Improving Care Through Research, Evidenced

Report
EVIDENCE-BASED PRACTICE:
WHAT’S IN IT FOR YOU?
Sharon Bond, PhD, CNM
Associate Professor
Special Thanks to:
Barbara J. Edlund RN, PhD, ANP, BC
Professor
College of Nursing, MUSC
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!

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
DELIVERY!




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 questions
2. one’s clinical experience and expertise
3. patient preference and values

LEVELS OF EVIDENCE

I
II
 III
 IV


V
VI
 VII

Evidence - Systematic reviews, meta-analysis
RCTs, EB clinical practice guidelines based on RCTs
Evidence - One well designed RCT
Evidence - CTs without randomization
Evidence - Well-designed case control or cohort
studies
Evidence - Systematic reviews of descriptive or
qualitative studies
Evidence - Single descriptive or qualitative study
Evidence – Opinions of authorities, reports of
experts
EVIDENCE-BASED PRACTICE
The 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
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: 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 evidencebased 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 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 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 working

NONPF
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 MODEL

Plan
- Test objectives
- Who will do what
- Predict outcomes



Do
- What happened
- Did it work
Study
- Analyze outcomes in context of predicted
- Summarize lessons learned
Act
- What modification needs to be made
- Statement of new plan ….. PDSA cycle repeats
NATIONAL GUIDELINES OR
BENCHMARKS
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
PRACTICE
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 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:
WHEN EVIDENCE IS NOT THERE/NOT SUFFICIENT
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 study
1 - 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…..
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?
DNP: Experts in EBP
PhD: Experts in Research
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
QUALITY IMPROVEMENT (QI) VS. 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….
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 innovations
 Apply evidence-based interventions
 Propose changes to care delivery models
 Implement quality improvement projects
 Develop and implement health policy
You are a Change Agent !
REFERENCES
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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/

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