Chapter 12 Evidence-Based Practice and Nursing Theory - PowerPoint Presentation

Slide1

Chapter 12

Evidence-Based Practice and Nursing TheorySlide2

Overview of Evidence-Based Practice

Evidence-based practice (EBP) was introduced in the 1970s by Dr. Archie Cochrane.

Dr. Cochrane focused on critical review of research (emphasis on RCTs) to improve medical practice.

Application in nursing has been delayed but has been growing over the past 10 years.Slide3

Overview of Evidence-Based Practice—(cont.)

EBP is based on the premise that health professionals should not base practice on tradition and belief but on information grounded in research.

EBP is not synonymous with research.

Research focuses on discovery.

EBP focuses on application.Slide4

Overview of Evidence-Based Practice—(

cont.)

EBP involves:

Identifying a clinical problem

Searching the literature and critically evaluating research evidence

D

etermining appropriate interventions

EBP integrates research, theory, and practice.Slide5

Evidence-Based Practice

EBP is “the conscientious, explicit, and judicious use of theory-derived, research-based information in making decisions about care delivery . . . in consideration of individual needs and preferences”

Key concepts of EBP

Best evidence

Expertise

Patient values

Careful review of research findings according to guidelines.

De-emphasizes ritual, isolated, and unsystematic clinical experiences, options, and tradition as basis for practiceSlide6

Question

Which of the following is NOT considered to be a key concept of EBP?

Best evidence

Patient values

Provider expertise

Traditional practicesSlide7

Answer

D.

Traditional practices

Rationale: EBP de-emphasizes ritual, unsupported practices, and tradition and focuses on research-supported interventions that considers patients’ desires and needs and provider expertise. Slide8

Evidence-Based Nursing

Some sources for EBP information/guidelines

Cochrane Collaboration/Cochrane Database of Systematic Reviews—network that helps health care providers make informed decisions about health care

Agency for Healthcare Research and Quality (AHRQ)—maintains database of evidence-based clinical practice guidelinesSlide9

Evidence-Based Nursing—(

cont.)

Concerns

T

oo much focus on EBP could result in “cookbook care” and loss of “art” of nursing.

L

essening of attention to holistic care

Health care reimbursement might drift exclusively to interventions substantiated by “evidence.”

Not all health care practices can or should be based on science per se (What about “care”?).

Consensus agreement that EBP in nursing should consider all types of evidence (not just RCTs), as well as clinical experience, patient experiences and desires, and relevant local/organizational influences.Slide10

Practice-Based Evidence

PBE is a relatively new concept in nursing and health care.

Based on the observation that many interventions have limited formal research support

PBE recognizes the importance of the environment in determining practice

recommendations.

Premise of PBE is that large databases should be reviewed or “mined” to gather data on quality and effectiveness.Slide11

Practice-Based Evidence—(

cont.)

PBE seeks to determine what works best for which patients, under what circumstances, and at what costs.

More comprehensive picture than RCTs

Sources include:

Benchmarking data

Clinical expertise

Cost-effective analyses

Infection control data

Medical record data

National standards of care

Quality improvement data

Patient and family preferencesSlide12

Relationships

among practice, theory, research, and the PBE/ EBP cycle.

(

From Walker, L. O., & Avant, K. C. [© 2011].

Strategies for theory construction in nursing

[5th ed., Fig. 2-3; p. 46]. Reprinted by permission of Pearson Education, Inc., Upper Saddle River, NJ.) Slide13

Theory and Evidence-Based Practice

More awareness of EBP has renewed appreciation for linkages among research, theory, and practice.

Research and clinical data provide evidence for EBP and/or PBE and can generate practice guidelines and/or situation-specific theories.

Preference for term “theory-guided, evidence-based practice”

Slide14

Models for Evidence-Based Practice

For some EBP models, the goal is to create or establish EBP protocols, procedures, or guidelines.

Some EBP models focus on implementation of EBP in the setting or institution.Slide15

Models for Evidence-Based Practice—(

cont.)

Most commonly used and described in nursing literature are:

Academic Center for Evidence-Based Practice Star Model (ACE Star Model) (Stevens, 2004)

Advancing Research and Clinical Practice Through Close Collaboration (ARCC Model) (Melnyk & Fineout-Overholt, 2011)

Iowa Model (Titler et al., 2001)

Johns Hopkins Nursing Evidence-Based Practice Model (JHNEBP) (Newhouse et al., 2007)

Stetler Model of Evidence-Based Practice (Stetler, 2001)Slide16

Evidence-Based Practice Models—ACE Star Model

Developed by faculty at University of Texas Health Science Center at San Antonio

Depicted by five points of sequential knowledge transformation

Discovery research

Evidence summary

Translation to guidelines

Practice integration

Process and outcome evaluationSlide17

Diagram

of the ACE star model for evidence-based practice

.

(

Used with permission from Stevens, K. R.

[2012

]

.

ACE Star Model: Knowledge transformation

©

. Academic Center for Evidence-Based Practice. Available at http://www.acestar.uthscsa.edu/acestar-model.asp) Slide18

Evidence-Based Practice Models—ACE Star Model—(

cont.)

Knowledge transformation (KT) consists of eight premises.

KT is necessary prior to using research for clinical decision making.

KT is derived from multiple sources (e.g., research, experience, authority).

Research process is the most stable source of knowledge.

Evidence can be classified by strength of evidence based on rigor.Slide19

Evidence-Based Practice Models—ACE Star Model—(

cont.)

Knowledge transformation (KT) consists of eight premises—(cont.)

As research is converted through a system of steps, other knowledge is created.

The form in which knowledge exists can be referenced to its use.

The form of knowledge determines its usability.

KT takes place through steps (summarization, translation, application, integration, and evaluation).Slide20

Evidence-Based Practice Models—ACE Star Model

—(cont.)

ACE Star Model has been shown useful in teaching the process of research evidence.

For more information, see

:

http://

www.acestar.uthscsa.edu/index.asp

Slide21

Evidence-Based Practice Models—ARCC Model

The Advancing Research and Clinical Practice Through Close Collaboration (ARCC) Model was developed to advance and sustain EBP (Melnyk & Fineout-Overholt, 2002).

Basis in control theory and cognitive behavioral theories

A

ppropriate in clinical practice—particularly acute careSlide22

Evidence-Based Practice Models—ARCC Model—(

cont.)

Central constructs of the ARCC Model

Assessment of organizational culture and readiness for EBP

Identification of strengths and barriers to EBP

Development and use of EBP mentors

EBP implementation

Outcome evaluation (providers’ satisfaction, cohesion, intent to leave, turnover, improved patient outcomes, hospital costs)Slide23

Evidence-Based Models—ARCC Model—(

cont.)

Several scales have been developed to measure implementation of EBP using the ARCC Model.

Among them are scales to measure organizational readiness and EBP beliefs.

Considerable amount of research support for the ARCC modelSlide24

Evidence-Based Practice Models—Iowa Model of EBP to Promote Quality Care

The Iowa Model of EBP was developed in the 1990s.

Intent to promote quality care through research utilization

It was developed to provide guidance for nurses in making decisions about practice.Slide25

Question

Tell whether the following statement is true or false:

The rationale for development of the Iowa Model of EBP was to manage the costs of health care.Slide26

Answer

False

The Iowa Model for EBP was developed to promote quality nursing care through incorporation of research into practice.Slide27

Evidence-Based Practice Models—Iowa Model of EBP to Promote Quality Care—(

cont.)

Organized into starting points, decision points, and feedback loops

Starting points are problem-focused triggers or knowledge-focused triggers

Decision points:

I

s the topic a priority?

I

s there sufficient research base?

I

s change appropriate for adoption in practice?

There are numerous feedback loops based on the model.

After implementation of practice change, monitor and analyze the structure, process, and outcome data; then disseminate results. Slide28

Diagram

of the Iowa method of evidence-based practice.

(

Reprinted with permission from University of Iowa Hospitals and Clinics. © 1998. For permission to use or reproduce the model, please contact University of Iowa Hospitals and Clinics at 319-384-9098.) Slide29

Evidence-Based Practice Models—Iowa Model of EBP to Promote Quality Care—Resources

For more information, see:

http://

www.nnpnetwork.org/ebp-resources/iowa-model

http://

www.hinursing.org/pdf/IowaModel.pdf

Slide30

Evidence-Based Practice Models—Johns Hopkins Nursing EBP Model

The JHNEP Model is a problem-solving approach to clinical

decision making.

Developed to accelerate research into nursing practice and promote nursing autonomy, leadership, and engagement with colleagues

Combines the nursing process, the ANA Standards of Practice, critical thinking, and research utilizationSlide31

Evidence-Based Practice Models—Johns Hopkins Nursing EBP Model—(

cont.)

Three core elements (PET)

Practice question

Evidence

Translation

Several phases composed of 18 steps.

Each step helps clarify the processes.

Assist in understanding how to proceedSlide32

Evidence-Based Practice Models—Johns Hopkins Nursing EBP Model—(

cont.)

Model begins with an EBP question

(PICO)

consisting of:

P

ractice question (patient, population and problem)

I

ntervention

C

omparison as appropriate

Desired

O

utcome(s)

Other steps involve defining the scope of the question, assigning reasonability for leadership, recruiting a team and scheduling conferences. Slide33

Question

When developing a PICO question, the “C” represents which of the following?

Care options

Comparison with a baseline or standard

Consideration of patient or provider values/wishes

Costs of interventionsSlide34

Answer

B.

Comparison with a baseline or standard

Rationale: A

PICO

question

consists of:

P

ractice question (patient, population, and problem)

I

ntervention

C

omparison as appropriate

Desired

O

utcome(s)Slide35

Evidence-Based Practice Models—Johns Hopkins Nursing EBP Model—(

cont.)

Evidence phase includes:

Literature search

Team appraisal and recommendations

Translation phase:

Team decides whether and how to implement changes.

Evaluation of implementation

Communicate the findings PRNSlide36

Evidence-Based Practice Models—Johns Hopkins Nursing EBP Model—Resources

For more information (optional course):

http://

www.hinursing.org/pdf/IowaModel.pdf

Data collection tool:

http://

www.nursingworld.org/DocumentVault/NursingPractice/Research-Toolkit/JHNEBP-Research-Evidence-Appraisal.pdfSlide37

Evidence-Based Practice Models—Stetler Model

Originally implemented in the 1970s as a quality improvement effort

Similar to the nursing process thus easily implemented

Five steps or phases

Preparation

Validation

Comparative evaluation/decision making

Translation/application

EvaluationSlide38

Evidence-Based Practice Models—

Stetler Model—(cont.)

Preparation

Propose, control, and source research evidence

Validation

Determine credibility of findings and potential for qualifiers for application

Comparative evaluation/decision making

Synthesis of information and decisions for recommendations for criteria and applicability

Translation/application

Create operational definitions for use and actions for change

Evaluation

Determine alternate types of evaluationSlide39

Evidence-Based Practice—Summary

EBP has become one of the key tenets of quality nursing care.

In nursing, it is critical that EBP go beyond research and be theory based.

Growing attention to the concept of PBE has renewed attention to the critical role of theory in excellent nursing practice.