MS CH 2 Evidence-Based Practice.pdf

4068_Ch02_012-018 15/11/14 12:31 PM Page 12 2 Evidence-Based Practice KEY TERMS BETTY ACKLEY evidence-based practice (EH-va-dense based PRACK-tis) randomized controlled trial (RAN-dumb-eyesd cun-TROLLD TRY-ull) research (re-SURCH) systematic review (SISS-tem-AT-ick re-VIEW) 12 LEARNING OUTCOM...

4068_Ch02_012-018 15/11/14 12:31 PM Page 12 2 Evidence-Based Practice KEY TERMS BETTY ACKLEY evidence-based practice (EH-va-dense based PRACK-tis) randomized controlled trial (RAN-dumb-eyesd cun-TROLLD TRY-ull) research (re-SURCH) systematic review (SISS-tem-AT-ick re-VIEW) 12 LEARNING OUTCOMES 1. Define evidence-based practice (EBP). 2. Discuss why EBP should be used. 3. Explain how to identify nursing evidence that should be put into practice. 4. Describe the EBP process. 5. List the six steps of EBP. 6. Identify the best method for oral care. 7. Identify who should give evidence-based nursing care, including when and where care should be given. 8. Describe how the Quality and Safety Education for Nurses (QSEN) project can promote safe patient care. 4068_Ch02_012-018 15/11/14 12:31 PM Page 13 Chapter 2 Amanda, an LPN, is caring for residents on Unit 4 in an extended care agency. One of the residents, Mr. Samuel, had a right-sided stroke and curr ently has a gastr ostomy tube through which a formula is administer ed 12 hours per day. He has halitosis, and his teeth look fuzzy . He curr ently receives oral care twice daily with or al foam swabs. Let’s explore with Amanda what the evidence says should be done for oral care for Mr. Samuel. (See discussion and answer s throughout the chapter.) Evidence-based practice (EBP) is a systematic process that employs current evidence to make decisions about patient care. It includes evaluation of the quality and applicability of existing research, patient preferences, costs, clinical expertise, and clinical settings (Meln yk et al, 2010). Evidence gi ves assurance that nursing practice will be ef fective. Using evidence-based nursing practice will increase your po wer to give the best nursing care possible. EBP involves much more than simply evaluating research (scientific study, investigation, or experimentation) to determine which results apply to nursing care. Clinical reality can be very different from a research setting. It could be unsafe to apply a research study that was done in a controlled laboratory environment to the very different environment found in an actual clinical situation. Or it could be unsafe to apply research results obtained on people of one age or medical diagnosis to those of another age or with multiple diagnoses. The context in which the evidence will be used must be considered. This includes the health care environment, the patient involved, the nurse’s expertise, and the cost. Using EBP is a complex process, but it is an important way to ensure quality care and optimal patient outcomes. REASONS FOR USING EBP The use of EBP allo ws nurses to give patients the best care possible, which is the goal of all caring nurses. The reasons Evidence-Based Practice 13 given for nursing care used to be “This is ho w it was taught in nursing school,” “This is what they told us in orientation,” or “That’s the way it is done here.” Now the rationale behind the best nursing care is “Nursing care is based on e vidence and how it applies to an indi vidual patient in a specif ic setting.” EBP is considered the gold standard of health care. Evidence-based outcome measurement is b uilt into the EBP process as a way to measure and confirm the value of a change in nursing practice. For example, nurses are measuring the number of ne w pressure ulcers, new cases of pneumonia, and new urinary tract infections in health care settings. Measuring outcomes as a part of EBP reenergizes nursing by helping nurses see the results of their nursing care. Measured outcomes show nurses that they are giving the best care possible, based on the evidence available at the time. Evidence comes from multiple sources. Medical research and research from many other professions such as psychology, gerontology, and social work are utilized, in addition to nursing research to develop EBP nursing care guidelines. IDENTIFYING NURSING EVIDENCE How do you identify nursing evidence that should be put into practice? It depends in part on the strength of the e vidence. Evidence ranges from strong to weak, and le vels can be assigned to rate its strength and quality. The rating scale used to label the quality of evidence ranges from Level I to Level IV (Table 2.1). Level I is the best evidence. It includes systematic reviews and analysis of many high-quality randomized controlled trials (studies designed to assess the effects of a variable by randomly assigning subjects to experimental, placebo, or control groups). Level IV evidence is the weakest and includes the non–research-based opinions of e xperts or published but non–research-based clinical articles. Two of the best known sources for Level I evidence are the Cochrane Reviews (www.cochrane.org/reviews) for medical e vidence and the TABLE 2.1 LEVELS OF EVIDENCE Level Level I Type of Evidence Systematic reviews, such as Cochrane Reviews and Joanna Briggs Best Evidence Guidelines Evidence from a systematic review of all relevant randomized clinical trials or evidence-based clinical practice guidelines that are based on systematic reviews of randomized controlled trials. Three or more randomized controlled trials of good quality that have similar results also have been considered Level I evidence. Level II Randomized controlled trials Evidence obtained from at least one well-designed randomized controlled trial. These are true experimental studies in which as many factors as possible that could falsely change the results are controlled. Level III Quasi-experimental studies Evidence obtained from quasi-experimental research studies. These studies do not control factors that could falsely change the results and, as a result, are less predictive of effectiveness of nursing care. Level IV Expert opinion Evidence from the opinion of authorities and/or reports of expert committees. Also nursing journal articles that are opinion based, not research based. 4068_Ch02_012-018 15/11/14 12:31 PM Page 14 14 UNIT ONE Understanding Health Care Issues Joanna Briggs Best Practice reviews (www.joannabriggslibrary .org/) for nursing practice. THE EBP PROCESS Evidence that guides nursing care can be used in tw o ways, generally based on whether the evidence is a dependent or an independent nursing intervention. Dependent nursing inter ventions are those that are delegated by a health care provider. Here any change in practice must go through a committee, such as the policy and procedure committee, to determine if it is appropriate for adoption. If the interv ention is independent, however, the nurse can implement an e vidence-based change based on personal knowledge of the value of the intervention, as long as the change is safe and cannot harm the patient. An example is the intervention of reality orientation. Excellent research shows that the use of reality orientation can improve thinking ability in patients with dementia and delirium. The nurse can implement this interv ention independently because it does not require an order . Other intervention examples include the use of hand massage, music therapy, and other anxiety-relieving interventions. A simplified version of the EBP process is discussed next and shown in Figure 2.1. The acronym “ASKMME!” Step 6 Evaluate the practice change. Step 5 Make it happen. Step 4 Measure outcomes before and after change. Step 3 Think critically. Step 2 Search for and collect the most relevant and best evidence available. Step 1 Ask the burning question. FIGURE 2.1 The six steps of the evidence-based practice process. (Source: Ackley, B. J., Ladwig, G. B., Swan, B. A., & Tucker, S. J. (2008). Evidence-based nursing care guidelines: Medical-surgical interventions. Philadelphia: Elsevier, with permission.) is designed to help you remember the six essential steps: Ask, Search, thinK, Measure, Make it happen, and Evaluate (Ackley et al, 2008). Step 1: Ask the Burning Question EBP begins with questioning the status quo, trying to solve a problem, or learning about new evidence that should be used in nursing practice. The initial question nurses often ask is, “Why do we do it that way?” or “How could we do this better?” Questioning the existing way of doing things is part of critical thinking. It helps ensure that the patient recei ves the best care possible. As a student nurse, you can do this as well. For Mr. Samuel, in the case study at the start of the chapter, Amanda was motivated to find the best way to give or al care, because her instincts told her the current care was not effective. Amanda took her clinical question to the policy and procedure committee and, working with members, they began the evidence-based process to find the best way to give or al care to all tube-fed patients at their agency. Step 2: Search for and Collect the Most Relevant and Best Evidence Available A thorough search of the literature in the subject area needs to be conducted. As a student nurse, you will f ind medical librarians most helpful. It is important that you learn basic computer skills so that you also have the ability to search the nursing and medical literature. Se veral databases can help you find journal articles and reviews. For nursing literature, the best known database is CINAHL, which stands for Cumulati ve Index to Nursing and Allied Health Literature (www.ebscohost.com/cinahl). CINAHL is available through college and hospital libraries. Evidencebased care sheets are a vailable on CINAHL. These sheets summarize current best practice on a specif ic topic. For best practice nursing reviews, visit the Joanna Briggs Best Practices website, which may be a vailable at the nearest nursing library. For medical literature, the comprehensi ve Medline/ PubMed database can be accessed at www.ncbi.nlm.nih.gov. Cochrane Reviews are a vailable at www.cochrane.org /reviews. An easy way to find Cochrane Reviews is to type in “Cochrane” when searching for a topic. Amanda worked with a medical libr arian and other members of her agency’s policy and procedure committee to conduct an EBP search on oral care. They then summarized the research articles they found in this area (Table 2.2). Step 3: Think Critically Always appraise the evidence you find for validity, relevance to the situation, and applicability. First, evaluate the quality of the evidence you find. It is helpful to determine the le vel of the evidence to make sure you have the best information available (see Table 2.1). Then, using critical thinking, evaluate the evidence as it applies to the indi vidual patient or patient population, the clinical e xpertise of the nurse(s) involved, the values in the situation, and agenc y policies that affect making a change in practice. 4068_Ch02_012-018 15/11/14 12:31 PM Page 15 Chapter 2 Evidence-Based Practice 15 TABLE 2.2 ORAL CARE FOR PATIENTS WHO ARE BEING TUBE FED Study Pearson, L. S., & Hutton, J. L. (2002). A controlled trial to compare the ability of oral foam swabs and toothbrushes to remove dental plaque. Journal of Advanced Nursing, 39(5), 480–489. Population 34 volunteers Interventions Group 1 received oral care in the a.m. using a toothbrush. Group 2 received oral care in the a.m. using oral foam swabs. Key Findings Use of toothbrushes for oral care was much more effective than foam swabs in removing plaque from the teeth. Leibovitz, A., Plotnikov, G., Habot, B., et al (2003). Pathogenic colonization of oral flora in frail elderly patients fed by nasogastric tube or percutaneous enterogastric tube. Journal of Gerontology Series A: Biological Sciences and Medical Sciences, 58(1), 52–55. 215 subjects (patients in long-term care facilities) Group 1: Patients fed via nasogastric (NG) tube had 81% pathogenic bacteria in mouth. Group 2: Patients fed by percutaneous enterogastric (PEG) tube had 51% pathogenic bacteria in mouth. Group 3: Patients fed orally had 17.5% pathogenic bacteria in mouth. Patients fed by NG tube had more pathogenic bacteria in their mouths than those fed by PEG tube or those fed orally. If oral secretions are aspirated, the risk of pneumonia increases. Adachi, M., Ishihara, K., Abe, S., et al (2007). Professional oral health care by dental hygienists reduced respiratory infections in older adults requiring nursing care. International Journal of Dental Hygiene, 5(2), 69–74. 190 subjects Experimental group received professional oral health care by dental hygienists. Control group received regular oral care. Oral care reduced pathogenic organisms in mouth, reduced fever above 103.5°F (37.9°C), reduced onset of influenza, and reduced fatal pneumonia. Panchabhai, T. S., Dangayach, N. S., Krishnan, A., et al (2009). Oropharyngeal cleansing with 0.2% chlorhexidine for prevention of nosocomial pneumonia in critically ill patients. Chest, 135(5), 1150–1156. 512 subjects Experimental group received oral care with chlorhexidine. Control group received oral care with 0.2% potassium permanganate. Both experimental group and control group had greatly decreased incidence of pneumonia as compared with “usual” oral care. Yakiwchuk, C., Bertone, M., Ghiabi, E., Brown, S., Liarakso, M., Brothwell, D. (2013). Suction toothbrush use for dependent adults with dysphagia: A pilot examiner blind randomized clinical trial. Canadian Journal of Dental Hygiene, 47(1), 15–23. 22 dysphagic subjects Experimental group received oral care using a suction toothbrush. Control group received oral care using a manual toothbrush. Both the experimental and control group demonstrated less plaque, decreased calculus, and improved gingival health after 1 month. Both groups also demonstrated a decreased incidence of pneumonia as compared with the usual rate of pneumonia in long-term care patients. 4068_Ch02_012-018 15/11/14 12:31 PM Page 16 16 UNIT ONE Understanding Health Care Issues Amanda found many research articles on the value of oral care, and the results were exciting. When the research was analyzed, it became obvious that tube-fed patients should have oral care with a soft bristle toothbrush and toothpaste. Because Mr. Samuels had trouble swallowing, it was also important that suction be r eadily available as or al care was given. Amanda discovered that there are suction toothbrushes and oral swabs for patients such as Mr. Samuels (Figure 2.2). The studies also found that inadequate oral care resulted in more than just halitosis and fuzzy teeth; it could r esult in pneumonia. Amanda felt a renewed sense of purpose. Step 4: Measure Outcomes Before and After Change Next, determine the patient outcomes that are likely to occur as a result of a change in nursing care. Usually, a small pilot study is done within the agenc y before an y widespread change in practice is made. That way, it can be determined if the change will be effective, as intended, when the change is implemented across the agency. The committee members decided to measure the number of new pneumonia cases in their agency, which is an important patient outcome. Step 5: Make It Happen Institute the desired change in nursing practice based on evidence. This is done through education and by setting up quality systems to ensure that the desired change is actually happening. The policy and pr ocedure committee de veloped an evidence-based procedure guideline for oral care of all patients, with a separate policy for tube-fed patients. The new policy and procedure was introduced and became a car e requirement for all patients at the agency. A quality audit was then done at intervals on selected patients to ensure the appropriate oral care was being given. Step 6: Evaluate the Practice Change Evaluation is the process used to determine if the change made a significant difference. What were the results of the initial small study? Was the change in practice ef fective in improving patient outcomes? If it did make a difference, was the difference worth the extra cost or time it required? Wow! Because of Amanda’s concern about or al care, a change had been made that impr oved the car e for e very patient. Also, after making the change in oral care and evaluating the outcome, it was clear that Amanda’s agency had a decrease in new-onset pneumonia. This was exciting and reinforcing to the committee, and especially to Amanda. WHO SHOULD PROVIDE EVIDENCEBASED NURSING CARE? All nursing care should be based on use of appropriate evidence, including care provided by nursing assistive personnel such as Competency Evaluated Nursing Assistants (CENAs). Evidencebased care should be gi ven at all times, if possible, and in all settings where nursing care is given. A good way to ensure that evidence-based care is provided by CENAs is to explain why the care should be given when the care is delegated. For example, when Amanda asks a CENA to give thorough oral care to a tube-fed patient with a toothbrush, she explains that research studies have shown that toothbrushing can help reduce the incidence of pneumonia in older adults. With this knowledge the CENA understands the importance of giving effective oral care. EBP, QUALITY, AND SAFETY: THEY BELONG TOGETHER! Multiple quality initiatives are currently ha ving a positive impact on health care. Insurance companies, b usinesses, patients, and the government are demanding quality care. All quality initiatives require collection of data, which is greatly facilitated by the health care agenc y having an EBP framework. Some quality initiatives are required, such as those of the Joint Commission that accredits health care agencies. Others are v oluntary but desirable for the agenc y’s wellbeing. All quality initiatives should begin with a literature search to determine the most effective interventions. Quality and Safety Education for Nurses Project The Quality and Safety Education for Nurses (QSEN) project focuses on nursing education that promotes the continual improvement of quality and safety in patient care. The goal is for students to develop understanding, attitudes, skills, and the desire to continually improve the quality and safety of patient care. Information on the QSEN project can be found at http://qsen.org. The development of teaching strate gies for nursing students involves six areas of focus: FIGURE 2.2 Oral suction toothbrush kit with thumb ports. (Courtesy of Sage Products, Cary, Illinois.) 1. Evidence-based practice: Look for Evidence-Based Practice boxes throughout the book. 4068_Ch02_012-018 15/11/14 12:31 PM Page 17 Chapter 2 2. Safety: We all want our patients to be safe! Many interventions are available that can help us reach this goal. Look for Be Safe! throughout the chapters and the section on safety in Chapter 3. 3. Teamwork and collaboration: These are important aspects of providing safe, quality care. In Chapter 3, you are introduced to members of the health care team with whom you may work and collaborate. For example, you may talk with the pharmacist if you have a question about a patient’s medication to ensure it is given safely, or you might alert the registered nurse to a change in a patient’s vital signs so that the physician can be informed for treatment orders. This illustrates teamwork to ensure that the patient receives safe, high-quality care. 4. Patient-centered care: When collaborating on the development of nursing care plans, it is important to individualize interventions to provide patientcentered care. As nursing interventions are performed, they should meet the patient’s needs and preferred schedules rather than those of the institution or caregiver. You will find Nursing Care Plans throughout the chapters, but always remember that no plan fits all patients. You will always evaluate each suggested intervention to see if it fits your patient and then individualize it to the patient’s needs. 5. Quality improvement: Quality improvement (QI) is an ongoing process to improve patient care (see Fig. 3.3). You might participate in a QI project by collecting data, which is one aspect of a QI project. 6. Informatics: Informatics is a growing area in health care because of the increasing use of technology to provide safer care. Examples you may use include computerized medical records, medication dispensing systems, medication barcoding systems, or computerized resources. Concern for Patient Safety Safety is on everyone’s mind. Many people know of someone who has been af fected by a medical error or who has been Evidence-Based Practice 17 unhappy with his or her care. As a result, guidelines to reduce errors in health care and impro ve patient outcomes have been developed and based on e vidence when available. The Joint Commission’s 2014 National Patient Safety Goals can be found at www.jointcommission.org. As you will see at the website, these goals address care in various types of health care settings. BE SAFE! One important safety goal is to use at least two ways to identify patients—but not the patient’s room number or location—when providing care, treatment, or services. This is because wrongpatient errors occur in virtually all stages of diagnosis and treatment. The intent for this goal is twofold: first, to reliably identify the patient as the person for whom the service or treatment is intended; second, to match the service or treatment to that patient (© The Joint Commission, 2013. Reprinted with permission.). You will f ind other 2014 Joint Commission national patient safety goals in the Be Safe! feature throughout the text of this book. These goals are included to increase your awareness and understanding of patient safety. They address important areas of concern, such as administering medications safely, identifying patients correctly, identifying operative sites correctly, improving communication, reducing fall injuries, and reducing the risk of infection in institutionalized older persons, to name a few. You will want to become familiar with them and to look for updates at the Joint Commission website. Of course, it tak es critical thinking to use them at the right times and in the right circumstances. Using them appropriately helps you provide safer care with fewer errors. EBP is critical thinking at its finest, working to determine the best care for the patient based on the evidence. The evidence provides core information to direct safe, quality-dri ven, excellent patient care. REVIEW QUESTIONS 1. The nurse requests the CENA to provide oral care to a patient. Which of the following methods of request by the nurse would be most appropriate to achieve evidencebased care? 1. Request that oral care be given with use of a toothbrush and toothpaste. 2. Instruct the CENA to give oral care using oral swabs to clean the teeth and mouth. 3. Ask the CENA to have the patient use a mouthwash rinse for daily oral care. 4. Explain that use of a toothbrush and toothpaste decreases pneumonia in older adults. 2. The nurse is contributing to the plan of care for a patient. In considering appropriate care, the nurse bases the care on which of the following to provide excellent care? 1. Content taught throughout a nursing educational program. 2. Orientation to the health care agency for new employees. 3. A nurse’s personal judgment of what is best for each patient. 4. Evidence that is evaluated for the health care agency and each patient. 4068_Ch02_012-018 15/11/14 12:31 PM Page 18 18 UNIT ONE Understanding Health Care Issues 3. A policy and procedure committee is reviewing evidence for a new policy. When considering the evidence, which of the following sources would generally be safest for a health care agency to implement? 1. A Joanna Briggs Best Practices Guideline. 2. One randomized controlled trial. 3. Four quasi-experimental studies that show similar results. 4. The opinion of a national nursing expert on the subject. 4. The nurse reads about a research study that affects nursing care and could lead to decreased wound infections. Which of the following actions should the nurse take regarding the information in the study? 1. Put the information into practice while performing wound care. 2. Discuss the research with a trusted coworker and, if the coworker agrees, put the information into practice at work. 3. Present the proposed practice change to the policy and procedure committee at work for evaluation and possible adoption. 4. Do a journal search to look for similar studies, and if three similar studies are found, incorporate the information into practice. References Ackley, B. J., Ladwig, G. B., Swan, B. A., & Tucker, S. J. (2008). Evidence-based nursing care guidelines: Medical-surgical interventions. Philadelphia: Elsevier. Joint Commission. (2013). Joint Commission’s 2014 National Patient Safety Goals. Retrieved July 6, 2013, from www .jointcommission.org/standards_information/npsgs.aspx Melnyk B. M., Fineout-Overholt, E., Stillwell S. B., Williamson, K. M. (2010). Evidence-based practice: Step by step. The seven 5. A policy and procedure committee is revising the nursing intervention of insertion of a urinary catheter. Where should the committee begin looking for evidence to write an effective policy and procedure on this intervention? 1. In current nursing skills textbooks. 2. In nursing articles written by national nursing experts based on opinion. 3. In research articles, preferably systematic reviews of randomized controlled trials. 4. In the policies and procedures of other nursing facilities. 6. A nurse is preparing to give oral care to a patient who is receiving a tube feeding. Which of the following is the best evidence-based method to give oral care? 1. Use oral foam swabs with mouthwash and then swab the teeth and the mouth. 2. Use a soft toothbrush and toothpaste to brush the teeth. 3. Use a tongue scraper to remove debris from the tongue twice daily. 4. No oral care is needed for a patient who is receiving tube feedings. Answers can be found in Appendix C. steps of evidence-based practice: following this progressive, sequential approach will lead to improved health care and patient outcomes. American Journal of Nursing, 110(1), 51–53. For additional resources and information visit davispl.us/medsurg5