Evidence based practice & future nursing

Evidence-Based Practice and the

Future of Nursing

Jayesh Patidarwww.drjayeshpatidar.blogspot.com

The Evolution of

Evidence-Based Practice

www.drjayeshpatidar.blogspot.in

What is - Evidence?

Anything that provides material or

information on which a conclusion or proof

may be based; used to arrive at the truth,

used to prove or disprove the point at issue.

(Webster)



• Evidence-Based Practice – Conscientious, explicit and judicious use of current best evidence with clinical expertise, and patient values to make decisions about the care of patients. (Sackett, 2000)

• Evidence-based nursing practice is the process of shared decision-making between practitioner, patient and significant others, based on research evidence, the patient’s experiences and preferences, clinical expertise, and other robust sources of information.

(STTI , 2007)


• EBP is both a process and a product…

requiring that the evidence which is produced –

is also applied to practice.

(D. Rutledge, 2002)


Evolution of EBP

• 1991 – Evidence-based medicine -first described in the American College of Physicians Journal Club.

• 1992 – the Evidence-based Medicine Working Group described it as a “paradigm shift” in JAMA

– Clinical observations and experience, principles of pathophysiology, knowledge gained from authoritative figures, and common sense -- are no longer a sufficient guide for clinical practice, decision-making, or the development of practice guidelines


Evolution of EBP

• Early 1990’s – US Prev. Services TF – began developing EB Guidelines for Screening and Prevention

• 1992 – AHCPR (now AHRQ) – started publishing systematic reviews and consensus statements in the form of Clinical Practice Guidelines, starting with the guideline for Acute Pain, 19 guidelines were produced from ’92-’96

• 1993 - the first annual Cochrane Colloquia was held at the New York Academy of Sciences

• 1993 – Online Journal of Knowledge Synthesis for Nursing


Evolution of EBP

1997 – Jan 2011 – 198 Evidence Reports published by the EBP centers

– May, 2005 – Episiotomy Use

– “…no health benefits from episiotomy…routine use is harmful …”


Recent Evidence Reports

193. Alzheimer's Disease and Cognitive Decline

192. Lactose Intolerance and Health

190. Enhancing Use and Quality of Colorectal Cancer Screening

189. Exercise-induced Bronchoconstriction and Asthma

188. Impact of Consumer Health Informatics Applications

187. Treatment of Overactive Bladder in Women

185. Management of Ductal Carcinoma in Situ (DCIS)

184. Treatment of Common Hip Fractures

151. Nurse Staffing and Quality of Patient Care140. Tobacco Use: Prevention, Cessation, and Control

This is just one example of literature syntheses that are available

to support EBP.


http://www.ahrq.gov/clinic/tp/alzcogtp.htm

http://www.ahrq.gov/clinic/tp/lactinttp.htm

http://www.ahrq.gov/clinic/tp/crcprotp.htm

http://www.ahrq.gov/clinic/tp/eibeiatp.htm



http://www.ahrq.gov/clinic/tp/chiapptp.htm

http://www.ahrq.gov/clinic/tp/bladdertp.htm

http://www.ahrq.gov/clinic/tp/dcistp.htm

http://www.ahrq.gov/clinic/tp/hipfractp.htm

http://www.ahrq.gov/clinic/tp/nursesttp.htm

http://www.ahrq.gov/clinic/tp/tobusetp.htm

Nurse Staffing and Quality of

Patient Care

• Objectives: To assess how nurse to patient ratios and

nurse work hours were associated with patient outcomes

in acute care hospitals

• Results: Higher RN staffing was associated with less

mortality, failure to rescue, cardiac arrest, hospital

acquired pneumonia, and other adverse events. Limited

evidence suggests that the higher proportion of RNs with

BSN degrees was associated with lower mortality and

failure to rescue. More overtime hours were associated

with an increase in hospital related mortality, nosocomial

infections, shock, and bloodstream infections.


Evolution of EBP

• 1998 – Evidence-Based Nursing journal debuted

• 1999 – The UK Department of Health stipulated that, to enhance the quality of care, nursing, midwifery, and health visiting practice must be evidence-based

• 2002 - JCAHO begins requiring monitoring of evidence-based core measures

• 2004 – WorldViews on Evidence-Based Nursing

• 2004 – AACN began publishing “Practice Alerts”


Evolving Interest in Evidence-Based Practice

0 0 1 0 0 525 35 47 51 67 83

139

530

0

100

200

300

400

500

600

'91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04

2011 – Medline search > 38,000www.drjayeshpatidar.blogspot.in

Within one decade, the concept of

evidence-based practice has

evolved and been embraced by

nurses in nearly every clinical

specialty, across a variety of roles

and positions, and in locations

around the globe.

EBP – means many things to many

people

Factors Contributing to Emphasis on

Evidence-Based Nursing Practice

• Scientific knowledge expansion

– Knowledge expands exponentially q 2 yrs

– 12 yrs. from now – 128 x as much knowledge

• Knowledge availability -- The Internet

• Highly educated nurses in clinical settings

– APNs – focusing on evidence-based clinical problem-solving

– Clinical Nurse Researchers

– DNP Movement


Factors Contributing to Emphasis on

Evidence-Based Nursing Practice

• Aggressive pursuit of cost-effectiveness

• Focus on quality of care, Risk & error reduction

• Highly educated consumers

• JCAHO/Accreditation expectations

• Increased attention to institutional image

– Magnet hospital movement


• Most nurses agree that EBP is important…

but how do we make it happen?


What is the 1st step toward EBP for the

practicing nurse?

• Asking good clinical questions

• Nurses must be empowered to ask

critical questions in the spirit of

looking for opportunities to improve

nursing care and patient outcomes

• Risk-taking environment


Nursing vs. Medical Questions

• Often more exploratory

• Less frequently focused on intervention selection

• Less evidence to support many nursing

interventions

• Most nursing interventions have less capacity for

harm

• Many nursing challenges often go beyond

individual clinical interventions

(e.g. nurse staffing, education, recruitment)


Clinical Nursing Questions

• In postoperative patients, does prn or

ATC analgesic administration yield better

pain relief?

• Among critically ill patients, is controlled

or open visitation more effective in

reducing patient anxiety?


Questions for APNs

• In acute care hospitals, is the CNS more

effective by focusing on a specific

patient population or a specific unit?

• What else?


What kind of questions might the

Nurse Manager ask?

• On medical-surgical units, do 12 hour or 8

hour shifts result in more medication

errors?


Key Questions to Ask When

Considering EBP

• Why have we always done “it” this way?

• Do we have evidence-based rationale?

• Or, is this practice merely based on tradition?

• Is there a better (more effective, faster, safer, less expensive, more comfortable) method?

• What approach does the patient (or the target group) prefer?

• What do experts in this specialty recommend?


Key Questions to Ask When

Considering EBP

• What methods are used by leading/benchmark, organizations?

• Do the findings of recent research suggest an alternative method?

• Are organizational barriers inhibiting the application of best practices in this situation?

• Is there a review of the research on this topic?

• Are there nationally recognized standards of care, practice guidelines, or protocols that apply?


Steps in the EBP Process

• Developing a well-built question

• Finding evidence-based resources to

answer the question

• Evaluating the strength and applicability of

the evidence

• Applying the evidence to practice

• Evaluating the effects


• Once we agree upon the question that

poses an opportunity for improvement, then

we must find the evidence

• Where should we look?

• Are all forms of evidence equivalent in

quality?


Strength of Evidence

• Level I - meta-analysis of multiple studies

• Level II - experimental studies, RCTs

• Level III - quasiexperimental studies

• Level IV - nonexperiemental studies

• Level V - case reports, clinical examples

AHCPR/AHRQ

• At what level is most nursing evidence?www.drjayeshpatidar.blogspot.in

AACN Levels of Evidence (Armola, et al. , C C Nurse, 2009)

• Level A

• Level B

• Level C

• Level D

• Level E

• Level M

• Meta-analysis or metasynthesis of multiple

controlled studies, supporting a specific action

• Controlled, randomized, or nonrandomized studies,

supporting a specific action

• Qualitative, descriptive or correlational studies or

systematic reviews with consistent results

• Peer-reviewed prof. organ. standards with studies

to support them

• Theory-based evidence from expert opinion or

case studies

• Manufacturer’s recommendations only


What constitutes the “Evidence” in

Evidence-Based Practice?

“Evidence-based practice has been defined

as the use of the best clinical evidence

from systematic research (referring to

meta-analysis, integrated reviews, & RCTs

– as the gold standard). …Others (often

nurses) believe that experimental studies,

observational studies, and correlational

studies are also suitable evidence.”

C. Goode, Applied Nursing Research, 2000


A major dilemma for the

practicing nurse:

Finding the time, access, and research expertise that are

needed to search and analyze the evidence to find

answers to their clinical questions.

For those of you who are already pursuing EBP, which of

these issues pose the greatest challenges for you?


Finding the Evidence

• Don’t reinvent the wheel

• If other experts have reviewed the

evidence on your topic … start there


Preprocessed Evidence

(A. DiCenso, 2009)www.drjayeshpatidar.blogspot.in

Resources to Support


• Government agencies

• Cochrane Collaboration

• Professional Organizations

• Benchmark Institutions


AHRQ – Agency for Healthcare

Research and Quality

Cochrane Collaboration

• “an international, independent, not-for-profit organization of over

27,000 contributors from more than 100 countries, dedicated to

making up-to-date, accurate information about the effects of health

care readily available worldwide.

• Contributors produce systematic assessments of healthcare

interventions, known as Cochrane Reviews, which are published

online in The Cochrane Library.

• Rely heavily on RCTs

• Primarily focused on effectiveness of interventions, more medical and pharmaceutical than nursing


http://www.cochrane.org/cochrane-reviews

http://www.thecochranelibrary.com/

Cochrane Collaboration http://www.cochrane.org


http://www.cochrane.org/

Substitution of Drs by Nurses in Primary Care

Objectives: to evaluate the impact on patient outcomes, processes of care, and costs. Outcomes included: morbidity; mortality; satisfaction; compliance; and preference.

Studies were included if nurses were compared to doctors providing a similar primary health care service. Doctors included: general practitioners, family physicians, pediatricians, internists or geriatricians. Nurses included: nurse practitioners, clinical nurse specialists, or advanced practice nurses.

Results: 4253 articles were screened, 25 articles met our inclusion criteria. No appreciable differences were found between doctors and nurses in health outcomes, processes of care, or cost; but patient satisfaction was higher with nurse-led care. www.drjayeshpatidar.blogspot.in

Professional Nursing Organizations

Supporting Evidence-Based Practice

• AACN

• AWHONN

• AORN

• ONS

• Sigma Theta Tau


Am. Assoc. of Critical Care Nurses

Succinct dynamic directives…supported by evidence to ensure excellence in practice and a safe and humane work environment.

• Venous Thromboembolism Prevention

• Oral Care in the Critically Ill

• Noninvasive BP Monitoring

• Verification of Feeding Tube Placement

• Ventilator Associated Pneumonia

• Dysrthymia Monitoring

• Published since 2005

• Available free on AACN website

• Include ppt presentations and audit toolswww.drjayeshpatidar.blogspot.in

Oncology Nursing Society

• EBP Resource Center

• http://onsopcontent.ons.org/toolkits/evidence/

• Also provides topical toolkits, on specific topics, plus:

• How To Find The Evidence

• How To Critique Evidence

• How To Develop An Evidence Based Presentation

• Evidence Based Practice Education Guidelines

• Evidence on Clinical Topics

• How to Change Practice

• Levels of Evidence Tablewww.drjayeshpatidar.blogspot.in

http://onsopcontent.ons.org/toolkits/evidence/

Sigma Theta Tau EBP Initiatives

• Strategic Plan

• Online Resources– NKI http://www.nursingknowledge.org > 200

resources for EBP – some free, some for purchase

• New Award for EBP (formerly Clin Scholarship)

• Conferences

– International EBP and Research Congress

– July, 2010 – Orlando

– July, 2011 – Cancun

– July, 2012 – Australia


http://www.nursingknowledge.org/

Journals Supporting EBP

– Evidence-Based Nursing

– Online Journal of Clinical Innovations

– WorldViews on Evidence-Based Nursing

– The Online Journal of Knowledge Synthesis for

Nursing – (archived, no longer being published)

– Reflections on Nursing Leadership (Vol 28, 2)


Local vs. Global Evidence

• Institutional/Local > National/International

– CPI Data/Research Results

– Standards & Protocols/Practice

Guidelines

– Expert Advice

– Patient/Family Preferences


Values and Preferences

EBN - integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families and communities …

Yasmin Amarsi, RNL, 2002:

“The crux is to ensure that EBN attends to what is important to nursing and that caring is not sacrificed on the altar of scientific evidence.”


Amy’s Blog

• I consulted a well-regarded oncologist in New York. After the tests

she regretfully informed me that my disease was not curable. She

recommended an evidence-based course of medications aimed at

slowing the progression. Before I committed, I wanted a second

opinion. I secured an appointment with the pre-eminent researcher/

clinician in inflammatory breast cancer. …

• The building was beautiful, the staff attentive. …I had no doubt that

the care would be top-notch.

• Everything changed when I sat down with the physician. He never

asked about my goals for care. He recommended an aggressive

approach of chemotherapy, radiation, mastectomy, and more

aggressive chemotherapy. My doctor in New York had said this was

the standard, evidence-based protocol for patients in Stage III B…But

since I am in Stage IV (with mets) she said I wouldn’t get the benefit

of this aggressive, curative approach.www.drjayeshpatidar.blogspot.in

• “All of my patients use this protocol,” he said.

• I was shocked. “Does this mean I could get better?” I asked.

• “No, this is not a cure.” he answered. “But if you respond to the

treatment, you might live longer, although there are no guarantees.”

• My goals are to maximize my quality of life so I can live, work, and

enjoy my family … Would I undergo a year or more of grueling,

debilitating treatment only to live with spinal fractures if the cancer

progressed? … Would I get the possibility of quantity and no quality?

• I pressed him. “Why do the mastectomy? If the cancer has already

spread to my spine. You can’t remove it.”

• His brow furrowed. “Well, you don’t want to look at the cancer, do

you?” He made it sound like cosmetic surgery.

• Right now, I feel fine. I can work. I am pain free. Did I want to trade

that for a slim chance of a little extra time (no guarantees, of course)?


• “But what about the side effects of radiation?” I asked. “I’ve

heard they are terrible.”

• He frowned and seemed annoyed by my questions. “My

patients don’t complain to me about it,” he replied.

• Inwardly, I shook my head. Of course his patients never

complained to him. Most of them were probably unaware that

less aggressive treatments were viable options. To me, there

were real drawbacks. Undergo aggressive therapy that might

buy me a longer life…at what cost? I might never recover my

health for the limited period of time I have.

• This doctor, top in his field, was reflecting the bias of our

medical system towards focusing (evidence-based) survival.

He was focused only on quantity and forgot about quality.www.drjayeshpatidar.blogspot.in

• The patient’s goals and desires, hopes and fears, were not

part of the equation. He was practicing one-size-fits-all

(cookbook?) medicine that was not going to be right for me,

even though scientific studies showed it was statistically more

likely to lengthen life.

• Based on a perverse set of metrics, this oncologist was

offering technically the “best” care America had to offer.

• Yet this good care was not best for me. It wouldn’t give me

health. Instead, it might take away what health I had. It

doesn’t matter if care is cutting-edge, technologically

advanced, (and evidence-based); if it doesn’t take the

patient’s goals into account, it may not be worth doing.www.drjayeshpatidar.blogspot.in

• I returned to my original New York oncologist.

• I was determined not only to choose treatment that

would maximize the healthy time I had remaining, but

also to use that time to call on our health care institutions

and professionals to make a real commitment to listening

to their patients.


Moving Toward our Destiny

Evidence-based practice is every nurses’

responsibility

What can you do to make this goal a reality?


Educator’s Role

– EB Education for EB Practice

– Base educational content on evidence

– Seek the most current forms of

evidence, e.g. journals & online

sources vs. texts

– Encourage students to question and

challenge

– Teach research content in a manner

that is interesting and useful


Manager/Administrator’s Role

– Encourage inquisitive minds

– Promote risk-taking and flexibility in the clinical

environment

– Incorporate EBP activities into performance

evals

– Provide time & resources – unit internet

access

– Provide support personnel

– Empower staff to make EB practice changes

– Acknowledge and reward EB improvements


Researcher’s Role

– Remain clinically in touch

– Conduct clinically useful studies

– Support clinicians in accessing and

synthesizing the evidence

– Collaborate with clinicians and patients

– Disseminate findings that are

understandable and accessible

– Emphasize clinical implications


Nurse Clinician’s Role

– “Worry and Wonder”

– Be the Inquiring Mind

– Question clinical traditions

– Stay abreast of the literature - guidelines

– Find your niche – and become the expert

– Collaborate with APNs & researchers

– Be an advocate for evidence-based changes

– LISTEN to your PATIENTS – to guard patient &

family preferences


Join us:

STTI Research & EBP Congress

July 11-14, 2011


THE 2010 IOM REPORT ON THE

FUTURE OF NURSING


Center to Champion Nursing in

America http://championnursing.org

• Center to Champion Nursing in America is an initiative of AARP, the

AARP Foundation and the Robert Wood Johnson Foundation. The

Center, a consumer-driven, national force for change, works to

increase the nation’s capacity to educate and retain nurses who are

prepared and empowered to positively impact health care access,

quality, and costs.


Nursing has an unprecedented

opportunity to have one voice on behalf

of patient care…

• 18 member committee

– Donna E. Shalala (Chair), President, University of Miami

– Linda Burns Bolton (Vice Chair), Vice President and

Chief Nursing Officer, Cedars-Sinai Health

• Evidence based

• IOM part of National Academy of Sciences– Private, nonprofit, society of distinguished scholars engaged in

scientific research, dedicated to the furtherance of science and

technology and to their use for the general welfare


Interprofessional Team-Based

Competencies

• IPEC Expert Panel Presentation

• HRSA, Macy Foundation, Robert Wood Johnson

Foundation, and ABIM Foundation

• Amy Blue, PhD

• Jane Kirschling, DNS, RN, FAAN

• Madeline Schmitt, PhD, RN, FAAN-Chair

• Thomas Viggiano, MD, MEd


“Work in

Interprofessional

Teams”

Core

Competencies

Utilize

Informatics

Employ Evidence-

Based

Practice

Provide Patient-

Centered

Care

Apply Quality

Improvement

IOM 5 core competencies, adapted to IPEC Expert Panel Workwww.drjayeshpatidar.blogspot.in

Institute of Medicine October 2010 Report:

The Future of Nursing Leading Change, Advancing Health

1. Remove scope-of-practice barriers

2. Expand opportunities for nurses to lead and diffuse collaborative improvement efforts

3. Implement nurse residency programs

4. Increase the proportion of nurses with a baccalaureate degree to 80% in 2020

5. Double the number of nurses with a doctorate by 2020

6. Ensure that nurses engage in lifelong learning

7. Prepare and enable nurses to lead change to advance health

8. Build an infrastructure for the collection and analysis of interprofessional health care workforce data


• Remove scope-of-practice barriers

Nurses should

practice to the full

extent of their

education & training

IOM Key Message

RECOMMENDATION NO. 1


The many faces of advanced

practice registered nurses in 2011

High

quality,

safe,

affordable

health care

provided by

teams of

health care

professionals


Health care reform

• Survey published in JAMA 2008, only 2% fourth-

year medical students plan to work in general

internal medicine (primary care) after graduation,

despite need for 40% increase in number of

primary care physicians in the U.S. by 2020

• Association of American Medical Colleges predicts

shortage of 35,000-44,000 primary care physicians

by 2025

• Expanded opportunities for APRNs


Hospital care…

• Evolution of opportunities for advanced

practice registered nurses

– Change in residency hours

– 24 x 7 coverage

– Evolving recognition of specialty needs


National barriers

• National nursing organizations are

working to

Improve APRN reimbursement, Medicare

reimburses NPs and CNSs at 85% of

physician rate

Amend rules that prohibit APRNs from

ordering such things as home health and

hospice services or diabetic shoes


Recent national advances

Medicare now

– Allows NPs to serve as the attending for a

hospice patient

– Allows Governors of states to opt out of

supervision rule for CRNAs – 16 states

have opted out

– Reimburses CNMs at 100%


“Messaging”

Barriers to practice reduce access

to care

Main issue is access to care and

this should define our focus


• Implement nurse residency programs

Nurses should achieve higher

levels of education &

training through an improved education

system that promotes seamless academic

progression

IOM Key Message


New graduates

and nurses in

transition


The Problem – Transition to

Practice: Promoting Public Safety

• 35 to 60% new nurses leave position in first

year of practice, estimated replacement cost

$46,000 to $64,000 per nurse

• 10% typical hospital’s nursing staff comprised

of new graduates

• New nurses experience increased stress 3-6

months after hire, increased stress levels are

risk factors for patient safety and practice errors


• NCSBN – transition programs reduce 1st

year turnover from 35-60% to 6-13%,

results in positive return on investment

from 67 to 885%


University Healthsystem Consortium (UHC)

and American Assoc. of Colleges of Nursing

A one year education and support program

to assist new BSN graduates employed as

staff nurses on clinical units to transition to

professional nursing practice

Now 54 sites nationwide in 25 states

› Over 12,000 BSNs have been enrolled

nationwide

National research component to determine

the best practice for integrating new BSN

nurses into the workforcewww.drjayeshpatidar.blogspot.in

What is the Residency Research Showing?

Retention nationally 94.4% for new grad first

year vs. about 73% without residency

Surveys completed initially, 6 months, and 12

months; scores improve in new graduate’s

ability to

› organize and prioritize

› communicate and be leaders at bedside

› decreased stress over the year (less so at Kentucky)


• Increase the proportion of nurses with a baccalaureate degree to 80% by 2020



training through an improved

education system that promotes seamless academic

progression

IOM Key Message



Rationale (Institute of Medicine, 2011, p. 169-170)

“Several studies support significant

association between educational level of RN

and outcomes for patients in acute care

settings, including mortality”


Enrollments increasing in both DNP

and PhD programs (1997-2009)

AACN 2009: over 9,500 applicants turned away master’s and

doctoral programswww.drjayeshpatidar.blogspot.in

• Ensure that nurses engage in lifelong learning



training through an improved

education system that promotes seamless academic

progression

IOM Key Message



Faculty partner with health

care organizations

• Develop and prioritize competencies so

curricula updated regularly across all

programs

– go beyond task-based proficiencies to higher-

level competencies

• demonstrate mastery over care management

knowledge domains

• provide foundation decision-making skills under

variety clinical situations across care settings


Academic administrators

• Require all faculty

– participate continuing professional

development

– Perform cutting-edge competence in practice,

teaching, and research


Health care organizations and

schools of nursing

• Foster culture of lifelong learning

• Provide resources for interprofessional

continuing competency programs

• If offer continuing competency programs,

regularly evaluate for flexibility,

accessibility, and impact on clinical

outcomes


Institute of Medicine October 2010 Report: The

Future of Nursing Leading Change, Advancing

Health

2. Expand opportunities for nurses to lead and

diffuse collaborative improvement efforts

7. Prepare and enable nurses to lead change to

advance health

8. Build an infrastructure for the collection and

analysis of interprofessional health care

workforce data


…IN CONCLUSION

We must commit to take action on

recommendations from IOM report

Affirm that this is about access to

access to patient-centered care and

health care reform

Essential that nurses mobilize

Not just to support nursing, but

more importantly – to support the

publicwww.drjayeshpatidar.blogspot.in

THANK YOU


Evidence based practice & future nursing

Health & Medicine

Transcript of Evidence based practice & future nursing