Evidence-Based

Practice in a Hospital

Environment

Pamela K Ginex EdD, RN, OCN

Nurse Researcher, Center for Evidence-Based Practice and Research

Memorial Sloan-Kettering Cancer Center

Evidence-Based Practice:

What is it?

 The conscientious, explicit, and judicious use of current best evidence in making decisions regarding patient care.

 Practice based on research evidence is more likely to achieve quality patient outcomes.

Why Evidence-Based Practice?

 Despite an aggressive research agenda, the majority

of findings from research are not integrated into

practice.

 It takes approximately 17 years to incorporate

findings from research into practice.

 Without current best evidence, practice becomes

rapidly out-of-date to the detriment of patients

Thinking Outside the Box

 Does what we are doing make theoretical sense?

 Why are we still doing it?

 We work in dichotomous silos

 Discipline-to-discipline

 Department-to-department

 Do not positively impact patient outcomes

What is an Evidence-Based

Culture?

 An EBP culture is

 a practice environment that values and provides high-

level evidence-based care based on an organizational

commitment to evidence-based nursing practice; and

 a practice environment that includes partnerships with

other disciplines, as needed.

 Not a destination, but an ongoing journey

The Nursing Process and

Evidence-Based Practice

 Assessment

 Diagnosis

 Planning

 Implementation

 Evaluation

Assessment

NURSING

PROCESS

ACTIONS EVIDENCE

BASED

PRACTICE

ACTIONS

Assessment Collects patient data Asking the question Clearly identifies

specific patient

problems/needs

NURSING

PROCESS

ACTIONS EVIDENCE

BASED

PRACTICE

ACTIONS

Diagnosis Analyses assessment

data and determines

diagnosis

Search for evidence Collects information

relevant to the

identified problem

Diagnosis

NURSING

PROCESS

ACTIONS EVIDENCE

BASED

PRACTICE

ACTIONS

Planning Develops a plan of

care

Analyzing the

evidence

Critically appraises

the published

literature

Planning

NURSING

PROCESS

ACTIONS EVIDENCE

BASED

PRACTICE

ACTIONS

Implementation Initiates the

interventions

identified in the plan

of care

Applying the

evidence to practice

Integrates evidence

with clinical

expertise

Implementation

NURSING

PROCESS

ACTIONS EVIDENCE

BASED

PRACTICE

ACTIONS

Evaluation Evaluates the

patient’s progress

toward attainment

of outcomes

Evaluating the

effectiveness

Evaluates the

effectiveness of the

integration of

evidence

Evaluation

EBP Process

 Ask the question

 Question, background, objectives

 Search for evidence

 Literature search engines

 Evidence-based practice web sites

 Experts in the field

EBP Process

 Analyze the evidence

 Selection of evidence (critiquing the literature)

 Levels of evidence

 Summary of findings

 Apply the evidence to practice

 Applicability to practice

 Feasibility

 Recommendations for practice

 Evaluate the evidence

Asking the Question

 Frame the question

 Describe the background related to the issue

 What are the specific objectives you want to

accomplish?

Searching the Evidence

 What search strategy should be used to obtain

the information?

 Describe the database/s utilized

 Literature Search Engines

 Evidence-Based Web Sites

 Organization Web Sites

 Electronic Journals

Analyzing the Evidence

 What search criteria were used in the

analysis?

 How were articles selected?

 What was the level of evidence?

 What were the main results?

Providing Research Evidence

for Best Practice

Level Definition

Level I Evidence from a systematic review or meta-

analysis of all relevant randomized control

trials (RCT) or evidence-based clinical

practice guidelines based on systematic

reviews of RCTs

Level II Evidence obtained from at least one well

designed RCT

Level III Evidence obtained from well designed

controlled trials without randomization

Providing Research Evidence

for Best Practice

Level Definition

Level IV Evidence from well designed case control and

cohort studies

Level V Evidence from systematic reviews of

descriptive and qualitative studies

Level VI Evidence from a single descriptive or

qualitative study

Level VII Evidence from the opinion of authorities

and/or reports of expert committees

Applying Evidence to Practice

 What conclusions can be made as the

evidence is applied to nursing practice?

Evaluating Practice

 What recommendations can be made to

evaluate patient outcomes?

 What metrics are necessary to measure patient

outcomes?

 Need to “close the loop” – evaluate patient

outcomes, not just “collect data”

Outcomes of Evidence Based

Practice

 Justification for standards of care

 Evidence of practice standards for

patients, regulatory agencies, third party

payors

 Improved patient outcomes

Moving Toward an Evidence-

Based Approach to Practice

 Practice areas are unique

 Many standards of practice are shared

 There needs to be representation from all areas

 Policy review and all new policies need an evidence-

based approach

 A major organizational commitment and culture

change

Template for EBP presentations

 Use the following slides for your EBP presentation

to your peers

Question

Simply state your question

Specific Objectives

One or two specific objectives

Search Strategies

 (example – describe your specific strategy)

 MEDLINE

 CINAHL

 Cochrane Collaboration

Sources of Evidence from

Literature Search Engines

 ____ studies were chosen for review based on the

research evidence provided

 Briefly describe each study

Summary of Evidence

 Summarize key points from your review

NUR 350

 There are two main types of research – quantitative and qualitative ◦ Quantitative – uses numbers, data to answer a

question

◦ Qualitative- uses thoughts and experiences to explore a topic

 We’ll discuss each in more detail in a few weeks but for now we’ll review the overall steps involved in each

 Number of steps can differ but: ◦ Research always proceeds in an orderly fashion

◦ Research always starts with the identification of the problem and ends with the utilization of the findings

 Identify the problem/determine purpose of study

 Review of the literature/develop framework  Formulate hypothesis/research question  Define study variables/terms  Select research design  Identify the population  Select the sample  Collect data  Analyze the results  Interpret and communicate the findings

 ???????

 Start with broad topic area  Narrow to specific problem statement  Get study problem from ◦ Personal experiences ◦ Literature sources ◦ Prior research ◦ Theory testing

 State problem as a question  Include population and variables  Determine the Purpose ◦ Difference between purpose and problem ◦ Problem tells what is studied ◦ Purpose tells why study is done

 Studies may have one or both

 Finds out what exists on the topic  Helps look at theory/framework  Helps address the study methods  Search a variety of sources ◦ Indexes ◦ Abstracts ◦ Dissertations ◦ Computer searches

 Continue until time to collect data  Develop a Theoretical/Conceptual Framework ◦ Research helps test, develop, refine theories ◦ Process assists in selection of study variables ◦ Directs the hypothesis and interprets findings ◦ Answers the “so what” question(s) ◦ Adds to our nursing body of knowledge

 Hypothesis predicts relationships between

variables  Hypothesis provides predicted answer to

question  Hypothesis contains two types of variables ◦ Independent variable ◦ Dependent variable

 Hypothesis is testable empirically  Types of hypothesis vary  Hypothesis mostly in quantitative studies ◦ Directional ◦ Non-directional ◦ The Null hypothesis

 They must be clear to the researcher and reader

 The definitions may be ◦ Dictionary

◦ Theoretical

◦ Operational

 The operational definition helps with study replication

 Helps determine how study is planned

 Varies with the type of study conducted ◦ Quantitative vs. Qualitative

◦ Experimental vs. Non-experimental

◦ Experimental may be divided

 True experimental

 Quasi-experimental

 Pre-experimental

Population ◦ Target ◦ Accessible

 Generalization Select the Sample  A subgroup of the population  It represents the population  It helps with generalization Types of samples ◦ Probability Samples ◦ Non-probability Samples

Voluntary aspect of participation Permission secured and rights protected

Data

 Pieces of information or facts

 Data collection procedures are followed

 Questions asked are ◦ What data? ◦ How is it collected? ◦ Who collects the data? ◦ Where is it collected? ◦ When will it be collected?

Organize the Data for Analysis

 This step is planned from the beginning

 It uses the help of a statistician

 Decisions are made about missing data

 The process is easier now

 Data is placed into computerized statistical packages

 Results are analyzed instantaneously

Interpret the Findings  Do the data support the research hypothesis?  Do the data not support the research hypothesis?  Problems encountered are discussed  Limitations of the study are presented  Results are compared with other studies  Implications are identified  Recommendations are proposed Communicate the Findings  A very critical component of the process  A variety of ways are used

◦ Journals ◦ Presentations ◦ Posters

Utilize the Findings  Recommendations need considerations  Integration into practice are critical components  Researcher may act as a consultant for using findings  Researcher must disseminate findings in many ways

 Inductive or open to new ideas and theories

 Concerned with in-depth descriptions of people or events

 4 common approaches ◦ Phenomenology

◦ Grounded theory

◦ Ethnography

◦ Historical

 Identify the phenomenon to study

 Select the research design

 Review the literature

 Select the sample

 Collect the data

 Analyze the data

 Communicate the study results

 General to more focused

 Broad statements

 Purpose statement

 Depends on the phenomenon being studied

 Debate on when to do this

 May bias the study results

 Preferred at the end of the study

 Tells how results fit with the body of knowledge

 Smaller in size

 No set rules

 Saturation is more important

Also need to gain entry to the research site ◦ IRB approval

◦ Key informants

 Begins when the data is collected

 Content analysis procedures (software programs)

Knowledge Development in Nursing

Strategies for Knowledge Development Found in the Nursing Literature

• Qualitative Research

• Quantitative Research

• Borrowed Theory

• Borrowed Concept

• Analysis of a Theory or Concept

• Synthesis of a Theory or Concept

Concepts are the Building Blocks of Knowledge

• A concept is a term or label given to

phenomenon or group of phenomena

(aspects of reality that can be consciously

sensed or experienced

• Examples: Adherence, Self-Esteem,

Hope, Social Support, Courage, Book

Concepts

• A concept has properties

(For example, the properties of a “book”)

• There are feelings, values and attitudes

associated with the word and with the

perception of the thing

Concrete to Abstract Concepts

• Directly Observable

• Height, weight, temperature

• Indirectly Observable

• Hemoglobin level, cardiovascular fitness

• Inferred from Multiple Direct and Indirect

observations

• Self-Esteem, self-efficacy, wellness

Example of Concepts of Concern to Nursing

• Coping

• Hope

• Loss

• Social Support

• Anxiety

• Fatigue

• Uncertainty in Illness

• Self-Efficacy

• Courage

• Resilience

• Grief

• Pain

• Therapeutic Touch

• Families

• Self-Care

Concepts are Dynamic

• The definition and description of a concept will vary from one theorist to another

• The definition, description and meaning of a concept may change over time (Example: “Family” 1950 vs. 2006)

• The concept label may change (Example: “Compliance” vs. “Adherence”

Theory

• Concepts are the building blocks of a theory

• A theory is a set of interrelated concepts,

definitions, and relational statements and,

• Presents a systematic view of essential

elements in a field of inquiry by specifying

relationships among variables

• Theories are dynamic

Promoting Wellness for Women with MS Stuifbergen, Becker, Rogers, Timmerman, & Kullberg (1999)

The Journal of Neuroscience Nursing, 31 (2), 73-79.

Perceived Health

and Well-Being

Barriers

Resources

Self-

Efficacy

Health

Promoting

Behaviors

Antecedents Health Behaviors Outcomes

Alexa Stuifbergen PhD, RN, FAAN

The Purpose of Theories

• To guide practice, research, and

education

• Provides a language for talking about

the nature of nursing practice

• Enhances communication

Relational Statements (Also Called Propositions)

• Relational statements describe how one

concept is related to another concept

• Found in the theoretical literature

• According to Bandura (1997), self-

efficacy is the most predictive factor of

perseverance in a new behavior

Relational Statements can also be Found in Research Studies

• There is an inverse relationship

between level of disability and self-

esteem.

• There is a positive relationship between

self-efficacy and adherence to wellness

behaviors in non-insulin-dependent

diabetics.

Levels of Theory

• Descriptive

• Explanatory

• Predictive

Descriptive Theory

• Beginning description in a new area of

interest

• Describes two or more concepts

• Does not specify exactly how concepts

are related

• Qualitative research often is used to

develop new knowledge

Explanatory Theory

• Explains specific relationships

between concepts (positive or inverse)

• There is a positive relationship between problem-focused coping and well being

(Lazarus & Folkman, 1984)

• There is an inverse relationship between level of disability and self-efficacy (Fraser, 2005)

Predictive Theory

• Predicts relationships between concepts

• Well developed theory

• Researched extensively

• Self-efficacy is the most predictive

factor of perseverance in a new

behavior (Bandura, 1997)

Models in the Nursing Literature

Sense of Belonging Hagerty, Lynch-Sauer, Patusky, Bouwsema, and Collier (1992)

1. Energy for involvement 2. Desire for meaningful involvement 3. Potential for shared or complimentary characteristics

1. Valued involvement 2. Fit

1. Involvement 2. Attribution of meaningfulness 3. Foundation for emotional and behavioral responses

Antecedents Sense of Belonging Consequences

Model of Perceived Uncertainty in Illness

(Mishel, 1988)

Nola Pender’s Health Promotion Model

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