Chapter 12 EvidenceBased Practice and Nursing Theory Copyright

Overview of Evidence-Based Practice • Evidence-based practice (EBP) was introduced in the 1970 s by Dr. Archie Cochrane. • Dr. Cochrane focused on critical review of research (emphasis on RCTs) to improve medical practice. • Application in nursing has been delayed but has been growing over the past 10 years. Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Overview of Evidence-Based Practice —(cont. ) • EBP is based on the premise that health professionals should not base practice on tradition and belief but on information grounded in research. • EBP is not synonymous with research. – Research focuses on discovery. – EBP focuses on application. Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Overview of Evidence-Based Practice —(cont. ) • EBP involves: – Identifying a clinical problem – Searching the literature and critically evaluating research evidence – Determining appropriate interventions • EBP integrates research, theory, and practice. Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evidence-Based Practice • EBP is “the conscientious, explicit, and judicious use of theory-derived, research-based information in making decisions about care delivery. . . in consideration of individual needs and preferences” • Key concepts of EBP – Best evidence – Expertise – Patient values • Careful review of research findings according to guidelines. • De-emphasizes ritual, isolated, and unsystematic clinical experiences, options, and tradition as basis for practice Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question Which of the following is NOT considered to be a key concept of EBP? A. Best evidence B. Patient values C. Provider expertise D. Traditional practices Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer D. Traditional practices Rationale: EBP de-emphasizes ritual, unsupported practices, and tradition and focuses on researchsupported interventions that considers patients’ desires and needs and provider expertise. Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evidence-Based Nursing • Some sources for EBP information/guidelines – Cochrane Collaboration/Cochrane Database of Systematic Reviews— network that helps health care providers make informed decisions about health care – Agency for Healthcare Research and Quality (AHRQ)—maintains database of evidence-based clinical practice guidelines Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evidence-Based Nursing—(cont. ) • Concerns – Too much focus on EBP could result in “cookbook care” and loss of “art” of nursing. – Lessening of attention to holistic care – Health care reimbursement might drift exclusively to interventions substantiated by “evidence. ” – Not all health care practices can or should be based on science per se (What about “care”? ). • Consensus agreement that EBP in nursing should consider all types of evidence (not just RCTs), as well as clinical experience, patient experiences and desires, and relevant local/organizational influences. Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Practice-Based Evidence • PBE is a relatively new concept in nursing and health care. • Based on the observation that many interventions have limited formal research support • PBE recognizes the importance of the environment in determining practice recommendations. • Premise of PBE is that large databases should be reviewed or “mined” to gather data on quality and effectiveness. Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Practice-Based Evidence—(cont. ) • PBE seeks to determine what works best for which patients, under what circumstances, and at what costs. • More comprehensive picture than RCTs • Sources include: – Benchmarking data – Clinical expertise – Cost-effective analyses – Infection control data – Medical record data – National standards of care – Quality improvement data – Patient and family preferences Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Relationships among practice, theory, research, and the PBE/ EBP cycle. (From Walker, L. O. , & Avant, K. C. [© 2011]. Strategies for theory construction in nursing [5 th ed. , Fig. 2 -3; p. 46]. Reprinted by permission of Pearson Education, Inc. , Upper Saddle River, NJ. ) Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Theory and Evidence-Based Practice • More awareness of EBP has renewed appreciation for linkages among research, theory, and practice. • Research and clinical data provide evidence for EBP and/or PBE and can generate practice guidelines and/or situation-specific theories. • Preference for term “theory-guided, evidence-based practice” Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Models for Evidence-Based Practice • For some EBP models, the goal is to create or establish EBP protocols, procedures, or guidelines. • Some EBP models focus on implementation of EBP in the setting or institution. Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Models for Evidence-Based Practice— (cont. ) • Most commonly used and described in nursing literature are: – Academic Center for Evidence-Based Practice Star Model (ACE Star Model) (Stevens, 2004) – Advancing Research and Clinical Practice Through Close Collaboration (ARCC Model) (Melnyk & Fineout -Overholt, 2011) – Iowa Model (Titler et al. , 2001) – Johns Hopkins Nursing Evidence-Based Practice Model (JHNEBP) (Newhouse et al. , 2007) – Stetler Model of Evidence-Based Practice (Stetler, 2001) Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evidence-Based Practice Models— ACE Star Model • Developed by faculty at University of Texas Health Science Center at San Antonio • Depicted by five points of sequential knowledge transformation – Discovery research – Evidence summary – Translation to guidelines – Practice integration – Process and outcome evaluation Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Diagram of the ACE star model for evidence-based practice. (Used with permission from Stevens, K. R. [2012]. ACE Star Model: Knowledge transformation©. Academic Center for Evidence-Based Practice. Available at http: //www. acestar. uthscsa. edu/acestar-model. asp) Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evidence-Based Practice Models— ACE Star Model—(cont. ) • Knowledge transformation (KT) consists of eight premises. – KT is necessary prior to using research for clinical decision making. – KT is derived from multiple sources (e. g. , research, experience, authority). – Research process is the most stable source of knowledge. – Evidence can be classified by strength of evidence based on rigor. Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evidence-Based Practice Models— ACE Star Model—(cont. ) • Knowledge transformation (KT) consists of eight premises—(cont. ) – As research is converted through a system of steps, other knowledge is created. – The form in which knowledge exists can be referenced to its use. – The form of knowledge determines its usability. – KT takes place through steps (summarization, translation, application, integration, and evaluation). Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evidence-Based Practice Models—ACE Star Model—(cont. ) • ACE Star Model has been shown useful in teaching the process of research evidence. • For more information, see: http: //www. acestar. uthscsa. edu/index. asp Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evidence-Based Practice Models— ARCC Model • The Advancing Research and Clinical Practice Through Close Collaboration (ARCC) Model was developed to advance and sustain EBP (Melnyk & Fineout-Overholt, 2002). • Basis in control theory and cognitive behavioral theories • Appropriate in clinical practice— particularly acute care Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evidence-Based Practice Models— ARCC Model—(cont. ) • Central constructs of the ARCC Model – Assessment of organizational culture and readiness for EBP – Identification of strengths and barriers to EBP – Development and use of EBP mentors – EBP implementation – Outcome evaluation (providers’ satisfaction, cohesion, intent to leave, turnover, improved patient outcomes, hospital costs) Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evidence-Based Models—ARCC Model —(cont. ) • Several scales have been developed to measure implementation of EBP using the ARCC Model. • Among them are scales to measure organizational readiness and EBP beliefs. • Considerable amount of research support for the ARCC model Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evidence-Based Practice Models— Iowa Model of EBP to Promote Quality Care • The Iowa Model of EBP was developed in the 1990 s. – Intent to promote quality care through research utilization – It was developed to provide guidance for nurses in making decisions about practice. Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question Tell whether the following statement is true or false: The rationale for development of the Iowa Model of EBP was to manage the costs of health care. Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer False The Iowa Model for EBP was developed to promote quality nursing care through incorporation of research into practice. Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evidence-Based Practice Models—Iowa Model of EBP to Promote Quality Care— (cont. ) • Organized into starting points, decision points, and feedback loops – Starting points are problem-focused triggers or knowledgefocused triggers – Decision points: • Is the topic a priority? • Is there sufficient research base? • Is change appropriate for adoption in practice? – There are numerous feedback loops based on the model. – After implementation of practice change, monitor and analyze the structure, process, and outcome data; then disseminate results. Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Diagram of the Iowa method of evidence-based practice. (Reprinted with permission from University of Iowa Hospitals and Clinics. © 1998. For permission to use or reproduce the model, please contact University of Iowa Hospitals and Clinics at 319 -384 -9098. ) Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evidence-Based Practice Models— Iowa Model of EBP to Promote Quality Care—Resources • For more information, see: http: //www. nnpnetwork. org/ebp-resources/iowa-model http: //www. hinursing. org/pdf/Iowa. Model. pdf Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evidence-Based Practice Models— Johns Hopkins Nursing EBP Model • The JHNEP Model is a problem-solving approach to clinical decision making. • Developed to accelerate research into nursing practice and promote nursing autonomy, leadership, and engagement with colleagues • Combines the nursing process, the ANA Standards of Practice, critical thinking, and research utilization Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evidence-Based Practice Models— Johns Hopkins Nursing EBP Model— (cont. ) • Three core elements (PET) – Practice question – Evidence – Translation • Several phases composed of 18 steps. – Each step helps clarify the processes. – Assist in understanding how to proceed Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evidence-Based Practice Models— Johns Hopkins Nursing EBP Model— (cont. ) • Model begins with an EBP question (PICO) consisting of: Practice question (patient, population and problem) Intervention Comparison as appropriate Desired Outcome(s) • Other steps involve defining the scope of the question, assigning reasonability for leadership, recruiting a team and scheduling conferences. Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Question When developing a PICO question, the “C” represents which of the following? A. Care options B. Comparison with a baseline or standard C. Consideration of patient or provider values/wishes D. Costs of interventions Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Answer B. Comparison with a baseline or standard Rationale: A PICO question consists of: Practice question (patient, population, and problem) Intervention Comparison as appropriate Desired Outcome(s) Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evidence-Based Practice Models— Johns Hopkins Nursing EBP Model— (cont. ) • Evidence phase includes: – Literature search – Team appraisal and recommendations • Translation phase: – Team decides whether and how to implement changes. – Evaluation of implementation – Communicate the findings PRN Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evidence-Based Practice Models— Johns Hopkins Nursing EBP Model— Resources • For more information (optional course): http: //www. hinursing. org/pdf/Iowa. Model. pdf • Data collection tool: http: //www. nursingworld. org/Document. Vault/Nursi ng. Practice/Research-Toolkit/JHNEBP-Research. Evidence-Appraisal. pdf Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evidence-Based Practice Models— Stetler Model • Originally implemented in the 1970 s as a quality improvement effort • Similar to the nursing process thus easily implemented • Five steps or phases – Preparation – Validation – Comparative evaluation/decision making – Translation/application – Evaluation Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evidence-Based Practice Models— Stetler Model—(cont. ) • Preparation – Propose, control, and source research evidence • Validation – Determine credibility of findings and potential for qualifiers for application • Comparative evaluation/decision making – Synthesis of information and decisions for recommendations for criteria and applicability • Translation/application – Create operational definitions for use and actions for change • Evaluation – Determine alternate types of evaluation Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins

Evidence-Based Practice—Summary • EBP has become one of the key tenets of quality nursing care. • In nursing, it is critical that EBP go beyond research and be theory based. • Growing attention to the concept of PBE has renewed attention to the critical role of theory in excellent nursing practice. Copyright © 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins