Evidence based practice
Evidence-Based Practice (EBP) is a thoughtful integration of the best available evidence, coupled with clinical expertise. As such it enables health practitioners of all varieties to address healthcare questions with an evaluative and qualitative approach. EBP allows the practitioner to assess current and past research, clinical guidelines, and other information resources in order to identify relevant literature while differentiating between high-quality and low-quality findings.
Evidence based practices was founded by Dr.Ardice Cochrane , a British epidemiologist.Cochrane was a strong proponent using evidence from randomized clinical trials because he believed that this was the strongest evidence on which clinical practice division is to be based.Evidence based health care practices are available for a number of conditions such as asthma,smoking cessation,heart failure and others.However these practices are not be implemented in care delivery and variation of practices[CMS,2008;Institute of medicine ,2001].Recent findings in the united states and Netherlands suggest that 30% to 40 % of patients are not receiving evidence based care,and 20% to30% of patients are receiving unneeded or potentially harmful care.
The most common definition of Evidence-Based Practice (EBP) is from Dr. David Sackett. EBP is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” (Sackett D, 1996) Muir Gray suggests that evidence based health care is:
“an approach to decision making in which the clinician uses the best evidence available, in consultation with the patient, to decide upon the option which suits the patient best”(Muir Gray, 1997)
1. Evidence based practice is an approach which tries to specify the way in which professionals or other decision mkers should make decisions by identifying such evidence that there may be for a practice and rating it according to how scientifically sound it may be. 2. Its goal is to eliminate unsound or excessively risky practices in favour of those that have better outcomes. 3. Evidence based practices has contributed a lot towards better patient outcomes. 4. The ultimate goal of evidenced based nursing is to provide the highest quality and most cost-efficient nursing care possible. 5. The purpose of evidence based practice in nursing is mainly to improve the quality of nursing care.
For example: If you are caring for a child who was in a motor vehicle accident and sustained a severe head injury, would you want to know and use the effective ,empirically supported treatment established from randomized controlled trials to decrease his or her intracranial pressure?
If the answer is “yes“,the empirical evidences are essentially very important in most of the clinical decision-making situations. The goal of EBP is the integration of: (a) clinical expertise/expert opinion, (b) external scientific evidence, and (c) client/patient/caregiver values to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve. Conceptually, the trilateral principles forming the bases for EBP can be represented through a simple figure:
STEPS OF EVIDENCED BASED PRACTICE :
Evidence based practice process involves 5 steps as:
1. Formulating a clear question based on a clinical problem 2. Literture review to search for the best available evidences 3. Evaluating and analyzing the strengths and weaknessof that evidence in terms of validity and genelisability 4. Implementing useful findings in clinical practice based lon valid evidence 5. Evaluating efficacy and performance of evidences through a process of self reflection , audit, or peer aseessment 1.Formulating a clear question based on a clinical problem:[ ASK the question ] The first step is to formulate a clear question based on clinical problems.Ideas come from different sources but are categorized in two areas: Problem focused triggers and Knowledgee focused triggers. Problem focused triggers are identified by healthcare staff through quality improvement,risk surveillance,benchmarking data,financial data, or recurrent clinical problems.Problem focused triggers could be clinical problems,or risk management issues.
Example:Increased incidence of deep vein thrombosis and pulmonary emboli in trauma and neurosurgical patients.Diagnosis and proper treatment of a DVT is a very important task for health care professionals and is meant to prevent pulmonary embolism.This is an example of an important re tht more research can be conducted to add into evidence –based practice. Knowledge focused triggers are created when health care staff read research, listen to scientific papers at research conferences.Knowledge based triggers could be new research findings that further enhance nursing ,or new practice guidelines. Example: Pain management .,prevention of skin breakdown , assessing placement of nasogastric tubes, and use of saline to maintain patency of arterial lines.
When selecting a question ,nurses should formulate questions that are likely to gain support from people within the organization.The priority of the question should be considered as well as the sevearity of the problem.Nurses should consider whether the topic would apply to many or few clinical areas.Also,the availability of the solid evidence should be considered.This will increase the staff willingness to implement into nursing practice.
When forming a clinical question the following should be considered:the disorder or disease of the patient, the intervention or finding being reviewed, possibly a comparison intervention and the outcome.An acronym used to remember this is called the PICO model.:
P-Who is the patient population?
I-What is the potential intervention or area of interest?
C-Is there a a comparison intervention or control group?
O-What is the desired outcome?
2.Literature review to search for the best available evidence :[ ACQUIRE the evidence ]
Once the topic is selected ,the research relevant to the topic must be reviewed . It is important that clinical studies , integrative literature reviewes , meta analysis, and well known and reliable existing evidence based practices guidelines are accessed in the literature retrieval process .The article can be loaded with optionated nd or biased statements that would clearly taint the findings, thus lowering the credibility and quality of article.Time management is crucial to information retrieval.To maintain high standards for evidence based practice implementation, education in research review is necessary to distinguish good research from poorly conducted research.it is important to review the current materials.Once the literature is located, it is helpful to classify the articles either conceptual or data-based.Before reading and critiquing the research ,it is useful to read theoretical and clinical articles to have a broad view of the nature of the topic and related concepts , and to then review existing evidence based practice guidelines. 3. Evaluating and analyzing the strengths and weakness of that evidence in terms of validity and generalisability: [APPRAISE the evidence]
Use of rating systems to determine the quality of the research is crucial to the development of evidence based practice. Once you have found some potentially useful evidence it must be critically appraised to determine its validity and find out whether it will indeed answer your question. When appraising the evidence the main questions to ask, therefore, are: Can the evidence (e.g. the results of the research study) be trusted? What does the evidence mean?
Does this answer my question?
Is it relevant to my practice?
Different appraisal and interpreting skills must be used depending on the kind of evidence being considered. Additionally, guidance and training on appraising different types of evidence are available from some of the websites listed on the Useful Internet Resources. 4.Implimenting useful findings in clinical practice based on valid evidence :Evidence is used alongside clinical expertise and the patient’s perspectives to plan care:[ APPLY:talk with the patient ]
After determining the internal and external validity of the study ,a decisions is arrived at whether the information gathered does apply to your initial question.It is important to address questions related to diagnosis ,therpy ,harm, and prognosis. Once you have concluded that the evidence is of sound quality, you will need to draw on your own expertise, experience and knowledge of your unique patient and clinical setting. This will help you to decide whether the evidence should be incorporated into your clinical practice.
You must consider both the benefits and risks of implementing the change, as well as the benefits and risks of excluding any alternatives. This decision should be made in collaboration with your patient, and in consultation with your manager or multidisciplinary team where appropriate.The information gathered should be interpreted according to many criteria and should always be shared with other nurses . 5.Evaluating efficacy and performance of evidences through a process of self reflection ,audit , or peer assessment: [self-evaluation ]
Finally after implementation of the useful findings for the clinical practices;efficacy and performance is evaluated through process of self reflection ,internal or external audit or peer assessment.Part of the evaluation process involves following upto determine if your actions or decisions achieved the desired outcome.
The Steps in the EBP Process:
1. Start with the patient — a clinical problem or question arises from the care of the patient ASK
2. Construct a well built clinical question derived from the case ACQUIRE
3. Select the appropriate resource(s) and conduct a search
4. Appraise that evidence for its validity (closeness to the truth) and applicability (usefulness in clinical practice) APPLY:
talk with the patient
5. Return to the patient — integrate that evidence with clinical expertise, patient preferences and apply it to practice Self-evaluation
6. Evaluate your performance with this patient
BARRIERS IN EVIDENCE BASED PRACTICE
There are many barriers to promoting evidence based practices such as: Lack of professional ability to critically appraise research.this includes having a considerable amount of research evaluation skills ,access to journals ,nd hospital support to spend time are limited to the nurses. Lack of time workload pressure ,and competing priorities of patient care can impede use of evidence based practice. Lack of knowledge of research methods
Lack of support from the professional colleges and organizations , and lack of confidence nd authority in the research area Practice environment can be resistant to changing tried and true conventional methods of practice.It is important to show nurses who may be resistant to changes the nursing practice the benefits that nurses, their patients and their institutions can reap from the implementation of evidence base nursing practices which is to provide better nursing care. Values ,resources and evidence are the three factors that influence decision making with regard to health care.In adition the nurses need to be more aware of how to assess the information and determine its applicability to the practice.
Lack of continuing educational programs . Practices donot give have the means to provide workshops to teach new skills due to lack of funding, staff and time ;therefore research may be tossed dismissed.if this will occur valuable treatment may never be utilized in the practice. Another barrier is introducing newly learned method for improving the treatments or patients.New nurses might feel it is not their place to suggest oreven tell a superior nurse that newer , more efficient methods and practices are available. The perceived threat to clinical freedom offered by evidence – based practice is neither logical nor surprising.When we make decisions based upon good quality information we are inconsistent and biased.
MODELS OF THE EVIDENCE – BASED PRACTICE PROCESS
A number of different models and theories of evidence based practice has been developed and are important resources.These models offer frameworks for understanding the evidence based practice process and for implementing an evidence based practice project in a practice setting.Models that offer a framework for guiding an evidence based practice include the following : Advancing research and clinical practice through close collaboration(ARCC) model [Melynk and fineout-overholt ,2005] Diffusion of innovations theory [Rogers , 1995]
Framework for adopting an evidence –based innovation [DiCenso et.al.,2005] Iowa model of research in practice [titler et al ,2001]
Johns Hopkins nursing evidence based practice models [Newhouse et.al, 2005] Ottawa model of research use [Logan and Graham ,1998]
Promoting action on research implementation in health services (PARIHS] model-,[Rycroft – Malone et.al2002 ,2007] Stetler model of research utilization.[Stetler ,2001]
Although each model offers different perspectives on how to translate research findings into practice .It provides an overview of key activities and processes in evidence based practice efforts ,based on a a distillation of common elements from the various models.The most prominent models are Stetler model of research utilization and Iowa model of research in practice. Stetler model of research utilization:
The Stetler model of evidence-based practice would help individual public health practitioners to use evidence in daily practice to inform program planning and implementation. 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.
Research use occurs in three forms
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.
The Stetler model of evidence-based practice based on the following assumptions 1. The formal organization may or may not be involved in an individual’s use of research or other evidence. 2. Use may be instrumental, conceptual and/or symbolic/strategic. 3. Other types of evidence and/or non-research-related information are likely to be combined with research findings to facilitate decision making or problem solving. 4. Internal or external factors can influence an individual’s or group’s review and use of evidence. 5. Research and evaluation provide probabilistic information, not absolutes.
6. Lack of knowledge and skills pertaining to research use and evidence-informed practice can inhibit appropriate and effective use Phase I: Preparation—Purpose, Context and Sources of Research Evidence Identify the purpose of consulting evidence 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 .Determine whether a given source has no credibility or fit and thus whether to accept or reject it for synthesis with other evidence .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
reflect studied variables or relationships in ways that could be practically used 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 others involved). Based on the comparative evaluation, the user makes one of four choices: Decide to use the research findings by putting knowledge into effect Consider use by gathering additional internal information before acting broadly on the evidence. Delay use since more research is required which you may decide to conduct based on local need Reject or not use .
Phase IV: Translation/Application—Operational Definition of Use/Actions for Change
Write generalizations that logically take research findings and form action terms Identify type of research use (cognitive, symbolic and instrumental). Identify method of use (informal/formal, direct/indirect).
Identify level of use (individual, group, organization).
Assess whether translation or use goes beyond actual findings/evidence. Consider the need for appropriate, reasoned variation in certain cases. Plan formal dissemination and change strategies.
Phase V: Evaluation
Clarify expected outcomes relative to purpose of seeking evidence Differentiate formal and informal evaluation of applying findings in practice. Consider cost-benefit of various evaluation efforts.
Use Research Utilization as a process to enhance the credibility of evaluation data. Include two types of evaluation data: formative and outcome
Evidence based practices as using the best evidence available to guide clinical decision making.Evidence based practice in nursing is a pocess of locating ,appraising and applying the best evidence from the nursing and medical literature to improve the quality of clinical nursing practices. Evidence-Based Practice (EBP) is a thoughtful integration of the best available evidence, coupled with clinical expertise. As such it enables health practitioners of all varieties to address healthcare questions with an evaluative and qualitative approach. EBP allows the practitioner to assess current and past research, clinical guidelines, and other information resources in order to identify relevant literature while differentiating between high-quality and low-quality findings.Evidence based practice involves making clinical division on the basis of the best possible evidence ,usually best evidence come from the rigrous research.
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