rosswurm and Larrabee, 1999 1. Assess the need for change 2. Linking the problem with the interventions and outcomes 3. Synthesizing the best evidence 4. Designing a change in practice 5. Implementing and evaluating the practice change 6. Integrating and maintaining the practice change
Formulating the Question P I C O Patient/problem Intervention Comparison intervention Outcome
Patient/Population Describe the patient or target of interest How would you describe a group of patients similar to yours What are the most important characteristic? Primary problem, disease, co-existing conditions, sex, age or ethnicity What is too narrow or too broad
Allegheny County Health Profile 2007 17.9% population > 65 years Median age: 40.7 8.8% received no prenatal care in first trimester Adult behavioral health risk factors Overweight, smoker, lack of immunizations Selected Major Causes of Death Disease of heart, cancer, stroke Cancer Incidence Female breast, prostate, lung Mhttp://www.dsf.health.state.pa.us/health/lib/health/countyprofiles/2007/allegheny.pdf
Intervention Which main interventions, prognostic factor, or exposure do you wish to investigate? What do you want to do for the patient? Drug, test, therapy What factor may influence the prognosis of the patient? Age, co-existing problems What was the patient exposed to? Smoke, Asbestos
Comparison Relevant when reviewing therapy questions What is the main alternative to compare with the intervention? Two drugs, drug and placebo, two diagnostic tests The clinical question may not always have a specific comparison
Outcome Clinical outcome of interest to you and your patient What do you hope to accomplish, measure, improve, affect What patient results do you wish to obtain? Are you seeking symptomatic relief, improve function, test scores, adverse events?
Problem As an APN you have just seen a 58-year-old patient with type 2 diabetes with a normal blood pressure. You consider treating this patient with ace inhibitors because the attending said treatment could delay progression to diabetic nephropathy.
PICO Patient Intervention Comparison/Control Outcome
Background information UptoDate Harrison s Online E-Books Filtered Resources ACP Pier Cochrane Natural Standard InfoPOEMS MDConsult Natural Medicines Comprehensive Database OTseeker Physiotherapy Evidence Database (PEDro) National Guideline Clearinghouse Unfiltered Resources OVID MEDLINE PubMed CINAHL PsycINFO BIOSIS
Individual Barriers to EBP (other than time) Lack of value for research in practice Lack of understanding of structure of electronic databases Difficulty accessing research material Lack of computer skills Difficulty understanding research articles Lack of access to computer Lack of library access Lack of search skills Lack of knowledge about research Lack of skills to critique literature
Institutional Barriers (other than time) Presence of other goals with higher value Difficulty in recruiting and retainer staff Organizational budget for acquisition of information resources Organizational budget for training in resource use Perception that nursing staff is not eager or prepared to pursue EBP Perception that EBP is not achievable in real world
What questions can you investigate?