Chapter 13

1. Chapter 13 Building an Evidence-Based Nursing Practice

2. Evidence-Based Practice Conscientious integration of best research evidence with clinical expertise and patient values and needs in delivery of quality cost-effective health care Has a broader focus than research use Goal is implementation of quality cost-effective care to promote positive outcomes

3. Barriers to EBP Practical Conceptual May create a “cookbook” approach to care

4. Benefits to EBP Improved patient outcomes for patients, providers, and agencies Leads to best treatment (Gold Standard) plan An integral part of the Magnet Status process

5. Evidence-Based Sources Systematic reviews Meta-analyses Integrative reviews Metasummaries Metasyntheses

6. Developing Evidence-Based Practice for Nursing Findings from a study are different from research evidence. Research evidence is a synthesis of quality, relevant studies to form a body of empirical knowledge for selected area of practice.

7. Synthesis of Research Findings Knowledge comes from quantitative, qualitative, and outcomes research. Content clustering: integration of findings from scientifically sound research to determine what is currently known or not known Accomplished through: Integrative reviews Systematic reviews Meta-analyses, metasummaries, metasyntheses

8. Integrative Reviews Identifies, analyzes, and synthesizes results from independent quantitative and qualitative studies to determine current knowledge Includes multiple types of research designs and literature types A complicated review, but gives breadth and depth to conclusions Annual Review of Nursing Research publishes integrative reviews.

9. Qualitative Research Contributions to Integrative Reviews Identifies and refines questions and outcomes Identifies types of participants and interventions Augments and provides data for research synthesis Highlights inadequacies in methods Explains findings and interpretation of findings Helps make recommendations

10. Systematic Reviews of Research A narrowly focused synthesis of research findings from quantitative studies Looks at studies of similar methodology Has same standards of clarity, rigor, and replication as primary research studies

11. Steps in Systematic Reviews Formulate purpose and identify scope. Develop specific questions or hypotheses. Establish criteria for inclusion/exclusion of studies. Conduct extensive literature search of all sources. (Melnyk & Fineout-Overholt, 2005; Whittemore, 2005)

12. Steps in Systematic Reviews (cont’d) Develop questionnaire and contact authors to gather data. Critique studies for scientific merit and data analysis. Analyze and interpret data. Report the review. (Melnyk & Fineout-Overholt, 2005; Whittemore, 2005)

13. Meta-analyses of the Research Literature Statistically pools results from previous studies into single quantitative analysis Allows for application of scientific criteria For example, sample size, level of significance, variables

14. Results of Meta-analysis A large, diverse sample that is more representative of target population Determination of overall significance of probability of pooled data Indication of the efficacy of the intervention from the average effect size determined from several quality studies Strength of relationship between variables

15. Metasummaries in Qualitative Research Definition: a synthesis of multiple primary qualitative studies to produce a narrative about a selected phenomenon Expands our knowledge base

16. Metasynthesis of Qualitative Research Synthesizes qualitative research with a critical analysis of primary studies and synthesis of findings into a new theory

17. Best Evidence for Use in Practice The strength of the evidence is on a continuum from high-quality results to lower-quality results. Evidence-based guidelines are essential in developing evidence-based practice for nursing.

18. Continuum of Strength of Research Evidence

19. Strength of Evidence Strongest evidence Meta-analysis Integrative reviews Experimental studies Weakest evidence Descriptive surveys Qualitative studies Correlational studies Quasi-experimental studies

20. Stetler Model of Research Utilization Phase I: Preparation Phase II: Validation Phase III: Comparative Evaluation/Decision Making Phase IV: Translation/Application Phase V: Evaluation

21. Iowa Model of Evidence-Based Practice Provides direction for development of evidence-based practice in an agency Looks at triggers for change, such as: Risk management data Financial data Organizational standards Philosophy of care

22. Iowa Model of Evidence-Based Practice (cont’d)

23. Application of the Iowa Model What are effective strategies for implementation? What are outcomes from using the research findings? Do the data support the change? Is the proposed change an agency priority?

24. Scientific Merit Critique According to the Iowa model, research should be examined for: Conceptualization and internal consistency of the study Methodological rigor of the design, sample methods, data, and analysis Generalizability of the findings Number of replications

25. Determining Agency Compatibility with the Change in Practice Who needs to approve the change in the agency? What steps are needed to get the change approved in the institution? Do physicians support the change? Do nurses support the change? Who are the leaders and will they support the change?

26. Instituting the Change in Practice Will the implementation take a long time? What support is needed to make the change? Are there barriers to instituting change in the agency?

27. Utilization Barriers Administration barriers Research not valued Limited change in agency or change not based on research Limited resources to make research-based change

28. Utilization Barriers (cont’d) Clinician barriers Do not read research reports Lack education about research process Do not believe research findings Do not know how to implement findings

29. Monitoring Outcomes After the change is effected, the outcomes must be monitored for effectiveness. Change should be documented regarding improved quality of care, decreased costs, saved nursing time, and improved access to care. Feedback is needed.

30. The Cochran Collaboration P – Population or participant of interest I – Intervention needed for practice C – Comparison of interventions to determine best practice O – Outcomes needed for practice

31. Development of Evidence-Based Guidelines AHRQ helps with guidelines through development of an expert panel. The group designates the scope of the guidelines. They synthesize the findings to develop recommendations for practice. Guidelines developed are presented at meetings and published.

32. Examples of AHRQ Practice Guidelines Pain management Decubiti prediction/prevention Cataract treatment in adults Depression treatment Screening, diagnosis, management of sickle cell disease in newborns and infants Otitis media treatment in children Availability of cardiac rehabilitation services

33. Access to Evidence-Based Guidelines Agency for Healthcare Research and Quality (AHRQ) National Guideline Clearinghouse (NGC) Academic Center for Evidence-Based Nursing American College of Physicians American Academy of Pediatrics

34. Implementing a Model of Evidence-Based Practice Identify practice problem. Search for best research evidence. Determine quality of guideline by assessing: Authors Significance of problem Strength of evidence Link to national standards Cost-effectiveness of guideline

35. Translational Research An evolving concept defined by the NIH as the translation of basic scientific discoveries into practical application Encouraged by nursing and medicine to increase the implementation of evidence-based interventions in practice and determine if these interventions are effective