Evidence-Based Practice Notes

Evidence-Based Practice

• Finding what's best for the patient is the goal.
• The evidence base might conflict with patient autonomy.
• Respect patient autonomy even when disagreeing with their choices.

Nursing Scope and Standards

• Registered nurses integrate scholarship, evidence, and research findings into practice.
• Continuously ask "why" to understand the reasons behind practices.
• Evidence-based practice can be unit-specific.

Example: Status Asthmaticus Patient

• Patient on a ventilator in the ICU for asthma experienced hypertension and sinus bradycardia.
• The intensivist suggested disconnecting the patient from the vent and physically pushing air out of hyperinflated lungs.
• The rationale: hyperinflated lungs were compressing the vena cava, preventing blood return to the heart, leading to hypotension and tachycardia.
• Disconnecting the patient from the ventilator was contrary to standard evidence-based practice but proved effective.
• This example highlights the importance of understanding the underlying physiology and questioning established protocols.

Benefits of Evidence-Based Practice

• Improves patient satisfaction, prognosis, and outcomes.
• Lowers costs, making it a "great equalizer."

Components of Evidence-Based Practice

• Best research evidence, preferably the highest tier.
• Specific to the patient's needs
• Respect patient autonomy.

Clinical Expertise and Intuition

• Gut instinct is valuable.
• New policies must undergo an implementation process.
• Be the voice of change.

Awareness of Constraints

• Resources
• Patient advocacy is crucial.

Example: Comfort Care in Burn Unit

• System-wide policy: comfort care patients receive 2mg/hour PCA-based analgesic.
• Burn unit nurses knew this was insufficient due to the extreme pain experienced by burn patients during dressing changes.
• They advocated for higher doses based on their clinical expertise and patient needs, overriding the policy.

Implementation of Evidence-Based Practice

• Guided by QSEN (Quality and Safety Education for Nursing).
• Systematic approach to evaluating new evidence.
• Patient-centered care is the focus.
• Teamwork and collaboration are essential.
• Quality improvement is the goal.

Determining if a New Policy is Working

• Is it better for the patient?
• Can it improve nursing efficiency and safety?

Bedside Shift Report

• Improves patient outcomes, safety, and satisfaction.
• Nurses often dislike it due to increased time and potential for difficult patient interactions.

Evidence-Based Practice vs. Best Practice

• Terms used interchangeably but are not the same.
• Evidence-based practice integrates research.
• Best practice is informed by evidence but can include expert opinion and consensus guidelines.

Levels of Evidence

• Pyramid structure with increasing credibility at higher levels.
• Peer review is a key aspect of credible research.
• Meta-analysis: synthesis of multiple research studies.
• Randomized controlled trials: blind studies

Levels of Evidence (Pyramid)

1. Meta-Analysis and Systematic Reviews: highest level, synthesizes findings from multiple studies. (Meta−analysis > Multiple
   RCTs)
2. Randomized Controlled Trials (RCTs): experimental studies with random assignment to groups. The blind study is defined as:
   $Blind <br />\newline study = names <br />\newline in <br />\newline hat + random<br />\newline effect$.
3. Cohort Studies: longitudinal studies following groups with shared characteristics
4. Case-Control Studies: comparing individuals with a condition to those without.
5. Cross-Sectional Studies: data collected at a single point in time.
6. Expert Opinion, Case Reports: lowest level, based on individual experiences or opinions.

Example: Unit Morale

• Research identified six components for a positive work environment for nurses.
• Committee members dismissed two key points, hindering progress.
• Highlight the importance of advocating for evidence-based changes, even when met with resistance.

Evaluating Resources

• Be cautious of .com websites due to potential bias.
• .Gov and .org websites are generally more reliable.
• Back up .com sources with peer-reviewed articles.

Website Credibility

• .com: Commercial, potentially biased, lacks peer review.
• .gov: Government, generally peer-reviewed and reliable.
• .org: Organization, typically reliable.

Clinical Practice Guidelines

• Recommendations for specific conditions.
• Insurance companies use DRGs (diagnosis-related groups) based on these guidelines.
• Hospitals may use protocols based on these guidelines.

Example: Diabetic Ketoacidosis (DKA)

• Guidelines dictate the standard treatment (fluids, insulin, education).
• Additional interventions require justification.

Critical Thinking

• Develops with time and experience.

Building Knowledge

• Information gained through education and practice.
• Foundation for problem-solving and decision-making.

Example: Septic Patient in the ICU

• Initially overwhelming, but knowledge builds with repeated exposure to similar cases.

• Recognizing patterns leads to proactive problem-solving.

  A lot of students and new graduate nurses become very tunnel visioned and task focused.

  But you're building your knowledge every time you you go into work for a week and every day, not the same patient, but the same diagnosis all week long, you get a GI bleed. You get used to the smell of the GI bleed.

Applying Knowledge

Example: GI Bleed Patient

• Recognizing a heparin order (anticoagulant) is inappropriate.
• Questioning the order demonstrates critical thinking.

Example: Hemorrhagic Stroke Patient

• Applying the same principle (avoiding anticoagulants) in a different context.

Constantly learning is crucial.If you think I know it all, you scare If you think you know it all, you should leave. Not necessarily nursing, but go to a different type of nursing because you're not doing yourself or your patient any good if you ever have that thought. That's dangerous. You're constantly learning.

Clinical Judgment

• Integrates critical thinking, experience, and evidence-based practice.

Taking that heparin. Do I just go ahead and give it?

• No. Because clinical judgment says if I go ahead and put them on heparin, they're going to keep bleeding.

Ask. Alright?Don't don't be confrontational, but ask because that's gonna help build your experience and your knowledge for the next time. Sound clinical judgment needs critical thinking, acknowledging your experience, and bring in that evidence based practice.

ADPIE (Assessment, Diagnosis, Implementation, Planning, Evaluation)

• Evidence-based practice, experience all contribute to ADPIE.
• Patient willingness is a key factor in clinical decisions.

Strengthening Skills

• Practice and time are essential.
• New graduates will feel inexperienced for a while.

Example: New Graduate ICU Nurses

• It takes about twelve months for new graduate ICU nurses to feel comfortable.
  For every hole, we have a tube.And if we don't have a hole for it, we'll make one.It is time to grow your experience.

New graduates will need to build practice and experience.That's what it's for.Over time, this is going to grow.Alright? And you'll be able to that they're admitted for an ischemic stroke. What body system are we gonna be focused on?

`neuro` because it's my brain that took the hit. I will probably look at cardiovascular seconds, but now I'm starting to narrow my focus on, okay. This is what they're admitted for.

Critical Thinking levels:

1. Basic: tasks focus
2. Seasoned Nurses: independent
3. Veteran Nurse: many years, ask questions.

Reflection

• Reviewing the day, especially after negative outcomes, helps to learn and improve.
• Debriefs after codes are essential for identifying what went well and what could have been better.

Example: COVID Patient with Pulmonary Embolism

• Patient's anxiety and tachypnea were initially attributed to anxiety.
• The nurse suspected PE but the physician ordered a chest X-ray instead of immediate action.
• The patient died shortly after. The nurse reflected how to improve outcomes on such cases.
  *After a code, there's a debrief after every code with everyone involved. What went well? What could have gone better? How do you feel.What could you have done better because that's gonna actually make him or her better next time. Be tactful

Problem Solving

• The evidence will ask you: What does the evidence say? Does it apply here?
• Practice problems stimulate problem-solving skills.
• Seek out evidence and question its applicability.

Stages of Critical Thinking

1. Basic: task focused.
2. Complex: independent, less reliance on others.
3. Commitment: anticipate outcomes based on experience.

Example: Vasopressin and Hypertension

• A new nurse focused on following orders to administer vasopressin, even though the patient's blood pressure was elevated.
• A senior nurse recognized the issue and discontinued the vasopressin, demonstrating clinical reasoning.