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EVIDENCE BASED MIDWIFERY PRACTICE

INTRODUCTION
Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. (Fineout-Overholt E, 2010). Health care that is evidence-based and conducted in a caring context leads to better clinical decisions and patient outcomes. Gaining knowledge and skills in the EBP process provides nurses and other clinicians the tools needed to take ownership of their practices and transform health care. Evidence-based maternity care uses the best available research on the safety and effectiveness of specific practices to help guide maternity care decisions and to facilitate optimal outcomes in mothers and newborns. Although the field of pregnancy and childbirth pioneered evidence-based practice, resulting in a wealth of clear guidance for evidence-based maternity care, there remains a widespread and continuing underuse of beneficial practices, overuse of harmful or ineffective practices, and uncertainty about effects of inadequately assessed practices. Effective maternity care with least harm is optimal for childbearing women and newborns.

KEY WORDS
Evidence: Knowledge derived from a variety of sources that has been found to be credible (Higgs & Jones 2000) Evidence refers to a particular form of research Research: Research is defined as a systematic and objective analysis and recording of controlled observation that may lead to the development of generalization of principles, theories, resulting in prediction and possible ultimate control of events (J.W. Best).

Research in its broadest sense is an attempt to gain solutions to problems; more precisely it is the collection of data in a rigorously- controlled situation for the purpose of prediction or explanation (Treece & Treece). Nursing: ICN defines nursing as the unique function of nurse that is to assist the individual sick or well in the performance of those activities contributing to health or its recovery (or a peaceful death) that he would perform if he had the necessary strength, will or knowledge. Professional nursing is a devoted occupation with ethical components that are devoted to the promotion of human and social welfare. The services are based on specialized knowledge and skills that have been developed in a scientific manner (Sr. Stephaine). Nursing research: Nursing research refers to the use of systematic, controlled, empirical, and critical investigation in attempting to discover or confirm facts that relate to specific problem or question about the practice of nursing (Walls & Bauzell, 1981). Nursing research is a way to identify new knowledge, improve professional education and practices and use of resources effectively (International council of nurses, 1986). Practice: A repeated exercise in an activity requiring the development of skill (oxford dictionary). Decision: A conclusion or resolution reached after consideration (oxford dictionary).

DEFINITION
Evidence based medicine: The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. It is conscientious, explicit and judicious use of current evidence in making decision about the care of individual patients. Evidence based nursing: Sharma (2011) defines evidence based nursing as a process of identifying the solid research findings and implementing them in nursing practice, in order to increase the quality of patient care. Evidence based nursing is a type of evidence based practice in nursing. It involves identifying solid research findings and implementing them in nursing practices, in order to increase the quality of patient care. Evidence based nursing is a process founded on the collection, interpretation, and integration of valid, important, and applicable research. Evidence based practice: Sackett etal (1996) define EBP as the conscientious, explicit and judicious use of current best evidence in making nursing decisions about the care of individual patients. Carnwell defines EBP as the systematic search for, and appraisal of, best evidence in order to make clinical decisions that might require changes in current practice, while taking into account the individual needs of the patient. Benefield defines evidence based practices as using the best evidence available to guide clinical decision making.

Evidence based decision making: "Evidence-based decision-making is a continuous interactive process involving the explicit, conscientious and judicious consideration of the best available evidence to provide care."-Position Statement by Canadian Nurses'

ORIGIN
Evidence based practice was founded by Dr. Archie Cochrane, a Scottish epidemiologist. Cochrane was a strong proponent of using evidence from randomized clinical trials because he believed that this was the strongest evidence on which clinical practice division is to be based. In the early 1970s, Archie Cochrane recognized the need to collate research data from randomized controlled trials (RCTs), critique it and conclude what was effective care, so that limited resources could be used wisely (Cochrane 1972 cited in Reynolds 2000). This led to the systematic review. The work of Iain Chalmers and like-minded colleagues led the way in healthcare, providing professionals within the maternity services with a register of RCTs and a database of what care options were effective, not effective, or of unknown value based on systematic reviews of RCTs on each topic (Chalmers et al 1989). Prof. Archie Cochrane through his book Effectiveness and efficacy: random reflections of health services. The publication of these two volumes provided an accessible and essential reference text. After the demise Dr. Archie Cochrane in 1988, the Cochrane centre was launched in oxford, England, in 1992. The major purpose of the centre is to assist individuals in making well informed decision about health care with international collaboration by developing, maintaining and updating systematic review of healthcare intervention and ensures that these reviews are accessible to the public. Technological advances in worldwide communication, the internet, meant this was soon followed by quarterly updated, online resources known as the Cochrane Library, now covering most aspects of healthcare (www.thecochranelibrary.com).

EVIDENCE BASED NURSING AIMS:


To provide the highest quality and most cost-efficient nursing care possible. To advance quality of care provided by nurses. To increases satisfaction of patients To focus on nursing practice away from habits and tradition to evidence and research

COMPONENTS OF EVIDENCE-BASED NURSING PRACTICE


Key elements of a best practice culture are EBP mentors Partnerships between academic and clinical settings EBP champions Clearly written research Time and resources Administrative support ( Fineout - Overholt E, 2005) When delivered in a context of caring and in a supportive organizational culture, evidence based practice can help to achieve the highest quality of care and best patient outcomes (Baumann SL, 2010).

PURPOSE
The aim of EBP is to do the right thing, at the right time, for the right person, in other words ensure quality care for the individual client. This is achieved by evaluating ideas, practices and previous events and applying the learning achieved to future practice. Evidence based is an approach which tries to specify the way in which professionals or other decision makers 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. Its goal is to eliminate unsound or excessively risky practices in favor of those that have better outcomes.

EBP has contributed a lot towards better patient outcome. Heater and colleagues reported that patients who receive research based nursing care make sizeable gains in behavioral knowledge, and physiological and psychological outcomes compared with those receiving routine nursing care. The ultimate goal of EBP is to provide the highest quality and most cost efficient nursing care. The purpose or utility of evidence based practice in nursing is mainly to improve the quality of nursing care.

Levels of EBP
Gabby and le May (2004) explored how professionals used formal evidence sources such as research, and describe a pyramid with four levels of EBP. The foundation layer is described as a social movement, but could be considered as representing the underpinning philosophy on which everything is based. The second layer refers to national and local EBP policies and/or guidelines. This is the EBP process, the practical interpretation of the concepts. The third layer represents the practitioners who utilize the concepts and processes. The clients receiving care based on the current best evidence, which is related to their individual circumstances, complete the layers. These four layers, however, do not consider how the philosophy is converted into policies, or how practitioners adopt the policies and make EBP information and care available to clients.

Professionals may use policies/guidelines without subscribing to, or understanding the EBP philosophy, while clients may receive the best care, without anyone having considered EBP. The pyramid could also be turned upside down as it could be argued that it is consumers that are contributing to the upsurge of EBP. Clients increasingly demand high-quality care, with expectations increasing each year (Department of Health 2004). There is increased emphasis on partnership, working with clients in the provision of a service that is responsive to their needs (Department of Health 2003). Therefore a circular relationship between clients, practitioners and evidence may be a useful representation of the interaction of each within an overall philosophy of EBP. This is congruent with the principles of effective and high-quality care, in which midwives, and all practitioners, strive to provide the very best care to each individual.

EVIDENCE BASED PRACTICE PHILISOPHY

PRACTITIONERS CLIENTS AND SERVICE EVIDENCE

As Sackett etal (2000) emphasize, EBP is more than just the best evidence, it is the integration of best evidence with high-quality clinical skills, such as communication and assessment, as well as the application of evidence to the particular belief systems, values and context of the clients life. Evidence is forever changing in the light of new research, new technology, new ideas, as well as old ideas and options put together in new ways. This is challenging as it means best practice cannot conclusively and finally be established. The onus/ responsibility is on each practitioner to establish the evidence for each case. An important feature of EBP is the way it is dynamic and open to reviewing, its purpose to be a way of constantly updating practice. Therefore all midwives need to develop the skills required for EBP practice. These skills are the same skills that midwives need for midwifery care, some of which are listed below.

Characteristics needed for EBP


Clinical competence, knowledge and skills Observant and sensitive and thus able to identify the needs of individual women Empathic to the needs women may not be able to articulate Effective communication, to enable women to be equal partners in their care Reflective practitioner, and therefore able to develop clinical expertise based on personal practice and experience Questioning and open to questions in all aspects of practice Lifelong learner knowledge is never stationary and the midwife must continuously and conscientiously keep her/himself updated Research aware

BASIC

PRINCIPLES BEST

FOR

DETERMINING EVIDENCE
Question common assumptions.

AVAILABLE

Maternity care practices based on the opinions of experts or the general public or on tradition are unreliable guides for decision making. These views and patterns of care have been shaped by many factors and often do not reflect the best current research. They may lead to inadequate care, poor outcomes, and wasted resources. It is important to demand to be shown the best evidence. Know that many studies of interventions are unreliable guides for decision making. Careful evaluation of the quality of research using critical appraisal skills is essential. Many studies are flawed or limited in scope and do not provide valid answers to key questions. One newly reported study rarely offers the best, most definitive answer, and commercial interests influence many studies. It is important to ask what is already known about a particular question on the basis of the best available research, and what, if anything, a new study adds. Look for the gold standard. When available, well-designed and well-conducted systematic reviews of research should inform maternity care decisions. If systematic reviews are not available, well-designed and well-conducted studies with randomized controlled trial designs can provide the most valid answers to many questions. For many reasons, it may be important to consider other types of studies as well.

WHAT IS THE GOLD STANDARD FOR KNOWLEDGE ABOUT EFFECTS OF MATERNITY CARE? A rigorous and transparent systematic review of original studies that has been conducted according to established guidelines and with discernment regarding both methodology and topic (Cochrane Methodology Register 2008; Moher et al. 2007; Sheikh et al. 2007) is a powerful tool for understanding the weight of the best available evidence. Such a review gives the most trustworthy knowledge about beneficial and harmful effects of specific health interventions. Systematic review procedures help limit investigator bias and error that can easily distort results of single studies and of more conventional and haphazard research reviews. A systematic review establishes the scope and other basic review parameters at the outset as a guide for conducting the review. It involves a thorough search for all the studies that meet explicit criteria for inclusion. Using criteria for assessing methodological rigor, researchers include only better quality studies in the review. When possible, researchers reach a conclusion by pooling data from the included studies using statistical techniques of meta-analysis. Systematic reviews should be updated over time to incorporate new relevant high-quality research and to refine and strengthen the original analysis when possible. A recent Milbank Report describes the history, methodology, and uses of systematic reviews (Moynihan 2004), and another highlights the use of systematic reviews in policymaking (Sweet and Moynihan 2007). The earliest systematic reviews were carried out more than twenty-five years ago to evaluate pregnancy and childbirth care. This pioneering work led to the formation of the Cochrane Collaboration to continue the pregnancy and childbirth research and to develop and update systematic reviews across all clinical and public health fields (Chalmers 1993). Many hundreds of systematic reviews are now available to guide maternity policy and practice from the highly regarded Cochrane Pregnancy and Childbirth Group and many other entities and individuals throughout the world. These invaluable tools for providing high-quality maternity care and obtaining good value have been grossly underutilized in the United States (see, for example, Chauhan et al. 2006). Among individual studies, randomized controlled trials (or RCTs) can provide especially trustworthy results about many effects of specific interventions. In this type of research, participants are randomly assigned to receive one or another form of care. Those receiving usual care (or placebo treatment such as a sugar pill) are in the control group. Those receiving the type of care that is being studied are in the treatment or experimental group. Random assignment helps ensure that the groups being compared are truly similar and that any differences in outcomes are due to the treatment under study rather than some other difference between the groups. RCTs are not the best study design for answering many important questions. For example, due to the great expense that would be required to enroll large numbers of participants and/or to follow participants over time, RCTs generally do not provide meaningful data about (1) less common but important outcomes (such as maternal mortality) and (2) outcomes that may occur far in the future (such as effects of cesarean section on mothers and babies in future pregnancies) or at earlier points when a high rate of follow-up may be difficult and expensive. Due to the expense, many pregnancy and childbirth RCTs do not collect any outcome data after postpartum hospital dischargea serious limitation. For ethical reasons, it may not be possible to carry out RCTs (for example, researchers would not randomly assign babies to a non-breastfeeding group). RCTs can be misleading when they are not carried out according to plan. Notably, when large proportions of participants do not receive the care of the group to which they were assigned, the experience of the groups becomes more similar and RCTs lose power to detect true differences in effects. Thus, reports of no difference may be inv alid in the many RCTs where such group crossover occurred. Even if feasible and ethical, RCTs may not have been conducted to answer key questions. In general, we need to complement knowledge from RCTs with best options among other types of studies and carefully weigh the better studies (Jadad and Enkin 2007).

Make informed decisions that consider evidence about safety and effectiveness and the values and circumstances of individual childbearing women. When making maternity care decisions, it is crucial to consider the best available evidence as well as values, preferences, and individual circumstances of childbearing women who have been supported to understand this evidence. It is also important to consider the options within specific care settings, such as the skills of caregivers and available forms of care. Beware of misleading claims. With growing recognition of the value of evidence-based policy and practice, it is important to describe evidence-based products and services and of deeply flawed execution that may not in fact reflect these principles.

LEVELS OF EVIDENCE HIERARCHY


Primary sources of evidence are considered superior to other forms of evidence and the most important primary source is research findings. However, not all research is valued to the same degree. This led to the development of a hierarchy of evidence, with an expectation that practitioners will base their practice on the best evidence as described by a hierarchy of evidence. Best evidence includes empirical evidence from randomized controlled trials evidence from other scientific methods such as descriptive and qualitative research; as well as use of information from case reports, scientific principles, and expert opinion. One of the most cited hierarchies is that by Guyatt etal (1995): 1. Systematic reviews and meta-analyses 2. Randomized controlled trials with definitive results 3. Randomized controlled trials with non-definitive results 4. Cohort studies

5. Case control studies 6. Cross-sectional studies 7. Case reports

LEVEL-I SYSTEMATIC REVIEW OF ALL RELEVANT RCT LEVEL-II SINGLE RCT LEVEL-III SYSTEMATIC REVIEW OF CORRELATIONAL / OBSERVATIONAL STUDIES LEVEL-IV SINGLE COORELATIONAL / OBSERVATIONAL STUDY LEVEL-V SYSTEMATIC REVIEW OF DESCRIPTIVE / QUALITATIVE/ PHYSIOLOGIC STUDIES LEVEL-VI SINGLE DESCRIPTIVE / QUALITATIVE/ PHYSIOLOGIC STUDY Level-VII OPINIONS OF AUTHORITIES, EXPERT COMMITTEES

THE PROCESS OF EVIDENCE-BASED PRACTICE


The EBP process can be considered as a series of steps: 1) Formulating a clear question based on a clinical problem 2) Literature review to search for the best available evidence

3) Evaluating and analyzing the strengths and weaknesses of that evidence in terms of validity and generalisability 4) Implementing useful findings in clinical practice based on valid evidence; evidence is used alongside clinical expertise and the patients perspective to plan care 5) Evaluating efficacy and performance of evidences through a process of self reflection, audit, or peer assessment

FORMULATING A CLEAR QUESTION BASED ON A CLINICAL PROBLEM

LITERATURE REVIEW TO SEARCH BEST AVAILABLE EVIDENCE

ANALYSIS OF STRENGTHS AND WEAKNESSES OF EVIDENCES

USE OF BEST EVIDENCE IN CLINICAL PRACTICE

EVALUATING THE EFFICACY OF EMPERICAL EVIDENCES

1) Formulating a clear question based on a clinical problem


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

KNOWLEDGE FOCUSED TRIGGERS

Problem focused triggers: are identified by health care staff through quality improvement, risk surveillance, bench marking data, financial data, or recurrent clinical problems. Problem focused triggers could be clinical problems, or risk management issues Knowledge focused triggers: are created when health care staff read research, listen to scientific papers at research conferences or encounter EBP guidelines published by federal agencies or organizations. Knowledge based triggers could be new research findings that further enhance nursing, or new practice guidelines. It is important that individuals work closely together to reach the optimum outcome for the chosen topic. Some things that would ensure collaboration are working in groups to review performance improvement data, brainstorming about ideas, and achieving consensus about the final selection. When selecting a question, nurses should formulate questions that are likely to gain support from people within the organization. The priority of the problem should be considered as well as the severity of the problem. Also, availability of solid evidence should

be considered because providing proof of the research. This will increase staffs willingness to implement into nursing practice. The most challenging issue in using EBP in the clinical setting is learning how to adequately frame a clinical question so that an appropriate literature review can be performed. An acronym used to remember this is called the PICO model;

P I C O

= Who is the patient population? = What is the potential intervention or area of interest? = Is there a comparison intervention or control group? = What is the desired outcome?

The importance of asking the right question is highlighted by Bastin (2004). Evidence on the administration of bromocriptine to suppress lactation suggested effectiveness, but later it was discovered that it increased mortality and morbidity. Perhaps the EBP process to establish the quality of all the evidence was flawed but much more likely the wrong question was asked, or there was an absence of evidence.

Examples of EBP questions for a topic


Example one: Topic is water immersion in labour Question 1: Does immersion in water during the first stage of labour reduce the use of pharmacological analgesia? P = women in labour I = immersion in water C = not in water O = analgesia used Question 2: Is birth in water safe for the fetus/neonate? P = neonates born of women who birthed in water I = immersion in water C = not in water O = wellbeing e.g. APGAR score, or cord gases Example two: Topic is nuchal fold screening Question 1: Do women understand what nuchal fold screening can tell them? P = women undergoing nuchal fold screening I = nuchal fold screening C = there is no comparison in this case O = knowledge base Question 2: Is the process of nuchal fold screen safe for the fetus/neonate P = fetuses I = nuchal fold screening C = fetuses who were not screened O = short- and long-term outcomes of wellbeing and neurological integrity

2) Literature review to search for the best available evidence


Having defined the question, the next step is to locate all the evidence that may be pertinent. This can be very time-consuming, and can require lateral thinking, imagination, ingenuity and perseverance, but with practice it does get easier. Once the topic is selected the research relevant to the topic must be reviewed in addition to other literature. It is important that clinical studies, integrative literature reviews, meta-analysis and well known and reliable existing EBP guidelines are accessed in the literature retrieval process. Time management is crucial to information retrieval. Once the literature is located, it is helpful to classify the articles as either conceptual or data based. Finding the evidence is so fundamental to all aspects of knowledge acquisition and interpretation that it is now a key component of all education programmes, both pre-registration and post-qualification, regardless of the academic level of the course. There are two sources of evidence, people and literature, although they are often interrelated, as no practice occurs in a vacuum. Accessing people means participating in professional and inter professional conversations, talking to women and consumer groups, attending conferences and engaging with researchers, educationalists, managers and those who shape policy at all levels. Online networks, covering midwifery research, normal birth and more general email communication networks make this possible on a national and global scale previously unheard of. Accessing such networks is usually a relatively simple matter of registering and then getting online to the network o your choice, having heard of/been given the contact point of such a network through colleagues. Types of literature Literature is classified as primary or secondary. Primary literature refers to original sources of information.

Secondary literature includes systematic reviews, reviews, guidelines/policies, editorials, opinions, critiques, and any information that is a reconsideration of primary data. Some types of literature can be either primary or secondary. Published letters, for example, may be commenting on a previously published study, or provide original data from another unit supporting or refuting a study, or even highlighting a completely new point. It is also important to remember that people are a vital resource. Speaking to experts on a topic, networking within the area of interest may provide contacts and links to invaluable sources of evidence. This additional time investment is warranted in terms of the quality of the finished evidence-based review. Sources of Evidence-Based Nursing Information Systematic review Cochrane Collaboration (www.cochrane.org) Evidence-Based Journals Evidence-based practice guidelines National Guidelines clearinghouse (www.guidelines.gov)

3) Evaluating and analyzing the strengths and weaknesses of that evidence in terms of validity and generalisability
Using the rating system to determine the quality of the research is crucial to the development of EBP. There are several rating systems available online. The National Guideline Clearing house is a database of published EBP guideline abstracts at (http://www.guideline.gov)

4) Implementing useful findings in clinical practice based on valid evidence; evidence is used alongside clinical expertise and the patients perspective to plan care
After determining the internal and external validity of the study, a decision is arrived at whether the information gathered does apply to your initial question. It is important to address questions related to diagnosis, harm, and prognosis. The information gathered should be shared with other nurses and fellow researchers.

5) Evaluating efficacy and performance of evidences through a process of self reflection, audit, or peer assessment
Finally after the implementation of the useful findings for the clinical practices, efficacy and performance is evaluated through processes of self reflection, internal or external audit or peer assessment.

MODELS PRACTICE

FOR

EVIDENCE

BASED

A number of models of research utilization have been developed by nurse researchers in the United States, Canada and U k. These models offer guidelines for designing and implementing research utilization and evidence based practice projects. Some models focus on use of research from the perspective of an individual clinician, some focus on the utilization from an organizational perspective where as others have multiple perspectives. Models includes STETLER MODEL OF RESEARCH UTILIZATION IOWA MODEL THE ROSSWURM MODEL EVIDENCE BASED MULTI DISCIPLINARY PRACTICE MODEL (GOODE & PIEDALUE, 1999) CENTRE FOR ADVANCE NURSING PRACTICE MODEL (SHUNKUP 2000) FRAMEWORK FOR ADOPTING AN EIDENCE BASED INNOVATION (DILENSO etal 2005) JOHNS HOPKINS NURSING EBP MODEL (NEWHOUSE etal 2005) MODEL FOR CHANGE OF EBP (ROSS WARM OF LARABEE 1999) Although each model offers different perspectives, on how to translate research findings into practice, several steps and procedure are similar across the models. Models prominent of these models are Stetler model, IOWA model, and Rosswurm model.

STETLER MODEL OF RESEARCH UTILIZATION This model was first developed in 1976 and refined in 1994 and was designed with the assumption that the research utilization could be undertaken not only by the organizations but also by individual clinicians and managers. It was a model designed to promote and facilitate critical thinking about the application of research findings in practice. It involves 5 phases A) Preparation: Nurse would define the underlying purpose of the project. Search for and select sources of research evidence. Consider external factors that can influence potential application and internal factors that can diminish objectivity. Affirm the clinical significance of solving the perceived problem. B) Validation: The second phase involves a critique of each source of evidence and check whether it is sufficiently sound for practical application. The process stops at this point if the evidence sources are rejected. C) Comparative evaluation and decision making: It involves synthesis of findings and these findings are used to determine the desirability and feasibility of applying findings from validated sources to nursing practice. The end result of comparative evaluation is to make a decision about using the study findings. If the decision is negative no further steps are necessary. D) Translation and application: It involves how findings will be used and then implementing a plan.

E) Evaluation: In this final phase application would be evaluated. Although this model was designed as a tool for individual practitioners, it has also been the basis of formal research utilization and evidence based practice projects by group of nurses. IOWA MODEL IOWA model of evidence based practice is an organizational, collaborative model developed by the university of IOWA hospital and University of IOWA College of nursing. This model was revised in 2001 and renamed as IOWA model of evidence based practice to promote quality care. According to current version of IOWA model a formal project starts with a trigger -an impetus to explore possible changes to practice. The start point of EBP can be either a Knowledge focused trigger Awareness of innovative research findings Problem focused trigger Clinical /organizational problem E.g. If pain management for a specific patient population the area of focus for EBP. Here Knowledge focused trigger is the emergent knowledge related to developments in pain management. Problem focused trigger-is the current practices of pain management that needs improvement.

IOWA model has 4 phases Evidence triggered. Evidence supported Evidence observed Evidence based phase THE OTTAWA MODEL OF RESEARCH USE (OMRU) This model is developed by Logan and Graham consists of 6 key components interrelated through the process of evaluation.6 components includes Practice environment Potential research adopter Evidence based innovation Strategies for transferring innovation into practice Adoption of evidence Health and other outcomes. Systematic assessment, monitoring and evaluation are central to ERMU and applied to each of 6 components before during and after any effort to transfer research findings. THE ROSSWURM MODEL It was developed and tested by ROSSWURM and LARRABEE at the West Virginia university school of nursing. The process guide the practioners through the process of EBP, beginning with the assessment of the need for change and ending with integration of an evidence based practice.

According to this model EBP involves 6 steps: Assess the need for change. Define the problem identified. Synthesis of best evidence. Design a change in practice. Implement and evaluate the change. Integrate and maintain the change in practice.

This model may be applicable for various health care settings.

BARRIERS

TO

EVIDENCE

BASED

MATERNITY CARE
Efforts to increase access to evidence-based maternity care should address barriers to quality improvement. Barriers to evidence-based maternity care include the following:

Lack of a set of robust maternity performance measures with buy-in of key stakeholders to use them for measuring, reporting, rewarding, and improving performance Perverse incentives of payment systems Adverse effects of the malpractice system Primary reliance on specialists for providing maternity care to a predominantly healthy, low- risk population Limited reliance on best evidence in leading guidelines for maternity care Loss of core childbearing knowledge and skills among health professionals Limited attention to harms and iatrogenesis Challenge of translating research into practice Adverse effects of pressure from industry Inadequate informed consent processes and womens lack of preparation for making informed decisions Limitations of views put forth in media and popular discourse Efforts to improve payment systems, the liability system, consumer decision making processes, and other factors that impact clinical decisions should identify best evidence and develop policies, programs, and processes that align these systems with optimal care.

ADVANTAGES
The widespread promotion and adoption of EBP is due to its perceived advantages, in particular the goal of facilitating care based on the best evidence and available to everyone, rather than being locality specific due to knowledge, expertise or funding. The advantages of EBP include: Better informed practitioners

EBP guidelines, enabling consistency of care across professional boundaries Client-focused care pathways Structured processes for dissemination of the best evidence Explicit and transparent ways of working with less scope for misinterpretation Information available to the public so that they can be genuinely involved in the decision-making processes about their care Clarification of what is known and what is not known to target further research. All of which should lead to higher-quality and more effective care and a reduction in the theorypractice gap.

DISADVANTAGES
Disadvantages of EBP include: Takes time and resources to develop the skills to undertake EBP Not enough evidence about EBP Reduced client choice Does not cater for unique clients with complex and multifaceted needs Reduced professional judgement /autonomy Suppression of creativity Undermining perceived value of forms of evidence not at top of hierarchy of evidence Influences legal proceedings Some disadvantages of EBP are more statements of ongoing problems that are common to all aspects of healthcare, such as lack of evidence, or poor evidence, or lack of resources to provide the identified care Experience and tacit knowledge can identify health needs and facilitate healthcare provision. Each of these forms of evidence is vital and the emphasis on EBP and clinical trials is not intended to be to the detriment of other evidence. LIMITATIONS

Resistant to changes in nursing practice. Ability to critically appraise research findings. Time, workload pressures, and competing priorities. Lack of continuing education programs. Fear of stepping on one's toes" Poor administrative support.

THE CONSUMER OF RESEARCH The ultimate consumer of the research is the person who receives or preferably, participates in care. In midwifery this is the childbearing women and her family. It is likely, though, that for the women to experience research based care and the staff involved should practice EBP. For this reason ,the midwives also becomes a consumer of research .To extend further range of consumers of research ,also include midwifery student. This is because her midwifery education provides the foundation for her subsequent midwifery practice. 1) The Midwifery student: The midwifery student learns about research in number of ways. First, research is integrated into her formal education by those who teach .The student also learns the techniques that are outlined below to evaluate or make a critique of the relevant studies.

Secondly in her experience of clinical practice, the student is able to observe the utilization of research by her mentor, who acts as role model of in this respect. Thirdly the student become actually involved in research .This is likely to be by attending journal clubs that are organized by active researchers at research seminars and by meeting researchers at research seminars and conferences. Finally the student may found that she is presented with opportunities undertaking the research .This is an immense responsibility, which may not available to all midwifery students. 2) The Midwife

The midwife is likely to encounter research reports in a wide range of midwifery, nursing and other journals as well as at meeting and conferences. The midwife may be convinced that the research findings are likely to resolve a problem that has been identified in her own clinical setting on the basis of the this she may seek to implement it in her own clinical area and subsequently evaluate the change in care. The midwife may decide to reject the study on the grounds that: It does not relate to her working situation The work is too seriously flawed to be of any value The research was undertaken in a country with a different system of maternity care and is not easily transferrable. Although the research has limitation or was undertaken in different country ,some of the problems may identified may relate to those in the midwifes clinical area .For these reasons , a researcher will be approached to assist the midwifery staff in further investigating this work by replicating this study locally and with suitably sized sample. 3) The woman The childbearing woman, who is the ultimate consumer of research, may be involved in a number of ways. Increasingly women are becoming involved in the earlier stages of research. This is through the need for this specialized input into planning and implementing the study. Women have for long time acted as the subjects of research. The information and advice that the midwife gives to the woman during her child bearing experience should, as far as possible, be research based. This information may be provided verbally, in the form of evidence based leaflets or both. With the increasing availability of research evidence through the internet, the woman is often able to find her own information.

EVIDENCE-BASED MIDWIFE

PRACTICE

AND

Evidence-based practice is a philosophy and a process. It is logical, sensible and scientific; there are frameworks and processes that meet a need for certainty and structure in many professionals and consumers alike. Healthcare, like life, is often uncertain, and decision-making can be problematic. EBP is a way of helping with everyday and tricky decisions that can be quantified and justified. Skillfully used, EBP can enhance practice. So every midwife and health practitioner should: Develop the skills associated with EBP Be able to undertake both the full and the short process Adopt a personal EBP philosophy Encourage an EBP philosophy within their practice setting Encourage client participation in local practice development Remember EBP is a tool for high quality practice; it is not an end in itself. EBP highlights that we do not know everything and practitioners need to be honest and open; indicating where there is a dearth/ inadequacy of information, or the evidence is incomplete, inconclusive, weak and open to interpretation or in some way limited. This means acknowledging, more than some professionals are used to, that we really practice in many shades of grey and very rarely in black and white. It must also be acknowledged that EBP has limitations as well as benefits. As yet, qualitative evidence is not incorporated within EBP. EBP is a tool, achieving the skills of which provides many benefits to practitioners, related to identifying, accessing, and evaluating evidence. However, it must be done using a discerning, reflective and critical judgment, and applied to clinical practice so that it is not an academic activity but a real practice development strategy.

CONCLUSION
Evidence based nursing started in the 1800s with Florence Nightingale. EBN is a problem solving approach to clinical decision making. EBN integrates providers' clinical expertise with the best external clinical evidence. EBN is the process of integrating Clinical knowledge Judgment Proficiency skills with the best available clinical evidence, such as nursing practice in to patient care.

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INTRODUCTION KEY WORDS DEFINITION ORIGIN EVIDENCE BASED NURSING AIMS COMPONENTS OF EVIDENCE BASED NURSING PRACTICE PURPOSES OF EBP LEVELS OF EBP CHARACTERISTICS NEEDED FOR EBP BASCIC PRINCIPLES LEVELS OF EVIDENCE HIERARCHY PROCESS OF EBP MODELS FOR EBP BARRIERS OF EVIDENCE BASED MATERNITY CARE ADVANTAGES AND DISADVANTAGES OF EBP LIMITATIONS CONSUMER OF RESEARCH EBP AND MIDWIFE CONCLUSION

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CENTRAL OBJECTIVE At the end of the seminar students gain adequate knowledge regarding evidence based maternity practice, develops a positive attitude towards evidence based maternity care and apply this knowledge in day to day clinical practice

SPECIFIC OBJECTIVE At the end of seminar students able to

Define Evidence based practice? List down evidence based nursing aims? Specify the components of evidence based nursing practice? Describe purposes of EBP? Explain levels of EBP? Identify the characteristics needed for EBP? Describe the levels of evidence hierarchy? Explain the process of EBP? Describe the models for EBP? Identify the barriers, advantages, disadvantages and limitations of EBP?

EVIDENCE BASED MIDWIFERY PRACTICE

SUBMITTED TO:

MRS JYOTHI.K.DIVAKARAN ASSIST. PROFESSOR GOVT COLLEGE OF NURSING ALAPPUZHA

SUBMITTED BY:

VRINDHA.V.G I ST YR MSC NURSING GOVT COLLEGE OF NURSING ALAPPUZHA