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Implementing EvidenceImplementing Evidence
Based Practice in ICUBased Practice in ICU
DongOak Debbie Kim, RN, PhD,DongOak Debbie Kim, RN, PhD,
Associate Professor, Daejeon University,Associate Professor, Daejeon University,KoreaKorea
2010. 10. 05 72010. 10. 05 7thth. WFCCN, Manila. WFCCN, Manila
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Basic concept of21st. C
Evidence
Based
Paradigm shift inhealth care services
& edu.
Cost-effective
Nursing
Quality Improvement
of Nursing services
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Definition of EBPDefinition of EBP
Integration of the best researchIntegration of the best research
evidence with clinical expertise andevidence with clinical expertise and
patient valuespatient values (Sackett , 1996)(Sackett , 1996)
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Definition of EBPDefinition of EBP
AA process of shared decision makingprocess of shared decision makingbetween practitioner, patient & othersbetween practitioner, patient & others
significantsignificant to themto them based onbased on researchresearchevidenceevidence, the, the ptpts experiences &s experiences &preferencespreferences,, clinical expertiseclinical expertise or knowor know--how, & otherhow, & other available robust sourcesavailable robust sources ofof
information. (Rycroftinformation. (Rycroft--MaloneMalone et al,et al,2004; Sackett2004; Sackett et alet al, 2000), 2000)
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EBP ModelEBP Model
(Satterfield, J.M.,(Satterfield, J.M., et alet al., 2009)., 2009)
Best available
research evidence
Resourcesincludingpractitionersexpertise
Client
sCharacteristics,
status, needs,
values,
& preference
Decision Making
Environment &
Organizationalcontext
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Components of EBPComponents of EBP
The most relevant evidence to answer aThe most relevant evidence to answer aclinical questionclinical question
Clinical expertiseClinical expertise PatientPatients preferences & valuess preferences & values
But!!! Implementation be considered in theBut!!! Implementation be considered in the
context of available resources, organizationalcontext of available resources, organizational
policies, & prioritiespolicies, & prioritiesCf. Research utilization: The use of knowledgeCf. Research utilization: The use of knowledgetypically based on a single study, does nottypically based on a single study, does nottake into account clinical expertise or pttake into account clinical expertise or ptss
preference/valuespreference/values
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Steps of EBP :Steps of EBP :
Identifying/ Appraising/ SynthesizingIdentifying/ Appraising/ Synthesizing
1.1. Ask : utilize PICO formatAsk : utilize PICO format
2.2. Acquire : search evidenceAcquire : search evidence
3.3. Appraise : critical appraisal for the validity,Appraise : critical appraisal for the validity,relevance, applicability of evidencerelevance, applicability of evidence
4.4. Apply : Integration of the results ofApply : Integration of the results ofsystematic reviews with clinical expertise &systematic reviews with clinical expertise &
ptpts preferences/valuess preferences/values5.5. Assess : evaluation for the effectiveness ofAssess : evaluation for the effectiveness of
results/applicationresults/application
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Steps of EBPSteps of EBP
ClinicalClinical
questionsquestions
Searching evidencesSearching evidences
Critical appraisalCritical appraisalApplication to PracticeApplication to Practice
(Demonstration)(Demonstration)
Evaluating theEvaluating the
effectiveness of resultseffectiveness of results
Changing &Changing &
disseminatingdisseminating
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PICOPICO
Formulation of the clinical issue into aFormulation of the clinical issue into a
searchable and answerable questionsearchable and answerable question
PP : Patient population, Problem: Patient population, Problem
II : Intervention or Interest: Intervention or Interest
CC : Comparison with other treatment, if: Comparison with other treatment, if
applicableapplicableOO : Outcome: Outcome
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Hierarchy of EvidenceHierarchy of Evidence
Pyramid from: Evidence-Based Practice Tools Summary. University of Washington, Health
Sciences Library
Strong
Weak
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Influencing factors toInfluencing factors to
implement EBPimplement EBP
Evidence dimensionEvidence dimension
Nurse dimensionNurse dimension
Organizational dimensionOrganizational dimension
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Process of Implementing EBPProcess of Implementing EBP
ToTosucceedsucceed
in implementing EBPin implementing EBP
strong evidence itself canstrong evidence itself cant lead EBPt lead EBP
establish strategies considered influencing factors;establish strategies considered influencing factors;
evidence, nurse, organizationevidence, nurse, organization
require multidimensionalrequire multidimensional complex actioncomplex action
Change in anOrganization
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Strategies for evidenceStrategies for evidence
the evidencethe evidence
has high priority & consensus among expertshas high priority & consensus among experts
is strong enough & congruent with ptis strong enough & congruent with pts needs &s needs &organizational policiesorganizational policies
the guidelinesthe guidelines
have to be developed multidisciplinaryhave to be developed multidisciplinary
are clearly describedare clearly described
have specific recommendations & userhave specific recommendations & user
convenience.convenience.
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Strategies for nurseStrategies for nurse
1. Education & training1. Education & training To improve knowledge, skill, attitude &To improve knowledge, skill, attitude &
selfself--confidence about EBPconfidence about EBP
Content : 5 EBN competencies (StraussContent : 5 EBN competencies (Strauss etetal.,al., 2005)2005) describing clinical questionsdescribing clinical questions
searching evidencessearching evidences
critical appraisalcritical appraisal
integrating the evidences in clinical decisionintegrating the evidences in clinical decisionmaking,making,
evaluating the outcomes.evaluating the outcomes.
MethodsMethods workshop : interactive education is effectiveworkshop : interactive education is effective
Staff nurse internshipStaff nurse internship
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Strategies for nurseStrategies for nurse
2. Mentoring2. Mentoring Support to learn new knowledge & skillSupport to learn new knowledge & skill
Counsel & Support for the process ofCounsel & Support for the process of
reading research results & translating themreading research results & translating themto practiceto practice
During implementingDuring implementing Support the fear & skepticism to changeSupport the fear & skepticism to change
Solve misconceptions (eg. EBN needs lots ofSolve misconceptions (eg. EBN needs lots oftime)time)
Overcome the resistance against practice changeOvercome the resistance against practice change
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Strategies for nurseStrategies for nurse
3. Encourage to participate in various3. Encourage to participate in various
projects related to EBPprojects related to EBP
ConferenceConference
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Strategies for OrganizationalStrategies for Organizational
dimensiondimension
Organizationalstrategies
Establishing
EBN Culture
Leadership
Change
AgentPreparing
Resources
Audit &
Evaluation
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Establishing EBN CultureEstablishing EBN Culture
Organizational mission & vision supportingOrganizational mission & vision supportingEBNEBN
EvidenceEvidence--based decision making on everybased decision making on everypolicy & procedure, & nurse executivepolicy & procedure, & nurse executivessadministrative decisionadministrative decision
Create clinical inquiry cultureCreate clinical inquiry culture
Operate journal clubOperate journal club Encourage presentation & publication ofEncourage presentation & publication ofresearchresearch
Sacred cow searching competitionSacred cow searching competition
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LeadershipLeadership
Strong and supportive leadershipStrong and supportive leadership
LeaderLeaders participation in whole process ofs participation in whole process of
developing & implementing EBN strategiesdeveloping & implementing EBN strategies Encourage nurses to share and practice theEncourage nurses to share and practice the
visionvision
Support the change agents & responsibleSupport the change agents & responsibleperson for projectperson for project
Develop the EBN model of nursingDevelop the EBN model of nursing
departmentdepartment
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LeadershipLeadership --
contcontdd--
Integrate EBN guideline/protocol withIntegrate EBN guideline/protocol withorganizational policy & procedureorganizational policy & procedure
Connect EBN to Quality ImprovementConnect EBN to Quality Improvementactivitiesactivities
Identify barriers to implementing EBNIdentify barriers to implementing EBN
& set up the strategies reducing them& set up the strategies reducing them Develop the ownership in whole level ofDevelop the ownership in whole level oforganizationorganization
etc.etc.
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Change agent, championChange agent, champion
Roles :Roles :
Facilitate for apply EBNFacilitate for apply EBN
Influence to build up EBN culture in unitInfluence to build up EBN culture in unit
Mentoring to nursesMentoring to nurses
Educational outreach visitEducational outreach visit
Selection : nursing department, unitSelection : nursing department, unit
Developing competencies for change agents,Developing competencies for change agents,
opinion leaders, & core groupsopinion leaders, & core groups
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ResourcesResources
Administrator has to allocateAdministrator has to allocate
appropriate resources for EBN :appropriate resources for EBN :
human resources, time, finance,human resources, time, finance,facilitiesfacilities
Establish EBN communication systemEstablish EBN communication system
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Audit & EvaluationAudit & Evaluation
AuditAuditUtilized as instrument for implementUtilized as instrument for implement
guideline recommendations to practiceguideline recommendations to practiceFocusing on measuring compliance of theFocusing on measuring compliance of the
guidelineguideline
providing productive feedbackproviding productive feedback
Include the process, outcomes, andInclude the process, outcomes, andevaluation plan for continuance of changeevaluation plan for continuance of change
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ConclusionConclusion
As activating and anchoring the EBPAs activating and anchoring the EBP
successfully in icu is the complexsuccessfully in icu is the complex
process required organizational changes,process required organizational changes,various strategies in terms of evidence,various strategies in terms of evidence,
nurse, and organizational dimension arenurse, and organizational dimension are
required.required.
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To conduct EBN change isTo conduct EBN change is
challengeable, but highlychallengeable, but highly
compensated work.compensated work.
Never, never, never, never, never,Never, never, never, never, never,
never quitnever quit
-- Winston ChurchillWinston Churchill --
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