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

Biography

Discuss Evidence Based Practice (EBP)

Examples of EBP

Evidence Based Renal Care - The ‘PACKS’ study

Importance to Nursing

Barriers to EBP

AIMS OF PRESENTATION

BIOGRAPHY

BIOGRAPHY

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

CAREER CHANGE

THE LADS!

QUEENS UNIVERSITY BELFAST

The conscious use of current best evidence in making decisions about patient care ( S a c ket t e t a l 2 0 0 0 Ev id en ce -Ba sed

M ed ic in e : H ow to P r a c t i c e a n d Tea c h E B M ) .

Definitions of EBP have broadened in scope. Now defined as

“a l ifelong 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)

WHAT IS EVIDENCE BASED PRACTICE

TRIAD OF EVIDENCE BASED PRACTICE

Best Available

Evidence

Patient values &

Expectations

Individual

Clinical

Expertise

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

EBP

LEVELS OF EVIDENCE

I Evidence - Systematic reviews, meta-analysis

RCTs, EB clinical practice guidelines based on RCTs

I I Evidence - One well designed RCT

I I I 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

One of the simplest but most power ful tools of research.

People are al located at random to receive one of several cl inical interventions.

Used to examine the ef fect of interventions on par ticular outcomes such as death or the recurrence of disease.

Some consider randomized control led tr ials to be the best of al l research designs, or “the most power ful tool in modern cl inical 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 – 9 7 8

KEY:

the act of randomizing patients to receive or not receive the intervention ensures that, on average, al l 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 pd a t e - s o f t w a r e . c o m / a b s t r a c t s / a b 0 0 1 8 7 7 . h t m

RCTS

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

FORMS OF EVIDENCE

ASSESS the patient

1. Start with the patient -- a clinical problem or question arises from the care of the patient

ASK the question

2. Construct a well built clinical question derived from the case

ACQUIRE the evidence

3. Select the appropriate resource(s) and conduct a search

APPRAISE the evidence

4. Appraise that evidence for its validity (closeness to the truth) and applicability (usefulness in clinical practice)

APPLY: talk with the patient

5. Return to the patient -- integrate that evidence with clinical expertise, patient preferences and apply it to practice

Self-evaluation

6. Evaluate your performance with this patient

STEPS IN THE EBP PROCESS

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

WHY DO NURSES NEED TO DELIVER

EVIDENCE BASED PRACTICE

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?

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.

SCOPE OF NURSING AND MIDWIFERY

PRACTICE FRAMEWORK

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

A NURSE-LED EVIDENCE BASED PRACTICE PROJECT

MONITORING & IMPROVING MANAGEMENT OF

CHEMOTHERAPY-INDUCED NAU

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

Poor access to facilities and information

Lack of educational skills in critiquing research

Lack of experience and little confidence in using computers

The quality of the resources that nurses access remains contentious

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’

SUMMARY