Research &

Statistics

Evidence
based practice

Avni Khalasi
 What is Evidence?
• Evidence: It is
something that
furnishes proof or
testimony or
something legally
submitted to ascertain
in the truth of matter.
 Introduction
• Many areas of professional practice, such as
medicine, nursing, psychology, psychiatry, and
so forth, have had periods in their past where
practice was based on loose bodies of
knowledge.
• Some of the knowledge was simply lore that
drew upon the experiences of professionals,
and much of it had no truly scientific evidence
on which do justify various practice.
• Furthermore, nursing practices are generally
based on nurses’ past experiences; however,
there is little scientific evidence to support
nurses’ clinical decision making and expected
outcome.
• While, nursing practices based on research
evidences contribute to achieving client
outcome and making nursing practices credible.
• Therefore, nurses need to base their practices
on empirical evidences to optimize client
outcomes, to provide cost-effective safe
practices, and to enhance the credibility of
nursing care.
• Sometimes, the terms research utilization and
EBP are used interchangeably.
• However, in real sense, the term research
utilization is a narrow term, which is used for
the use of empirically generated knowledge
for nursing practices.
• In addition, research utilization has been
defined as the use of research findings in any
or all aspects of one’s work as a registered
nurse or at its simplest, the use of research.
 History Of EBP
• Roots of EBP can be traced in Florance
Nightingale's era of nursing practices. Her
concepts of promoting health, prevention of
disease, and care of the sick were central ideas
of her system.
• It involves identifying solid research findings
and implementing them in nursing practices, in
order to increase the quality of patient care.
• Archie Cochrane, a British epidemiologist,
founded the evidence-based practice
movement in which his influence and
dedication were key in helping individuals make
well-informed decisions about healthcare.
• Cochrane’s work is most evident in the
Cochrane Database of Systematic Reviews,
published several years after his death in 1988.
The database contains highly structured and
systematic reviews on a multitude of priority
healthcare topics.
• In addition, Sigma Theta Tau International
provides systematic reviews, entitled
Worldviews on Evidence-Based Nursing, to
guide nursing practice across many priority
topics.
• Tutorials that teach the five steps of evidence-
based practice can be found through the
Teaching/Learning Resources for Evidence-
Based Practice at Middlex University in London.
• Tutorials on evidence-based practice also can be
found through the university of Rochester
Medical Center.
 Concept of EBP
• “Evidence-based medicine is the integration
of best research evidence with clinical
expertise and patient values”
-Sackett D et al.
• Evidence based practice describes a
healthcare system in which evidence from
published studies, often mediated by
systematic reviews or processed into
medical guidelines is incorporated into
clinical practice.
Example: For example, a health care provider
recommends acetaminophen to treat
arthritis pain in a patient who has recently
had stomach bleeding.
• The health care provider makes this
recommendation because research shows
that acetaminophen is associated with less
risk for stomach bleeds than other common
pain relievers.
• The health care provider’s recommendation
is an example of evidence-based practice.
• EBP can be represented through a simple
figure.
 Definition of EBP
• EBP is defined as using the best evidence
available to guide clinical decision making.
- Benefield
• Evidence based practice: It is systemic inter
connection of scientifically generated
evidence with the knowledge of the expert
practitioner to achieve a change in a
particular practice for the benefit of a well-
defined client / patient group. (French
1999).
• Evidence-Based Nursing(EBN) is a process
founded on the collection, interpretation,
and integration of valid, important, and
application of research.
 Purposes of EBP
• To eliminate unsound or excessively risky practices
• Better patient outcome
• To provide the highest quality and most cost-efficient
nursing care possible.
• Improve the quality of nursing care.
 NEED FOR EBP
• For making sure that each client get the best
possible services.
• Updating the knowledge and is essential for
lifelong learning.
• Provide clinical judgment.
• Improvement care provided and save lives.
 Importance of EBP
• Improve patient care outcome
• Keep your knowledge up to date
• Improve care
• Provide the highest quality of nursing care.
• Best possible outcomes at possibly lower cost.
• Clinical expertise
• Keep pace with advances
Evidence-based Practice
 Sorces of Evidence

Filtered Unfiltered
Sources Sources

Clinical experience

Knowledge from
Patient

Knowledge from local

context
 Sources of Evidence
• Filtered resources- Clinical experts and subject
specialist pose a question and then synthesize
evidence to state conclusion based on
available research.
• These sources are helpful because the
literature has been searched and results
evaluated to provide an answer to clinical
question.
• Unfiltered resources (Primary literature)- It provides
most recent information. E.g MEDLINE, CINHAL etc
provides primary and secondary literature for medicine.
1. Clinical experiences- Knowledge through professional
practice and life experiences makes up the second part
in the evidenced based , person-centered care.
2. Knowledge from patients- Evidence delivered from
patient’s knowledge of themselves, their bodies and
social lives.
3. Knowledge from local context -Audit and performance
data Patient stories and narratives Knowledge about the
culture of the organization & individuals within it. Social
& professional networks. Information from feedback of
Local & national policy.
• Evaluating the efficacy of empirical evidences 5.
• Use of best evidences in clinical practices 4.
• Analysis of strengths and weakness of that evidence 3.
• Literature review to search for the best available evidence 2.
• Formulating a clear question based on a clinical problem 1.
Steps for EBP
 1. Formulating a clear question based on a
clinical problem:
The source for formulating a question generally
categorized in two broader classes, i.e. (i) problem-
based source and (ii) knowledge-based source.
• Problem-based sources: For example, increased
incidence of pressure sore in critical care units may be
one of the important issues to be considered for EBP.
• Knowledge-based sources: For example, new
evidences on nursing care interventions on prevention
of bed sore, pain management, tube feeding
techniques, arterial and venous line potency, infection
control, deep vein thrombosis prevention, etc.
• While formulating a clinical question for EBP,
the following should be included. An acronym
used to remember this is called the PICO
model:
• P = Who is the patient population?
• I = What is the potential intervention or area of
interest?
• C = Is there a comparison intervention or
control group?
• O = What is the desired outcome?
 2. Literature review to search for the best
available evidences:
• The literature review for EBP must start with
theoretical and clinical articles to have overview
about the topic of concern.
• If any available then should go for reading and
critiquing the original research articles.
• It is better to include high levels of evidences for
review, such as meta-analysis and systemic
reviews of randomized control trials, original
randomized clinical trials, etc.
3. Analysis of strengths and weakness of that
evidence

• Use of rating systems to determine the quality

of the research is crucial to the development
of EBP.
• There are several rating scales proposed to
determine the validity, strengths, and
weakness of the available evidence.
 LEVELS OF EVIDENCE
• Level I – Evidence from a systemic review or meta-
analysis of all relevant randomized control
trials (RCT) or evidence-based clinical practice
guidelines based on systemic review of RCTs.
• Level II – Evidence obtained from at least one
well-designed RCT.
• Level III – Evidence obtained from well-designed
controlled trial without randomization.
• Level IV – Evidence from well-designed case-
control and cohort studies.
• Level V – Evidence from systemic review of
descriptive and qualitative studies.
• Level VI – Evidence from a single descriptive
or qualitative study.
• Level VII – Evidence from the opinion of
authorities and/or reports of expert
committees.
4. Use of best evidences in clinical
practices
• Once study findings are analyzed for strengths,
weakness, internal and external validity, a
decision is made about appropriateness of
evidence for the particular question initiated for
EBP.
• The final evidences must be extensively
discussed among the users with the risk-benefit
ratio of evidence and extent and level of harms
are involved with particular evidence.
 5. Evaluating the efficacy of empirical
evidences

• Finally after the implementation of the useful

findings for the clinical practices, efficacy and
performance is evaluated through processes
of self-reflection, internal or external audit or
peer assessment.
 Advantages of EBP
• Provide better information to practitioner
• Better patient outcome
• Provide client focused care
• Increases confidence in decision-making
• Generalize information
• Provide guidelines for further research
• Helps nurses to provide high quality patient
care
• Helps to keep knowledge up-to-date
 Disadvantages of EBP

Supress Publication
creativity bias

Reduced Time
client choice consuming

Reduced professional
judgement/
autonomy
 Shortage of
Physicians research in
Lack of dominance some areas
time Lack of
initiatives
Lack of
administrative
Lack of
support
Barriers In EBP knowledge of
research
Lack of
support Workload
pressure
Lack of ability to
critically appraise Lack of continung
the research Create education
confusion programme