Chpter 5.pdf

9/25/2022 Chapter 5 Evidence-Based Practice Dr. Asomani 1 Evidence-Based Practice Evidence originates from research findings Evide...

9/25/2022 Chapter 5 Evidence-Based Practice Dr. Asomani 1 Evidence-Based Practice Evidence originates from research findings Evidence-based practice decisions involve Clinician Convincing body of evidence Patient preferences and values See box 5.1, Key Steps in Implementing Evidence-Based Practice 2 Aims of Nursing Research for Clinical Practice Systematic pursuit of knowledge to answer questions of import Generate understanding and validation of existing knowledge Conduct studies to develop a body of nursing knowledge E B P: gathering information from published literature to make decisions about its application to clinical practice Considerations about evidence 3 1  9/25/2022 A Brief History of Evidence-Based Practice Origins traced back to Archie Cochrane Encourage medical profession to establish a collection of R C T’s to validate rigor of published research First conceptualized by nursing as research utilization (R U) Stetler Model Evolution into concept of E B P 4 Development of Best Practice Guidelines Traditional approach Common practice is correct practice Appropriate in the past—fewer diagnostic tests or interventions Today’s approach Developed from scientific evidence Framework for creation of guidelines 5 Development of Best Practice Guidelines (continued_1) Agency for Healthcare Research and Quality Lead the way for E B P Mission of A H R Q Improve quality, safety, efficiency, and effectiveness of health care for all Americans Guideline use Reference for health-care providers Framework for insurance utilization review  Quality assurance and reimbursement Influencing malpractice litigation outcomes 6 2  9/25/2022 Development of Best Practice Guidelines (continued_2) Implementing A H R Q Guidelines Overcoming barriers Evidence-based practice centers—private-public partnership  Produce evidence on topics from providers  Provide evidence for use in guidelines National Guideline Clearinghouse  Electronic repository for guidelines Research and evaluation activities to develop guidelines, implementation strategies, and outcome- based research 7 Applying Clinical Practice Guidelines to Clinical Practice Practice standards and guidelines Standards relate to a framework for practice Inflexible Intended for use in all circumstances Guidelines focus on individual patient care decisions Provide a reference point and general direction for decision making Deviation only with a clear rationale for an individual 8 Applying Clinical Practice Guidelines to Clinical Practice (continued) Practice standards: intended to be used under all circumstances and define correct overall practice A N A types of standards Practice guidelines: intended to provide a reference point and general direction for decision making 9 3  9/25/2022 Development of Evidence-Based Practice Guidelines and Grading of Evidence Essential elements Identification of the topic Expert panel Systematic review of the literature—with rating of literature Development of evidence-based tables Draft of recommendations based on the evidence External review of recommendations Final acceptance of the revised recommendation 10 Research Designs for Level One Evidence Systematic review or meta-analysis of R C T’s Highest level of evidence to base a change in practice Searches all R C T’s that address similar clinical question Compiles the studies Cochrane Library has extensive compilation 11 Research Designs for Level Two Evidence Single well-designed R C T Establishes cause of a disease Efficacy of a treatment or intervention Maintains high degree of control with experimental conditions Random assignment allows for high degree of confidence Double-blinding further strengthens support for cause- and-effect relationships 12 4  9/25/2022 Research Designs for Level Three Evidence Well-designed controlled trials without randomization Evaluate effectiveness of intervention or treatment Subjects are not randomly assigned Attempt to improve internal validity with control of extraneous variables and standardization of treatment 13 Research Designs for Level Four Evidence Well-designed case control or cohort studies Useful for answering clinical questions related to prognosis or causation Compare those with the disease to those without the disease Prior exposures Course of disease observed without interference Observation studies 14 Research Designs for Level Four Evidence (continued) Risks introducing bias with no case-control in study Most commonly used epidemiological design currently in literature 15 5  9/25/2022 Research Designs for Level Five Evidence Systematic reviews of descriptive or qualitative studies Portray characteristics of a population or clinical situation Quantitative or qualitative Quantitative—measurable characteristic Qualitative—increasing understanding of the phenomena of the clinical question 16 Research Designs for Level Six Evidence Single descriptive or qualitative study Case study Likelihood of decreased objectivity Utilize to Alert to an adverse event Alert to a rare disease Add to provider’s knowledge base No inferences can be made to general population 17 Research Designs for Level Seven Evidence Opinion of authorities and/or expert committees This follows the tradition approach May or may not be based on strong evidence Should not be a sole determination of changing practice May be the only evidence in rare situations 18 6  9/25/2022 Evaluation of Clinical Practice Guidelines A provider should ask: Who created the guideline? What date is the revision? Is the guideline clinically important? How strong are the recommendations? How strong is the available evidence? Is the guideline applicable to my patient? 19 Evaluating the Evidence to Change Practice Critical to distinguish between intermediate and clinical outcomes before applying research findings to practice Improvement in intermediate outcomes does not necessarily lead to improvements in clinical outcomes Example: use of angiotensin-converting enzyme (A C E) inhibitors in patients with congestive heart failure (C H F) 20 Developing a Point-of-Care Strategy Asking a clinical question Having evidence resources readily available Completing the search using those resources Examining the results of the search Applying the findings to the individual patient 21 7  9/25/2022 Building the Evidence for Practice National Institute for Nursing Research Aligned nursing science with other institutes in N I H Increased federal funding for nursing research Many methods of knowing Combination of methods 22 Clinical Decision Making and the Patient’s Health-Care Decisions First, determine the outcome the patient is desiring Collect and analyze evidence Make a judgment on intervention ability for health outcome desired by the patient 23 8