Chapter 5: EBP
Chapter 5: Evidence-Based Practice
Copyright © 2023, Elsevier Inc. All Rights Reserved.
The Need for Evidence-Based Practice
Definition of Evidence-Based Practice (EBP):
A problem-solving approach in clinical practice that integrates:
Best evidence from research studies.
Clinician’s expertise.
Patient preferences and values.
Available health care resources for decision-making concerning patient care.
Sources of Best Scientific Evidence:
Well-designed and systematically conducted research studies, typically published in scientific, peer-reviewed journals.
Examples of Evidence-Based Clinical Decision Making
Research Evidence:
Implement repositioning every two hours based on studies indicating it reduces pressure ulcers.
Patient Assessment & Resources:
Refer a heart failure patient to a specialized program after assessing signs of increased fluid retention.
Clinical Expertise:
Recognize early symptoms of sepsis in a patient, leading to timely intervention from clinical experience.
Patient Preferences:
Support a terminal cancer patient in opting for palliative care instead of aggressive treatment.
Steps of Evidence-Based Practice
Overview of Steps:
Cultivate a spirit of inquiry.
Formulate a clinical question in PICOT format.
Search for the best evidence.
Critically appraise the evidence.
Integrate the evidence into practice.
Evaluate outcomes of the practice decisions or changes.
Communicate the outcomes of the evidence-based practice decisions.
Step 1: Cultivate a Spirit of Inquiry
Description:
Engage in an attitude of questioning; foster curiosity and openness to learning for improving patient outcomes.
Identify knowledge gaps and value continuous research-oriented mindset.
Example:
A nurse observing that patients with central lines often develop phlebitis explores alternative antiseptic solutions for enhanced effectiveness in infection reduction.
Step 2: Ask a Clinical Question in PICOT Format
PICOT Format Breakdown:
P = Patient population of interest
I = Intervention of interest
C = Comparison of interest
O = Outcome of interest
T = Time frame for observation
Purpose:
Narrow and specify research to relevant clinical concerns.
Example Clinical Questions:
"In adult ICU patients with central lines (P), how does chlorhexidine (I) compared to povidone-iodine (C) affect the rate of phlebitis (O) over 30 days (T)?"
"Does hand hygiene compliance (I) among healthcare workers decrease the incidence of hospital-acquired infections (O) in adult patients (P) when measured over a 6-month period (T) compared to baseline infection rates (C)?"
Step 3: Search for the Best Evidence
Sources of Evidence:
Agency Policy:
Internal regulations ensuring compliance with clinical standards; e.g., protocols for central line care.
Procedure Manual:
Guidelines for clinical procedures promoting safety and consistency; e.g., protocol for urinary catheter insertion.
Quality Improvement Data:
Results from initiatives aimed at enhancing patient care; e.g., data showing reduced pressure ulcer rates.
Clinical Practice Guidelines:
Recommendations by professional organizations based on systematic reviews; e.g., CDC guidelines for infection prevention.
Journal Articles:
Peer-reviewed studies and reviews providing contemporary evidence; e.g., research on advanced wound dressings.
Ask Experts:
Consult healthcare professionals, educators, and librarians for assistance with research evidence and interpretation.
Step 4: Critically Appraise the Evidence
Description:
Evaluate the research's quality, validity, and relevance.
Assess whether the evidence warrants implementation in practice considering any limitations or biases.
Example:
A nurse examines various studies' methodologies, examining variables, sample sizes, and consistency in findings, identifying chlorhexidine as superior in infection reduction.
Levels of Evidence
Hierarchy of Evidence:
Level I:
Systematic reviews or meta-analyses of randomized controlled trials (RCTs) and clinical practice guidelines based upon systematic reviews.
Level II:
Well-designed RCTs.
Level III:
Controlled trials without randomization (quasi-experimental studies).
Level IV:
Single non-experimental studies (case-control, correlational, cohort studies).
Level V:
Systematic reviews of descriptive and qualitative studies.
Level VI:
Single descriptive or qualitative studies.
Level VII:
Opinions of authorities and expert committee reports.
(From LoBiondo-Wood G, Haber J: Nursing research, ed 9, St Louis, 2018, Elsevier).
Step 5: Integrate the Evidence
Implementation in Care Plans:
Apply findings from research into individual patient care plans for rational decision-making.
Education on changes is crucial.
Large-scale changes necessitate thorough planning and potential pilot studies to assess feasibility.
Policy modifications and procedural adjustments may be warranted.
Example:
Following presentation of findings regarding chlorhexidine, hospital decides it will be used as standard for central line antiseptic care due to supporting evidence.
Step 6: Evaluate the Outcomes of the Practice Decision or Changes
Evaluation Objectives:
Determine the effectiveness of the change.
Assess if modifications or discontinuation of the change is required.
Consider unexpected results.
Important to evaluate changes before full-scale implementation.
Example:
The analysis shows that central line infection rates have decreased significantly following the new antiseptic protocol over the six months of observation.
Step 7: Communicate the Outcomes of the Evidence-Based Practice Decision
Description:
Disseminate results with the healthcare team and stakeholders through reports, presentations, or publications.
Communication fosters sustained changes and encourages adoption of evidence-based practice throughout the organization.
Example:
A nurse presents positive outcomes at a hospital meeting and submits findings to a national nursing conference to advocate for similar evidence-based practices.
Scientific Method
Nurses use the scientific method to conduct original research enhancing knowledge, while EBP employs existing research to improve patient care.
Scientific Method Steps:
Make an observation.
Ask questions and gather information.
Analyze literature and formulate a research hypothesis.
Conduct a rigorously designed study.
Analyze data and reach conclusions.
Example Scenario:
Observation: Nursing students report fatigue affecting focus.
Question: What is the impact of sleep deprivation on cognition?
Hypothesis: Students with less than 5 hours of sleep will perform worse on cognitive assessments compared to those getting 7-8 hours.
Study: Compare cognitive performances between sleep-deprived students and well-rested counterparts.
Outcome: Sleep-deprived individuals show reduced problem-solving capabilities.
Why Not EBP?
The focus is on understanding sleep’s cognitive effects rather than immediate clinical practice changes.
Quantitative vs. Qualitative Research
Quantitative Research:
Definition: Collects numerical data and employs statistical methods for hypothesis testing or variable description.
Purpose: Quantifies problems and identifies patterns using objective measures.
Types:
Experimental Research: Manipulates variables for cause-effect determination.
Example: RCTs assessing new drug successes.
Nonexperimental Research: Observes phenomena without manipulation.
Example: Correlations between smoking and lung dysfunction.
Surveys: Gather data from populations via questionnaires or interviews.
Example: Assessing patient satisfaction with care.
Qualitative Research:
Definition: Examines subjective experiences and behaviors using open-ended interviews to derive insights.
Purpose: Understand the motivations and nuances behind human behaviors, unraveling complex issues.
Types:
Inductive Reasoning: Starts from specific observations, leading to broader conclusions.
Example: Interview patients to grasp experiences in managing chronic pain.
Translational Research
Phases of Translational Research:
Preclinical and animal studies (basic science).
Phase 1 clinical trials (assess safety in small human groups).
Phase 2 and 3 clinical trials (further assess safety and efficacy in larger human groups, comparing to standard treatments).
Phase 4 clinical trials (translation to practical use).
Phase 5 (population-level outcomes research - community implementation).
Outcomes Research
Focus:
Assessment of healthcare intervention results: effectiveness, costs, and patient satisfaction to identify optimal practices across diverse settings.
Example of Outcomes Research:
Evaluate how various diabetes management programs impact blood sugar control and hospitalizations.
Relation to EBP:
Outcomes research informs EBP by providing data critical for effective intervention selection in clinical settings.
Outcomes Research Design Examples
Quantitative Outcomes Research Example:
Objective: Measure impact of new heart failure program on readmissions.
Outcome: 30-day readmission rates decreased by 20%.
Qualitative Outcomes Research Example:
Objective: Understand patient experiences with said program.
Outcome: Patients report increased confidence in self-management, with reduced anxiety attributed to the program support.
Translational Research and Outcomes Contribution to EBP
Translational Research:
Purpose: Systematically transitions scientific discoveries into clinical applications.
Role in EBP: Lays the evidence foundation ensuring new interventions are both safe and effective for clinical application.
Example: Development and testing of new diabetes medication from laboratory to clinical practice.
Outcomes Research:
Purpose: Evaluates real-world effectiveness of healthcare interventions focusing on safety, quality of life, and cost-effectiveness.
Role in EBP: Assesses if current interventions lead to expected outcomes, refining clinical practices.
Example: Analyze the impact of a diabetes management program on patient outcomes and readmission rates.
In Summary:
Translational Research ensures clinical safety and efficacy.
Outcomes Research assesses practical effectiveness in real-world scenarios.
Together, they offer a feedback loop vital for enhancing EBP, ensuring best clinical outcomes for patient care.
Performance/Quality Improvement (PI/QI)
Focus:
Enhance existing processes and outcomes within healthcare settings.
Goal:
Improve efficiency, safety, and patient satisfaction.
Methodology:
Employ data-driven approaches like Plan-Do-Study-Act (PDSA) cycles to identify, implement changes, and track outcomes.
Examples of PI/QI Initiatives:
New triage system to minimize ER wait times.
Streamlined discharge processes integrating Electronic Health Records (EHR) and pharmacy communications for real-time prescription status tracking, ensuring timely patient discharges.
Importance of PI/QI:
Directly impacts care quality by highlighting areas needing improvement, facilitating immediate evidence-based changes.
The Relationship Among EBP, Research, and PI
Research:
Generates new scientific knowledge and evidence through studies aimed at answering research questions and testing hypotheses.
Research findings serve as a foundation for both EBP and PI/QI practices.
Evidence-Based Practice (EBP):
Application of optimal research evidences along with clinical expertise and patient preferences for clinical decisions.
Relies on research outcomes to implement evidence-backed interventions for improving patient care.
Performance Improvement (PI/QI):
Focuses on refining processes in healthcare organizations through data analysis to identify gaps and enact changes influenced by research and EBP.