Evidence Based Practice

In Nursing

Dr. Abdul-Monim Batiha

Assistant Professor
Critical Care Nursing
Philadelphia university
Today’s health care system has become
increasingly more costly and complex.
Consequently, in this market-driven delivery
system, there is a greater emphasis on outcomes,
cost-effectiveness, and consumer satisfaction.
 These pressures operate in an environment of
rapid information exchange, technological
advancements, and an increasing nursing
workload
 Nurses are challenged to maintain clinical
competence, to demonstrate how their care
positively affects patient outcomes, & to
participate actively in clinical decision-making
& practice improvements
 Nurses are now mandated to demonstrate cost-
effectiveness and efficiency with the use of time and
resources, while continuing to demonstrate their
value added impact on outcomes. These mandates
provide a strong rationale for adopting an evidence-
based model of practice
What Is Evidence- Based Nursing?
 Evidence – Based Nursing (EBN)
 Process by which nurses make clinical
decisions using the best available research
evidence, their clinical expertise & patient
preferences"
Clinical expertise
 Ability to use our clinical skills & experience
to rapidly identify each patient's unique
health state &diagnosis, their individual risks
& benefits of potential interventions, & their
personal values & expectations
 Patient values & preference

 Unique preferences, concerns &

expectations each patient brings to a clinical
encounter & which must be integrated into
clinical decisions if they are to serve the
patient
 Goals of EBN are to apply valid & reliable
nursing research to clinical practice
"Research utilization" & to bring the most
current knowledge to clinicians. This is
particularly important due to the knowledge
explosion in nursing and health care
 Steps to Evidence-Based Critical
Care Nursing Practice
 Accept the fact that health care is evolving, with the
consequent need to base nursing care on evidence,
rather than on tradition or previous education

 Identify a need for change in practice by examining

less-than-favorable patient outcomes; causes of
patient, family/significant other, or staff
dissatisfaction; or situations in which compelling new
evidence exists in an aspect of care
 Frame a clinical question and search the literature
for evidence regarding the topic

 Once current research data and evidence have

been collected, evaluate the evidence for
scientific merit, quality, and applicability
 Synthesize to determine the strength of the evidence
to support a change in practice

 Conduct a comparison between current practice

recommendations and current research
 If there is sufficient evidence to suggest a change
in practice and the change in practice is practical in
respect to costs, staff skill, and resources required,
application of the evidence into practice can occur

Implicit in the implementation of evidence are the issues

associated with change, including fear of change & the
need for information, staff training, leadership, & ongoing
evaluation of the change
 Continueto evaluate the evidence through
an ongoing and systematic review to
promote state of- the-science nursing care
Converting information needs
into clear questions
 Art to Phrasing Questions

 An art to phrasing questions in such a way as

to elicit a meaningful answer, there are three
key reasons for focusing questions:
 Facilitating the search for relevant evidence. The more
explicit the question, the easier it is to run searches on
electronic databases such as those contained within the
Library shelves, CINAHL (Cumulative Index of Allied
Health and Nursing Literature, or MEDLINE

A non-focused question is more likely to yield larger numbers

of non-relevant studies than a focused question, and valuable
search time will be wasted trying to sift through the long list
of retrieved references for relevant studies
 Sorting best evidence from weaker, less valid evidence

 Deciding whether the evidence is applicable to our patients

 The PICO (population, intervention, comparison

intervention, outcome) framework, devised by Saekett et al
(1997), is a useful method for making questions more
focused. The question is built in four (or three) parts
 PICO Frame
 Population or Problem, it may be necessary to specify
age, gender, disease type, disease severity or co-
morbidity. This will depend on whether the results of a
very broad, inclusive population could be applied to
your specific patient group

Define who or what the question

is about
 PICO Frame
 Intervention: Define which intervention, test or
exposure you are interested in. An intervention is a
planned course of action. An exposure is something
that happens such as a fall, anxiety. The intervention
(or test or exposure) may need to be described in some
detail to ensure clarity

Describe what it is you are considering doing

or what it is that has
happened to the patient
 PICO Frame
 Comparison intervention: Define the
alternate intervention

Describe the alternative that can be compared

with the intervention Outcomes:
Define the important outcomes, beneficial or
harmful
Define what you are hoping to achieve or avoid
 PICO Frame
 Outcomes: very general outcomes may be
difficult to measure, and details of how
outcomes can be objectively measured may
need to be specified
Searching Literature
 Basic search principles

 Analyzing the question

 Generating a word list
 Linking
word lists( Boolean logic: AND,
OR, NOT)
Boolean Operator
Boolean Operator
Boolean Operator
Types Of Evidence Used
 Health Care Indexes
 Research
 Retrospective or Concurrent Chart Review
 Quality Improvement & Risk Data &
Benchmarking
 International, National, & Local Standards
 Infection Control Data
 Pathophysiology
 Cost-effectiveness Analysis
 Patient Preferences
 Clinical Expertise
 Health care indexes
 Two of the most common indexes used by nurses are
MEDLINE, produced by the National Library of
Medicine (NLM)

 CINAHL (Cumulative Index for Nursing & Allied

Health Literature) produced by the C1NAHL
corporation. Both of these are available in print &
computerized forms
 The International Nursing Index, Hospital
Literature Index, Psych Index, and Social Sciences
Index are other common used indexes that would
reference articles and books pertinent to nursing
practice
 Many libraries subscribe to computerized
databases such as Ebsco and Proquest, which
provide citations, abstracts, and some whole
articles
 The Cochrane library Collaboration prepares
maintains and disseminates systematic reviews of
health care interventions focusing primarily on
systematic reviews of controlled trials of
therapeutic interventions (the gold standard for
experimental research design)
 Research
 Most experts consider the well-designed double-blind
experiment (often referred to as the randomized control trial)
the best type of evidence

 Another type of evidence is found in research studies that have

fewer controls. Some of these types of studies are included in
the discussion of reading research. The Centers for Disease
Control and Prevention identify these types of research
evidence as the most important in demising their guidelines for
disease and injury prevention and control
 Retrospective or concurrent chart
reviews, Quality improvement and
risk data
 Aggregating data across an institution or several institutions
provides an opportunity to assess how well current practices are
working

 Determining patient outcomes for large groups provides a firm

foundation of data that, although not part of a research study,
can guide practice

 Individual health care institutions and health plans are compiling

information for statistical analysis & making decisions about
health care based on these statistical measures
 International, national, and local
standards
 Bring together the opinions & expertise of many health care
providers

 The standards are based on the collective experience & goals

of individuals who are intimately involved with health care
practice

 Individuals who have worked with many patients, seen the

results of multiple trials, & identified at first hand the
complexity of the care have a special insight into effective
practice. Because of this involvement & knowledge, the
standards provide guidance and support for practice
 Infection control data
 Because infection remains a major complicating factor in
health care, infection control data assume major
importance as guide for practice

 The incidence of infection is of critical importance to both

the patient and the entire system in terms of its impact on
overall health outcomes

 Practices that decrease the potential for infection have high

priority
 Modern understanding of
pathophysiology
 Modern understanding of pathophysiology at even
the cellular level has changed thinking about many
health care practices
 Information regarding cost-
effectiveness analysis

 Helps an institution weigh possible benefits

against costs

 It compares how much improvement a certain

practice makes versus how much that practice
costs
 Patient preferences
 the importance of self-care in managing health
and illness, practices to which patients will adhere
and ones that make their lives simpler are more
likely to be incorporated

 Failure to take into consideration patient

preferences may make the best-designed therapy
ineffective
 Opinions of clinical experts

 Remain an important aspect of evidence.

Individuals who have worked with many patients,
seen the results of multiple trials, and identified at
first hand the complexity of the care have a special
insight into effective practice
Systematic Analysis of Information
&Evidence
 Not all published research evidence can be used for making
decisions about patient care
 Deficiencies in research design can make an intervention
look better than it really is
 The location and subjects of a particular research study may
affect the results in a unique way
 Assess the quality, importance and applicability of any
research evidence that is being consulted to answer a specific
clinical question critical appraisal
 Critical Appraisal
 The purpose of the critical appraisal for evidence-
based practice is to decide whether the quality of a
research study is good enough for the results it
provides to be used to answer a question posed by a
health care practitioner or patient

 Critical appraisal can be broken down into three

distinct but related parts:
 Isthe quality of the study good enough to
use the results?

 Are the findings applicable in my setting?

 What do the results mean for my patients?

 Criteria & questions for use in assessing the quality of research
studies
Question about the effectiveness Question about whether a Question about finding out the
Question of a therapy or intervention particular diagnostic test or likely pattern and/or outcome
method of assessment works of a particular health problem/
disease
Comparative / prospective, Cross-sectional/ (longitudinal) cohort or case
Design ideally randomized, controlled comparative study control study
trial.
Random allocation to Appropriate spectrum of Defined, representative
Sample intervention or control group. subjects sample.
Baseline group comparability Assembled at a common
(usually | early} point
Intervention clearly described. New test compared against a Appropriate end points
Measures Appropriate outcome measures reference standard

Clinician/assessor/ patient Clinician/assessor masked No dependent relationship

Researcher masked (blinded) as to which (blinded) as to the results of between subject &
group the patient has been the reference standard investigator
allocated to
Data All entrants adequately accounted All entrants given both new Follow-up of adequate
collection for at the end of the study and reference standard test duration & completeness

Analysis carried out on an Reliability reported Effect of time confounders

Data analysis intention to treat basis explored
 Matching study design to questions
Type of question Example question
The effectiveness of a therapy Does a nurse-led discharge Comparative/prospective
or intervention package for children admitted randomized controlled trial
with acute asthma reduce
readmission rates?
Finding out the likely pattern Are women oral
and/ or outcome of a particular contraceptive users who
health problem or disease (i.e. smoke at greater risk of
prognosis) myocardial infarction (Ml
Whether a particular diagnostic In primary care, does asking
test or method of assessment patients about feeling
works depressed and loss of interest
accurately identify those who
are clinically depressed?
Research design
Cohort study: participants
exposed to an agent
(contraceptive pill) are followed
forward in time to see if they
develop an outcome (Ml)
Case-control study: participants
with the condition (Ml) are
matched with controls (no Ml),
study looks back in time to
identify exposure to an agent
(contraceptive pill)
Cross-sectional study where the
'new' test (or method of
assessment) is compared with a
reference standard test
 Factors to consider when assessing
the quality of a study
 Randomization
 The group to which the patient has been allocated must be
concealed from the clinician/researcher until the patient
has been accepted into the trial
 Demographic and health status details for the two groups
are of interest
 It is helpful if the intervention is described in sufficient
detail to allow clinicians to reproduce it in their own
setting
 Keeping patients, clinicians and researchers blinded as
to whether a patient is in the treatment or control group
is a useful way of minimizing bias

 People drop out of studies for all sorts of reasons: death,

relocation to another geographical area, treatment found
to be too unpleasant, etc. It is important that the
researcher tries to identify whether the reasons relate to
the outcomes of interest
 Factors to consider when assessing
applicability
 The characteristics of the participants in the study
 Is it feasible to introduce the intervention or test
described in the study?
 When thinking of the costs and benefits of the
intervention or test, think beyond purely financial
terms
 Questions for assessing & screening
applicability
 Is it clear what the study about?
 Is the same sample adequately considered?
 Are my patients / context sufficiently different that results
will not apply?
 Is the action indicated, or the intervention available, or the
change possible in my setting?
 Do the benefits of any change for my patients / context
outweigh the like costs?
 Are the patient’s values and preferences satisfied by
change? Are my colleagues and mine?
 Questions that must be included in
deliberations for evaluating information
 Is the source identified?
 Is the source reliable?
 Is the source biased?
 How timely is the information relative to the need?
 How does the information fit with the purpose for
which it will be used?
 How does the setting that originated the information
compare with your setting?
Evaluation the studies results
using the Meta analysis test
 Meta Analysis Test

 Like all quantitative studies, systematic reviews

often include a statistical analysis

A meta-analysis combines the results of several

studies that address a set of related research
hypotheses, in an attempt to overcome the problem
of reduced statistical power in studies with small
sample sizes; analyzing the results from a group of
studies can allow more accurate estimation of
effects
 Meta-analysis is a collection of systematic techniques
for resolving apparent contradictions in research
findings
 Meta-analysis translates results from different studies to
a common
 Metric and statistically explore relations between study
characteristics and findings
 Modern meta-analysis does more than just combine the
effect sizes of a set of studies. It tests if the studies
outcomes show more variation than the variation that is
expected because of sampling different research
participants
 Steps in performing meta-analysis

 Meta-analysis should be viewed as an

observational study of the evidence. The
steps involved are similar to any other
research undertaking:
 Formulation of the problem to be addressed
 Collection and analysis of the data

 Reporting of the results

 Researchers should write in advance a detailed research
protocol that clearly states the objectives, the hypotheses to
be tested, the subgroups of interest, and the proposed
methods and criteria for identifying and selecting relevant
studies and extracting & analyzing information
 As with criteria for including and excluding patients in
clinical studies, eligibility criteria have to be defined for the
data to be included
 Criteria relate to the quality of trials and to the
combinability of treatments, patients, outcomes, and lengths
of follow up
 Quality and design features of a study can influence the
results. Ideally, researchers should consider including only
controlled trials with proper randomization
 The strategy for identifying the relevant studies should be
clearly delineated. In particular, it has to be decided
whether the search will be extended to include unpublished
studies, as their results may systematically differ from
published trials

 A standardized record form is needed for data collection. It

is useful if two independent observers extract the data, to
avoid errors. At this stage the quality of the studies may be
rated, with one of several specially designed scales
 Blinding observers to the names of the authors and their
institutions, the names of the journals, sources of
funding, and acknowledgments leads to more consistent
scores

 This entails photocopying papers, removing the title

page, and concealing journal identifications and other
characteristics with a black marker, or scanning the text
of papers into a computer and preparing standardized
formats
 Levels of evidence
1++ High-quality meta-analyses, systematic reviews of
randomized controlled trials (RCTs) or RCTs with a
very low risk of bias
I+ Well-conducted meta-analyses, systematic reviews of
RCTs, or RCTs with a low risk of bias
1 Meta-analyses, systematic reviews of RCTs, or RCTs
with a high risk of bias
2++ High-quality systematic reviews of case control or
cohort studies. High-quality case control or cohort
studies with a very low risk of confounding, bias or
chance and a high probability that the relationship is
causal
 Levels of evidence
Well-conducted case control or cohort studies with a
2+ low risk of confounding, bias or chance and a
moderate probability that the relationship is causal
Case control or cohort studies with a high risk of
2 confounding, bias, or chance and a significant risk that
the relationship is not causal
3 Non-analytic studies, e.g. case reports, case series

4 Expert opinion
The process of changing practice

Evidence- based guidelines

 Clinical guidelines are systemically
developed statement to assist practitioner
decisions about appropriate health care for
specific clinical circumstances
 Prioritizing topic areas for
guideline development
 Situations where there is evidence of excessive morbidity,
disability or mortality
 Conditions for which available treatment offers the
potential for improvement in any of the above
 Those where there is evidence of wide variation in practice
 Conditions that are resource intensive either because they
are high cost or high volume
 Situations involving cross-boundary issues, e.g.,
interprofessional working or the need for joint working
between primary and secondary care
 How are guidelines developed?
 Selection of guideline topic
 Composition of the guideline development group
 Defining the scope of the guideline
 Systematic literature review
 Formation of recommendations
 Consultation and peer review
 Presentation and dissemination
 Local implementation
 Audit and review
 skills are required in guideline
development group
 Clinical expertise
 Other specialist expertise (e.g. Health
economics, research methods)
 Practical understanding of the problems
faced in the delivery of care
 Critical appraisal skills
 Characteristics of effective
guidelines
 Attribute
 Validity
 Cost-effectiveness
 Reproducibility
 Reliability
 Representative development
 Clinical applicability
 Clinical flexibility
 Clarity
 Scheduled review
 Benefits of clinical guidelines
 Ensure safe practice
 Improve consistency of care in different parts of the
country/settings
 patients receive correct treatment
 Build parity of knowledge amongst staff
 Bring the expert opinion to everyday clinical care
 Allow for individual patient variation - non-application is
not disallowed, it simply has to be justified
 Provide more information for patients about what they
should expect from the health care system
 Distill the vast array of knowledge relating to individual
clinical conditions into a manageable guide for busy
clinicians
 disbenefits of clinical guidelines
 Stifle individual clinical judgment
 De-skill professionals by reducing their capacity to think
for themselves
 Limit quality of care by restricting care/treatment options
 Introduce practice which could be ineffective or dangerous
 Encourage the illusion that there is clear-cut direction to be
taken in every clinical situation
 Be very resource-intensive in relation to their development
and implementation
Introducing guidelines into practice

 Dissemination

 Implementation
 Diagnosing the challenges to
changing practice
 Identifying all the groups involved in, affected by, or
influencing the proposed change (s) in practice
 Assessing the characteristics of the proposed change that
might influence its adoption
 Assessing the preparedness of the health professionals to
change and other potentially relevant internal factors
within the target group
 Identifying the potential external barriers to change
 Identifying the likely enabling factors, including resources
and skills
 Methods exists for gaining
a purchase
 Surveying key groups of stakeholders (such as senior staff,
managers, and patient representatives
 Adapting ward meetings or clinical supervision sessions so
that potential problems can be identified, recorded and fed
into the strategic planning process
 Establishing a focus group of professionals, managers and,
where appropriate, patient representatives, to identify
pertinent barriers and drivers
 Isolating some of the barriers to research uptake in clinical
practice
 Common complexities associated
with nursing and research use
 Professional culture
 Clinical information
 Environment
 Individual decision – maker
Knowledge and educational attainment
Valuing research
Valuing change
Forces working for and against an evidence-based
organizational culture
Planning for and managing
resistance and change
 Social marketing mode
The model has six stages:
 Research the group(s) you wish to target and identify the
resources you have available to help you achieve the
change
 Select the 'raw materials' for the change you want to
introduce
 Develop and pilot the materials used to facilitate the
change
 Implement the change
 Evaluation
 Feedback
 Precede—proceed mode
 Its name is derived from the fact that it specifies the steps
that should precede any change and the ways in which
organizations should proceed with the change

 The first stage of the precede-proceed model is concerned

with specifying the problem to be addressed and isolating
those factors which contribute to the presence of the
problem
 This stage recognizes that problems will have
different priorities for different organizational
stakeholders & so it is important to try to reach
some form of consensus regarding the factors
which predispose & contribute to the problem, the
importance of these factors and their susceptibility
to change
 Commonly, this takes the form of a ranking or
rating approach. Common factors include:
Predisposing: the perceptions, attitudes, motivations
and beliefs of stakeholders involved with the change

Enabling: resources such as skills, knowledge (& funds)

Reinforcing: rewards or incentives - even if only in the

form of positive feedback
Strategic approaches for bridging
the gap between the research and
practice
 General
 Continuing education

 Clinical guidelines

 Other broad approaches

 Specific interventions classified according to
the degree of effect on clinical practice

 Educational outreach / detailing

 Reminder

 Multifaceted interventions
 Mixed effects
 Audit and feedback

 Local opinion leaders

 Local consensus approaches

Little or no effect
 Strategies to Overcome Challenges

 Lack of knowledge or skill

 Identify resources
 Staff development plans
 Supervision and mentoring
 Collaborative training and technical assistance
 Developing shared vision and commitment
 Strategies to Overcome Challenges
 Beliefs and Attitudes
 Articulate existing beliefs and attitudes
 Hold frequent meetings to discuss change
 Utilize motivational strategies to move staff
ambivalence toward positive change
 Ensure a clear understanding of terms
 Enlist a neutral facilitator
 Affect beliefs through information
 Provide opportunities to speak with people who have
done it
 Provide incentives and recognition
 Strategies to Overcome Challenges

 Lack of Adequate Resources

 Resource sharing with other providers

 Cross-site training and technical assistance

 Community-wide collaboration
 Strategies to Overcome Challenges

 Lack of collaboration
 Implement a collaborative planning model

 Use stakeholder teams to make decisions

 Partner with other agencies implementing the
same intervention
 Develop a community-wide system of care where
the evidence-based practice is essential to
producing desired outcomes