Onderzoek ontmoet praktijk Evidence meets practice Helen Spiby

Onderzoek ontmoet praktijk Evidence meets practice Helen Spiby Mother and Infant Research Unit University of York, UK 11 th December 2007

Where evidence meets experience PLAN • Overview EBP process • Identifying research questions from midwifery practice • Early Labour Support & Assessment trial • Suggest ways to increase midwives’ involvement in evidence based practice

The three elements of evidence-based health care The best available evidence Evidence-based healthcare The needs and preferences of patients and clients The professional’s expertise, skills and judgement

Evidence Based Practice in Midwifery Why? • Best possible care & outcomes • Ethical imperative • Reduce variations in practice • Efficient use of finite resources • Professional accountability • Women & families as partners

Alternatives to Evidence Based Practice • Opinion-based practice • Custom • Interventions implemented/ practice changes without a strong evidence base

Procedures : evidence of harm/mixed effects/no clear evidence/evidence applied inappropriately • Supplementation with formula for • • • breastfed babies Routine rupturing of membranes Not suturing second degree tears Placing babies prone to sleep

Overview of the EBP process • • • Identifying questions from practice Locating the evidence Critically appraising the evidence Utilisation in practice Evaluation & reflection

Identifying questions from practice Formulating the question: PICO • Population • Intervention/exposure • Comparison • Outcome

Identifying questions from practice: PICO • Population - description of a similar group of women/babies

Identifying questions from practice: PICO • Intervention – – treatment therapeutic intervention screening diet

Identifying questions from practice: PICO • Comparison – alternative option – control/current treatment

Identifying questions from practice: PICO • Outcome – clinical : wellbeing enhanced – organisational – economic

Relating questions to research methods • Effectiveness of treatment: systematic • • reviews/ randomised controlled trials Effect of environmental factors on health: cohort & case control studies Women’s experiences : qualitative (interviews) & quantitative (questionnaire surveys)

Locating the evidence: Evidence Based Healthcare: Resources • Pre-synthesized information • E. g. systematic reviews, evidence • • summaries; higher quality clinical guidelines (NICE); Practice Standards (KNOV) Cochrane Reviews Individual studies

Critical appraisal • Was an appropriate research method • • used to answer that question? Is the research described comprehensively? Was the context relevant? Resource: CASP www. phru. nhs. uk

Critical appraisal • Is there a clear focus to the research • • • question? Appropriate allocation between groups? How were outcomes measured? What is the risk of bias? How are results presented? Valid conclusions?

Identifying questions from practice: some examples • Are there midwifery practices that • • prevent perineal trauma ? What are women’s experiences of labouring in water ? Should women in early labour receive midwifery care at home ?

Practices: impacts unknown & evidence required • When should support start once women • • are in labour? What information do women need in early labour? What is the appropriate schedule for vaginal examinations in early labour?

Asking questions about effectiveness • Impacts at individual level • Improvements in physical/ emotional • • wellbeing Consequences/ side-effects Uptake/ acceptability

Identifying & measuring outcomes • Clearly defined & interpreted • • consistently Valid & reliable methods of measurement Risk of bias minimised

The Early Labour Support and Assessment trial (ELSA) Funded by: NIHR Service Delivery & Organisation of Care programme Conducted by: a midwifery-led multidisciplinary research team

Background (1) • Arriving at hospital early- more intervention during labour; higher rate of instrumental & operative births • 10 -33% women admitted to a delivery suite are not in labour • 97% births in UK in hospital • Caesarean Section rate 22%: national concern • 40%-50% first babies born by CS/ instrumental birth in Yorkshire in 2001

Background (2) Critical appraisal of existing research: • • • Methodologically prone to bias Settings unrepresentative of current UK maternity care Home visits not tested as a single intervention

Aim & Research design To determine the effect of offering home visits by a midwife to nulliparous women in early labour Using A multi-centre randomised controlled trial with cost-effectiveness analysis

Intervention Offer of a home visit by a community midwife (08. 00 -21. 00) Advice & support, assessment of wellbeing & progress Control Group Standard care - telephone contact with labour & delivery suite; advice to attend for assessment

Outcomes Primary: • Caesarean section in labour & instrumental vaginal birth Secondary: • Impacts on labour: length, pain relief, procedures • Maternal & neonatal complications • Breastfeeding • Women’s emotional wellbeing & experiences of care • Health professionals’ views & experiences • Economic analysis

Timetable & progress • Recruitment August 2004 – July 2006 • 3500 participants; 11 clinical sites in • • • England Analysis in progress; Final report March 2008 Active dissemination to all stakeholders Conference September 2008

Workshops • Please divide into 4 groups • Work in small groups • Identify a writer, work through the task; hand notes to facilitator

Workshops • Identify an issue from practice that you • encounter nearly every day with your students & develop a research question. Using the PICO framework Which type of research would answer that question?

Challenges to EBP in midwifery • Access to & quantity of evidence • Providing women with evidence • Changing professional practice

Changing professional practice Consistently effective: • Educational outreach visits • Manual/computerised reminders • Multifaceted interventions • Interactive educational meetings Haines A. (2001) Getting research into practice. 2 nd ed. London: BMJ

Changing professional practice Mixed effects: • Audit & feedback • Local opinion leaders • Local consensus processes • Patient-mediated interventions

Evaluation & reflection • Evaluation - early, under-resourced, • methodologically weak Reflection- individual & system-based approaches

Evidence based practice in midwifery: making it happen • Throughout midwifery –policy, • • • education, practice; avoid divisions Education & skills Building capacity Infra-structure support

Core skills & attitudes for EBP in midwifery • • • Formulating questions about practice Ability to locate evidence Skills in critical appraisal Ability to collaborate & lead research Implementation knowledge

Evidence based practice in midwifery: making it happen Build capacity by creating opportunities • Secondments- clinical midwives join research teams ; mentorship • Joint appointments – shared funding between academic & practice settings • Academic midwifery practices • How do we involve midwifery students?

Evidence based practice in midwifery: making it happen Build capacity by creating opportunities • Career pathways • Academic development funding streams • What opportunities are there for you ?

Opportunities- in the Early Labour trial • Midwifery Research Fellow –Ph. D • Local Midwifery Co-ordinators – 10 • • midwives, part –time, working in practice Midwives : investigators, all Trial Committees & working groups 2 Midwives seconded into MIRU working on the trial

Evidence based practice in midwifery: making it happen Infrastructure support • Identify existing systems that could foster EBP e. g. Journal clubs ; academic assessments • Information specialists • Link activity to policy, professional & public health priorities • Develop skills in acquiring funding • National & international collaborations

Evidence based practice in midwifery: making it happen • Identify support systems • Engage stakeholders • Set achievable goals, celebrate early • success Evaluate & disseminate all experiences