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EVIDENCE BASED NURSING

Kailyn Hemani & Danielle Danoski

What is Evidence Based Nursing?

EBN is a type of evidence-based healthcare that involves identifying solid research findings and implementing them in nursing practices in order to increase the quality of patient care. The goal of EBN is to provide the highest quality and most cost-efficient nursing care possible.

Significance To The Nursing Profession

EBN keeps the nursing field up to date with the latest research to provide the best possible care to patients using the most practical and efficient way possible. It synchronizes the form of care provided by nurses around the nation. It is the driving force that determines what students learn in nursing school. It allows nurses to make well informed decisions based on evidence from the research.

Florence Nightingale

The term EBN was not used in her day but it is a concept that was central to her own theory of nursing and health care.
 Her

leadership was very much knowledge based.  She is considered a pioneer in graphical representation of data and a developer of survey  She collected data on soldier mortality/ morbidity during the Crimean War.

EBN Process: The 5 “A’s”

1. ASK: Information needs from practice are converted into focused, structured questions. 2. ACQUIRE: the focused questions are used as a basis for literature searching in order to identify relevant external evidence from research. 3. APPRAISE: the research evidence is critically appraised for validity. 4. APPLY: the best available evidence is used alongside clinical expertise and the patient’s perspective to plan care. 5. ASSESS: performance is evaluated through a process of self reflections, audit, or peer assessment.

Levels of Evidence

Editorials, Expert Opinion

The clinical experience, expertise, and judgment of a respected healthcare professional do play important roles in EBN. Sometimes there is not enough resources or time to research every aspect of the topic. Therefore, we ask the healthcare professionals about the key findings and recommendations. Does not attempt to find all existing knowledge on a topic

Editorials, Expert Opinion

Advantage: easy access, time efficient, limited resources needed Disadvantage: The expert opinion can be biased and must be evaluated before using it as evidence.

Editorials, Expert Opinion

Example: A well renowned nurse who specializes in the integumentary system has been in the field for 30 years gives her expert opinion on sunscreen use.

Case Series

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A descriptive report on a relatively small number of patients. Patients have the same outcome Often used to introduce practitioners to unusual and rare conditions Often the basis for future research using strong evidence study designs

Case Series

Advantages:
   

Can help in the identification of new trends or diseases Can help detect new drug side effects and potential uses (adverse or beneficial) Educational – a way of sharing lessons learned Identifies rare manifestations of a disease
Weakest type of evidence Cases may not be generalizable Not based on systematic studies Causes or associations may have other explanations Can be seen as emphasizing the bizarre

Disadvantages:
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Case Series Example

A physician treated a young and otherwise healthy patient who came to her office reporting numbness all over her body. The physician had never seen anything like it. After taking an extensive history the physician discovered that the patient had recently been to the beach and had used a very new type of spray sunscreen. The patient had stored the sunscreen in her cooler at the beach. The physician suspected that the spray sunscreen had undergone a chemical reaction from the coldness which caused the numbness. She also suspected that because this is a new type of sunscreen. A report was made on the small amount of patients who used this sunscreen and experienced the same numbness. This report was helpful to doctors because it helped identify this rare situation.

Case-Control Studies

An observational, retrospective study which involves identifying patients who have the outcome of interest and control patients without the same outcome We would look back to see if the two different groups had the exposure of interest

Case-Control Studies

Advantages
    

Good for studying rare conditions or diseases Less time needed to conduct the study because the condition or disease has already occurred Lets you simultaneously look at multiple risk factors Useful as initial studies to establish an association Can answer questions that could not be answered through other study designs Retrospective studies have more problems with data quality because they rely on memory and people with a condition will be more motivated to recall risk factors (also called recall bias). Not good for evaluating diagnostic tests because it’s already clear that the cases have the condition and the controls do not It can be difficult to find a suitable control group

Disadvantages

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Case-Control Studies

There is a suspicion that zinc oxide, the white non-absorbent sunscreen traditionally worn by lifeguards is more effective at preventing sunburns that lead to skin cancer than absorbent sunscreen lotions. A case-control study was conducted to investigate if exposure to zinc oxide is a more effective skin cancer prevention measure. The study involved comparing a group of former lifeguards that had developed cancer on their cheeks and noses (cases) to a group of lifeguards without this type of cancer (controls) and assess their prior exposure to zinc oxide or absorbent sunscreen lotions. This study would be retrospective in that the former lifeguards would be asked to recall which type of sunscreen they used on their face and approximately how often. Efforts would need to be made to ensure that the former lifeguards are of the same average age, and lifeguarded for a similar number of seasons and amount of time per season.

Cohort Study

An observational, prospective or retrospective study which involves two groups One group receives the exposure of interest, and one does not. The researchers do not assign the exposure or randomize the groups in any way.

Cohort Study

Advantages:
Subjects in cohorts can be matched, which limits the influence of confounding variables  Standardization of criteria/outcome is possible  Easier and cheaper than a randomized controlled trial (RCT)

Disadvantages:
Cohorts can be difficult to identify due to confounding variables  No randomization, which means that imbalances in patient characteristics could exist  Blinding/masking is difficult  Outcome of interest could take time to occur

Cohort Study Example

A cohort study was designed to assess the impact of sun exposure on skin damage in beach volleyball players. During a weekend tournament, players from one team wore waterproof, SPF 35 sunscreen, while players from the other team did not wear any sunscreen. At the end of the volleyball tournament players' skin from both teams was analyzed for texture, sun damage, and burns. Comparisons of skin damage were then made based on the use of sunscreen. The analysis showed a significant difference between the cohorts in terms of the skin damage.

Randomized controlled trials

An experimental, prospective study in which participants are randomly put into an experimental group or controlled group and are followed over time for the outcome of interest.

Randomized Controlled Trials

Advantages
Good randomization will “wash out” any population bias  Easier to blind/mask than observational studies  Results can be analyzed with well known statistical tools  Populations of participating individuals are clearly identified

Disadvantages
Expensive in terms of time and money  Volunteer biases: the population that participates may not be representative of the whole  Does not reveal causation  Loss to follow-up attributed to treatment

Randomized Controlled Trials

To determine how a new type of short wave UVA-blocking sunscreen affects the general health of skin in comparison to a regular long wave UVA-blocking sunscreen, 40 trial participants were randomly separated into equal groups of 20: an experimental group and a control group. All participants' skin health was then initially evaluated. The experimental group wore the short wave UVA-blocking sunscreen daily, and the control group wore the long wave UVA-blocking sunscreen daily. After one year, the general health of the skin was measured in both groups and statistically analyzed. In the control group, wearing long wave UVA-blocking sunscreen daily led to improvements in general skin health for 60% of the participants. In the experimental group, wearing short wave UVA-blocking sunscreen daily led to improvements in general

Systematic Reviews

A summary of the medical literature that uses methods to perform a comprehensive literature search and critical appraisal of individual studies Strongest and most detailed type of evidence

Conducted to answer a specific clinical foreground question

Systematic Reviews

Advantages
Exhaustive review of the current literature and other sources (unpublished studies, ongoing research)  Less costly to review prior studies than to create a new study  Less time required than conducting a new study  Results can be generalized and extrapolated into the general population more broadly than individual studies  More reliable and accurate than individual studies  Considered an evidence-based resource

Disadvantages
Very time-consuming  May not be easy to combine studies

Systematic Reviews

Does the regular wearing of ultravioletblocking sunscreen prevent melanoma? An exhaustive literature search was conducted, resulting in 54 studies on sunscreen and melanoma. Each study was then evaluated to determine whether the study focused specifically on ultraviolet-blocking sunscreen and melanoma prevention; 30 of the 54 studies were retained. The thirty studies were reviewed and showed a strong positive relationship between daily wearing of sunscreen and a reduced diagnosis of melanoma.

The Future Of Evidence Based Nursing
EBN is the future of nursing.  It dictates the direction nursing is going and constantly evolves the field.  Without EBN nursing would stand still and not progress.

How To Become A Clinical Research Nurse
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While the need and demand for nurses continue, the same need and demand exists for nurse researchers. Step 1: Obtain a bachelor's degree in nursing Step 2: Get licensed

you can then start working as a registered nurse and gain work experience

Step 3: Get your Master’s of Science in Nursing (MSN) Step 4: Get your Doctor of Philosophy in Nursing (PhD)

Getting your PhD is optional to work in the specialty, but might be required to conduct certain types of research. That’s why many schools offer programs that allow students to do research while working on higher degrees.

Step 5: Become a Nurse Researcher

Summary

Even if you don’t want to go into the research aspect of nursing EBN will still be apparent in your every day nursing career. All advances promoted in the nursing environment will be because of the researchers who sought out to make the nursing field as efficient as possible.

Any Questions?

References

(2006). Levels of evidence. Evidence-Based Practice in the Health Sciences Retrieved from http://ebp.lib.uic.edu/nursing/node/12 (2011). Study Design 101. The Himmelfarb Health Sciences Library. Retrieved from http://www.gwumc.edu/library/tutorials/studydesign101/casereports. html (2013). Using Evidence Based Nursing in Practice. UNC Health Sciences Library. Retrieved from http://guides.lib.unc.edu/content.php?pid=118474&sid=1021248 Evidence-based nursing. Wikipedia. Retrieved October 17, 2013 from http://en.wikipedia.org/wiki/Evidence-based_nursing. Glover, Jan. (2006). Evidence-Based Clinical Practice Resources. Harvey Cushing/John Hay Whitney Medical Library. Retrieved from http://guides.library.yale.edu/content.php?pid=9786&sid=73113 McDonald, Lynn. (2001). Florence Nightingale and the early origins of evidence-based nursing. Evidence-Based Nursing, 4, 68-69 doi: 10.1136/ebn.4.3.68