Chapter 10 EvidenceBased Practice Sharon E Lock Copyright

Introduction Research evidence provides a scientific basis for practice; thus using research to support practice will result in better client outcomes and more efficient practice Research evidence is not always available to use for decision making; when that is the case, other sources of evidence are used to make clinical decisions Copyright © 2010, 2006, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc. 2

Definitions Related to Evidence-Based Practice Evidence-based medicine: being aware of the evidence on which one’s practice is based, the soundness of the evidence, and the strength of inference the evidence permits Evidence-based public health: a public health endeavor in which there is an informed, explicit, and judicious use of evidence that has been derived from any of a variety of science and social science research and evaluation methods Evidence-based nursing: an integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families, and communities who are served Evidence-based practice: includes the best available evidence from a variety of sources, including research studies, evidence from nursing experience and expertise, and evidence from community leaders Copyright © 2010, 2006, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc. 3

History of Evidence-Based Practice Mid- to late 1970 s Growing consensus among nursing leaders that scientific knowledge should be used as a basis for nursing practice Ø Medicine also began to call for physicians to increase their use of scientific evidence to make clinical decisions Ø Division of nursing began funding research utilization projects Ø 1990 s Ø Paradigm shift – need to be able to critically appraise the research literature in order to appropriately apply research findings in practice Copyright © 2010, 2006, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc. 4

Types of Evidence Systematic review: a summary of the research evidence that relates to a specific question and to the effects of an intervention Meta-analysis: a specific method of statistical synthesis used in some systematic reviews, where the “results from several studies are quantitatively combined and summarized” Randomized control trial (RCT): generally ranks as the highest level of evidence followed by other RCTs, nonrandomized clinical trials, prospective cohort studies, case-control studies, case reports, and expert opinion Copyright © 2010, 2006, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc. 5

Evaluating Evidence Sample selection Randomization Blinding Sample size Description of intervention Outcomes Length of follow-up Attrition Confounding variables Statistical analysis Copyright © 2010, 2006, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc. 6

Grading the Strength of Evidence The evidence is assigned a “grade” based on: Ø Ø Ø The quality of the evidence The number of well-designed studies The presence of similar findings in all of the studies Three domains for evaluation systems Ø Ø Ø Quality Quantity Consistency Copyright © 2010, 2006, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc. 7

Implementation Recognizing the current status of one’s own practice and believing that care based on the best evidence will lead to improved client outcomes Steps for EBP Ask a clinical question Collect the most relevant and best evidence Critically appraise the evidence Make a clinical decision or change by integrating all the evidence with clinical expertise, client preferences, and values Ø Evaluate the clinical decision or change Ø Ø Copyright © 2010, 2006, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc. 8

Barriers to Implementation Misunderstood communication between nursing leaders about the process involved Inferior quality of available research evidence Inability to assess and use research evidence Unwillingness of organizations to fund research and make decisions based on evidence Concern that EBP will lead to a “cookbook” approach to nursing while ignoring individual client needs and the nurse’s ability to make clinical decisions Community-focused nursing agencies may lack the resources needed for EBP implementation Copyright © 2010, 2006, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc. 9

Current Perspectives Cost versus quality Individual differences Appropriate EBP methods for communityoriented nursing practice Copyright © 2010, 2006, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc. 10

Future Perspectives Rising costs of health care = continued challenge of finding resources to implement EBP Emphasis on quality care, equal distribution of health care resources, and cost control will continue Use of Internet for evidence data Copyright © 2010, 2006, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc. 11

Healthy People 2010 Objectives Offer a systematic approach to health improvement Provide general direction and focus for measuring progress of improving health status within a specific amount of time CDC data system tracks all 467 objectives Partners in Information Access for the Public Health Workforce makes information and evidence-based strategies related to HP 2010 objectives easier to find Copyright © 2010, 2006, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc. 12

Nursing Interventions Related to the Core Public Health Functions Assessment Ø Ø Ø Policy development Ø Ø Monitoring health Diagnosis Investigation Informing and educating the public Mobilizing the community Assurance Ø Ø Ø Linking or providing care to the community Ensuring a competent workforce Evaluation Copyright © 2010, 2006, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc. 13

The Minnesota Model 1994: the Minnesota Department of Health nursing staff aimed to develop a model of public health nursing interventions The model received input from public health nurses, clinicians and educators, and a national expert panel Final model defines the scope of public health nursing practice by type of intervention and the client level of practice 17 interventions were identified Copyright © 2010, 2006, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc. 14

Minnesota Model: 17 Interventions 1. Surveillance 2. Disease and health event investigation 3. Outreach 4. Screening 5. Case finding 6. Referral and follow-up 7. Case management 8. Delegated functions 9. Health teaching 10. Counseling 11. Consultation 12. Collaboration 13. Coalition building 14. Community organizing 15. Advocacy 16. Social marketing 17. Policy development and enforcement Copyright © 2010, 2006, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc. 15

Minnesota Model: Actions For each intervention listed on the previous slide, the following actions are taken: The intervention is defined Assumptions about the intervention are given Practice examples are given for type of client How the intervention relates to other interventions is explained Ø Basic steps are given for implementing the intervention. Ø Best practices are explained Ø The evidence used to develop the intervention is given Ø Ø Copyright © 2010, 2006, 2002 by Mosby, Inc. , an affiliate of Elsevier Inc. 16