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Definitions

  Evidence-based practice can be thought of as requiring

"the integration of the best research evidence with our
clinical expertise and our patient's unique values and
circumstances." (Straus, et al., 2005)

  "Fortunately, evidence-based practice (EBP) is an

approach that enables clinicians to provide highest
quality of care in meeting the multifaceted needs of their
patients and families." (Melnyk & Fineout-Overholt, 2005)

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Definitions

  “The
 conscien+ous,
 explicit
 and
 judicious
 use
 of


current
 best
 evidence
 in
 making
 decisions
 about
 the

healthcare
of
pa+ents”
(Sacke?
et
al,
1997).

  In
2000,
Sacke?
et
al
(2000)
also
include
pa+ent
values

as
well
as
clinical
exper+se
:


 The
prac+ce……integrates
clinical
exper+se
and

pa+ent
values
with
the
best
available
research

evidence

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 Clinical
Exper-se


Best
available

research
 Pa-ent
values

evidence


The three elements of evidence‐based practice 
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 Goals of EBP

  Provide
prac-cing
nurses
with
evidence‐based
data

  Resolve
problems
in
the
clinical
se=ng

  Achieve
excellence
in
care
delivery

  Introduce
innova-on

  Reduce
varia-ons
in
nursing
care

  Assists
with
efficient
and
effec-ve
decision‐making


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 Goals
(con’t)


  Using
best
evidence
to
implement
the
regula-on
of

nurses

  Resolve
regulatory
problems

  Achieve
excellence
in
regula-on

  Introduce
regulatory
innova-on



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 Why the rapid spread of
evidence-based practice?

Some of major reasons cited by Sackett et al (1997)

for the spread of the EBP movement have been :
  the lack of research-based information to support
clinical decision making
  the lack research-based guidelines and protocols to use
in clinical practice
  the overwhelming volume and variability of new journal
information
  the inadequacy of traditional sources of information (e.g.
textbooks out of date) LOGO
What are the benefits of
evidence-based practice?

1.  To patients/consumers

Patient typically accept recommended care

from health professionals with the unspoken
assumption that the practitioner know what
works

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 What are the benefits of
evidence-based practice?

2.  To nurses

  EBP allows a more structured and streamlined way of

keeping abreast of relevant new developments without
becoming over-whelmed by information overload
  EBP also allows nurse to communicate effectively with
their patients and with the healthcare team about the
rationales for decision making and care plans
  An EBP nurse is a confident professional, feeling
assured that they are providing care that is supported by
facts rather than habits, and can take legal
accountability for their practice LOGO
What are the benefits of
evidence-based practice?

3.  To the healthcare organization

  EBP philosophy allow healthcare organization to position themselves
in the market as quality institution.
  An EBP-compliant institution should be less likely to attract
litigation, or to successfully defend the care delivered.
  EBP allows the scrutinizing of practice for effectiveness.
  This process often results in practice changes that allow significant
cost savings, or alternatively justify necessary additional
expenditure
  This is attractive to organizations frequently struggling to meet
assigned budgetary limits, or lobbying government for additional
funds
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What are the benefits of
evidence-based practice?

4.  To
the
community

  Through
the
u-liza-on
of
EBP,
finite
resources
are

not
wasted
on
the
delivery
of
ineffec-ve

interven-ons.

  EBP
limits
the
amount
of
disability
and
suffering

throughout
the
community
by
ensuring
the
most

current
and
effec-ve
care
is
provided.


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1.  Ask or identify the important clinical question
2.  Collect the best and more pertinent evidence
3.  Critically analyze and rate the evidence
4.  Integrate the evidence into clinical decisions
5.  Implement best evidence in clinical practice
6.  Evaluation

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 1. Ask or identify the important
clinical question

  HOW?? PICO

  Patient
  Age, sex, ethnicity, etc.
  Condition, diseases, general health status
  Intervention
  Education, diagnostics, treatment plan, self-care, etc.
  Comparison Intervention
  Placebo, etc.
  Outcome
  Expected and actual effects on patient LOGO
 PICO
  The nurses want to know:
What is the best way of obtaining a urine specimen
culture, from a child?

Population: Children suspected of having UTI (Urinary

tract infection), who are not yet toilet training
Intervention: Bag-catch urine specimen, clean-catch urine
specimen
Comparison: Suprapubic aspiration
Outcome: Culture contamination

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 PICO
The revised question:
In children suspected having of UTI, who are not yet toilet
training, what is the risk of culture contamination when
urine is obtained by bag-catch or clean catch, as
compared with urine obtained by suprapubic aspiration
directly from the bladder?

  Not all questions are of a clinical nature

  Intervention can be interpreted very broadly

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  Do nurse led tobacco cessation interventions
result in decreased smoking rates after hospital
admission for coronary heart disease?

  What are the factors, identified by mothers who

live in the deprived inner city areas, that
influences them to breastfeed or to bottle-feed
using infant milk formula

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 2. Collect the best and more
pertinent evidence
Where is the evidence located?
  CINAHL® (Cumulative Index to Nursing and the Allied Health Literature)
  Medline www.ncbi.nlm.nih.gov/PubMed/.
  Proquest
http://www.proquest.com/pqdweb
username: 0NQTKKWNKM& Password:brawijaya
  Ovid
http://gateway.ovid.com/
ID & Password : hsll199
  EBSCO
http://search.epnet.com/
user : cathedral & password : dc
NEW: http://search.ebscohost.com
Id: n5000145, passwords LOGO
 3. Critically analyze and rate the
evidence

  Critical Appraisal of the evidence

  Grading of the evidence

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Grading of research studies that measure the
effect of an intervention, treatment or therapy

Level of Study designs

evidence
I Evidence obtained from a systematic
review or meta-analysis of all relevant
randomized controlled trials
II Evidence obtained from at least one
properly designed randomized controlled
trial
III-1 Evidence obtained from well-designed
pseudo-randomized controlled trials
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Source : NHMRC 1999
Grading of research studies that measure the
effect of an intervention, treatment or therapy
Level of Study designs
evidence
III-2 Evidence obtained from comparative
studies with concurrent controls and
allocation not randomized (Cohort studies,
case-control studies or interrupted time-
series with control group)
III-3 Evidence obtained from comparative
studies with historical control, two or more
single-arm studies, or interrupted time-
series without a parallel control group
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Source : NHMRC 1999
Grading of research studies that measure the
effect of an intervention, treatment or therapy

Level of Study designs

evidence
IV Evidence obtained from case series (either
post-test or pretest and post-test

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Source : NHMRC 1999
 Levels of evidence of effectiveness

Level Evidence of effectiveness

1 Systematic review (with homogeneity) of experimental
studies, or one or more large experimental studies with
narrow confidence interval
2 Quasi-experimental studies (e.g without randomization)
3a Cohort studies (with control group)
3b Case-controlled
3c Observational studies without control groups
4 Expert opinion without explicit critical appraisal, or
based on physiology, bench research or consensus
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Source:The Joanna Briggs Institute.Available at www.joannabriggs.edu.au/pubs/approach.php.
 QUALITY OF EVIDENCE

TRIP = turning research into practice

Simultaneously searches evidence-based sources of systematic reviews, practice
guidelines, and critically-appraised topics and articles
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 4. Integrate the evidence into
clinical decisions

Key points:
•  Research evidence is, on its own, insufficient to ensure
the robust clinical decisions necessary for clinically
effective health care

•  Good clinical decisions require the sophisticated

application of research findings in the context of
clinical expertise, patient preferences and values, and
the individual decisions

•  The availability of resources influences how research

evidence is interpreted and applied LOGO
 4. Integrate … cont’

The seven rights of the clinical effectiveness

(Royal College of Nursing, 1996)

1.  Right thing for the

2.  Right patient from the
3.  Right person at the
4.  Right time in the
5.  Right way to achieve the
6.  Right outcome at the
7.  Right cost
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 4. Integrate … cont’
Influences on clinical decision making

Clinical
expertise

Consensus Intuition

Values and Decision Research

belief making

Available
Experts
Resources

Media

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 4. Integrate … cont’

Clinical expertise:
The ability to use our clinical skills and past experience to rapidly
identify each patient’s unique health state and diagnosis, their
individual risks and benefits of potential interventions, and their
personal values and expectations (Sackett et al 2000)

Intuitive practice:
A way in which we know and behave about the situation that is not
based on conscious reasoning or rational thought process
(Parahoo 1997)
… Builds on repeated practice situations, it is context specific and it
enables the integration of complex pieces of a data to derive a
decision that is difficult to articulate through linear rules
(Greenhalgh 2000)

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 5. Implement best evidence in
clinical practice
Where to start?

•  Identifying appropriate topics to address

  Consider local and national views on the topic
  Attitudes to using research evidence

•  Choosing a project manger

•  Diagnosing the situation

The organizational environment, stakeholders and
practitioner opinion leaders, grassroots workers, Users’ views,
”the way we do things round here”, SWOT analysis
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 5. Implement … cont’

How to implement the changes?

•  Developing a dissemination and implementation
strategy
•  General/ specific approaches to manage change
Educational approach, epidemiological stances,
marketing of a product, information or strategies,
behavioural changes, social interactionism,
organizational approach, resources and management
issues, realistic goals and time frames, reviewing.

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 6. Evaluation

Evaluating the progress and effects of the

changes?

•  Maintaining close contact with the progress and effects

•  Formal evaluation and dissemination

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 How Do I Participate in an Evidence-
Based Practice?

  Ask an authority or expert in the field

  Consult a textbook
  Look for an article in a nursing journal
  Look for an article in a scholarly journal
  Ask a nursing peer
  Use simple trial and error
  Use your intuition, judgment, or reasoning skills
to solve the particular problem

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Godshall, Maryann 2010
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