Evidence Based Practice Models

EVIDENCE BASED PRACTICE MODELS

BYLIDIYA

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; one’s own clinical expertise; and patient preferences and values. (Sackett, Straus, Richardson, Rosenberg, Haynes)

Knowledge sources of EBP

• BEST RESEARCH EVIDENCE• ONE’S OWN CLINICAL EXPERTICE• PATIENT’S VALUES , PREFERENCES• CLINICAL SETTING• ASSESSMENT & HISTORY

BACK GROUND OF EBP

• [3] The EBP movement was founded by Professor Archibald Leman Cochrane, CBE, FRCP, FFCM (1909-1988) 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 influential book in the early 1970’s that drew attention to the dearth of solid evidence about the effects of health care.

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

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

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 plan and provide care that takes into account cultural and personal values and preferences.

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”.

EBP Vs RU

EVIDENCE BASED NURSING

• Complex process• Newer concepts- developed

approximately 10 years ago. • .• Includes patient’s preferences• Includes a system to grade or level the

quality of the research.• .• Includes evaluation of the evidence

based on the clinical setting in which it will be applied.

• Includes an evaluation of cost effectiveness

•

NURSING RESEARCH UTILISATION

• Less complex process• Older concepts- used in the

1970’s toearly 1990’s• PATIENT’S PREFERENCES NOT

INCLUDED• No defined system to evaluate

the research; may change the practice based on the study

• Clinical setting is not considered

• Cost not addressed

EVIDENCE HIERARCHIES

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.

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

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 generated”. (Melnyk & fineout overhaul, 2005).

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.”

Types of S.R

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

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 research

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 same outcome, into a single pooled or summary estimate”. - Di lenso et al

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.

EBP MODELS:

• 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.

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 professional development are key components, along with the use of EBP ambassadors for each unit.

2. THE ARCC MODEL: Advancing research and clinical practice through close collaboration (ARCC) model

• 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.

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.

3.Integrating Evaluation-Informed and Evidence-Based 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 use byhelping professionals

• the PRAISES Model is an attempt to integrate, structure, and

• systematize the process of evidence-based practice, while highlighting the interrelationships among interventive practices and evaluation in the overall process

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 demonstrated effectiveness. The second meaning

• is in the careful and systematic evaluation of the effects of our interventions. This framework highlights the points of planning and contact with the clients where evaluation-informed and evidence-based decisions need to be made


• 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.


• 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.


• 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 others


• 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, outcome-oriented, structured, fl exible depending on the needs of the client, evidence-based, informed by ongoing evaluation, and up- to-date with the relevant literature. All of this is grounded in the ethics and values—

• the scientifi c humanism—that underlie the philosophy and practices of the helping professions.

Phases of PRAISES model

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


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


• PHASE III. Intervention• 9. Develop intervention plan• 10. Develop evaluation plan• 11. Negotiate contract• 12. Prepare for intervention• 13. Implement intervention


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


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

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, O'Conner, & Graham, 2006). The OMRU views research use as a dynamic process of interconnected decisions and actions by different individuals relating to each of the model elements (Logan & Graham, 1998). This model addresses the implementation of existing research knowledge

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

OTTAWA MODEL

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 of critical thinking and reflective practice. The model links research use, as a first step, with evidence-informed practice.

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 or decision, or otherwise influence the thinking and behaviour of others.

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); • fit of the substantiated evidence for the user group and

settings; and • feasibility of implementing the research findings

(risk/benefit assessment, availability of resources, stakeholder readiness).

STETLER MODEL ;PHASES

• Phase I: Preparation • Phase II: Validation • Phase III: Comparative Evaluation/Decision

Making • Phase IV: Translation/Application • Phase V: Evaluation

• Phase I: Preparation—Purpose, 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 that the reasons for using evidence will also identify measurable outcomes for Phase V (Evaluation

• Phase II: Validation—Credibility 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 light of additional evidence. Determine whether a given source has no credibility or fit and thus whether to accept or reject it for synthesis with other evidence (rather than simply determine whether the evidence is weak or strong). Summarize relevant details regarding each source in an 'applicable statement of findings' to look at the implications for practice in Phase III. A summary of findings should:

• reflect the meaning of study findings for the issue at hand; and • reflect studied variables or relationships in ways that could be practically used

(eg. in terms of the actual operational nature of interventions and potential qualifiers or conditions of application that may be key to future use).

Phase III: Comparative Evaluation/Decision Making

• —Synthesis and Decisions/Recommendations per Criteria of Applicability

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 findings in practice, based on applicability criteria, i.e. substantiating evidence, in terms of the overall strength of the accumulated findings. The criteria are fit to the targeted setting; current practice; and feasibility ("r, r, r" = evaluation of risk factors, ned for resources, readiness of others involved).

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 implications that answer the overall question, "So what?".

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. • Use Research Utilization as a process (Stetler, 2001) to

enhance the credibility of evaluation data. • Include two types of evaluation data: formative and

outcome.

6.ACE STAR MODEL: (ACADEMIC CENTRE FOR EVIDENCE BASED PRACTICE)

• The Star Model of Knowledge 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 and approaches

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.

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 correlational to causal; and from randomized control trials to qualitative. This stage builds the corpus of research about clinical actions.

http://www.acestar.uthscsa.edu/acestar-model.asp


• Star Point 2. Evidence Summary• Evidence summary is the first unique step in EBP—the

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 systematic review methods outlined in the Cochrane Handbook) from randomized control trials. Some evidence summaries employ more rigorous methods than others, yielding more credible and reproducible results.



• 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 summarized evidence to clinicians and clients in a form that suits the time, cost, and care standard. Recommendations are generically termed clinical practice guidelines (CPGs) and may be represented or embedded in care standards, clinical pathways, protocols, and algorithms.



• 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 formal and informal channels. Major aspects addressed in this stage are factors that affect individual and organizational rate of adoption of innovation and factors that affect integration of the change into sustainable systems.



• 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 suffering through the diagnosis and

• treatment of human response, and advocacy in the care of individuals,

• families, communities and populations”


7.The Johns Hopkins Nursing Evidence-Based PracticeModel

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

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

• 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 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, 2000), which narrows the question by identifying the following:

• ■ Patient, population, or problem• ■ Intervention• ■ Comparison with other treatments• ■ Outcome

• 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 assists the team in

identifying the appropriate• individuals and stakeholders who should be involved

in, and kept informed of, the• EBP process.

• 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 interdisciplinary team. It is also helpful for this individual to be knowledgeable of the organizational structure and strategies for implementing change within the organization

• 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 recommended that individuals such as bedside clinicians,who are close to the problem and issues, be included

• 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 assigned to record discussion points and group decisions, and to keep track of important items (e.g., copies of the EBP tools, extra paper, dry erase board, and so on); (4) providing for a place to keep project files; and (5) establishing a time line for the process.

• 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.

• 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 front of each tool includes a set of key questions to determine the type of evidence, its strength, and its quality. The back of each tool includes reference definitions for each evidence type and a scale to rate the evidence quality.

• 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 (I–V) are summarized in narrative form, and the overall quality for each level is determined by team consensus.

• 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 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 appropriate and feasible for the specific practice setting. It is also essential to obtain organizational support, which helps ensure that necessary resources are allocated to make the change.

• 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 needed to implement the change (including the evaluation process and reporting of results), and (3) the solicitation of feedback from organizational leadership, bedside clinicians, and others

• 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 examine• why these outcomes occurred. This examination may

indicate the need to make• alterations to the practice change or in the implementation

process, followed by reevaluation.

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 be needed. Additionally, what works in one context of care may or may not work in another setting, thereby suggesting that context variables matter in implementation

Evidence Based Practice Models

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Evidence Based Practice Models