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實證護理概念
國立陽明大學 穆佩芬 教授
2012
發生了什麼事?為什麼?
如何改變?
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Department of Health, Taiwan
Nursing Policy
Three Action Projects Anticipated Challenges Core Functions
Quality education & training: EBN Model
Satisfactory workplace: The consensus of a promising
nursing career
Quality care & practice: Nursing Leadership Development
Competent health workforce
Adequate & satisfied health workforce
Productive health workforce
Highest standards of practice for health workforce
Management of health workforce & information systems
Evidence based practice
Advocacy & pluralism 4 partnership with nursing groups & stakeholders
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1. DEFINITION OF EVIDENCE-
BASED NURSING
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DEFINITION OF EVIDENCE-BASED NURSING
Joanna Briggs Institute (1996) Cochrane nursing care field (2009) The integration of the best research evidence with
clinical expertise and patient values (Sackett, Straus, Richardson, Rosenberg & Haynes, 2000)
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實證護理 認識論 研究者如何理解社會生活?如何去理解這個世界?了解的方式是什麼?也可以說是研究者自己在想些什麼?到底想知道什麼?
本體論 研究者的終極關懷與為何要進行學術研究?是呈現各種生命情調互相激盪的存在論。
技藝 以人為本之實證照護
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(1)實踐哲學的知識論
知識形成方式 它的思考方式為何
成立的可能性 它的知識成立的條件為何
知識的客觀性、適用性、檢證性及選擇性
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1.1.實踐哲學的架構
宇宙論 現象存在問題的知識
本體論 價值命題 人生追求的理想目標
工夫論 價值意義的心理修養工夫 或是 身體能力的鍛鍊
境界論 主體達到理想的狀態
此四架構能進行 討論概念定義 以及這些概念之間的關係 此為存有論
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1.2. Three forms of knowledge
Aristotle (400BC) Episteme (科學): scientific knowledge, theoretical
knowledge Techne (技藝): the kind of knowledge we need for
producing and creating and for manufacturing various products
Phronesis (實踐智): practical knowledge or wisdom, and is the knowledge used in the processes of social interaction
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Episteme (科學) 實證基礎
Techne (技藝): 實證操作
Phronesis (實踐智): 實證操作
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1.1. Evidence generation
Evidence: the basis of belief, the substantiation or confirmation that is needed in order for us to believe that something is true (Miller & Fredericks, 2003)
Make a decision: the type of evidence
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FAME
Evidence of feasibility: activity is practical and practibable
Evidence of appropriateness: an intervention or activity fits with or is apt in a situation
Evidence of meaningfulness: an intervention or activity is positively experienced by the patient
Evidence of effectiveness: an intervention, when used appropriately achieves the intended effect
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1.2. Evidence synthesis
The synthesis of the results of quantitative research (meta-analysis)
The synthesis of the results of qualitative research (meta-synthesis)
The synthesis of evidence arising out of expert opinion and text (expert opinion)
The synthesis of evidence arising out of economic analyses (economic analysis)
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1.3. Evidence (knowledge) transfer
Developing understandable and actionable knowledge
Accommodating the context of a target audience’s information needs
Delivering messages in cost-effective ways (including information technology, print materials, meetings, workshops and training programmes)
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1.4. Evidence utilization
Practice change
Embedding evidence through system/organization change
Evaluating the impact of the utilization of evidence on the health system, the process of care and health outcomes.
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Evidence Pyramid
Meta-Analysis
Meta-synthesis
Systematic Review
Randomized Controlled Trial Qualitative Research Method
Cohort studies
Case Control studies
Case Series/Case Reports
Animal research
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Unsound
Research
Sound
Research
Systems (bottomline± ref)
Synopses (user summary of research)
Systematic Reviews and CATs (search; appraisal; synthesis)
Aware Accepted Applicable Able Acted on Agreed Adhered to
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文獻
摘要
精要
從知識到實踐的管道
注意到→接收到→可行→有能力作→開始做→認同→養成習慣
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2. A PARADIGM SHIFT
Thomas Kuhn (1970): scientific paradigms as ways of looking at the world which define both the problems which can legitimately be addressed and the range of admissible evidence which may bear on their solution.
量性 PICO
P: 問題 I: 護理措施 C: 其他護理處置 O: 結果
質性 PICO P: 問題 I:護理現象 Co:護理脈絡
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DEFINITION OF EVIDENCE-BASED PRACTICE (SIGMA THETA TAU INTERNATIONAL POSITION)
EBP is the process of shared decision-making between practitioner, patient, and others significant to them based on research evidence, the patient’s experiences and preferences, clinical expertise or know-how, and other available robust sources of information (Rycroft-Malone et al. 2004)
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Nursing paradigm vs. medical model
What kinds of competence in evidence-based
nursing in undergraduate program, graduate
program, PGY, and ANP
How do we design EBN into nursing teaching and
learning environment or activities into curriculum?
What kind of preparation of teachers?
The possibilities in nursing knowledge development
in EBP
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3. SIX STEPS OF EVIDENCE-BASED NURSING IMPLEMENTATION
Question A clinical problem Recurrent problem
Search** Appraisal** Synthesis the findings** Practice** Assessment and Evaluation
(Flemming, 1998) 32
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背景問題 vs 前瞻問題
Background question (背景問題) 希望獲得處理病患的specific knowledge 預期有答案 Searchable answers 能比較各項選擇的優劣 Focus on evidence 決定行動方向 Decision-making oriented Foreground question (前瞻問題)
PICO (Pubmed, JBI, Cochrane review) Patient character or Problem Intervention Comparison intervention Clinical Outcome
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Concept map
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Different types of questions are best answered by different types of studies.
1. Intervention or Therapy Randomised Controlled Trial
2. Diagnosis/Screening 2.1. To assess the accuracy of the test
Cohort study where all subjects receive both the study test and gold standard reference test
2.2. To assess effect of test on health outcomes: Randomised Controlled Trial
3. Prognosis Longitudinal cohort
4. Aetiology/Risk factors Randomised controlled trial Cohort for rare exposure with common outcome Case-control for rare outcome with common exposure
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4. Search: 資料庫種類與方式
系統文獻查證
實徵資料
臨床指引
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(1) Evidence-based Medicine resources 實證醫學文獻資料庫
Uptodate Cochrane Lib Cinahl information systems ACP journal club
醫學期刊, 電子期刊, 電子資料庫 Medline, Medscape PubMed Evidence based nursing journal Center for evidence-based nursing, University of
York JBI web journal Ovid PsycINFO MEDLINEPlus
教課書, 電子書
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Evidence-based practice resources Uptodate
PubMed
Cochrane Library
Abstract of Cochrane reviews
Evidence-based practice centers
Joanna Briggs Institute
Clinical evidence
Evidence-based Medicine Resources Center: Clinical Practice Guideline
http://www.ebmny.org/thecentr.html
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Joanna Briggs Institute
網址: www.joannabriggs.edu.au
Taiwan Joanna Briggs Collaborating Center
(TJBCC)
網址: http://www.joannabriggs.edu.au/collab_ctrs/taiwan.p
hp
Cochrane Nursing Care Network
http://www.joannabriggs.edu.au/cncn/index.php
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5. APPRAISAL 文章評析 Meta-Analysis Systematic Review Randomized Controlled Trial Cohort Study Case Control Study Case series or Case Report Editorials, Letters, Opinions 44
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Yes No Unclear
1 The participants were randomised to study groups.
2 Allocation to treatment groups was concealed from allocator.
3 Other than the intervention, participants were treated the same.
4 The groups were comparable at entry.
5 The outcomes were measured in the same manner for all
participants.
6 Those assessing outcome were blinded to treatment allocation (if
outcome not objective such as survival or length of hospitalisation).
7 Outcomes were measured in a reliable manner.
8 The statistical analysis used was appropriate for the data
presented.
9 There was adequate follow up of participants.
In reflecting upon my critical appraisal I believe that this paper is
-- --
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Critical Appraisal for Intervention Study
2889Please chooseNextform1
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TJBCC 2008 46
6. EVIDENCE SYNTHESIS
The synthesis of the results of quantitative research (meta-analysis)
The synthesis of the results of qualitative research (meta-synthesis)
The synthesis of evidence arising out of expert opinion and text (expert opinion)
The synthesis of evidence arising out of economic analyses (economic analysis)
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TJBCC 2008 47
META-ANALYSIS
Uses various statistical methods to combine the results of multiple different studies to produce a stronger conclusion than can be derived from any one of the studies on its own.
Effectiveness or Therapy 治療性問題
Diagnosis 診斷性問題
Prognosis 預後性問題
Harm 傷害性問題
Economic analysis
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TJBCC 2008 48
The procedure of meta-analysis Identification of a clinical problem Develop a review protocol Locate studies Select relevant studies Appraise the quality of the research Collect data from individual studies Synthesize and summaries the findings of studies Document method in review report
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TJBCC 2008 49
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LEVELS OF EVIDENCE
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Meta-synthesis
1.Meta-data-analysis : research findings
2. Meta-method: research method
3. Meta-theory: theoretical and analytical
framework
4. Experts’ opinion
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Clinical Practice Guidelines:
Best Practice Guidelines (Registered Nurses Association of Ontario)
AGREE (Appraisal of Guidelines
Research & Evaluation) Recommended Clinical Practice
Guidelines (Guideline Advisory
Committee (GAC)) CMA Infobase: clinical practice
guidelines -- Canadian Medical Association
Clinical Practice Guidelines -- Alberta Medical Association
National Guideline Clearinghouse (United States)
Joanna Briggs Institute -- (TJBCC)
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7. EBP example
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Suction strategies of adult patients with tracheal
Domain of the
phenomeon
Suc
tion
care
Physica
l st
rate
gies
Position
str
ate
gies
Research method
Meta
-ana
lysis
Meta
-sy
nthesis
Foc
us g
roup
Sur
vey
Clinical guideline development: Suction strategies of adult patients
with tracheal
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FIVE STEPS
(1)Systematic review of the suction strategies of adult with tracheal
(2)Meta-analysis of the experience of adult with ventilator
(3) Focus group : the suction strategies of adult with tracheal
(4) Protocol of clinical guidelines
(5) Conduct a survey to investigate the appropriateness and usefulness of the protocol of clinical guidelines
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(1) Systematic review of the suction strategies of adult
with tracheal
Abstract 1. Background 2. Methods (1) searching literature 1.1. inclusive criteria 1.2. exclusive criteria 1.3. searching process 1.4. appraisal 3. Findings 3.1 Systematic review 3.2 Clinical Guideline 4. Results Each evidence: abstract, findings, clinical implications 5. Synthesis:Integrating the findings
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(2) META-SYNTHESIS: THE EXPERIENCE OF ADULT PATIENTS WITH VENTILATOR
Abstract Background Objective Inclusive criteria
Types of studies Types of participants Types of phenomenon of
interest Types of outcomes
Exclusive criteria Search Strategy
Software
The initial search terms included: Key words: Phenomenon Population Methods
Critical appraisal Data collection Data Synthesis Findings Discussion Clinical Guideline
suggestions
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(3) FOCUS GROUP: SUCTION STRATEGIES OF ADULT PATIENTS WITH TRACHEAL
1 Research purpose: what are the strategies of clinical experts in caring of adult patients with tracheal?
2 Research methods: focus group 3 Process: (1) Participants (2) Data collections Semi-structure interview (3) Data analysis
4 Findings 59
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(4) PROTOCOL OF CLINICAL GUIDELINE
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(5) Conduct a survey to investigate the appropriateness and usefulness of the protocol of clinical guidelines
1. Purpose
(1) Degrees of agreement of each item
(2) Factors affects on the degrees of agreement of each item
2. Research method
(1) data collections
(2) Subjects
3. Findings
(1) Experts opinion
12 experts to validate the items
(2) Survey 400 clinical nurses and RTS
(3) The correlations between the answers from experts and clinical nurses and RTS
4. Discussion
5. Findings
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THANKS FOR YOUR ATTENTION !!