Evidence-Based Practice Back to the Basics Anne Burnett, RN-BC, MSN, CRRN Veterans Healthcare System of the Ozarks April 4, 2011.

Evidence-Based PracticeBack to the Basics

Anne Burnett, RN-BC, MSN, CRRN

Veterans Healthcare System of the Ozarks

April 4, 2011

Learning Objectives

• Evidence-Based Practice History

• EBP Process

• An Example of Using EBP

• ABC Mnemonic

Florence Nightingale

“The most important practical lesson that can be given to nurses is to teach them what to observe – how to observe – what symptoms indicate improvement – what the reverse – which are of importance – which are of none”.

(Nightingale, 1860)

Translation

• Teach nurses what is important to monitor

• How to monitor it

• What trends show improvement

• What trends show negative change

• Which indications are important

• Which indications don’t matter

Professional Nursing

• Information– Collecting– Interpreting– Evaluating

EBP Defined

• Combines– Research – Data Collection– Nurse experience– Patient wishes and needs

DATA

• Nursing Assessment

• Observations

• Collecting

• Care improvement

• Evaluating

• Sharing

Academic & Publishing Landmarks

• 1860

• 1873

• 1900

• 1907

• 1912

• 1923

• 1923

• 1929

• 1952

• Nightingale

• Hospital RN Programs in US

• American Journal of Nursing

• Teacher’s college of Columbia

• National League of Nursing Education

• 1st Doctoral Program in Nursing Education

• Goldmark Report

• 1st Master of Nursing

• Nursing Research Journal

Key Drivers for the 20th Century

• Nursing Research Conferences – 1960’s– American Nurse’s Association

• Building Foundations– Developing Academic Programs

• Frameworks and understanding research– The Practice of Nursing Research– Burns & Grove, 1980’s

Key Drivers for the 21st Century

• Formalizing five steps of EBP– Melnyk & Fineout-Overholt; Evidence-Based Practice

in Nursing & Healthcare

• Nursing developing a researched body of knowledge– Boswell & Cannon; Introduction to Nursing Research

Incorporating Evidence-Based Practice

• EBP Conferences– Locally, Regionally, Nationally

Veterans Healthcare System of the Ozarks

• EBP Council

• Made up of nurses from diverse care delivery areas: – Acute care– Surgery– Outpatient areas– Psychiatric care

(Boswell & Cannon, Ch.1; Hockenberry, et al; Mantzoukas; Titler; Turkel, et al)

Challenges & Solutions

• Challenges– Culture Changes– Introducing EBP– Implementing EBP– Educational Gaps– Prior Experience

• Solutions– Education for staff

& the council– Poster Presentations– Developing

Nursing Projects– Research Critiques

EBP Council

• Serves as resource– Developing Change Strategies

• Share information– How to access research

• Guiding staff to other change venues– Appropriate change process– Example the Watson Theory Project

Integrating EBP

• Studies on how to integrate EBP• Culture of change• Recent research developments• Nurse Empowerment

Skills

• Developing skills• Overcoming resistance to change• Engaging staff

Mnemonic Development

• Mnemonics have been used by nurses for years

• Tool to integrate multiple step processes

• ADPIE

Mnemonic

• Reduce volumes of information

• Helps sequence– Complex information

• Building Blocks for EBP

The ABCs of EBP

= Ask

= Consider

= Facilitate

= Books

= Develop

= Evaluate

A = Ask the Question

• A is the essence of EBP

• Melnyk & Fineout-Overholt – “BURNING QUESTION”

• Right Question

• Right way

• Key to using EBP

• A has a secondary mnemonic:– PICOT

PICOT Format

• P = Population.

• I = Intervention.

• C = Comparison.

• O = Outcome.

• T = Time.

Secondary Mnemonic

• PICOT

• Filtering

• Project Goals

• Focus the research

Goals for PICOT

• Application of the collected evidence

• Narrow focus

• End product

• Application

PRACTICE PICOT

• So this sample question reads:

• Does this diabetic teaching tool help my diabetic patients reduce their A1c in six months compared to the current process we use?

Example of the PICOT

• Population: Diabetic patients

• Intervention: Diabetic teaching tools

• Comparison: A1c prior to the education

• Outcomes: A1c after the education

• Time: 3 months, 6 months, Ongoing

ABCs of EBP

= Ask

= Books= Consider

= Develop

= Evaluate

= Facilitate

B = Books

• B stands for books; meaning research• Use the question to narrow the search to

manageable amounts• Internet search engines & research sites• http://www.ahrq.gov • http://www.cdc.gov

(Boswell & Cannon, Ch.7; Burns & Grove, Ch.2; Melnyk & Fineout-Overholt, Ch.3)

B = Books

• Using Search engines & sites

• Nursing Organizations

• On-line libraries at work or school

Caution!!!!

• CINAHL Full Search under EBSCO Host• First run: Diabetes

– 57,163 results• Second run: narrow dates

– 35,672• Third run: add ‘education’

– 1,623• Fourth run: add ‘tool’

– 1 study

ABCs of EBP

= Ask

= Books

= Consider= Develop

= Evaluate

= Facilitate

C = Consider

• Evaluate the research• Tool developed• Using the tool

(Boswell & Cannon, Ch.5, Burns & Grove, Ch.2 4; Mantzoukas; Melnyck &

Fineout-Overholt, 2005, Ch. 5)

Research Evaluation ToolArticle Title

Target Population/is it applicable here?

What was tested/ is it applicable

Dates Strengths of Study

Weaknesses of study

Other comments/citation if indicated

Dick & Jane look for

Spot.

2 children looking for dog.N/A we don’t have pediatrics here.

Ф

Tested methods to look for dogs.N/A we don’t have dogs here.

Ф

This study is not dated. I would guess 1940’s.

Ф

In-depth casestudy.

Ф

Only 2 subjects. Needs larger sample size.

Ф

Citation if the study is going to be used to build a paper, or develop further research.Comments if the study might be used for something in the future.

ФAny other brief memory joggers you want to add.

Boswell & Cannon, p.108; Mantzoukas)

You might get ideas for other search parameters

Use them as a pilot study

ABCs of EBP

= Books

= Ask

= Consider

= Develop= Evaluate

= Facilitate

D = Develop & Apply

• Develop and apply the intervention being considered

• Use specific steps, specific details in order to make the project manageable

• Specific to your patient population

(Melnyk & Fineout-Overholt, Ch.10)

Develop the EBP Project

• Does this tool help my diabetic patients reduce their A1c in six months compared to the current process we use?– Tool adjusted for your patient population– Instructions for staff – Instructions for patients

ABCs of EBP

= Ask

= Books

= Consider

= Develop

= Evaluate= Facilitate

E = Evaluate

• Evaluating care delivery should be second nature for nurses

• Familiar from the nursing process

• Collecting data to drive the evaluation

• Statistical analysis may be necessary

• Decide what is going to be measured

(Boswell & Cannon, Ch.9; Melnyk & Fineout-Overholt, Ch.10 & 11)

Chocolate

Evaluate Results of the Project

• Does this tool help my diabetic patients reduce their A1c in six months compared to the current process?– Run A1c– Count – Pre/Post Test– Questionnaires

Note

• Research

• Ethics

• Privacy

• Institutional Review Board

ABCs of EBP

= Ask

= Books

= Consider

= Develop

= Evaluate

= Facilitate

F = Facilitate

• Facilitate EBP

• Academic Growth

• Professional Growth

• Skills Development

• Share Project Findings

(Melnyk & Fineout-Overholt, Ch.14)

Evidence at Work in Practice

• Fact sheets for nurses

• Publish research article reviews

• Share findings

• Attend conferences

• Support other staff development

• Culture changes

Getting EBP to the Staff

• Power Point Presentation

• New employee orientation

• Introduces new staff to our cultural environment

• EBP not in original curricula

Thank You

• “Let whoever is in charge keep this simple question in her head:– Not how can I always do this right thing

myself, but how can I provide for this right thing to be always done?”

– Florence Nightingale, 1860

The Answer is EBP!

Questions?

References

• Boswell, C. & Cannon, S. (Eds.) (2007). Introduction to nursing research: Incorporating evidence-based practice, p.108. Sudbury, MA: Jones & Bartlett.

• Burns, N., & Grove, S. (2005) The practice of nursing research ch.2, (5th ed.), Elsevier.

• Bradshaw, W. (2010). Importance of nursing leadership in advancing evidence-based practice. Neonatal Network, 29(2), 117-122.

• Dontje, K. (2008). Evidence-based practice: Understanding the process. Topics in Advanced Practice Nursing eJournal, 7(4). Retrieved May 13, 2010 from http:www.medscape.com/viewarticle/567786.

• Hockenberry, M., Walaen, M., Brown, T., Barrera, P. (2008). Creating an evidence-based practice environment: One hospital’s journey. Journal of trauma nursing, 15(3) p.136-142.

• Ireland, M. (2008) Assisting students to use evidence as a part of reflection on practice. Nursing Education Perspectives, 29(2) p.90-93.

References

• Melnyk, B, & Fineout-Overholt, E. (Eds.). (2005). Evidence-based practice in nursing & healthcare: A guide to best practice. (Ch1) Philadelphia:Lippincott Williams & Wilkins

• Nightingale, F. (1860). Notes on nursing: What it is and what it is not. Dover edition, NY, 1969 (original work published by D. Appleton and company, 1860).

• Seben, S., March, K., Pugh, L. (2010). Evidence-based practice: The forum approach. American Nurse Today, 5(11) p.32-34.

• Titler, M. (2010). Chapter 7, The evidence for evidence-based practice implementation.

• Retrieved Sep. 29, 2010 from http://wwwahrq.gov/qual/nurseshdbk/docs/TitlerM_EEBPI.pdf