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Evidence-Based

Practice

An Independent Study Short Course


for Medical-Surgical Nurses
This module was developed by the
Clinical Practice Committee of the
Academy of Medical-Surgical Nurses,
in accordance with
the 2006-2010 strategic plan.
Why is evidence-based practice
important and why now?

• Changing patient demographics


require new approaches to care.
• The evidence base for practice is
rapidly expanding and growing in
complexity for nursing and other
disciplines.
Why is evidence-based practice
important and why now?

• How to search, evaluate, and apply evidence


in practice is unknown by many or
inconsistently used.
• There continues to be a mismatch between
what we know to be quality care and the
quality of care that is delivered.
Why is evidence-based practice
important and why now?

• Quality problems occur even in the


hands of dedicated, conscientious
professionals.
• The burden of harm from the
underuse, misuse, and overuse
of care is staggering.
Why is evidence-based practice
important and why now?
• The 2003 report by the Institute of Medicine
(Health Professions Education: A Bridge to
Quality) recommends that all health care
professionals possess certain skills and
competencies in order to enhance patient
care quality and safety.

– All health professionals should be educated to deliver patient-


centered care as members of an interdisciplinary team,
emphasizing evidence-based practice, quality improvement
approaches, and informatics.
(Institute of Medicine, 2003)
Purpose of Module
• To provide an overview of evidence-based
practice (EBP), one of the five
competencies that all health care
professionals should possess (Institute of
Medicine, 2003).
– Where and how to find the best possible
sources of evidence for your practice.
– How to formulate clear clinical questions.
– How to search for relevant answers to the
questions.
– Determine when and how to integrate these
new findings into practice.
Objectives
At the end of this module, you will be
able to:
• Recognize evidence-based practice (EBP)
as one of five core competencies all health
professionals should possess regardless of
their title or discipline (Institute of Medicine,
2003) for crossing the quality chasm.

• Define EBP.
Objectives
• Identify two characteristics differentiating
research utilization and EBP in nursing.
• List three components of EBP.
• Provide two examples of how EBP
benefits the nurse.
• Provide two examples of how EBP
benefits the patient.
Objectives
• Describe the 5 steps of the EBP process.
• Write a researchable clinical question.
• Identify resources for developing relevant
answers to the question.
• Use clinical judgment and the 5-step
process for determining when and how to
integrate findings into practice.
Evidence-Based Practice
is
Knowing that what we do is
the best practice.
How do we know in nursing?

• Tradition
• Authority
• Borrowing
• Trial and error
• Personal experience
• Role modeling and mentorship
• Intuition and reasoning
• Nursing research
Nursing Research

Diligent, systematic inquiry to validate and


refine existing knowledge and generate new
knowledge that directly and indirectly
influences nursing practice. (Burns & Grove, 2004)
Types of Nursing Research

• Describe
Identify and understand phenomena, issues
• Explain
Clarify relationships
• Predict
Estimate the probability of outcome
• Control
Manipulate the situation to get desired outcomes
Much of what is known from research
has not been applied in practice.
This is known as

Research-Practice Gap
Research-Practice Gap

During the 1980s and 1990s, nursing


emphasized bridging this research-
practice gap through the development
of research utilization (RU) projects.
Research-Practice Gap
Steps of the process included:
– Dissemination of knowledge.
– Synthesis of findings.
– Critique of studies.
– Application of findings.
– Development of research-based practice
guidelines (i.e., Agency for Health Care Policy
and Research/AHCPR practice guidelines;
Conduct and Utilization of Research in
Nursing/CURN practice protocols).
Research-Practice Gap

Even though guidelines and knowledge


have been disseminated, the overall
effect on clinical practice and patient
outcomes is unclear.
Research-Practice Gap
• The problems of importance to medical-
surgical nursing (skin breakdown, pain,
bowel function, treatment adherence,
nausea) and related interventions are
largely not collected in medical record
databases.
• Nursing research studies are predominately
descriptive or qualitative in design, rather
than what is considered more rigorous and
quantitative.
EBP is…
• Needed to help bridge the research-
practice gap by:
– Strengthening the evidence base so that we know
what works and what doesn’t work in providing
patients with the best outcomes.
– Standardizing evidence across fields to reach the
best outcome for the patient.
– Housing evidence in online databases providing
reviews of the evidence base.
– Translating and consolidating state of the science into
clinical recommendations.
(Stevens, 2004)
EBP is…

• Conscientious, explicit, and judicious use of


theory-driven, research-based information in
making decisions about care delivery to
individuals or a group of patients, and in
consideration of individual needs and
preferences (Ingersoll, 2000).
EBP is…

• Integration of best research evidence,


clinical expertise, and patient values in
making decisions about the care of
individual patients (Institute of Medicine, 2001).
Key Components of EBP

Decisions about care are based on:


A. Research evidence.
B. Clinical expertise, judicious use.
C. Patient values and circumstances.
(Institute of Medicine, 2003)
A. Research Evidence

• Randomized controlled trials


• Laboratory experiments
• Clinical trials
• Epidemiological research
• Outcomes research
• Qualitative research
• Expert practice knowledge, inductive
reasoning
B. Clinical Expertise

• Knowledge gained from practice


over time
• Inductive reasoning
C. Patient Values, Circumstances

• Unique preferences
• Concerns
• Expectations
• Financial resources
• Social supports
Benefits for Med-Surg Nurses
Fewer Errors – Reduced likelihood of making
type 1 and type 2 errors in practice
Type 1 – Acceptance of a practice that is
incorrect. Example: Administration of a wrong dose,
using the wrong procedure, teaching patients using the
wrong information.
Type 2 – Rejection of a practice that is correct.
Example: Failing to screen patients for fall or pressure
ulcer risks; failing to wash hands before and after patient
contact; failing to provide patients with smoking cessation
information.

(Aherns, 2005)
Benefits for Med-Surg Nurses

Greater professional satisfaction from


working as part of a team and
experiencing effective practice.
Benefits for Med-Surg Nurses

• Better Care
– Less variation in care among caregivers where
knowledge for improvement is already available.
– More predictable health outcomes.
– Less waste and inefficiency yielding fewer delays
in diagnosis and treatment and fewer
complications.
EBP Process

There are 5 steps


in judging the
evidence and
determining the
circumstances and
patient values for
guiding application.
EBP Process
The EBP Process Steps are:
1. Assess practice (formulate question)
What isn’t working?
What do you want to know about?
2. Decide (evidence review)
What resources are available and are they any good?
What has worked in other places?
How can you change your practice?
3. Plan (develop a plan based on findings)
Make a plan to change care based on relevant, applicable information.
Let others help.
4. Intervene (take action to review process or change)
Implement revised caregiving protocol in clinical unit.
5. Evaluate (care improved or modify and again intervene)
How well is that working for you?
References
Aherns, T. (2005). Evidence-based practice: Priorities and implementation strategies.
AACN Clinical Issues. 16(1), 36-42.
Burns, N. & Grove, S. K. (2004) The Practice of Nursing Research: Conduct, Critique &
Utilization, 2-3.
Fineout-Overholt, E., Melnyk, B.M., & Schultz, A. (2005). Transforming health care from
the inside out: Advancing evidence-based practice in the 21st century. Journal of
Professional Nursing, 21(6), 335-344.
French, B. (2005). Evaluating research for use in practice: what criteria do specialist
nurses use? Journal of Advanced Nursing, 50(3), 235-43
Ingersoll, G. I. (2000). Evidence-based Nursing; What it is and what it isn’t, Nursing
Outlook, 48, 151-152
Institute of Medicine,(US) Committee on Quality Healthcare in America (2001). Crossing
the quality chasm: A new health system for the 21st Century, The National Academies
Press, 145-163
Institute of Medicine, (US)Greiner, A. & Knebel, E., (Eds.) (2003) Health Professions
Education: A bridge to quality, The National Academies Press, 45-74
Ledbetter, C. A, & Stevens, K.R. (2000). Basics of Evidence-Base Practice, Seminars in
Perioperative Nursing 9 (3) 91-97
National Patient Safety Goals. (2006). The Joint Commission (formerly JCAHO)
Stevens, K. R. (2004). ACE Star Model of EBP: Knowledge Transformation. Academic
Center for Evidence-based Practice. The University of Texas Health Science Center
at San Antonio. www.acestar.uthscsa.edu
Additional Readings
Cullen, L., Greiner, J., Greiner, J., Bombei, C., & Comried, L. (2005). Excellence in
evidence-based practice: Organizational and unit exemplars. Critical Care Nursing
Clinics of North America, 17, 127-142.
Greiner, A., & Knebel, E., (Eds.). (2003). Health professions education: A bridge to
quality. Washington, DC: The National Academies Press.
Stevens, K.R., & Staley, J.M. (2006). The Quality Chasm reports, evidence-based
practice, and nursing’s response to improve healthcare. Nursing Outlook, 54(2), 94-
101.
Titler, M., Kleiber, C., Steelman, V., Goode, C., Rakel, B., Barry-Wlker, J., et. al. (1994).
Infusing research into practice to promote quality care. Nursing Research, 43, 307-
313.
Titler, M., Kleiber, C., Steelman, V., Rakel, B., Budreau, G., Everett, L., et. al. (2001). The
Iowa Model of evidence-based practice to promote quality care. Critical Care Nursing
Clinics of North America, 13(4), 497-509.

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