Evidence based practice: Colorectal cancer nursing perspective

Evidence based practice: Colorectal cancer nursing perspective Professor Graeme D. Smith Editor Journal of Clinical Nursing Edinburgh Napier University China Medical University, August 2017

Editor JCN

Evidence based practicecolorectal cancer nursing perspective

GI Textbook

Editor: Gastrointestinal Nursing

Located in Scotland

Where is Edinburgh Napier University?

Evidence based practicecolorectal cancer nursing Consensus on methods for nursing research Smith GD (2012) Journal of Clinical Nursing 21, 599-601

Evidence based practicecolorectal cancer perspective

Evidence based practice- colorectal cancer perspective

Evidence based practicecolorectal cancer perspective

Evidence based practice- colorectal cancer perspective

Contents of lecture Introduction to evidence based practice colorectal cancer Hierarchy of evidence Systematic reviews Critical appraisal Framework of EBP colorectal cancer nursing Summary/Conclusion

Session Outcomes At the end of this lecture you will be able to: Define Evidence Based Practice Identify rationale for evidence based practice in cancer nursing/healthcare Identify nursing practice that might benefit from the use of evidence Appreciate different forms of evidence Generate appropriate research questions

The Evidence Quiz Evidence is important to nurses because: a) It minimises the risks to patients b) You don t need to think about your actions anymore because the evidence does that for you c) It ensure that patients receive care based on robust research d) It ensures that research journals stay in business

Definitions of Evidence Based Practice Sackett et al. (1996) defined EBP as: the conscientious, explicit and judicious use of current best evidence in making clinical (nursing) decisions about the care of individual patients British Medical Journal 1996

Why is best evidence and evidence based nursing important? Ensures patient/clients receive the care that fits their needs Facilitates sound decision making and makes it more explicit Minimises risk to the patient/client so that benefits outweigh harm Provides the nurse with the skills and knowledge to evaluate healthcare literature and practice Exposes gaps in knowledge and conflicts in evidence

What is Evidence? In the context of evidence based practice this is research published in professional and academic journals and systematic reviews of research found in databases of evidence. Knowledge derived from a variety of sources that has been found to be credible (Higgs & Jones 2000)

Other Forms of Evidence Evidence based on experiences (professional or personal) Evidence gathered from patients and/or carers. Evidence based theory that is not research based (role of clinical audit) Le May (1999) Evidence-based practice Nursing Times

Evidence base: Filtered information

Filtered Information Appraise and/or synthesize information from previous studies Organize it into a single coherent analysis Provide recommendations for future practice.

Systematic Reviews/ Meta-Analyses Systematic reviews Comprehensively synthesize and critically appraise information from various articles that meet specific selection criteria Provide recommendations based on the best evidence available

Systematic Reviews/ Meta-Analyses Meta-analyses Systematic reviews that use statistical methods to quantitatively combine and summarize several studies results

Unfiltered Information The evidence sources from which the above ones acquire their information (i.e. the primary sources) Useful when filtered information is not available

Randomized Controlled Trials Randomly assigns subjects into a treatment group or a control group in order to compare the efficacy of a particular treatment, diagnosis, etc. against the current standard, a placebo, or no intervention at all.

Cohort Studies Compare two groups of subjects over time, one having a particular condition or receiving a particular treatment, the other not Often used when a randomized controlled trial would be unreasonable or unethical.

Case-Controlled Studies Retrospective observational studies of a particular diagnosis or exposure Determine commonalities in medical history or other associations amongst the affected Can establish correlations, but cannot prove causation

Expert Opinion Based on clinical experience and case studies Varies in level of scientific rigor and usefulness. Who is expert?

What exactly is EBP? The integration of best evidence* from current research, patient preferences and values, and clinical expertise to clinical questions (Sackett, 2000) in a timely fashion. Patient Values/Local Conditions Best Evidence EBP Clinical Expertise *Best available evidence is: consistent research evidence with high quality and quantity

Why EBP? To improve care To bridge the gap between research & practice Kill as few patients as possible A new treatment might have fewer side effects. A new treatment could be cheaper or less invasive A new treatment may be necessary in case people develop resistance to existing therapies To keep clinical knowledge and skills current To save time to find the best information

The five step EBP process 1. ASK: Formulate an answerable clinical question 2. ACCESS: Track down the best Evidence Ask 3. APPRAISE: Appraise the evidence for its validity and usefulness Assess Access 4. APPLY: Integrate the results with your clinical expertise and your patient values/local conditions 5. ASSESS: Evaluate the effectiveness of the process Apply Appraise

Step 1: ASK a focused (answerable) clinical question Ask Background questions (What do I know about this?) Foreground (Clinical) Questions P = Patient, population or problem -Who are the patients or populations? (What is the disease?) I = Intervention -What do you want to do with this patient (e.g. treat, diagnose, observe)? C = Comparison intervention -What is the alternative to the intervention (e.g. placebo, different drug, nothing?) O = Outcome -What are the relevant outcomes (e.g. morbidity, mortality, death, complications)?

Why should I use PICO? To help define problem & clarify it in your own mind To prepare for searching To ask patient centered questions. Treatment of Pneumococcal Pneumonia SHOULD be different for Terminal Cancer Patient Older person with dementia Young athletic male Developing the question requires: Some background knowledge of the condition Understanding of the problem i.e. screening in colorectal cancer

Asking a focused clinical question PICO components: P = healthy, asymptomatic man at average risk of colorectal cancer I = screening for colorectal cancer with method X C = screening for colorectal cancer with method Y O = reduced mortality from colorectal cancer Now ready to generate the question

Asking a focused clinical question Appropriate clinical question: In a healthy, asymptomatic man at average risk of colorectal cancer, which method of screening for colorectal cancer leads to the greatest reduction in mortality from this disease? Now ready to search for appropriate evidence

Benefits of using PICO framework Although not always necessary to use a focused clinical question to structure search query PICO allows generation of clearly stated question Especially when search reveals several options treatment approaches screening options Makes search for evidence more efficient Helps provide focus to appraisal efforts

EBP Step 2: ACCESS Track Down the Best Evidence Access Start searching from the best resource: Match your question to the best medical information resource for this question. Well designed Systematic Reviews¹can be a great place to start they contain commentary about validity ¹A systematic review involves the application of scientific strategies, in ways that limit bias, to the assembly, critical appraisal, and synthesis of all relevant studies that address a specific clinical question.

Track Down Hierarchy of Evidence- Access evidence at the level that will give you the best evidence Filtered & Critically Appraised Expert Opinion and Not Filtered Background info. Most clinically relevant (at the top) Least clinically relevant (at the bottom)

Why not get info only from textbooks and review articles? Texts and review articles? Dated perhaps by several years Often biased Author chooses article that he/she agrees with topic Author chooses articles of his/her friends Author does not identify all the relevant literature Review s methods are not explained These resources help with background knowledge (learn about disease)

Colorectal cancer clinical guidelines

Why not get info only from guidelines? They can assure standards of care but: May be biased May not always be developed by experienced experts Are not always truly evidence-based May work for most patients but not for all May work in some circumstances but not in all Can be dated There may not be guidelines for everything

Cochrane Database of Systematic Reviews

Filtered and Critically Appraised Evidence-Based Resources The Cochrane Library by The Cochrane Collaboration via Wiley Independent non-for-profit international collaboration Reviews are among the studies of highest scientific evidence Minimum Bias: Evidence is included/excluded on the basis of explicit quality criteria Reviews involve exhaustive searches for all RCT, both published and unpublished, on a particular topic Abstracts searchable for free on the Internet; complete database is available via HINARI for most countries 1995-

EBP Step 3: Appraise: Determine if the results are valid and useful Appraise Appraisal principles (primary and secondary research) What is the PICO of the study? Does it match my question? How well was the study done? Is it biased? What do the results mean? Are they real and relevant? More information : University of Oxford s Center of EBM: http://www.cebm.net/index.aspx?o=1157

EBP Step 4: APPLY: Integrate the results with your clinical expertise and your patient values Apply Question to ask: Is the intervention feasible in my settings? What alternatives are available? Is my patient so different then those in the study that the results cannot apply? Will the potential benefits outweigh the potential harms of treatment? What does my patient think? What are his cultural beliefs? Individual decision making/group decision making/choice Explaining risks and benefits to patients

EBP Step 5: ASSESS Evaluate the effectiveness of the process. How am I doing? Assess Am I asking correct questions? Am I writing down my information needs? What is my success rate in the EBM steps? How is my searching going? Am I becoming more efficient? Am I periodically syncing (checking) my skills and knowledge with new developments? Teach others EBP skills Keep a record of your questions

If your institution does not have access to Cochrane. Access to abstracts free from a link at: http://www.cochrane.org/

Additional Evidence-based Health Resources Joanne Briggs Institute http://www.joannabriggs.org DARE: Database of Abstracts of Reviews of Effects http://www.crd.york.ac.uk/crdweb/ health-evidence.ca http://health-evidence.ca The Campbell Library http://www.campbellcollaboration.org/library.php

Limitations of evidence based practice Limited scope of evidence-it will never be 100% complete The quality of research available Keeping it patient centered, cost effective Evidence from Randomized Controlled Trials for real life patients pragmatic RCT studies Communicating uncertainties Decision making

Summary/Conclusion Evidence-based practice depends on knowing the most recent, valid scientific knowledge. This involves finding the best studies. Sometimes others have evaluated the quality of the studies, including methodology. When there is no evaluation available, it is essential to evaluate the validity of the study

Summary/Conclusion It is always important to consider studies in terms of applicability to and values of the local patient/situation. cultural differences Evidence-based practice is a developing field and new, useful resources are continuously being developed.

The Evidence Quiz 1. Evidence is important to nurses because: a) It minimises the risks to patients b) You don t need to think about your actions anymore because the evidence does that for you c) It ensure that patients receive care based on robust research d) It ensures that research journals stay in business

Evidence based practice- colorectal cancer perspective

Thank you Questions! email: smithgd0901@gmail.com Twitter @gds1903

References Carnwell, R. (2001) Essential differences between research and evidence-based practice, Nurse Researcher, Vol.8, No.2, pp.55-68. Donald, A. and Greenhalgh, T. (2000) A Hands-on Guide to Evidence Based Healthcare: Practice and Implementation, Blackwell Science, Oxford. Le May, A. (1999) Evidence-base practice, London, Nursing Times Books. Sackett, D.L., Rosenberg, W.M., Gray, J.A., Haynes, R.B. and Richardson, W.S. (1996) Evidence based medicine: What it is and what it isn t, British Medical Journal, 312, 7023, pp. 71-72. Sackett, D.L., Strauss, S.E., Richardson, W.S., Rosenberg, W. and Haynes, R.B. (2000) Evidence Based Medicine: How to Practice and Teach EBM, 2 nd edn, Edinburgh, Churchill Livingstone.