EVIDENCE-BASED PRACTICE: EVIDENCE-BASED PRACTICE: WHAT’S IN IT FOR YOU? WHAT’S IN IT FOR YOU?

Sharon Bond, PhD, CNMAssociate ProfessorSpecial Thanks to:

Barbara J. Edlund RN, PhD, ANP, BCProfessor

College of Nursing, MUSC

SO MANY QUESTIONS . . . SO MANY QUESTIONS . . . Evidence-Based Practice (EBP): What is the best approach for

managing neuropathic pain in the terminally ill patient?What research has been done that could provide clinical

practice guidelines?Quality Improvement (QI): Are we doing the right things to

appropriately manage patients’ neuropathic pain?How do we know? How are we measuring patient outcomes?

Research (R): What is it like to live with neuropathic pain?Does drug “A” work better than drug “B?”

What’s been studied? Where are the gaps?

COMMONALITIES – PROVIDE STRUCTURE!COMMONALITIES – PROVIDE STRUCTURE! Evidence-based practice (EBP) – utilizes the best clinical

evidence in making patient care decisions typically from research. EBP translates knowledge into practice

Quality improvement (QI) - utilizes a system to monitor and evaluate the quality and appropriateness of care (outcomes) based on EBP and research

Research (R) - applies a methodology whether quantitative or qualitative to develop, uncover, create, find, add new nursing knowledge

COMMONALITIES – IMPROVE CARE COMMONALITIES – IMPROVE CARE DELIVERYDELIVERY!

Involve teamwork – not done in isolation Call for critical thinking and creativity Commitment to improve care One informs the other

Nurses base their practice on emerging evidence from research (EBP)

Research starts in practice and ends in practice

Quality improvement evaluates and monitors care, and identifies opportunities to improve care as the processes and outcomes of care are measured, continuously evaluated and improved

WHAT IS EVIDENCE-BASED PRACTICE? Conscientious use of current best evidence to make

decisions about patient care A problem-solving approach to clinical practice Based on:

1. systematic search for and appraisal of most relevant evidence to answer questions2. one’s clinical experience and expertise3. patient preference and values

LEVELS OF EVIDENCELEVELS OF EVIDENCE I Evidence - Systematic reviews, meta-analysis RCTs, EB clinical practice guidelines based on RCTs II Evidence - One well designed RCT III Evidence - CTs without randomization IV Evidence - Well-designed case control or cohort studies V Evidence - Systematic reviews of descriptive or qualitative studies VI Evidence - Single descriptive or qualitative study VII Evidence – Opinions of authorities, reports of experts

EVIDENCE-BASED PRACTICEEVIDENCE-BASED PRACTICEThe process of doing the “right thing” Standards of care Baseline description of quality- may be discipline focused AANP standards of NP practice Clinical guidelines Broad-based recommendations Critical pathways Identify key/critical activities that must occur in predictable fashion Protocols Detailed procedures on how to proceed with evaluation and treatment NONPF

FIVE STEPS OF EVIDENCE-BASED PRACTICE FIVE STEPS OF EVIDENCE-BASED PRACTICE Ask the burning clinical question (Picot format) Search for and collect the most relevant and best evidence Critically appraise the evidence Integrate all evidence with one’s clinical expertise, patient

preferences and values in making a practice decision or change Evaluate the practice decision or change (Disseminate)

Unlike research utilization (info from a single study), EBP - takes into account expertise of the practitioner and patient preferences / values

Melnyk & Fineout-Overholt 2005

STAR MODEL – FIVE STAGES: EBPSTAR MODEL – FIVE STAGES: EBP

Depicts 5 major stages of knowledge in a relative sequence as research evidence is moved through several cycles, combined with other knowledge and integrated into practice

Converting knowledge into practice

Provides a framework for systematically putting evidence-based practice processes into operation

Stevens 2004 (www.acestar.uthscsa.edu)

Reference: Haynes (1998). Barriers and bridges to evidence-based clinical practice. BMJ, 317:273-276.

QUALITY IMPROVEMENTQUALITY IMPROVEMENT

Process that utilizes a system to monitor and evaluate the quality and appropriateness of care based on evidence-based practice and research

ASPECTS OF QUALITY IMPROVEMENTASPECTS OF QUALITY IMPROVEMENT On-going process to improve quality of care Whole team collaborates across departments and

systems…team with clear aims, clear outcome measures of results to be achieved…process for implementing change and institutional or organizational support

Information systems…show me the data System focused (not individual) Practice process changes to meet guidelines (EBP) and

to see if changes are workingNONPF

QUALITY IMPROVEMENT: FOCUS QUALITY IMPROVEMENT: FOCUS Questions (3)

1. What are we trying to accomplish?2. How will we know a change is an

improvement?3. What changes can we make that will

result in improvement?

Rapid Improvement or PDSA cycles

PDSA: THE DEMING MODELPDSA: THE DEMING MODEL PlanPlan

- Test objectives- Who will do what- Predict outcomes

DoDo- What happened- Did it work

StudyStudy- Analyze outcomes in context of predicted- Summarize lessons learned

ActAct- What modification needs to be made- Statement of new plan ….. PDSA cycle repeatsPDSA cycle repeats

NATIONAL GUIDELINES OR NATIONAL GUIDELINES OR BENCHMARKSBENCHMARKS

Need quantifiable measures Need to know the difference between your practice and

national benchmarks National Guidelines Clearing House Guidelines.gov National benchmarks or quality goals…AHRQ

NONPF

BARRIERS TO EVIDENCE-BASED BARRIERS TO EVIDENCE-BASED PRACTICEPRACTICE

Overwhelming patient workloads Misperceptions about EBP and research Lack of time and resources to search for and appraise

evidence Organizational constraints – lack of support Peer pressure to continue with practices that are

steeped in tradition – “we’ve always done it this way and we are not changing now”

Melnyk & Fineout-Overholt 2005

BARRIERS TO EVIDENCE-BASED PRACTICEBARRIERS TO EVIDENCE-BASED PRACTICE

Knowledge… lack of knowledge/awareness .… unfamiliar with guidelines and guideline accessibility

Attitudes …. lack of confidence in the guideline developer, lack of motivation to perform the guideline recommendations

Behaviors …. inability to incorporate patient preferences into the clinical decision making process

Melnyk & Fineout-Overholt 2005

WHAT ARE YOUR EXPERIENCES WITH CHANGE?

Have you ever tried to change a practice at your work site?

What worked?What didn’t?What was the final outcome?What would you do differently?Do facts (evidence) change behavior?

RESEARCH: RESEARCH: WHEN EVIDENCE IS NOT THERE/NOT WHEN EVIDENCE IS NOT THERE/NOT

SUFFICIENTSUFFICIENT Conduct a research study to determine the “what is it

we want to know” Nature of the question will determine the level of the

research study1 - What is the nature of the phenomenon?2 - Who, what, how many, how much?3 - What are the relationships among the variables?4 - Does one variable cause the other?

RESEARCH QUESTIONS…..RESEARCH QUESTIONS….. First three questions - reflect levels of research seeking

descriptive knowledge of the variables under study…non-experimental design

Fourth question reflects a level of research that examines cause and effect…experimental design

Before one conducts an experimental research study, one must have data from the three previous levels to support such a study…the preliminary work!

Value of research…adds new knowledge…to guide and improve nursing practice

QI VS. RESEARCH Intervention may be

multifactorial represents best practices

Rapid improvement cycles No risk to patients Audience is organization Data source: organization Design - no controls Not generalizable

NONPF

Untried intervention being tested

Risk may be present Complex protocol Audience is scientific

community Data source –randomized

population, multiple sites Design – focus on

controls Generalizable

HOW DOES FOCUS OF DNP DIFFER FROM PHD?

Eating during labor Identify the problem Find the evidence Appraise the evidence Integrate evidence with

clinical expertise, patient values

Evaluate outcomes Disseminate

Eating during labor Explore, compare cultural

differences Compare differences in

practice by geographic region, type of hospital, birth center

Physiologic effects of restriction

DNP: Experts in EBP PhD: Experts in Research

QUALITY IMPROVEMENT (QI) VS. QUALITY IMPROVEMENT (QI) VS. PERFORMANCE IMPROVEMENT (PI)PERFORMANCE IMPROVEMENT (PI)

Often used interchangeably Useful to think of PI as a “drill down process” to look

at a specific problem that occurs with the implementation of EBP

OTHER THOUGHTS….OTHER THOUGHTS…. Research, quality improvement and evidence based

practice are integral to the delivery of quality patient care

Each informs the other and improves upon the other Each requires commitment, team work, vision, critical

thinking, creativity, leadership, energy and endurance “Doing the right thing” in each of these areas

contributes to an environment of excellence, quality patient care and clinician satisfaction…and sets you apart as an organization!

YOUR DNP PRACTICE INQUIRY PROJECTS What are your burning issues in health care, in

your advanced nursing practice (why are you here)?Implement innovationsApply evidence-based interventionsPropose changes to care delivery modelsImplement quality improvement projectsDevelop and implement health policy

You are a Change Agent !

Burns & Grove (2005). The Practice of Nursing Research (5th ed).St. Louis: Elsevier Saunders

Polit & Beck (2008). Nursing Research: Generating and Assessing Evidence for Nursing Practice. Philadelphia : Lippincott Williams & Wilkins

Melnyk & Fine-Overholt (2005). Evidence-Based Practice in Nursing & Health Care. Philadelphia: Lippincott Williams & Wilkins Roberts & Bourke (1989). Nursing Research: A Quantitative and Qualitative Approach.

Boston: Jones & Bartlett NONPF ACE Star Model: http://www.acestar.uthscsa.edu/Learn_model.htm Deming Model:

http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/

REFERENCES