Evidence Based Practice (EBP) PC600 – Health Promotion and Disease Prevention Module 3.

Evidence Based Practice (EBP)Evidence Based Practice (EBP)

PC600 – Health Promotion and PC600 – Health Promotion and Disease PreventionDisease Prevention

Module 3Module 3

What is Evidence-Based Practice?What is Evidence-Based Practice?

• The definition of evidence-based practice The definition of evidence-based practice (EBP) has change over time. You will see (EBP) has change over time. You will see with the following definitions that as health with the following definitions that as health care providers gain new insight with regard care providers gain new insight with regard to the impact of implementing EBP the to the impact of implementing EBP the definition has changed.definition has changed.

Evidence-Based Practice according to Sackett et al (1996)Evidence-Based Practice according to Sackett et al (1996)

……is “the conscientious, explicit, and is “the conscientious, explicit, and judicious use of current best evidence in judicious use of current best evidence in making decisions about the care of making decisions about the care of individual patients. The practice of individual patients. The practice of evidence-based Medicine means integrating evidence-based Medicine means integrating individual clinical expertise with the best individual clinical expertise with the best available clinical evidence from systematic available clinical evidence from systematic research.”research.”

Evidence-Based Practice according to Melnyk & Fineout-Overholt (2005)Evidence-Based Practice according to Melnyk & Fineout-Overholt (2005)

……is “a problem solving approach to clinical is “a problem solving approach to clinical practice that integrates the conscientious practice that integrates the conscientious use of best evidence in combination with a use of best evidence in combination with a clinician’s expertise as well as patient clinician’s expertise as well as patient preferences and values to make decisions preferences and values to make decisions about the type of care that is provided.”about the type of care that is provided.”

Evidence-Based Nursing according to Whall, Sinclair, & Parahoo (2006)Evidence-Based Nursing according to Whall, Sinclair, & Parahoo (2006)

……is “the conscientious, explicit and judicious is “the conscientious, explicit and judicious use of theory-derived, research-based use of theory-derived, research-based information in making decisions about care information in making decisions about care delivery to individuals or groups of patients delivery to individuals or groups of patients and in consideration of individual needs and and in consideration of individual needs and preferences.”preferences.”

The Core Principles of EBPThe Core Principles of EBP

• Evidence-Based Practice InvolvesEvidence-Based Practice Involves• Finding the best evidence.Finding the best evidence.• Critiquing the evidence using established rating Critiquing the evidence using established rating

schemas.schemas.• Integrating evidence with the clinician’s Integrating evidence with the clinician’s

expertise and experience.expertise and experience.• Integrating evidence with the patient’s Integrating evidence with the patient’s

preferences and values.preferences and values.• Using the evidence to guide professional Using the evidence to guide professional

decision making and practice.decision making and practice.

A word about patient preference:A word about patient preference:

• Nursing has, for some time, recognized the Nursing has, for some time, recognized the importance of incorporating patient’s preferences importance of incorporating patient’s preferences and values into the plan of care. Evidence-based and values into the plan of care. Evidence-based practice for nurses then, requires individual nurses practice for nurses then, requires individual nurses to reflect on past experience, both theoretical and to reflect on past experience, both theoretical and experiential, and consider:experiential, and consider:

• Patient’s religious and cultural beliefsPatient’s religious and cultural beliefs• Patient’s literacy and prior knowledgePatient’s literacy and prior knowledge• Anything that makes an individual patient Anything that makes an individual patient

unique. unique. (Melnyk & Fineout-Overholt, 2006)(Melnyk & Fineout-Overholt, 2006)

Why Are We Teaching Evidence-Based Practice?Why Are We Teaching Evidence-Based Practice?

• In 2003, the Institute of Medicine issued a In 2003, the Institute of Medicine issued a report mandating that “all health report mandating that “all health professionals should be educated to deliver professionals should be educated to deliver patient-centered care as members of an patient-centered care as members of an interdisciplinary team, emphasizing interdisciplinary team, emphasizing evidence-based practice, quality evidence-based practice, quality improvement approaches and informatics”improvement approaches and informatics”

Why is EBP important for you to understand and implement as an advanced practice nurse?Why is EBP important for you to understand and implement as an advanced practice nurse?

• Failure to base nursing practice on the best Failure to base nursing practice on the best available evidence can leave your patients available evidence can leave your patients vulnerable to poor outcomes.vulnerable to poor outcomes.

• Sole reliance on textbooks and expert faculty Sole reliance on textbooks and expert faculty knowledge will not prepare you for the fast-paced knowledge will not prepare you for the fast-paced and ever changing clinical practice you’ll be faced and ever changing clinical practice you’ll be faced with in this age of the information explosion.with in this age of the information explosion.

• Evidence-based practice will provide you with a Evidence-based practice will provide you with a framework to meet the needs of life-long learning framework to meet the needs of life-long learning that is required when caring for patients.that is required when caring for patients.

What Constitutes “Best Evidence”?(A hot topic of debate)What Constitutes “Best Evidence”?(A hot topic of debate)

• Early definitions of “best evidence” included Early definitions of “best evidence” included only randomized controlled trials (RTCs).only randomized controlled trials (RTCs).

• Nursing and other health care specialties are Nursing and other health care specialties are currently debating whether or not this is true, currently debating whether or not this is true, or if in fact “evidence” is a broader/more or if in fact “evidence” is a broader/more diverse term that includes more than diverse term that includes more than information derived solely from empirical information derived solely from empirical research.research.

What Constitutes “Best Evidence”?(Empirically Speaking)What Constitutes “Best Evidence”?(Empirically Speaking)

• According to Sackett et al (1996), meta-According to Sackett et al (1996), meta-analysis or integrated research reviews offer analysis or integrated research reviews offer the strongest levels of evidence.the strongest levels of evidence.

• Utilizing randomized controlled trials in Utilizing randomized controlled trials in integrated reviews is thought to be the “gold integrated reviews is thought to be the “gold standard”.standard”.

• This type of evidence can only be This type of evidence can only be discovered through quantitative research.discovered through quantitative research.

What Do Others Think?What Do Others Think?

• There are many who believe that experimental, There are many who believe that experimental, observational, and correlational studies provide sound observational, and correlational studies provide sound evidence.evidence.

• Many of the issues and questions encountered by nurses Many of the issues and questions encountered by nurses can not be studied using randomized controlled trials.can not be studied using randomized controlled trials.

• Consequently, many nursing scholars believe that Consequently, many nursing scholars believe that the use of experimental, non-experimental, and the use of experimental, non-experimental, and qualitativequalitative research may be appropriate. research may be appropriate.

(Rycroft-Malone, Seers, Titchen, Harvey, Kitson, & McCormack, 2004).(Rycroft-Malone, Seers, Titchen, Harvey, Kitson, & McCormack, 2004).

• Some nursing scholars propose that evidence in Some nursing scholars propose that evidence in evidence-based practice should be considered evidence-based practice should be considered knowledge that has been derived from a variety of knowledge that has been derived from a variety of sources that has been subjected to testing and has sources that has been subjected to testing and has been found to be credible. been found to be credible. (Higgs & Jones, 2000)(Higgs & Jones, 2000)

• Other scholars recognize that including multiple Other scholars recognize that including multiple perspectives and ways of knowing (rather than just perspectives and ways of knowing (rather than just the positivist perspective recognized with RCTs) the positivist perspective recognized with RCTs) is an important element in conceptualizing the is an important element in conceptualizing the meaning of evidence-based practice in nursing. meaning of evidence-based practice in nursing.

(Whall, Sinclair, & Parahoo, (Whall, Sinclair, & Parahoo, 2006)2006)

The Bottom Line:The Bottom Line:

• Evidence must be critiqued in order to determine Evidence must be critiqued in order to determine its quality and whether or not the study design is its quality and whether or not the study design is appropriate to answer the question that is asked.appropriate to answer the question that is asked.

• Evidence that is used to inform practice must be Evidence that is used to inform practice must be subjected to rigorous scrutiny.subjected to rigorous scrutiny.

• Many organizations have systems in place to Many organizations have systems in place to determine which evidence can guide practice. determine which evidence can guide practice. Advanced practice nurses must work with these Advanced practice nurses must work with these established systems.established systems.

Evidence-Based Practice:A 5-Stage ProcessEvidence-Based Practice:A 5-Stage Process

• An easy way to remember the stages An easy way to remember the stages involved in evidence-based practice is to involved in evidence-based practice is to remember the 5 “A”sremember the 5 “A”s

• AskAsk• AcquireAcquire• AppraiseAppraise• ApplyApply• AssessAssess

The Five Stages of Evidence-Based PracticeThe Five Stages of Evidence-Based Practice

1.1. Asking a clinical questionAsking a clinical question2.2. Acquiring relevant research by searching the literatureAcquiring relevant research by searching the literature3.3. Appraising (critically) what has been found.Appraising (critically) what has been found.

• If the evidence suggests a need for change, and if it is If the evidence suggests a need for change, and if it is congruent with the skills of the clinician, available congruent with the skills of the clinician, available resources, and patient’s preference, then the following resources, and patient’s preference, then the following stages also occurstages also occur

4.4. Applying the evidence to implement change in Applying the evidence to implement change in practicepractice

5.5. Assessing the outcomes following the change in Assessing the outcomes following the change in practice practice (Ciliska, 2005)(Ciliska, 2005)

Life-Long Learning Starts NowLife-Long Learning Starts Now

• Always remember to bring Always remember to bring the same sense of inquiry the same sense of inquiry to your professional to your professional practice that you bring to practice that you bring to your studies for school.your studies for school.

• Ask “Why do we do it this Ask “Why do we do it this way?” or “Is there a better way?” or “Is there a better way to do this?”way to do this?”

Becoming a Master at Acquiring the EvidenceBecoming a Master at Acquiring the Evidence

• In this course you will learn In this course you will learn to structure questions to to structure questions to efficiently search for efficiently search for evidence.evidence.

• You will use these questions, You will use these questions, and build on what you have and build on what you have learned in the Library 101 learned in the Library 101 course to effectively search course to effectively search relevant, peer-reviewed relevant, peer-reviewed journals and data bases for journals and data bases for evidence.evidence.

But how do I appraise the evidence?But how do I appraise the evidence?

• Evaluating the quality and strength of evidence Evaluating the quality and strength of evidence requires that you review all that you learned in requires that you review all that you learned in your undergraduate nursing courses, especially your undergraduate nursing courses, especially content related to critically reading and content related to critically reading and interpreting research.interpreting research.

• This course will give you additional information This course will give you additional information that will assist you in determining the strength of that will assist you in determining the strength of evidence.evidence.

• Check the following web site for a glossary of Check the following web site for a glossary of terms used in EBP: terms used in EBP: (click on “Resources” once you are in (click on “Resources” once you are in

the site to access the glossary and other valuable information)the site to access the glossary and other valuable information) http://www.nursing.asu.edu/caep/index.htmhttp://www.nursing.asu.edu/caep/index.htm

Summary Summary

• The benefits of implementing evidence-The benefits of implementing evidence-based practice are many, and include based practice are many, and include improved outcomes and patient satisfaction, improved outcomes and patient satisfaction, and filling the gap between research and and filling the gap between research and practice. practice.

• Now that you have a basic understanding of Now that you have a basic understanding of the concept of evidence-based practice, the concept of evidence-based practice, return to the course module and proceed return to the course module and proceed with the learning activities and required with the learning activities and required readings.readings.

ReferencesReferences

Ciliska, D. (2005). Educating for evidence-based practice. Ciliska, D. (2005). Educating for evidence-based practice. Journal of Professional Nursing, 21Journal of Professional Nursing, 21(6), (6), 345-350.345-350.

Higgs, J., & Jones, M. (2000). Will evidence-based practice take the reasoning out of practice? In Higgs, J., & Jones, M. (2000). Will evidence-based practice take the reasoning out of practice? In J. Higgs & M. Jones (Eds), J. Higgs & M. Jones (Eds), Clinical Reasoning in the Health Professionals, 2Clinical Reasoning in the Health Professionals, 2ndnd Edition Edition. . Oxford, UK: Butterworth Heineman.Oxford, UK: Butterworth Heineman.

Institute of Medicine. (2003). Institute of Medicine. (2003). Health professions education: A bridge to quality.Health professions education: A bridge to quality. Washington, DC: Washington, DC: National Academies Press.National Academies Press.

Melnyk, B., & Fineout-Overholt, E. (2005). Melnyk, B., & Fineout-Overholt, E. (2005). Evidence-Based Practice in Nursing & Healthcare: A Evidence-Based Practice in Nursing & Healthcare: A Guide to Best PracticeGuide to Best Practice. Philadelphia: Lippincott Williams & Wilkins.. Philadelphia: Lippincott Williams & Wilkins.

Melnyk, B., & Fineout-Overholg, E. (2006). Consumer preferences and values as an integral key Melnyk, B., & Fineout-Overholg, E. (2006). Consumer preferences and values as an integral key to evidence-based practice. to evidence-based practice. Nursing Administration Quarterly, 30Nursing Administration Quarterly, 30(2), 123-127.(2), 123-127.

Rycroft-Malone, J., Seers, K., Titchen, A., Harvey, G., Kitson, A., & McCormack, B. (2004). Rycroft-Malone, J., Seers, K., Titchen, A., Harvey, G., Kitson, A., & McCormack, B. (2004). What counts as evidence in evidence-based practice? What counts as evidence in evidence-based practice? Journal of Advanced Nursing, 47Journal of Advanced Nursing, 47(1), 81-(1), 81-90.90.

Sackett, D., Rosenberg, W., Gray, J., Haynes, R., & Richardson, W. (1996). Evidence based Sackett, D., Rosenberg, W., Gray, J., Haynes, R., & Richardson, W. (1996). Evidence based medicine: What it is and what it isn’t. medicine: What it is and what it isn’t. British Medical Journal, 312British Medical Journal, 312(7032), 71-72.(7032), 71-72.

Whall, A., Sinclair, M., & Parahoo, K. (2006). A philosophic analysis of Evidence-Based Nursing: Whall, A., Sinclair, M., & Parahoo, K. (2006). A philosophic analysis of Evidence-Based Nursing: Recurrent themes, metanarratives, and exemplar cases. Recurrent themes, metanarratives, and exemplar cases. Nursing Outlook, 54Nursing Outlook, 54(1), 30-35.(1), 30-35.