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EBN Application. 莊情惠 , MSN, RN Head Nurse, Chang Gung. Quality of Care. Broad topic Critically important Implementation key concern Many component parts. Component Parts. Patient, clinicians, systems Problem identification and refinement Use of evidence Interventions

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Ebn application

EBN Application

莊情惠, MSN, RN

Head Nurse, Chang Gung


Quality of care
QualityofCare

  • Broad topic

  • Critically important

  • Implementation key concern

  • Many component parts


Component parts
Component Parts

  • Patient, clinicians, systems

  • Problem identification and refinement

  • Use of evidence

  • Interventions

  • Implementation

  • Adoption into practice


Quality of care1
Quality of Care

  • Similar to:

    • Evidence based nursing (EBN)

    • Quality improvement

  • Uses evidence & clinical expertise

  • Patient outcomes and preferences

  • Within systems of care


Why is ebn important
Why is EBN important?

  • Manage explosion

    • Literature

    • Technology

  • New way to think

    • Practice

    • Research

    • Knowledge development


Ebn promotes translation
EBN Promotes Translation

Research Literature

into

Individualized care


What nurses do with ebn
What Nurses Do with EBN

Obtain valid information

Search for, assess & use literature

Use information (evidence)

Develop interventions

and

Apply to clinical situations


Ebn promotes
EBN Promotes:

Systematic observation plus

Experience and

Research literature

to support

Nursing decisions


Origins of ebm in 1970s
Origins of EBM in 1970s

  • Started in Medicine

  • Synthesis of research literature

  • Guidance for practice


Ebp history in nursing
EBP History in Nursing

  • First (1970’s) called

    • Research utilization

    • Translation into practice

  • Now called

    • EBN

    • Evidence based nursing


Our outline
Our Outline

  • What is evidence based nursing (EBN)

  • Goals of EBN

  • Products

  • Procedures for EBN reviews

  • Strengths and Weaknesses


Ebn goals
EBN Goals

  • Improve patient outcome

  • Reduce healthcare costs


Ebn growing rapidly
EBN Growing Rapidly

  • Nursing - 2,500 citation

  • Medicine - 21,000 citations


Types of ebn reports
Types of EBN Reports

  • EBN to guide clinical decisions

  • How to do EBN

    Can be confusing to newcomer


Where are ebn reports
Where Are EBN Reports ?

  • Professional journals

  • World Wide Web (WWW)

  • Books


How do i get ebn reports
How Do I Get EBN Reports?

  • Your library

  • Web

    Many are free


Professional journals
Professional Journals

  • Evidence Based Nursing

  • World Views on EBN- Sigma Theta Tau product

  • Your professional journal?


Book most cited
Book Most Cited

DiCenso, Ciliska & Guyatt(2005). Evidence-based nursing; A guide to clinical practice. St. Louis, Elsevier Mosby.


Other sources on web
Other Sources on Web

  • Practice guidelines

  • Governmental sources

  • Cochrane Database


Our outline1
Our Outline

  • What is evidence based nursing (EBN)

  • Goals of EBN

  • Products – A model and an example

  • Procedures for EBN reviews

  • Strengths and Weaknesses


Ebn example
EBN – Example

  • Problem

    • Type II Diabetes Mellitus

    • Clinic management

  • Goal - Process improvement


Assess support
Assess Support

  • Nursing management

  • Other departmental leaders

  • Nursing team


Problem or question
Problem or Question

  • Current guidelines not followed

  • Lacked measures

    • Glycosylated hemoglobin (HbA1c)

    • Lipids (LDL)

  • Lacked performance

    • Blood pressure checks

    • Annual foot exams

    • Monofilament testing


Establish desired patient outcomes
Establish Desired Patient Outcomes

  • Control of HbA1c and LDL

  • Improve performance to >80%

    • Foot exams

    • Filament testing

  • Improve patient involvement


Challenges encountered
Challenges Encountered

Data base accuracy

Staff turnover

Computer software upgrades

Sustainability


Our outline2
Our Outline

  • What is evidence based practice (EBN)

  • Goals of EBN

  • Products

  • Procedures for EBN reviews

  • Strengths and Weaknesses


How do i get started
How Do I Get Started?

  • Read research reports

  • Develop skills for research critique

  • Understand research reports

    • Concepts

    • Terminology


Develop internet skills
Develop Internet Skills

  • Use data bases

  • Use major EBN sources

    • PubMed

    • CIHAHL

    • Google Scholar


Ask for help and help yourself
Ask for Helpand Help Yourself

  • Librarian

  • WWW

  • Lectures

  • Conferences


Work with others
Work with Others

  • Sharing helps refine process

  • Improves reliability

  • Increase commitment


Steps in a ebn review
Steps in a EBN review

  • Ask

  • Access

  • Appraise

  • Implement

  • Evaluate


Ask the question
Ask the question

  • Identify a question

  • Define and refine the question


Sources of questions
Sources of Questions

  • Practice question, problem or practice

  • Basis for question

    • Concern about adverse outcomes

    • Cost

    • Time use

    • Patient complaint


Components of question picot
Components of Question - PICOT

  • Patients

  • Intervention

  • Comparison (current practice)

  • Outcome

  • Time frame


Access the literature
Access the Literature

  • Search literature – Reports are sample

  • Develop sample criteria

    • Inclusion

    • Exclusion

  • Obtain reports


Picot advantages
PICOT Advantages

  • Pushes clear definitions

    • Population

    • Comparison

    • Outcome

  • Focuses search

    • Too narrow – miss important ones

    • Too broad – not apply to context


Appraise literature answer 3 questions
Appraise literatureAnswer 3 Questions

  • Quality high enough to use (valid)?

  • Findings fit my setting?

  • What impact would EBN have on my patients?


Is report quality good enough valid
Is Report Quality Good Enough (Valid)?

  • Use research critique skills

  • Consider statistical significance


Does report fit my setting
Does Report Fit My Setting?

  • Comparison = Current practice

  • Consider

    • Patients

    • Colleagues

    • Setting

    • Resources


Extract data from each report
Extract Data from Each Report

  • Write a summary

  • Include specific information

  • Develop data collection forms

  • Establish a code book


Code book includes
Code Book Includes

  • Methodological features

  • Quality assessment


Code methods
Code Methods

  • Study source

  • Publication year

  • Research design

  • Authors/investigators characteristics


Quality assessment
Quality Assessment

  • Scientific merit

  • Intervention description

  • Study outcomes


Steps in a ebn review1
Steps in a EBN review

  • Ask

  • Access

  • Appraise

  • Implement

  • Evaluate


Critical appraisal
Critical Appraisal

  • Uses individual report/articles

  • Assembles body of evidence

  • Focuses on a single practice issue


Critical appraisal two goals
Critical Appraisal Two Goals

  • Internal consistency

  • Clinical significance


Internal consistency questions
Internal Consistency Questions

  • Did authors

    • Answer the question?

    • Measure variables as planned?

  • Were measurements

    • Reliable?

    • Valid?


Internal consistency continued
Internal Consistency(continued)

  • Were analyses appropriate?

  • Were conclusions

    • Reasonable?

    • Supported by results?

    • Matched to initial question/aim?


Hierarchy of evidence
Hierarchy of Evidence

  • Single-case report

  • Case series report

  • Case-control studies

  • Cohort studies

  • Nonrandom trials

  • Randomized controlled trials (RCT)

  • Meta-analysis and evidence reviews


Hierarchy
Hierarchy

  • From single-case report to RCT

  • Internal validity increased

  • Bias in studies reduced


Rating the evidence
Rating the Evidence

  • Several approaches

    • Endorsed by professional bodies

    • Consensus reached when RCTs numerous

  • Quality of evidence rated

    • High

    • Moderate

    • Low or very low


Rating the evidence1
Rating the Evidence

  • Study limitations

  • Inconsistency of results

  • Indirectness of evidence

  • Imprecision

  • Publication bias


Clinical significance
Clinical Significance

  • Will it make a difference in clinical my setting?

  • How important is the study?

  • Clinical expertise valuable here at this point.


Steps in a ebn review2
Steps in a EBN review

  • Ask

  • Access

  • Appraise

  • Implement

  • Evaluate


Implement
Implement

  • Identify stakeholders

  • Seek support of stakeholders

    • Nursing managers

    • Hospital administration

    • Other departments


Consider effect of ebn
Consider Effect of EBN

  • Others EBN would affect

  • Processes that would be affected

  • Educate nurses

    • Who make change

    • Who are affected by change


Evaluate
Evaluate

  • Assess cost effectiveness

  • Patient

    • Acceptance

    • Satisfaction

    • Complaints


Measure relevant information
Measure Relevant Information

  • Wait times

  • Patient census

  • Staff turnover

  • Medication errors


Evaluate patient outcomes
Evaluate Patient Outcomes

  • Diabetes clinic care

    • HbA1c

    • Filament testing

  • Intensive care

    • Pneumonia in intubated patients

    • EBN

      • head elevation

      • hand washing


Use information already collected
Use Information Already Collected

  • Incident Reports

  • Satisfaction surveys


Evidence based nursing overview
Evidence Based Nursing Overview

  • What is evidence based nursing (EBN)

  • Goals of EBN

  • Products

  • Procedures for EBN reviews

  • Strengths and Weaknesses


Strengths
Strengths

  • Reduces variations in practice

  • Gives consistent results

  • Reduces knowledge/practice gap


Ebn success requires
EBN Success Requires

  • System wide support

  • Support of leaders

  • Evaluation

  • Monitoring adherence


Nursing interventions
Nursing Interventions

  • Behavioral Change Interventions

    • Patients

    • Nurses

    • Others in system

  • Few RCT trials

  • Fewer systematic reviews


Forces pushing ebn today
Forces Pushing EBN Today

  • Cost

  • Safety

    Allows nurses to do more with less


Summary
Summary

  • EBN – What it is

  • Goals of EBN

  • Products

  • Procedures for EBN reviews

  • Strengths and Weaknesses