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EVIDENCE BASED PRACTICE MODELS

BY Click to edit Master subtitle style LIDIYA

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definition: EBP

EBP is a conscientious use of current best evidence in making clinical decisions about patient care. It is a problem solving approach to clinical practice that integrates a systematic search for and critical appraisal of the most relevant evidence to answer a burning clinical question; ones own clinical expertise; and patient preferences 5/27/12

Knowledge sources of EBP


BEST RESEARCH EVIDENCE ONES OWN CLINICAL EXPERTICE PATIENTS VALUES , PREFERENCES CLINICAL SETTING ASSESSMENT & HISTORY

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BACK GROUND OF EBP

[3] The EBP movement was founded by Professor Archibald Leman Cochrane, CBE, FRCP, FFCM (19091988) in 1972. Dr. Cochran, a British epidemiologist, identified a gap between current practices and evidence-based guidelines One of the cornerstones of the EBP movement is the Cochrane collaboration. Cochrane published an 5/27/12

BACK GROUND OF EBP CONTD..

The aim of the collaboration is to help providers make good decisions about health care by preparing, maintaining, and disseminating systematic reviews of the effect of health care interventions

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EVIDENCE-BASED MEDICINE:

Evidence-based medicine is the conscientious, explicit and judicious used of current best evidence in making decisions about the care of individual patients

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DEFINITION:EBPN

The society defines EBN as an integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families and communities who are served. This assumes that optimal nursing care is provided when nurses and health care decision-makers have access to a synthesis of the latest research, a consensus of expert opinion, and are thus able to exercise their judgment as they 5/27/12 plan and provide care that takes into

RESEARCH UTILISATION AND EBP:

it is the use of findings from a disciplined study or set of studies in a practical application that is unrelated to the original research.

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EBP Vs RU

Complex process Less complex NURSING EVIDENCE

process RESEARCH BASED NURSING Newer conceptsUTILISATION developed Older conceptsapproximately 10 used in the years ago.

1970s toearly . 1990s

Includes patients PATIENTS preferences PREFERENCES Includes a system NOT INCLUDED to grade or level

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No defined

EVIDENCE HIERARCHIES

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STEPS IN EBP:

ASK: identify the research question. ACQUIRE: search the literature for preappraised evidence or research. Secure the best that is available APPRAISE: conduct the critical appraisal of the literature and studies.evaluate the validity and determine the applicability in practice.
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STEPS IN EBP:CONTD

APPLY: institute recommendations and findings and apply them to nursing practice. ASSESS: evaluate the application of the findings, outcomes and relevance to nursing practice

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TYPES OF EBP LITERATURE:

The key component of EBP is a systematic review. A systematic review is a summary of evidence typically conducted by an expert or a panel of experts in a particular topic, that uses rigorous process (to minimise bias) for identifying, appraising and synthesizing studies to answer a specific clinical question and draw conclusions about the data 5/27/12 generated. (Melnyk & fineout

TYPES OF EBP LITERATURE:


SYSTEMATIC REVIEW; DEFINITION: it is the consolidation of research evidence that incorporate a critical assessment and evaluation of the research(not simply a summary) and addresses a focused clinical question using methods designed to reduce the likelihood of bias.
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Types of S.R

The 3 types of S.R is important in EBPN. Integrative research review Meta- analysis Meta synthesis

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SYSTEMATIC REVIEW: TYPES


1. INTEGRATIVE RESEARCH REVIEW:

Panels or group of experts conduct integrative reviews and begin by identifying the topic or question. The result is a narrative summary of past research in which the reviewers extract findings from original studies and use analytical reasoning to produce conclusions about the findings of a body of 5/27/12

SYSTEMATIC REVIEW: TYPES CONTD


META-ANALYSIS: This is a research technique in which entire studies on a particular topic or question (PICO) are appraised to determine the state of knowledge on that topic. a statistical technique for quantitatively combining the results of multiple studies that measure the 5/27/12 same outcome, into a single pooled

SYSTEMATIC REVIEW: TYPES CONTD..


META-SYNTHESIS: Meta synthesis is a systematic review in which findings from several or many qualitative studies examining the issue are merged to produce generalization and theories. This review does not use statistical methods to combine the findings.
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EBP MODELS:

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A number of models are used to describe EBP in nursing. A model provides a description of a process and includes the impact of EBP on practice. These models offer framework for understanding the EBP process and for designing and implementing an EBP project in a practice setting.

THE IOWA MODEL OF EVIDENCE BASED PRACTICE (TO PROMOTE QUALITY OF CARE):

This model was created by the university of IOWA medical centre nursing administration as a method to support EBP to improve quality of care.

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THE IOWA MODEL OF EVIDENCE BASED PRACTICE (TO PROMOTE QUALITY OF CARE):CONTD

The model includes these questions.

What are the triggers for EBP? What will make an organisation include patient focused care? How does the work force get educated on EBP to implement it? Critical thinking, staff empowerment and 5/27/12 professional development are

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The ARCC model was originally conceptualized by Bernadette Melnyk in 1999 as a part of a research strategic planning initiative in an effort to more fully integrate research and clinical practice as well as to advance EBP within an academic medical centre and progressive health care community. 5/27/12

Advancing research and clinical practice through close collaboration (ARCC) model

ARCC MODEL CONTD

A central concept in an ARCC model is that of an EBP mentor, an advanced practice nurse with in depth EBP and clinical knowledge and skills who provides mentorship in EBP and facilitates improvement in clinical care and patient outcomes through EBP implementation and and outcomes management projects.
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3.Integrating EvaluationInformed and EvidenceBased Practice: The PRAISES Model a framework for
integrating evaluation-informed and evidence-based practice (Fischer, 1986). We understand that at fi rst glance this framework can be somewhat intimidating, as it may look more like a General Motors wiring diagram than a fl owchart for 5/27/12 use by

the PRAISES Model is an attempt to integrate, structure, and systematize the process of evidencebased practice, while highlighting the interrelationships among interventive practices and evaluation in the overall process

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Characteristics of PRAISES model

1. Empirically-based. To the extent possible, this framework attempts to enhance development of the empirical base for evidence-based practice. the empirical base of evidence-based practice has two meanings. The first is the use of the results of classical evaluation research to guide selection of interventions that have 5/27/12

Characteristics of PRAISES model

2. Integrative. The PRAISES Model fl owchart attempts to integrate all practice and evaluation activities. This is the basis for our earlier assertions that good practice incorporates good evaluation. There are no distinctions made between evaluation and practice in the flowchart. Only the different activities required at each step are described.
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Characteristics of PRAISES model

Eclecticism

refers to the use of clear, precise, systematic criteria to select knowledge

this framework is intended to apply whatever the theoretical orientation, methods, or approach of the user are.

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Characteristics of PRAISES model

4. Systematic. This framework is an attempt to systematize practice. This means clearly identifying the various phases of practice and organizing them in a step-by-step sequence 5. Accountable. This framework is an attempt to add to our professional accountability as practitioners. It brings the entire process of practice out into the open for scrutiny by 5/27/12

Characteristics of PRAISES model

6. Way of Thinking. The PRAISES Model is intended, perhaps more than anything else, to illustrate and enhance a way of thinking about practice: systematic,data- based, outcomeoriented, structured, fl exible depending on the needs of the client, evidence-based, informed by ongoing evaluation, and up- to-date 5/27/12

Phases of PRAISES model


PHASE I. PRe-Intervention 1. Evaluate the context 2. Process the referral 3. Initiate contact 4. Structure

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Phases of PRAISES model


PHASE II. Assessment 5. Select problem 6. Conduct assessment 7. Collect baseline information 8. Establish goals

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Phases of PRAISES model


PHASE III. Intervention 9. Develop intervention plan 10. Develop evaluation plan 11. Negotiate contract 12. Prepare for intervention 13. Implement intervention
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Phases of PRAISES model


PHASE IV. Systematic Evaluation 14. Monitor and evaluate results 15. Assess and overcome barriers 16. Evaluate goal achievement

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Phases of PRAISES model


PHASE V. Stabilize 17. Stabilize and generalize changes 18. Plan

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4.The Ottawa Model of Research Use


The Ottawa Model of Research Use (OMRU) is an interactive model developed by Logan and Graham (1998). The feasibility and effectiveness of using the OMRU in actual practice contexts was supported by findings from a number of studies (Hogan & Logan, 2004; Logan, Harrison, Graham, Dunn, & Bissonnette, 1999; Stacey, Pomey, 5/27/12 O'Conner, & Graham, 2006). The

OTTAWA MODEL: six key elements:


Evidence-based innovation Potential adopters The practice environment Implementation of interventions Adoption of the innovation Outcomes resulting from implementation of the innovation
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OTTAWA MODEL

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5.STETLERS MODEL

The Stetler model of research utilization helps practitioners assess how research findings and other relevent evidence can be applied in practice. This model examines how to use evidence to create formal change within organizations, as well how individual practitioners can use research on an informal basis as part 5/27/12

STETLER MODEL:RESEARCH USE

Instrumental use refers to the concrete, direct application of knowledge. Conceptual use occurs when using research changes the understanding or the way one thinks about an issue. Symbolic use or political/strategic use happens when information is used to justify or legitimate a policy 5/27/12 or decision, or otherwise influence

STETLER MODEL

The Stetler model of evidence-based practice outlines criteria to determine the desirability and feasibility of applying a study or studies to address an issue. These criteria are: substantiating evidence; current practice (relates to the extent of need for change);
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fit of the substantiated evidence for

STETLER MODEL ;PHASES


Phase I: Preparation Phase II: Validation Phase III: Comparative Evaluation/Decision Making Phase IV: Translation/Application Phase V: Evaluation

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Phase I: PreparationPurpose, Context and Sources of Research Evidence Identify the purpose of consulting evidence (such as need to solve a problem or revising an existing policy) and relevant related sources. Recognize the need to consider important contextual factors that could influence implementation. Note 5/27/12

Phase II: ValidationCredibility of Findings and Potential for/Detailed Qualifiers of Application Assess each source of the evidence for its level of overall credibility, applicability and operational details, with the assumption that a methodologically weak study may still provide useful information in 5/27/12 light of additional evidence.

Synthesis and Decisions/Recommendations per Criteria of Applicability

Phase III: Comparative Evaluation/Decision Making

Logically organize and display the summarized findings from across all validated sources in terms of their similarities and differences. Determine whether it is desirable or feasible to apply these summarized 5/27/12 findings in practice, based on

Phase IV: Translation/Application


Operational Definition of Use/Actions for Change Write generalizations that logically take research findings and form action terms (using the summary statements from Phase II/III). Specifically, articulate the how-to's of implementation of the synthesized findings, identifying the practice 5/27/12 implications that answer the overall

Phase V: Evaluation

Clarify expected outcomes relative to purpose of seeking evidence and whether the evaluation is related to a direct use or consider use decision. Differentiate formal and informal evaluation of applying findings in practice. Consider cost-benefit of various evaluation efforts.
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Use Research Utilization as a process

Transformation is a model for understanding the cycles, nature, and characteristics of knowledge that are utilized in various aspects of evidence-based practice (EBP). The Star Model organizes both old and new concepts of improving care into a whole and provides a framework with which to organize EBP processes 5/27/12 and approaches

6.ACE STAR MODEL: (ACADEMIC CENTRE FOR EVIDENCE BASED PRACTICE) The Star Model of Knowledge

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ACE STAR MODEL

Configured as a simple 5-point star, the model illustrates five major stages of knowledge transformation: 1) knowledge discovery, 2) evidence summary, 3) translation into practice recommendations, 4) integration into practice, and 5) evaluation. Evidence-based processes and methods vary from one point on the Star Model to the next.
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STAGES:ACE STAR MODEL


Star Point 1. Discovery This is a knowledge generating stage. In this stage, new knowledge is discovered through the traditional research methodologies and scientific inquiry. Research results are generated through the conduct of a single study. This may be called a primary research study and research designs range from descriptive to 5/27/12

STAGES:ACE STAR MODEL


Star Point 2. Evidence Summary Evidence summary is the first unique step in EBPthe task is to synthesize the corpus of research knowledge into a single, meaningful statement of the state of the science. The most advanced EBP methods to date are those used to develop evidence summaries (i.e., evidence synthesis, systematic reviews, e.g., the 5/27/12

STAGES:ACE STAR MODEL


Star Point 3. Translation The transformation of evidence summaries into actual practice requires two stages: translation of evidence into practice recommendations and integration into practice. The aim of translation is to provide a useful and relevant package of 5/27/12 summarized evidence to clinicians

STAGES:ACE STAR MODEL


Star Point 4. Integration Integration is perhaps the most familiar stage in healthcare because of society's long-standing expectation that healthcare be based on most current knowledge, thus, requiring implementation of innovations. This step involves changing both individual and organizational practices through 5/27/12

STAGES:ACE STAR MODEL


Star Point 5. Evaluation The final stage in knowledge transformation is evaluation. In EBP, a broad array of endpoin Nursing is a truly multidimensional profession. Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of 5/27/12 suffering through the diagnosis and

7.The Johns Hopkins Nursing Evidence-Based Practice Model


The Johns Hopkins Nursing EvidenceBased Practice Model (JHNEBP) depicts three essential cornerstones that form the foundation for professional nursing. These cornerstones are practice, education, and research

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. Practice is the basic component of all nursing activity (Porter-OGrady, 1984). Nursing practice is the means by which a patient receives nursing care. It is an integral component of health-care organizations.

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Education reflects the acquisition of the nursing knowledge and skills necessary to become a proficient clinician and to maintain competency. Research provides new knowledge to the profession and enables the development of practices based on 5/27/12 scientific evidence

Step 1: Identify an EBP question The clinical, educational, or administrative EBP question is identified. Keeping the question narrow and specific will make the search for evidence more manageable and will also help guide the search. The PET process uses the PICO approach (Sackett, Straus, Richardson, Rosenberg,& Haynes, 5/27/12

Step 2: Define the scope of the practice question The problem or question may relate to the care of an individual patient, a specific population of patients, or the general patient population in the organization. Defining the scope of the problem 5/27/12 assists the team in identifying the

Step 3: Assign responsibility for leadership For the EBP process to be successful, a leader responsible for facilitating the process and for keeping it moving forward must be identified. If possible, the leader should be experienced in evidence-based practice and have the necessary communication skills to work with an 5/27/12

Step 4: Recruit an interdisciplinary team When recruiting an interdisciplinary team, it is important to include team members for whom the question holds relevance. When team members are interested and invested in addressing a specific practice question, the work of the team is generally more effective. It is 5/27/12

Step 5: Schedule a team conference Setting up the first EBP team conference can be a challenge and includes such activities as (1) reserving a room conducive to group discussion with adequate space; (2) asking team members to bring their calendars so that subsequent meetings can be scheduled; (3) ensuring that a team member is 5/27/12

Step 6: Conduct an internal and external search for evidence Team members determine the type of evidence to search for and who will be responsible for conducting the search and bringing the items back to the committee for review. Enlisting the help of a health information specialist (library support) is critical.
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Step 7: Appraise all types of evidence Research and non-research evidence are appraised for their strength and quality. The Research Evidence Appraisal (Appendix F) and the Non-Research Evidence Appraisal (Appendix G) assist the team in this activity. The 5/27/12 front of each tool includes a set of

Step 8: Summarize the evidence The team totals the amount of evidence for each level using the Overall Evidence Summary . Then the findings for each level (IV) are summarized in narrative form, and the overall quality for each level is determined by team consensus.
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Step 9: Rate the strength of the evidence The team makes a determination as to the overall strength and quality of the body of evidence that they have appraised Step 10: Develop recommendations for change in systems or processes of care based on the strength of the 5/27/12 evidence

Step 11: Determine the appropriateness and feasibility of translating recommendations into the specific practice setting The team communicates and obtains feedback from appropriate organizational leadership, bedside clinicians, and all other stakeholders affected by the practice change to determine if the change is 5/27/12

Step 12: Create an action plan The team develops a plan to implement the recommended practice change, which may include (1) the development of (or change to) a protocol, guideline, critical pathway, or system/process related to the EBP question, (2) the development of a detailed time line assigning team members to the tasks 5/27/12

Step 14: Evaluate outcomes The team evaluates the degree to which the identified outcomes were met. Although positive outcomes are desired, unexpected outcomes often provide opportunities for learning. When unexpected outcomes occur, the team should 5/27/12 examine

CONCLUSION:

Although the science of translating research into practice is fairly new, there is some guiding evidence of what implementation interventions to use in promoting patient safety practices. However, there is no magic bullet for translating what is known from research into practice. To move evidence-based interventions into practice, several strategies may 5/27/12 be needed. Additionally, what works

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