EVIDENCE – BASED

PRACTICE

SHARON A. DENHAM, PHD, RN, CNE

SDENHAM@TWU.EDU
 OBJECTIVES

AT THE END OF THE SESSION, PARTICIPANTS WILL BE ABLE TO:

• DEFINE EVIDENCE-BASED NURSING PRACTICE AND ITS PURPOSES.
• IDENTIFY WHY EVIDENCE BASED PRACTICE IS CRITICAL TO CLINICAL PRACTICE.
• DESCRIBE SOME BARRIERS TO EVIDENCE-BASED PRACTICE.
• IDENTIFY WAYS TO SEARCH FOR THE BEST EVIDENCE.
• ASKING SEARCHABLE QUESTIONS AND KNOW THE TYPES OF EVIDENCE TO FIND.
• DISSEMINATE FINDINGS FROM SYSTEMATIC EVIDENCE-BASED REVIEWS
EVIDENCE-BASED PRACTICE IS NOT
• RESEARCH UTILIZATION
• QUALITY IMPROVEMENT
• PERFORMANCE IMPROVEMENT
 NURSING RESEARCH
• QUANTITATIVE STUDIES
• QUALITATIVE STUDIES
• TRIANGULATED APPROACHES/MIXED METHODS
 QUANTITATIVE STUDIES
(HARD SCIENCE – NARROW FOCUS)

• USE OBJECTIVE QUANTIFIABLE DATA

• RANDOM CONTROL TRIALS, EXPERIMENTAL DESIGNS, QUASI-
EXPERIMENTAL DESIGNS, DESCRIPTIVE, CORRELATIONAL
• USE SURVEY INSTRUMENTS (MEASURE: KNOWLEDGE, BELIEFS,
ATTITUDES, EXPERIENCES)

Test Relationships
 QUALITATIVE STUDIES
(SOFT SCIENCE – BROAD FOCUS)

• PURPOSE; UNDERSTAND A PARTICULAR PHENOMENA

• INTERVIEWS, OBSERVATIONS - RIGOR
• ETHNOGRAPHY, PHENOMENOLOGY, GROUNDED THEORY,
HISTORICAL, CASE STUDY
• NARRATIVE ANALYSES

Gain Insights
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 EVIDENCE-BASED NURSING PRACTICE
• ABILITY TO ACCESS, SUMMARIZE, AND APPLY INFORMATION FROM TO
ADDRESS EVERY-DAY CLINICAL PROBLEMS
• EVIDENCE-BASED PRACTICE REQUIRES EMPHASIS ON SYSTEMATIC
OBSERVATION AND EXPERIENCE AND KNOWLEDGE OF THE RESEARCH
LITERATURE TO SUBSTANTIATE CLINICAL DECISIONS
 EVIDENCE-BASED PRACTICE
• CONSCIENTIOUS PROBLEM-SOLVING APPROACH TO CAREGIVING
• INCORPORATES: (A) BEST RESEARCH EVIDENCE; (B) INDIVIDUAL’S
VALUES AND PREFERENCES; (C) CLINICIANS’ EXPERTISE
• NOT “THIS IS THE WAY WE HAVE ALWAYS DONE IT” --- INSTEAD,
PROVIDE HIGH QUALITY CARE BASED ON RESEARCH AND KNOWLEDGE
 EVIDENCE-BASED PRACTICE
• RESULTS: BETTER CARE DELIVERY & DECISIONS
• CONTRIBUTES TO SCIENCE OF NURSING
• CURRENT AND RELEVANT PRACTICE
 BARRIERS TO
EVIDENCE-BASED PRACTICE
• DO NOT VALUE RESEARCH IN PRACTICE
• LACK TIME TO READ RESEARCH
• RESEARCH REPORTS TOO COMPLEX
• DIFFICULT TO CHANGE PRACTICE
• LACK OF ADMINISTRATIVE SUPPORT OR KNOWLEDGEABLE MENTORS
• PROCESS SEEMS OVERWHELMING - LACK EDUCATION/UNDERSTANDING
ABOUT THE RESEARCH PROCESS & EVIDENCE-BASED PRACTICE
 EVIDENCE BASED PRACTICE AND
CLINICAL NURSING PRACTICE
• MANAGE THE EXPLOSION OF RESEARCH FINDINGS THAT MAY IMPROVE
CLINICAL OUTCOMES
• RELIANCE ON TEXTBOOKS DOES NOT PROMOTE THE NEEDED CRITICAL
THINKING
• ENHANCE ABILITY TO MAKE QUALITY DECISIONS USING THE MOST
CURRENT & RELEVANT EXPERTISE/KNOWLEDGE
 CLINICAL GUIDELINES
• AGENCY FOR HEALTHCARE RESEARCH AND QUALITY (AHRQ)
HTTPS://WWW.AHRQ.GOV/PROFESSIONALS/CLINICIANS-PROVIDERS/GUIDELINES-
RECOMMENDATIONS/INDEX.HTML
• COCHRANE LIBRARY
HTTP://WWW.COCHRANELIBRARY.COM/COCHRANE-DATABASE-OF-SYSTEMATIC-
REVIEWS/TABLE-OF-CONTENTS/CURRENT-ISSUE.HTML
• SPECIALTY ORGANIZATIONS: AMERICAN ASSOCIATION OF
NEUROSCIENCE NURSES
HTTP://AANN.ORG/PUBLICATIONS/CLINICAL-PRACTICE-GUIDELINES
 HIERARCHY OF EVIDENCE
LEVEL A:
• GOLD STANDARD: RANDOMIZED CONTROLLED TRIALS (RCT)
• SYSTEMATIC REVIEW OR META-ANALYSIS OF RELEVANT RCT
• CLINICAL PRACTICE GUIDELINES

LEVEL B:
• WELL-DESIGNED STUDIES (NOT RCT)
• CASE-CONTROLLED STUDIES
• UNCONTROLLED STUDIES (CONVENIENCE SAMPLES)
• EPIDEMIOLOGICAL STUDIES
• QUALITATIVE/QUANTITATIVE STUDIES (DESCRIPTIVE, CORRELATIONAL)
 HIERARCHY OF EVIDENCE
LEVEL C:
• CONSENSUS VIEWPOINT AND EXPERT OPINION (USE WHEN NO QUANTITATIVE
OR QUALITATIVE STUDIES IN THE AREA OF INTEREST)
• META-SYNTHESIS (SYSTEMATIC REVIEW THAT SYNTHESIZES FINDINGS FROM
QUALITATIVE STUDIES
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 ASKING YOUR QUESTION
PICO IS A MNEMONIC - DESCRIBES 4 ELEMENTS OF CLINICAL QUESTIONS:
• P = POPULATION/PROBLEM - HOW DO YOU DESCRIBE THE PROBLEM OR
A GROUP OF SIMILAR PATIENTS?
• I = INTERVENTION - WHAT MAIN INTERVENTION, PROGNOSTIC FACTOR
OR EXPOSURE IS TO BE CONSIDERED?
• C = COMPARISON - IS THERE AN ALTERNATIVE TO COMPARE WITH THE
INTERVENTION?
• O = OUTCOME - WHAT DO YOU HOPE TO ACCOMPLISH, MEASURE,
IMPROVE OR AFFECT?
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 LITERATURE REVIEWS
• ANSWER PICO QUESTION
• SYNTHESIZE THE LITERATURE IN A FIELD
• IDENTIFY GAPS IN THE LITERATURE
• EVALUATE THE STRENGTH OF THE LITERATURE
 SKILLS NEEDED
• NOTE TAKING SKILLS
• SYNTHESIS SKILLS - SEE RELATIONSHIPS AND PATTERNS
• SUMMARY SKILLS
• EVALUATION SKILLS
 NOTE-TAKING SKILLS
• SPREADSHEET: CITATION, MAIN ARGUMENTS & FINDINGS, STUDY
RELATIONSHIPS
• NOTES: KEY QUOTES & CITATIONS, RESPONSE TO QUOTES, CONNECTIONS
OR CONFLICTS SEEN AMONG KEY POINTS, THEMES IDENTIFIED
• BUCKETS: BASE ON DATABASES, SEARCH TERMS USED - BREAK DOWN THE
WRITING PROCESS INTO USEFUL SECTIONS
 SYNTHESIS
• STUDY QUESTIONS
• WHEN/WHERE WAS STUDY CONDUCTED
• WHO OR WHAT WAS STUDIED
• SAMPLE SIZE (TRAITS/CHARACTERISTICS)
• STUDY TYPE/METHODS
• FINDINGS
 SYNTHESIS
• MAKE RESPONSIBLE OBSERVATIONS OR GENERALIZATIONS ABOUT A SET OF TEXTS
• MAKE ASSERTIONS OR ARGUMENTS ABOUT THE AVAILABLE LITERATURE
• ARTICULATE CONSENSUS POSITIONS
• IDENTIFY TRENDS AND/OR CONTROVERSIES
• SUMMARIZE THE EXISTING BODY OF LITERATURE
 WRITING OF SYNTHESIS
• ONE STUDY WAS FOUND THAT DESCRIBES…..
• ANOTHER STUDY ADDRESSES…..
• THE NEXT STUDY IDENTIFIES…..

Discuss common findings

Describe contrasting opinions
Identify the state of research studies
Draw conclusions
Recommendations
 SEARCH FOR EVIDENCE
• IDENTIFY SEARCH TERMS
• IDENTIFY DATABASES TO BE USED FOR SEARCH
• INCLUSION CRITERIA
• EXCLUSION CRITERIA
 COMPLETING THE SEARCH
• SYSTEMATIC SEARCH OF RESEARCH
• GET A SMALL NOTEBOOK
• WHAT ARE YOU LOOKING FOR DURING THE SEARCH???
• KEEP LISTS OF SEARCH CHAINS AND DATABASES USED – NUMBERS/NAMES OF
REFERENCES FOUND
• CAREFULLY READ STUDIES – IDENTIFY THE PERTINENT ONES
 WHAT SPECIFIC CRITERIA ARE YOU LOOKING FOR
 WHY STUDIES ARE NOT INCLUDED
 CREATE TABLES
• AUTHORS/PUBLICATION YEAR
• TYPE OF RESEARCH STUDY
• SUBJECTS
• INTERVENTION(S)
• KEY STUDY FINDINGS
• CONCLUSIONS
• OTHER INFORMATION
SYNTHESIZE EVIDENCE
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 Question Type Problem Intervention Comparison Outcome

Therapy Disease or Condition Therapeutic Type of care, new Mortality rates,

measure (e.g., intervention, work days lost,
medication, placebo pain, level of
surgery, life style) disability

Prevention Reduce risk factors, Altered life style, Disease incidence,

improve health diet change, mortality, health
condition exercise indicators

Diagnosis Disease or condition Test or procedure Gold standard for Test utility, trends,
the problem diminished
complications, LOS

Prognosis
Causation
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 FIVE A’S –EVIDENCE –BASED PROCESS
• ASK: INFORMATION NEEDS FROM PRACTICE ARE CONVERTED INTO FOCUSED,
STRUCTURED QUESTIONS.
• ACQUIRE: THE FOCUSED QUESTIONS ARE USED AS A BASIS FOR LITERATURE
SEARCHING IN ORDER TO IDENTIFY RELEVANT EXTERNAL EVIDENCE FROM
RESEARCH.
• APPRAISE: THE RESEARCH EVIDENCE IS CRITICALLY APPRAISED FOR VALIDITY.
• APPLY: THE BEST AVAILABLE EVIDENCE IS USED ALONGSIDE CLINICAL EXPERTISE
AND THE PATIENT'S PERSPECTIVE TO PLAN CARE.
• ASSESS: PERFORMANCE IS EVALUATED THROUGH A PROCESS OF SELF
REFLECTION, AUDIT, OR PEER ASSESSMENT.
Disseminate
44
 RESOURCES
• AGENCY FOR HEALTHCARE RESEARCH AND QUALITY EVIDENCE-BASED PRACTICE
CENTERS: HTTPS://WWW.AHRQ.GOV/PROFESSIONALS/CLINICIANS-
PROVIDERS/GUIDELINES-RECOMMENDATIONS/INDEX.HTML
• THE COCHRANE COLLABORATION:
• COCHRANE REVIEWS: HTTP://WWW.COCHRANE.ORG/WHAT-IS-COCHRANE-
EVIDENCE
• EVIDENCE-BASED HEALTHCARE: HTTP://WWW.COCHRANE.ORG/WHAT-IS-
COCHRANE-EVIDENCE
• NATIONAL GUIDELINE CLEARINGHOUSE: HTTPS://WWW.GUIDELINE.GOV/
• EBSCO NURSING REFERENCE CENTER:
HTTPS://WWW.EBSCOHOST.COM/NURSING/PRODUCTS/NURSING-REFERENCE-
CENTER/NURSING-REFERENCE-CENTER-CONTENT