N494-M1

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Chapter 1

Making the Case for Evidence-Based Practice and Cultivating a Spirit of Inquiry

The Three Components of EBP

A lifelong problem-solving approach to clinical practice that integrates

Critical appraisal and synthesis of the most relevant and best research (external evidence)
One’s own clinical expertise, which includes internal evidence generated from outcomes management or quality improvement projects, patient assessment, and evaluation
Patient preferences and values

Types of Evidence Used in EBP

External evidence

Evidence generated through rigorous research (e.g., RCTs and cohort studies) that is intended to be generalized to and used in other settings

Internal evidence

Evidence typically generated through practice initiatives such as outcomes management or quality improvement projects that are not intended to be generalized to other clinical settings

The Components of EBP and Types of Evidence Used

Question

Is the following statement true or false?

Finding a quasi-experimental study in a peer-reviewed nursing journal article that tests a protocol for the frequency of turning for immobile patients is an example of external evidence.

Answer

True

Rationale: External evidence includes peer-reviewed publications that present the findings of research and are intended to be generalized to other clinical settings.

The Origins of Evidence-Based Practice

Concept began when Dr. Archie Cochrane published a report in 1972 for the Nuffield Provincial Hospitals Trust that demonstrated how slow the medical profession was in using published evidence to change practice

Cochrane died in 1988, and the Cochrane Center Collaboration was established in 1992 in his name to assist healthcare professionals in making clinical decisions based on the best external evidence

One of the best known sources of systematic reviews website: http://www.cochrane.org

Why Evidence-Based Practice (EBP)?

The focus of healthcare reform in the United States encompasses what is known as the Institute of Healthcare Improvement’s “Triple Aim,” which includes:

Enhancing the experience of care for those served
Improving the health of populations throughout the nation
Reducing per capita costs of national health care

( http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx)

EBP has been shown to be useful in reaching these aims

Examples of Initiatives to Advance EBP

Institute of Medicine’s Roundtable on Evidence-Based Medicine: The IOM set a goal that by 2020, 90% of clinical decisions will be supported by external evidence ( http://www.iom.edu/Activities/Quality/VSRT.aspx)
Preventive Services Task Force (USPSTF): Independent panel of experts who develop recommendations from best available external evidence for clinical preventive services, including screening, counseling, and preventive medications ( http://www.uspreventiveservicestaskforce.org)

Examples of Initiatives to Advance EBP—(cont.)

The Patient-Centered Outcomes Research Institute (PCORI): Authorized by Congress to produce and promote high-integrity, research-based information to help patients and their healthcare providers make more informed decisions ( http://www.pcori.org)
Magnet Recognition Program by the American Nurses Credentialing Center (ANCC): The program fosters EBP, as conducting research and using EBP are critical for attaining Magnet status ( http://www.nursecredentialing.org/Magnet)

Steps of the EBP Process

0. Cultivate a spirit of inquiry within the environment

1. Ask the burning clinical question in PICOT format

Search for and collect the most relevant best evidence
Critically appraise the evidence (i.e., rapid critical appraisal, evaluation, and synthesis)

4. Integrate the best evidence with one’s clinical expertise and patient preferences and values in making a practice decision or change

5. Evaluate outcomes of the change

6. Disseminate the outcomes of the evidence-based change

Step 0: Cultivate a Spirit of Inquiry Within the Environment

Key elements of an EBP culture and environment include:

● A spirit of inquiry

● A philosophy, mission, clinical promotion system, and evaluation process that incorporate EBP

● Knowledgeable EBP mentors

● An infrastructure that provides support in using EBP

● Administration and leadership that supports, values, and models EBP

● Consistent recognition of individuals and groups who implement EBP

Step 1: Ask the Burning Clinical Question in PICOT Format

Patient population
Intervention or issue of interest
Comparison intervention
Outcome
Time frame

Example: “In teenagers (patient population), how does cognitive-behavioral skills building (intervention) compared with yoga (comparison) affect anxiety (outcome) after 6 weeks of treatment (time frame)?”

Step 2: Search for and Collect the Most Relevant Best Evidence—Hierarchy of Evidence

Level I: Systematic reviews or meta-analyses of RCTs
Level II: Single RCTs
Level III: Controlled trials without randomization
Level IV: Case–control and cohort studies
Level V: Systematic reviews of descriptive and qualitative studies
Level VI: Single descriptive or qualitative studies
Level VII: Opinion of authorities and/or reports of expert committees/panels

Question

Is the following statement true or false?

A single randomized controlled trial (RCT) constitutes the highest level of evidence and is the most reliable guide to nursing practice.

Answer

False

Rationale: Meta-analyses and systematic reviews that synthesize the results of multiple RCTs or experiments are considered to be the highest form of evidence. A single RCT is classified as Level II evidence.

Step 3: Critically Appraise the Evidence

Critical appraisal of external evidence includes three areas of evaluation:

1. Are the results of the study valid? (Validity) Did the researchers conduct the study using the best research design and methods possible?

2. What are the results? (Reliability)

In quantitative research

Did the intervention work, and if so, how large was the effect? Can the results be generalized?

In qualitative research

Does the research approach fit the purpose of the study?

Step 3: Critically Appraise the Evidence— (cont.)

3. Will the results help me in caring for my patients? (Applicability) Are the subjects in the study similar to the patients for whom I care? Are the benefits greater than the risks of treatment? Is the treatment feasible to implement in my practice setting? Would my patients readily accept the treatment and do they have the resources needed?

Determining if Evidence Should Be Used to Make a Practice Change

Once an environment conducive to EBP is established, it needs to be remembered that the confidence to make an evidence-based change comes from a combination of:

Level of the evidence +	Quality of evidence =	Strength of evidence
(position of evidence in hierarchy)	(validity + reliability + applicability)	(confidence)

Step 4: Integrate the Best Evidence With Clinical Expertise and Patient Preferences

This step is the synthesis of the external and internal evidence, the practitioner expertise, and the patient/family preferences that produces the implementation of a practice change
Patients’ histories and circumstances have a significant bearing on the choice of practice changes
Availability of resources must also be considered

Question

An obstetrical nurse wants to implement a body of evidence related to fetal monitoring practices on the unit. What is the first step that this nurse should take?

Review the literature about fetal monitoring practices
Consult with the expert nurses on the unit
Begin to foster an attitude of curiosity in the OB staff
Evaluate the outcomes of current practices

Answer

c. Begin to foster an attitude of curiosity in the OB staff

Rationale: Cultivating an attitude of inquisitiveness, curiosity, and inquiry is foundational to the EBP process and is considered to be “step 0.” Although reviewing the literature and evaluating the current outcomes is important, if nurses are not open to questioning their practice, change will probably not occur. Consulting with the unit experts is a wise move but only if it is in an attempt to gain support for a practice change.

Step 5: Evaluate Outcomes of the Practice Decision or Change Based
on Evidence

Outcomes measurement determines whether the evidence-based change resulted in the expected outcome in the clinical practice setting

Step 6: Disseminate the Outcomes of the Evidence-Based Decision or Change

For change to be sustainable, outcomes need to be shared with project stakeholders
Internal communication strategies can include e-mail messages, reports at unit/department meetings, dashboards, and scorecards
External communication strategies include podium or poster presentations at conferences and professional publications

Question

A group of nurses have successfully implemented a new evidence-based protocol related to postoperative patient assessment. What is the next step for this project?

Tell others about the results of their project
Elicit feedback from patients and other stakeholders
Evaluate the costs of the change in practice
Search the literature for research that relates to the practice change

Answer

a. Tell others about the results of their project

Rationale: The EBP process culminates with the dissemination of results. Searching the literature, consulting with patients, and evaluating costs are actions that should already have been performed earlier in the EBP process.

Common Barriers to Using Evidence- Based Practice

Lack of administrative/management support and mentors
Resistance to change
Misperceptions or negative attitudes about EBP
Lack of EBP knowledge and skills
Lack of autonomy over practice and lack of incentives

Strategies to Eliminate Barriers to Using Evidence-Based Practice

Establishing a clear philosophy and organizational vision in which EBP is valued and expected
Developing a strategic plan to create a culture and environment that fosters EBP
Dispelling misperceptions about EBP
Teaching the basics of EBP
Encouraging questions about currently used clinical practices

Question

In performing a rapid critical appraisal of a research study as evidence, which three factors are the most important to be evaluated?

a. Study validity, study veracity, study strength

b. Study validity, study reliability, study confidence

c. Study validity, study reliability, study applicability

d. Study validity, study strength, study reproducibility

Answer

c. Study validity, study reliability, study applicability

Rationale: Terms in the incorrect distractors include study strength, which is actually derived from the study validity and reliability; study confidence, which results from the appraisal of the strength of the study; and study reproducibility, which is a component of study reliability.