How to read this presentation • On each slide, click on speaker icon twice to hear narration. In case the sound is not sufficiently loud, then use headphones. EEWR Mentoring & Assessing in Healthcare Settings (module 308CPD) – E-Learning programme SUPPORTING AND DEVELOPING PROFESSIONAL PRACTICE - I Evidence-Based Practice Research Implementation Practice Development Presenter: Neil Gopee Identifying the NMC (2008) outcomes for mentor that address EBP i) Comes under NMC (2008) domain: Evidence-based practice Competence: Apply evidence-based practice to their own work and contribute to the further development of such a knowledge and practice evidence base. Outcomes • Identify and apply research findings and evidencebased practice to their area of practice. • Contribute to strategies to increase or review the evidence-base used to support practice. • Support students in applying an evidence base to their own practice. Activity 1: If working in pairs or 3s, take 3-5 mins Do a brainstorm / ideas generation exercise and identify all the reasons you can think of, for EBP in nursing, midwifery or in your allied health profession. WHY EBP, clinical practice development , ……? Under Stage 1 ‘Nurses & Midwives’ outcomes (NMC, 2008) Evidence-based practice Further develop their evidence base for practice to support their own personal and professional development and to contribute to the development of others. Context of practice Whilst enhancing their own practice and proficiency, as a registered nurse or midwife, (the RN must) act as a role model to others to enable them to learn their unique professional role. WHY …. Benefits of EBP Kopp (2001) - through EBP, healthcare professionals can: • Instigate appropriate and up-to-date interventions. • Inform or advise patients more accurately. • Make better use of limited resources. • Measure practice against appropriate guidelines or standards. • Provide a more informed decision-making process to previously untreatable or more expensive treatments. … practice risks becoming tyrannised by evidence, but without available evidence, practice risks becoming rapidly out of date to the detriment of patients’ (Sackett et al, 1996 p71). EVIDENCE-BASED PRACTICE - definitions Evidence-based practice (EBP) is a problem-solving approach to clinical practice that integrates a systematic search for, and critical appraisal of, the most relevant evidence to answer a burning clinical question, one's own clinical expertise, patient preferences and values (Melnyk and Fineout-Overholt, 2005). WHAT is EVIDENCE-BASED PRACTICE (EBP), EBHC, EBM, …. • EBP refers to single clinical interventions (by nurse / midwife / doctor / AHP) • Evidence-based healthcare (EBHC) tends to refer to groups of patients, a health problem / an illness that affects many • Evidence-based medicine (EBM) • Evidence-based nursing (EBN) • Evidence-based management • Evidence-based education • Evidence-based assessment • …. Definitions of EBHC, EBN • Evidence-based healthcare (EBHC) is an approach to decision-making in which the clinician uses the ‘best evidence’ available (Gray, 2001). • Evidence-based nursing (EBN) is ‘an ongoing process by which evidence, nursing theory and the practitioners’ expertise are critically evaluated and considered, in conjunction with patient involvement, to provide delivery of optimum nursing care for the individual’ (Scott and McSherry, 2009 p1089). • EBN refers to holistic clinical interventions that are based on information that is available from valid and reliable relevant research, national clinical guidelines, and expert healthcare professionals (Gopee, 2010 p73) Classification of evidence (in EBP) as grades, levels or types of evidence e.g. Bandolier’s (2001 p6) hierarchy of evidence I–1: Systematic review of several double-blind randomised control trials (RCT) I–2: One or more large double-blind randomised control trials II–1: One or more well-conducted cohort studies II–2: One or more well-conducted case-control studies II–3: A dramatic uncontrolled experiment III: Expert committee sitting in review; peer leader opinion IV: Personal experience Systematic review of several double-blind randomised control trials One or more large double-blind randomised control trials One or more well-conducted cohort studies. One or more well-conducted case-control studies A dramatic uncontrolled experiment Expert committee sitting in review; peer leader opinion Personal experience Bandolier’s (2001 p6) hierarchy of evidence See also: Joanna Briggs Institute (2008) JBI Levels of Evidence. Why identify and apply research findings NMC (2008) outcomes for mentors – under ‘Evidence-based practice’: ‘Identify and apply research and evidence based practice to their area of practice’. NMC (2004) ‘Standards of proficiency’ for pre-registration nursing course under ‘care delivery’ CFP • access and discuss research and other evidence in nursing and related disciplines • identify examples of the use of evidence in planned nursing interventions Branch • ensure that current research findings and other evidence are incorporated in practice • engage with, and evaluate, the evidence base that underpins safe nursing practice. How identify and apply research By: • Critical appraisal or systematic reviews • Dissemination • Management of change • … Activity 2: Examples of EBP in your workplace Examples of EBP in your workplace 1 2 3 4 5 Activity 3 Make a list of different sources of critically appraised / systematically reviewed evidence. Different sources of research evidence Reports held locally Published papers Dissertations held in universities Local presentation National presentation International presentation Unfinished / ongoing research … EVIDENCE-BASED HEALTHCARE Possible sources of evidence that can be used to inform clinical practice • • • • Randomised controlled trials (RCT) Qualitative studies Personal intuition Policy directives (from local sources/central/ local govt legislation) • Textbooks • Own professional education Different sources of evidence • Cochrane library • Bandolier (based in Oxford), JBI, • MEDLINE, CINAHL, PUBMED, … • … Q7: HOW …. -Typical headings for critiquing a research study are (Gopee, 2011 p145): • How clear and specific is the research question? • Was the research funded by a particular organisation and, if so, does the researcher hold any allegiance to them? • Is the research design the most appropriate to answer the research question? • Are the sampling strategies the most appropriate? • Precisely what was measured? • Precise details and relevance of how the data was collected. • How researcher effects and other intervening variables were controlled. • Was the framework or method used for analysing the data the most appropriate? • Are the statistical tests used appropriate and accurately documented? • Are the conclusions drawn logically argued and is the generalisability statement justifiable? • To what extent is the study relevant to clinical practice in the particular practice setting? • Does the dissemination of the study indicate frameworks for implementation, including resources required such as costs? What is a systematic review? A systematic review comprises finding all relevant studies, published and unpublished, assessing each study, synthesising the findings from individual studies in an unbiased way, and presenting a balanced and impartial summary of the findings with due consideration of any flaws in the evidence (Bandolier, 2001 p1). Such systematic reviews usually provide a quantitative estimate … also termed meta-analysis. [see Gopee 2010] EVIDENCE-BASED PRACTICE – However, what are the problems you encounter with implementing EBP? Randomised controlled trials (RCTs) should not be seen as the 'gold standard' for all evidence. Best evidence should be judged by that which helps the individual patient / client, not just scientific evidence (Clarke, 1999). Barriers to implementation of EBP (Kopp, 2001): … are similar to those that present as obstacles to implementation of research findings, e.g. a lack of: • Awareness of evidence • Self-confidence • Peer support • Resources. Main barriers to using and developing EBP skills (Morris & Maynard, 2007; Palfreyman, et al 2003): Time and the practice setting’s culture. Identify the NMC (2008) outcomes for mentor that address PD i) Under NMC (2008) domain: Context of practice Competence: Support learning within a context of practice that reflects healthcare and educational policies, managing change to ensure that particular professional needs are met within a learning environment that also supports practice development. Outcomes: • Contribute to the development of an environment in which effective practice is fostered, implemented, evaluated and disseminated. • Set and maintain professional boundaries that are sufficiently flexible for providing inter-professional care. • Initiate and respond to practice developments to ensure safe and effective care is achieved and an effective learning environment is maintained. CLINICAL PRACTICE DEVELOPMENT What is PD? – definitions Clinical practice development is to do with developing clinical practice, i.e. hands-on patient care for particular components of nursing or midwifery? Practice development is taken to mean a broad range of innovations that are initiated to improve practice and the services in which that practice takes place (Bryar & Griffiths 2003). Practice development is a continuous process of improvement towards increased effectiveness in person-centred care, through the enabling of nurses and healthcare teams to transform the culture and context of care. It is enabled and supported by facilitators committed to a systematic, rigorous and continuous process of emancipatory change (McCormack et al 1999 p256). Activity 4 Think of care and treatment in general, and then within your own specialism, and try and identify specific changes in hands-on patients and service user care that have occurred recently or over the last 2 to 3 years. Examples of changes in - HANDS-ON CLINICAL PRACTICE, PATIENT TEACHING & ORGANISING / MANAGING CARE CLINICAL PRACTICE • No lift policy • Cognitive behaviour therapy • Using tympanic thermometers rather than glass thermometers. • Bedside handover • Treatment of leg ulcers – using Doppler machine • Red tray/green tray • Single Assessment Process (SAP) • MEWS – modified early warning score • Cardio-pulmonary resuscitation techniques • … [add your own] ‘How’ to develop practice Unsworth’s (2000) - critical attributes of practice development: • New ways of working which lead to a direct measurable improvement in the care or service to the client. • Changes which occur as a response to a specific client need or problem. • Changes which lead to the development of effective services. • The maintenance or expansion of business/work. Titchen (2003) - 3 overarching themes for effective practice development: (i) changing the practice philosophy, (ii) the process of change in practice, and (iii) investing in professional development. CHANGE STRATEGIES – How to introduce change MANAGEMENT OF CHANGE - If not ‘Management of change’, then what is it? • Imposed change • Unplanned change • Change of lifestyle / behaviour as in health education (role of the nurse) – Prochaska & Diclemente (1983) ‘Stages of Change model’: Pre-contemplation – aware of the change >>Thinking about the change >>Preparing to change >>Making changes >>Maintaining change >>Possible relapsing Recognition Analysis Preparation Strategies Implementation Evaluation Sustaining The 7-step RAPSIES framework for managing change effectively (Figure 4.2 of Gopee and Galloway, 2009) The RAPSIES framework for effective change management (Gopee & Galloway, 2009) RECOGNITION of the need for change to solve a problem, or to improve an element of practice. ANALYSIS of the available options related to the contemplated change. PREPARATION for the change, e.g. identifying a change agent, education, & involving relevant colleagues. STRATEGIES for implementing the change. IMPLEMENTATION of the change including piloting the change, and timing of implementation. EVALUATION of the impact of the change. SUSTAINING the change, i.e. how to ensure the change endures and is mainstreamed. CHANGE STRATEGIES a) Empirical-rational b) Power-coercive c) Normative-re-educative d) Combined e) Lewin’s 3-stage process of change e) Lewin's 3-stage process of change (in Mullins 2010 p912): Lewin's 3-stage process • Unfreezing • Movement • Refreezing Barriers to implementing research findings Activity 5 • What are the barriers to implementation of change in your clinical setting? • What mechanisms [levers] are available to overcome some of these barriers? Implementation, evaluation and sustaining change. Summary In summary, this presentation on Supporting and Developing Professional Practice as a mentor competence area entailed exploring Evidence-Based Practice, Research Implementation and Practice Development. FURTHER READING Gopee N, Galloway J (2009) Leadership and Management in Healthcare. London, SAGE Publications Gopee N (2010) Practice Teaching in Healthcare. London, SAGE Publications Gopee N (2011) Mentoring and Supervision in Healthcare (2nd edn). London, SAGE Publications Joanna Briggs Institute (2008) JBI Levels of Evidence. Available from: http://www.joannabriggs.edu.au/About%20Us/JBI%20Appr oach/Levels%20of%20Evidence%20%20FAME(accessed 29th August 2011). Morris J, Maynard V (2007) The value of an evidence-based practice module to skill development. Nurse Education Today, 27 pp534541 - Research on sources of knowledge used for informing professional practice REFERENCES – for SDPP Bandolier (2001) What is a systematic review? 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