Defining Evidence-Based Practice. What Does EBP Mean for Nursing? Page 1

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1 Defining Evidence-Based Practice Diffusing Innovation: Putting Evidence into Clinical Practice Regina Cunningham, PhD, RN, AOCN Associate Chief Nursing Officer Abramson Cancer Center University of Pennsylvania Health System Associate Adjunct Professor School of Nursing University of Pennsylvania School of Nursing Evidence-based practice (EBP): care that integrates best scientific evidence with clinical expertise, knowledge of pathophysiology, knowledge of psychosocial issues, and decision making preferences of patients Evidence can include research, integrative reviews, practice guidelines, quality improvement data, and case studies Rutledge & Grant (2002). Introduction. Seminars in Oncology Nursing, 18, EBP What Does EBP Mean for Nursing? An approach to clinical decision making that can be used by all nurses to improve patient care and outcomes Use the best available evidence to make clinical decisions that are most effective and beneficial for patient care Transition from the use of policy, experience, preference, tradition as the basis of action Jassak (2001) 3 4 What Does EBP Mean for Nursing? Recent Evidence-Based Practice Model The key difference between evidencebased practice and traditional nursing is not that EBP considers the evidence while the latter does not. Both take evidence into account; however, EBP demands better evidence than has been traditionally used. Patient Preferences Clinical State and Circumstances Research Evidence Kania-Lanchance DM et al. Evidence-based practice and the nurse practitioner. The Nurse Practitioner. 2008; 31: Page 1 1

2 Research Utilization versus EBP Nursing Practice RU and EBP are often used interchangeably, but they are not synonymous EBP is a more general term encompassing evidence broader than research findings and thus includes RU EBP includes the preferences and values of the patient and family in the process While clinicians may utilize the best evidence available, the application and outcomes can differ based on the patients values, preferences, concerns, and expectations. Only 15-20% of what we do is supported by scientific evidence The remaining 80-85% is based on: At best: reasonable assumptions beased on our understanding of anatomy, biochemistry, and physiology At worst: anecdote, dogma, myth, tradition 7 8 Barriers to EBP Almost half are not familiar with the term EBP 34.5% of nurses indicated they needed information about the topic Few have training to carry out aspects of this independently Barriers to EBP Lack of knowledge Negative views on research Lack of confidence in EBP effectiveness Lack of time Slightly over half have access to a medical library where they work Most rate hospital online resources as inadequate Results in significant variability in clinical practice. 9 Lack of administrative support Demands from patients for alternative treatment Complacency the need to support the status quo 10 Translating Research and Evidence in to Practice Although the evidence base is expanding, the translation of this knowledge is not happening rapidly One reason may be that the implementation of evidence into practice is not like the flow of water from researcher to practitioner It s more like a contact sport necessitating challenge, objects & players Greenlaugh et al., 2004 Types of Practice Research-based practice Best Practice Knowledge-based Practice Literature-based practice Data-driven practice Evidence-based practice Page 2 2

3 Research-Based Practice Application of findings from a study (s) that: Is well designed Is of acceptable quality (methodologically sound) Has produced meaningful results Has findings that are generalizable Can or has been replicated Best Practice Practice defined by regulatory, accreditation agencies, and professional standards Practice that may not have compelling evidence of research to support it Practice that has tradition and extensive documentation of proven effectiveness Practice based on sound rationales and good clinical sense Examples: Assessing pain on a regular basis Informing patients of their right to adequate pain control Knowledge Based Practice Data-driven Practice Derived from information from: Textbooks Educators Educational programs Experience Knowledge based practice is not always EBP Internal validation studies/projects Performance Improvement (PI) initiatives/projects Benchmarking studies projects Knowledge and performance deteriorates over time unless it is maintained Levels of Evidence for EBP Meta- Analyses Systematic Reviews Well-designed Experimental Studies (RCTs) Well-designed Nonexperimental Studies Observational Descriptive Studies Systematic reviews Systematic consolidation of the literature on a specific topic; Comprehensive identification of studies (critical) Review of study relevance Evaluation of methodological quality Extraction of data Analysis of data Drawing conclusions Expert Consensus Published Case Reports and Clinical Exemplars Page 3 3

4 Where can you find meta-analyses and systematic reviews? Cochrane Library published quarterly and available via the web Reviews are conducted both by individuals and groups Guidelines on how to conduct a Cochrane review are available Withdraws are issued regularly as evidence outdates Available in multiple languages How do you know if a review is any good? The FAST Method: Finding did they find most studies? Appraisal did they select the good ones for inclusion? Synthesis what does it all mean? Transferability of results Randomized Controlled Trials Quality Criteria Were the setting and subjects in the investigation clearly described? Was assignment randomized (how) and similarity between groups of subjects documented? Was allocation to study groups adequately concealed from patients and investigators, including blind assessment of outcome? Were all clinically relevant outcomes reported? Were > 80% of patients who entered the study accounted for at its conclusion? Were participants analyzed in the groups to which they were randomized (intention to treat)? Were both statistical and clinical significance considered? The CONSORT Statement Transparency in trial reporting Designed to improve the reporting of randomized clinical trials enabling readers to understand a trial s design, conduct, and analysis and interpretation, and to assess the validity of its results. It emphasizes that this can only be accomplished through complete transparency from authors. British journal of Medicine: CONSORT Checklist Topic Specific Information to be Included Title/Abstract Identified as randomized in the title Structured summary of trial design, methods, results, and conclusions Introduction Background and Scientific background and explanation of rationale Objectives Specific objectives or hypothesis Methods Trial design Description of trial design including allocation ratio Important changes to methods after trial initiation Participants Eligibility criteria for participation Description of settings and locations where trial was conducted Interventions Interventions for each group with sufficient details to allow replication, including how and when they were actually administered Outcomes Completely define pre-specified primary and secondary outcome measures, including how and when they were assessed Any changes to the trial outcomes after the trial commenced, with reasons Sample Size How sample size was determined When applicable, explanation an any interim analysis Randomization Method used to generate the random allocation sequence Sequence Type of randomization; details of any restriction Allocation Mechanism used to implement the random allocation sequence Who generated the random allocation sequence, who enrolled participants, and who assigned participants to interventions? Blinding If done, who was blinded after assignment to interventions EBP or Consensus Based CPGs Developed by a selected panel of experts Agreement about rating/grading system to be used Appraised by scientific rigor and methodologies used Informs readers how the evidence was identified, collected, and evaluated Includes recommendations for practice Includes review process by external experts Page 4 4

5 Developing an Evidence Based Project The Iowa Model Problem focused triggers Knowledge focused triggers Establishing priorities Assembling teams Determining research strategy, implementing Critiquing research Piloting practice changes Measuring results Iowa Model of EBP to Promote Quality Three critical decision points Is the problem a sufficient priority? Is there sufficient research evidence? Is a practice change appropriate? EBP Example Can making discharge phone calls to patients within 48 hours decrease readmission rates? What is known about discharge phone calls in oncology? Literature search Developed a table of Evidence Synthesized to identify gaps Developed an intervention Collected baseline data Pilot Review results adopt or not? EBP Resources ONS Putting Evidence into Practice (PEP) Cards Nausea & Vomiting Anorexia Pain Constipation Diarrhea EBP Resources Take Home: Why conduct EB research? Unprecedented accountability for the delivery of quality cost managed healthcare A major challenge is to deliver quality care with effectiveness and efficiency Our patients and the public deserve it Page 5 5