Evidenced Based Practice
a systematic, problem solving approach that:
- integrates best evidence
- uses clinical expertise & experience
- includes patient preferences and values
What are the steps of Evidenced-Based Practice (EBP)
- ask a clinical question in PICOT format
- collect the most relevant & best evidence
- critically appraise the evidence you gather
- integrate all evidence utilizing clinical expertise, patient preferences and values in making a decision of change.
- evaluate the outcomes of the practice decision or change
- share the outcomes of EBP changes with others
Step 1: Ask a Clinical Question
P: What is the patient population are you interested in?
I: What is the intervention of interest?
C: What are you trying to compare
O: What outcome are you trying to measure?
T: What is the time frame?
Step 2: Collect the most relevant and best evidence
- use your PICOT question to expeditiously access info/peer reviewed articles.
- search data base
Hierarchy of Evidence
….
Step 3: Critically appraise the evidence you gather
Evaluate: scientific merit, clinical applicability, and study limitations.
What are the elements of EBP articles?
- abstract
- introduction
- literature review
- manuscript narrative
- methods or designs
- results and conclusions
- clinical implications
manuscript narrative
the body of the article.
a. purpose statement
b. hypotheses
c. variables
Step 4: Integrate all evidence utilizing clinical expertise, patient preferences and values
- apply the research to your plan of care
- integrate evidence
Apply the research to your plan of care by asking yourself
- Does the practice change fit with scope of practice?
- Are the necessary resources available?
- Is a pilot study necessary?
- Who are the major stakeholders?
Integrate evidence through:
- teaching tools
- clinical practice guidelines
- policies and procedures
- assessment or documentation of tools
Step 5: Evaluate the practice decision or change
- How is the clinical practice change working?
- How effective was the change?
- Do modifications need to be made?
- Will this change be sustainable?
Step 6: Share the outcomes of EBP changes with others
- communicate the results
- sustainability more likely when: value is seen by the change, clinical staff “buys in” to the change, and clinical staff is allowed input in the process.
Outcomes Research
- focuses on benefits, risks, costs and holistic effects of a treatment on patients.
- helps make informed decisions on the basis of current evidence: justifies care practices and systems in terms of improved patient outcomes and costs.
Outcomes:
observable or measurable effects of an intervention or action
Focus of outcomes is
recipient of care
Scientific Method
- foundation of research; most reliable/objective
- systematic, step-by-step process
- minimizes bias or opinion by the researcher
- verifies findings from a study are: valid, reliable, generalizable to similar subjects researched.
Characteristics of scientific research
- Identifies the problem area of interest.
- Research is conducted in a systematic and orderly way.
- Researchers try to control external factors.
- Researchers gather empirical data through observations and assessments.
- Ultimate goal is to understand phenomena and applicability to a broad group of patients.
Quantitative Research
Precise measurement and quantification
Quantitative Research focus on
- Numerical data
- Statistical analysis
- Controls to eliminate bias in findings.
- Precise
- Systematic
- Objective
Experimental Research
tightly controls conditions to eliminate bias
Nonexperimental Research
describe, explain, or predict phenomena
Surveys
measure practices, perceptions, education, experience, opinions, and other characteristics of people
Evaluation research
determines how well a program, practice, procedure, or policy is working
Qualitative Research
- study of phenomena that are difficulty to quantify or categorize such as patient perception of illness
- requires inductive reasoning
Qualitative Research is obtained in
non-numerical form. ex) written transcripts, interviews and story telling
Qualitative Research Methods include:
ethnography, phenomenology, grounded theory
ethnography
explores cultural phenomena
phenomenology
explores structures of subjective experiences and consciousness
grounded theory
discovery of theory through analysis data
Nursing Process Compare to Research Process
- Assess vs Identify an area of interest
- Diagnose vs Develop research questions
- Plan vs Determine how the study will be conducted
- Implement vs Conduce the study
- Evaluate vs Analyze the results
Testing on Human Subjects: The Right of Informed Consent
- subjects are given full and complete information including potential harm, benefits and alternative methods of treatments.
- subjects must be fully capable of understanding the research and its implications.
- subjects have the power of free choice to voluntarily consent or decline participation.
- subjects must understand how the researcher maintains confidentiality or anonymity.
The Belmont Report of 1979: Outline fundamental ethical principles for using any human subject for research including:
- respect for persons: protecting autonomy
- beneficence: benefit
- non maleficence
- justice: non-exploitive, well-considered procedures
Focus of outcomes management to
increase patient safety and decrease medical errors.
includes:
- fall rates
- number of medication errors
- incidence of pressure ulcers
- infection rates
Quality improvement
improvement of health care related processes such as fall prevention
Performance improvement
Focused improvement actions, clinical projects in response to problems such as identifying patients at risk for falls and implementing a fall prevention protocol (yellow gown, signage etc…)
all members of the health care team collaborate in QI activities for
recognizing trends, identifying recurrent problems and initiating opportunities to improve
QI issues to consider:
- high-risk/high volume
- high-risk/low volume
- potential problems (for patients, staff and institution)
High risk/high volume
- potential for injury or death
- may be initiated secondary to a sentinel event.
sentinel event
involving death, serious physical or psychological injury
national patient safety goals purpose
is to improve patient safety.
Goals focus on problems in health care safety and how to solve them.
benefits of joint commision
….
Quality Improvement Models
- Six Sigma or Lean
- Rapid Cycle Improvement
Six Sigma or Lean
“bottom up approach” All members of the health care team are responsible for developing and integrating changes utilizing the fewest resources to reduce costs, enhance quality and improve teamwork.
Rapid Cycle Improvement
A response to a serious problem. Radical changes made in a short period of time.
QI Sustainability: Communication
ultimately sustainability will not take place without by-in from the end user
QI Sustainability: Communication
Must establish value in the change
Must utilize stake-holders input and suggestions/ideas
Must communicate results and report findings of of interventions
Must revisit interventions and analyze successes/potentials for improvement
Must utilize statistical data and sound evidence to measure the need for change and the resulting improvements
