Evidence based practice & future nursing

Evidence-Based Practice and the
Future of Nursing
Jayesh Patidar
www.drjayeshpatidar.blogspot.com

The Evolution of
Evidence-Based Practice
www.drjayeshpatidar.blogspot.in

What is - Evidence?
Anything that provides material or
information on which a conclusion or proof
may be based; used to arrive at the truth,
used to prove or disprove the point at issue.
(Webster)

• Evidence-Based Practice – Conscientious, explicit
and judicious use of current best evidence with
clinical expertise, and patient values to make
decisions about the care of patients. (Sackett, 2000)
• Evidence-based nursing practice is the process of
shared decision-making between practitioner, patient
and significant others, based on research evidence,
the patient’s experiences and preferences, clinical
expertise, and other robust sources of information.
(STTI , 2007)

• EBP is both a process and a product…
requiring that the evidence which is produced –
is also applied to practice.
(D. Rutledge, 2002)

Evolution of EBP
• 1991 – Evidence-based medicine -first described in the
American College of Physicians Journal Club.
• 1992 – the Evidence-based Medicine Working Group
described it as a “paradigm shift” in JAMA
– Clinical observations and experience, principles of
pathophysiology, knowledge gained from authoritative figures,
and common sense -- are no longer a sufficient guide for
clinical practice, decision-making, or the development of
practice guidelines

Evolution of EBP
• Early 1990’s – US Prev. Services TF – began developing
EB Guidelines for Screening and Prevention
• 1992 – AHCPR (now AHRQ) – started publishing
systematic reviews and consensus statements in the
form of Clinical Practice Guidelines, starting with the
guideline for Acute Pain, 19 guidelines were produced
from ’92-’96
• 1993 - the first annual Cochrane Colloquia was held at
the New York Academy of Sciences
• 1993 – Online Journal of Knowledge Synthesis for
Nursing

Evolution of EBP
1997 – Jan 2011 – 198 Evidence
Reports published by the EBP centers
– May, 2005 – Episiotomy Use
– “…no health benefits from
episiotomy…routine use is harmful …”

Recent Evidence Reports
193. Alzheimer's Disease and Cognitive Decline
192. Lactose Intolerance and Health
190. Enhancing Use and Quality of Colorectal Cancer Screening
189. Exercise-induced Bronchoconstriction and Asthma
188. Impact of Consumer Health Informatics Applications
187. Treatment of Overactive Bladder in Women
185. Management of Ductal Carcinoma in Situ (DCIS)
184. Treatment of Common Hip Fractures
151. Nurse Staffing and Quality of Patient Care
140. Tobacco Use: Prevention, Cessation, and Control
This is just one example of literature syntheses that are available
to support EBP.

Nurse Staffing and Quality of
Patient Care
• Objectives: To assess how nurse to patient ratios and
nurse work hours were associated with patient outcomes
in acute care hospitals
• Results: Higher RN staffing was associated with less
mortality, failure to rescue, cardiac arrest, hospital
acquired pneumonia, and other adverse events. Limited
evidence suggests that the higher proportion of RNs with
BSN degrees was associated with lower mortality and
failure to rescue. More overtime hours were associated
with an increase in hospital related mortality, nosocomial
infections, shock, and bloodstream infections.

Evolution of EBP
• 1998 – Evidence-Based Nursing journal debuted
• 1999 – The UK Department of Health stipulated that, to
enhance the quality of care, nursing, midwifery, and
health visiting practice must be evidence-based
• 2002 - JCAHO begins requiring monitoring of evidence-
based core measures
• 2004 – WorldViews on Evidence-Based Nursing
• 2004 – AACN began publishing “Practice Alerts”

Evolving Interest in Evidence-Based Practice
0 0 1 0 0 5
25 35 47 51 67 83
139
530
0
100
200
300
400
500
600
'91 '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04
2011 – Medline search > 38,000www.drjayeshpatidar.blogspot.in

Within one decade, the concept of
evidence-based practice has
evolved and been embraced by
nurses in nearly every clinical
specialty, across a variety of roles
and positions, and in locations
around the globe.
EBP – means many things to many
people

Factors Contributing to Emphasis on
Evidence-Based Nursing Practice
• Scientific knowledge expansion
– Knowledge expands exponentially q 2 yrs
– 12 yrs. from now – 128 x as much knowledge
• Knowledge availability -- The Internet
• Highly educated nurses in clinical settings
– APNs – focusing on evidence-based clinical
problem-solving
– Clinical Nurse Researchers
– DNP Movement

Factors Contributing to Emphasis on
Evidence-Based Nursing Practice
• Aggressive pursuit of cost-effectiveness
• Focus on quality of care, Risk & error
reduction
• Highly educated consumers
• JCAHO/Accreditation expectations
• Increased attention to institutional image
– Magnet hospital movement

• Most nurses agree that EBP is important…
but how do we make it happen?

What is the 1st step toward EBP for the
practicing nurse?
• Asking good clinical questions
• Nurses must be empowered to ask
critical questions in the spirit of
looking for opportunities to improve
nursing care and patient outcomes
• Risk-taking environment

Nursing vs. Medical Questions
• Often more exploratory
• Less frequently focused on intervention selection
• Less evidence to support many nursing
interventions
• Most nursing interventions have less capacity for
harm
• Many nursing challenges often go beyond
individual clinical interventions
(e.g. nurse staffing, education, recruitment)

Clinical Nursing Questions
• In postoperative patients, does prn or
ATC analgesic administration yield better
pain relief?
• Among critically ill patients, is controlled
or open visitation more effective in
reducing patient anxiety?

Questions for APNs
• In acute care hospitals, is the CNS more
effective by focusing on a specific
patient population or a specific unit?
• What else?

What kind of questions might the
Nurse Manager ask?
• On medical-surgical units, do 12 hour or 8
hour shifts result in more medication
errors?

Key Questions to Ask When
Considering EBP
• Why have we always done “it” this way?
• Do we have evidence-based rationale?
• Or, is this practice merely based on tradition?
• Is there a better (more effective, faster, safer,
less expensive, more comfortable) method?
• What approach does the patient (or the target
group) prefer?
• What do experts in this specialty recommend?

Key Questions to Ask When
Considering EBP
• What methods are used by leading/benchmark,
organizations?
• Do the findings of recent research suggest an
alternative method?
• Are organizational barriers inhibiting the
application of best practices in this situation?
• Is there a review of the research on this topic?
• Are there nationally recognized standards of care,
practice guidelines, or protocols that apply?

Steps in the EBP Process
• Developing a well-built question
• Finding evidence-based resources to
answer the question
• Evaluating the strength and applicability of
the evidence
• Applying the evidence to practice
• Evaluating the effects

• Once we agree upon the question that
poses an opportunity for improvement, then
we must find the evidence
• Where should we look?
• Are all forms of evidence equivalent in
quality?

Strength of Evidence
• Level I - meta-analysis of multiple studies
• Level II - experimental studies, RCTs
• Level III - quasiexperimental studies
• Level IV - nonexperiemental studies
• Level V - case reports, clinical examples
AHCPR/AHRQ
• At what level is most nursing evidence?

AACN Levels of Evidence
(Armola, et al. , C C Nurse, 2009)
• Level A
• Level B
• Level C
• Level D
• Level E
• Level M
• Meta-analysis or metasynthesis of multiple
controlled studies, supporting a specific action
• Controlled, randomized, or nonrandomized studies,
supporting a specific action
• Qualitative, descriptive or correlational studies or
systematic reviews with consistent results
• Peer-reviewed prof. organ. standards with studies
to support them
• Theory-based evidence from expert opinion or
case studies
• Manufacturer’s recommendations only

What constitutes the “Evidence” in
Evidence-Based Practice?
“Evidence-based practice has been defined
as the use of the best clinical evidence
from systematic research (referring to
meta-analysis, integrated reviews, & RCTs
– as the gold standard). …Others (often
nurses) believe that experimental studies,
observational studies, and correlational
studies are also suitable evidence.”
C. Goode, Applied Nursing Research, 2000

A major dilemma for the
practicing nurse:
Finding the time, access, and research expertise that are
needed to search and analyze the evidence to find
answers to their clinical questions.
For those of you who are already pursuing EBP, which of
these issues pose the greatest challenges for you?

Finding the Evidence
• Don’t reinvent the wheel
• If other experts have reviewed the
evidence on your topic … start there

Preprocessed Evidence
(A. DiCenso, 2009)www.drjayeshpatidar.blogspot.in

Resources to Support
• Government agencies
• Cochrane Collaboration
• Professional Organizations
• Benchmark Institutions

AHRQ – Agency for Healthcare
Research and Quality

Cochrane Collaboration
• “an international, independent, not-for-profit organization of over
27,000 contributors from more than 100 countries, dedicated to
making up-to-date, accurate information about the effects of health
care readily available worldwide.
• Contributors produce systematic assessments of healthcare
interventions, known as Cochrane Reviews, which are published
online in The Cochrane Library.
• Rely heavily on RCTs
• Primarily focused on effectiveness of interventions, more
medical and pharmaceutical than nursing

Cochrane Collaboration
http://www.cochrane.org

Substitution of Drs by Nurses in
Primary Care
Objectives: to evaluate the impact on patient outcomes,
processes of care, and costs. Outcomes included:
morbidity; mortality; satisfaction; compliance; and
preference.
Studies were included if nurses were compared to doctors
providing a similar primary health care service. Doctors
included: general practitioners, family physicians,
pediatricians, internists or geriatricians. Nurses
included: nurse practitioners, clinical nurse specialists,
or advanced practice nurses.
Results: 4253 articles were screened, 25 articles met our
inclusion criteria. No appreciable differences were
found between doctors and nurses in health outcomes,
processes of care, or cost; but patient satisfaction was
higher with nurse-led care.www.drjayeshpatidar.blogspot.in

Professional Nursing Organizations
Supporting Evidence-Based Practice
• AACN
• AWHONN
• AORN
• ONS
• Sigma Theta Tau

Am. Assoc. of Critical Care Nurses
Succinct dynamic directives…supported by evidence to
ensure excellence in practice and a safe and humane
work environment.
• Venous Thromboembolism Prevention
• Oral Care in the Critically Ill
• Noninvasive BP Monitoring
• Verification of Feeding Tube Placement
• Ventilator Associated Pneumonia
• Dysrthymia Monitoring
• Published since 2005
• Available free on AACN website
• Include ppt presentations and audit toolswww.drjayeshpatidar.blogspot.in

Oncology Nursing Society
• EBP Resource Center
• http://onsopcontent.ons.org/toolkits/evidence/
• Also provides topical toolkits, on specific topics,
plus:
• How To Find The Evidence
• How To Critique Evidence
• How To Develop An Evidence Based
Presentation
• Evidence Based Practice Education Guidelines
• Evidence on Clinical Topics
• How to Change Practice
• Levels of Evidence Table

Sigma Theta Tau EBP Initiatives
• Strategic Plan
• Online Resources
– NKI http://www.nursingknowledge.org > 200
resources for EBP – some free, some for purchase
• New Award for EBP (formerly Clin Scholarship)
• Conferences
– International EBP and Research Congress
– July, 2010 – Orlando
– July, 2011 – Cancun
– July, 2012 – Australia

Journals Supporting EBP
– Evidence-Based Nursing
– Online Journal of Clinical Innovations
– WorldViews on Evidence-Based Nursing
– The Online Journal of Knowledge Synthesis for
Nursing – (archived, no longer being published)
– Reflections on Nursing Leadership (Vol 28, 2)

Local vs. Global Evidence
• Institutional/Local > National/International
– CPI Data/Research Results
– Standards & Protocols/Practice
Guidelines
– Expert Advice
– Patient/Family Preferences

Values and Preferences
EBN - integration of the best
evidence available, nursing
expertise, and the values and
preferences of the individuals,
families and communities …
Yasmin Amarsi, RNL, 2002:
“The crux is to ensure that
EBN attends to what is
important to nursing and that
caring is not sacrificed on the
altar of scientific evidence.”

Amy’s Blog
• I consulted a well-regarded oncologist in New York. After the tests
she regretfully informed me that my disease was not curable. She
recommended an evidence-based course of medications aimed at
slowing the progression. Before I committed, I wanted a second
opinion. I secured an appointment with the pre-eminent researcher/
clinician in inflammatory breast cancer. …
• The building was beautiful, the staff attentive. …I had no doubt that
the care would be top-notch.
• Everything changed when I sat down with the physician. He never
asked about my goals for care. He recommended an aggressive
approach of chemotherapy, radiation, mastectomy, and more
aggressive chemotherapy. My doctor in New York had said this was
the standard, evidence-based protocol for patients in Stage III B…But
since I am in Stage IV (with mets) she said I wouldn’t get the benefit
of this aggressive, curative approach.

• “All of my patients use this protocol,” he said.
• I was shocked. “Does this mean I could get better?” I asked.
• “No, this is not a cure.” he answered. “But if you respond to the
treatment, you might live longer, although there are no guarantees.”
• My goals are to maximize my quality of life so I can live, work, and
enjoy my family … Would I undergo a year or more of grueling,
debilitating treatment only to live with spinal fractures if the cancer
progressed? … Would I get the possibility of quantity and no quality?
• I pressed him. “Why do the mastectomy? If the cancer has already
spread to my spine. You can’t remove it.”
• His brow furrowed. “Well, you don’t want to look at the cancer, do
you?” He made it sound like cosmetic surgery.
• Right now, I feel fine. I can work. I am pain free. Did I want to trade
that for a slim chance of a little extra time (no guarantees, of course)?

• “But what about the side effects of radiation?” I asked. “I’ve
heard they are terrible.”
• He frowned and seemed annoyed by my questions. “My
patients don’t complain to me about it,” he replied.
• Inwardly, I shook my head. Of course his patients never
complained to him. Most of them were probably unaware that
less aggressive treatments were viable options. To me, there
were real drawbacks. Undergo aggressive therapy that might
buy me a longer life…at what cost? I might never recover my
health for the limited period of time I have.
• This doctor, top in his field, was reflecting the bias of our
medical system towards focusing (evidence-based) survival.
He was focused only on quantity and forgot about quality.

• The patient’s goals and desires, hopes and fears, were not
part of the equation. He was practicing one-size-fits-all
(cookbook?) medicine that was not going to be right for me,
even though scientific studies showed it was statistically more
likely to lengthen life.
• Based on a perverse set of metrics, this oncologist was
offering technically the “best” care America had to offer.
• Yet this good care was not best for me. It wouldn’t give me
health. Instead, it might take away what health I had. It
doesn’t matter if care is cutting-edge, technologically
advanced, (and evidence-based); if it doesn’t take the
patient’s goals into account, it may not be worth doing.

• I returned to my original New York oncologist.
• I was determined not only to choose treatment that
would maximize the healthy time I had remaining, but
also to use that time to call on our health care institutions
and professionals to make a real commitment to listening
to their patients.

Moving Toward our Destiny
Evidence-based practice is every nurses’
responsibility
What can you do to make this goal a reality?

Educator’s Role
– EB Education for EB Practice
– Base educational content on evidence
– Seek the most current forms of
evidence, e.g. journals & online
sources vs. texts
– Encourage students to question and
challenge
– Teach research content in a manner
that is interesting and useful

Manager/Administrator’s Role
– Encourage inquisitive minds
– Promote risk-taking and flexibility in the clinical
environment
– Incorporate EBP activities into performance
evals
– Provide time & resources – unit internet
access
– Provide support personnel
– Empower staff to make EB practice changes
– Acknowledge and reward EB improvements

Researcher’s Role
– Remain clinically in touch
– Conduct clinically useful studies
– Support clinicians in accessing and
synthesizing the evidence
– Collaborate with clinicians and patients
– Disseminate findings that are
understandable and accessible
– Emphasize clinical implications

Nurse Clinician’s Role
– “Worry and Wonder”
– Be the Inquiring Mind
– Question clinical traditions
– Stay abreast of the literature - guidelines
– Find your niche – and become the expert
– Collaborate with APNs & researchers
– Be an advocate for evidence-based changes
– LISTEN to your PATIENTS – to guard patient &
family preferences

Join us:
STTI Research & EBP Congress
July 11-14, 2011

THE 2010 IOM REPORT ON THE
FUTURE OF NURSING

Center to Champion Nursing in
America http://championnursing.org
• Center to Champion Nursing in America is an initiative of AARP, the
AARP Foundation and the Robert Wood Johnson Foundation. The
Center, a consumer-driven, national force for change, works to
increase the nation’s capacity to educate and retain nurses who are
prepared and empowered to positively impact health care access,
quality, and costs.

Nursing has an unprecedented
opportunity to have one voice on behalf
of patient care…
• 18 member committee
– Donna E. Shalala (Chair), President, University of Miami
– Linda Burns Bolton (Vice Chair), Vice President and
Chief Nursing Officer, Cedars-Sinai Health
• Evidence based
• IOM part of National Academy of Sciences
– Private, nonprofit, society of distinguished scholars engaged in
scientific research, dedicated to the furtherance of science and
technology and to their use for the general welfare

Interprofessional Team-Based
Competencies
• IPEC Expert Panel Presentation
• HRSA, Macy Foundation, Robert Wood Johnson
Foundation, and ABIM Foundation
• Amy Blue, PhD
• Jane Kirschling, DNS, RN, FAAN
• Madeline Schmitt, PhD, RN, FAAN-Chair
• Thomas Viggiano, MD, MEd

“Work in
Interprofessional
Teams”
Core
Competencies
Utilize
Informatics
Employ Evidence-
Based
Practice
Provide Patient-
Centered
Care
Apply Quality
Improvement
IOM 5 core competencies, adapted to IPEC Expert Panel Workwww.drjayeshpatidar.blogspot.in

Institute of Medicine October 2010 Report:
The Future of Nursing Leading Change,
Advancing Health
1. Remove scope-of-practice barriers
2. Expand opportunities for nurses to lead and diffuse
collaborative improvement efforts
3. Implement nurse residency programs
4. Increase the proportion of nurses with a baccalaureate
degree to 80% in 2020
5. Double the number of nurses with a doctorate by 2020
6. Ensure that nurses engage in lifelong learning
7. Prepare and enable nurses to lead change to advance health
8. Build an infrastructure for the collection and analysis of
interprofessional health care workforce data

• Remove
scope-of-
practice
barriers
Nurses
should
practice to
the full
extent of
their
education
& training
IOM Key Message
RECOMMENDATION NO. 1

The many faces of advanced
practice registered nurses in 2011
High
quality,
safe,
affordable
health care
provided by
teams of
health care
professionals

Health care reform
• Survey published in JAMA 2008, only 2% fourth-
year medical students plan to work in general
internal medicine (primary care) after graduation,
despite need for 40% increase in number of
primary care physicians in the U.S. by 2020
• Association of American Medical Colleges predicts
shortage of 35,000-44,000 primary care physicians
by 2025
• Expanded opportunities for APRNs

Hospital care…
• Evolution of opportunities for advanced
practice registered nurses
– Change in residency hours
– 24 x 7 coverage
– Evolving recognition of specialty needs

National barriers
• National nursing organizations are
working to
 Improve APRN reimbursement, Medicare
reimburses NPs and CNSs at 85% of
physician rate
 Amend rules that prohibit APRNs from
ordering such things as home health and
hospice services or diabetic shoes

Recent national advances
Medicare now
– Allows NPs to serve as the attending for a
hospice patient
– Allows Governors of states to opt out of
supervision rule for CRNAs – 16 states
have opted out
– Reimburses CNMs at 100%

“Messaging”
Barriers to practice reduce access
to care
Main issue is access to care and
this should define our focus

• Implement
nurse
residency
programs
Nurses should
achieve higher
levels of
education &
training
through an
improved
education
system that
promotes
seamless
academic
progression
IOM Key Message
New graduates
and nurses in
transition

The Problem – Transition to
Practice: Promoting Public Safety
• 35 to 60% new nurses leave position in first
year of practice, estimated replacement cost
$46,000 to $64,000 per nurse
• 10% typical hospital’s nursing staff comprised
of new graduates
• New nurses experience increased stress 3-6
months after hire, increased stress levels are
risk factors for patient safety and practice errors

• NCSBN – transition programs reduce 1st
year turnover from 35-60% to 6-13%,
results in positive return on investment
from 67 to 885%

University Healthsystem Consortium (UHC)
and American Assoc. of Colleges of Nursing
 A one year education and support program
to assist new BSN graduates employed as
staff nurses on clinical units to transition to
professional nursing practice
 Now 54 sites nationwide in 25 states
› Over 12,000 BSNs have been enrolled
nationwide
 National research component to determine
the best practice for integrating new BSN
nurses into the workforce

What is the Residency Research Showing?
 Retention nationally 94.4% for new grad first
year vs. about 73% without residency
 Surveys completed initially, 6 months, and 12
months; scores improve in new graduate’s
ability to
› organize and prioritize
› communicate and be leaders at bedside
› decreased stress over the year (less so at Kentucky)

• Increase the
proportion of
nurses with a
baccalaureate
degree to 80%
by 2020
Nurses should
achieve higher
levels of
education &
training through
an improved
education
system that
promotes
seamless
academic
progression
IOM Key Message

Rationale (Institute of Medicine, 2011, p. 169-170)
 “Several studies support significant
association between educational level of RN
and outcomes for patients in acute care
settings, including mortality”

Enrollments increasing in both DNP
and PhD programs (1997-2009)
AACN 2009: over 9,500 applicants turned away master’s and
doctoral programs

• Ensure that
nurses
engage in
lifelong
learning
Nurses should
achieve higher
levels of
education &
training through
an improved
education
system that
promotes
seamless
academic
progression
IOM Key Message

Faculty partner with health
care organizations
• Develop and prioritize competencies so
curricula updated regularly across all
programs
– go beyond task-based proficiencies to higher-
level competencies
• demonstrate mastery over care management
knowledge domains
• provide foundation decision-making skills under
variety clinical situations across care settings

Academic administrators
• Require all faculty
– participate continuing professional
development
– Perform cutting-edge competence in practice,
teaching, and research

Health care organizations and
schools of nursing
• Foster culture of lifelong learning
• Provide resources for interprofessional
continuing competency programs
• If offer continuing competency programs,
regularly evaluate for flexibility,
accessibility, and impact on clinical
outcomes

Institute of Medicine October 2010 Report: The
Future of Nursing Leading Change, Advancing
Health
2. Expand opportunities for nurses to lead and
diffuse collaborative improvement efforts
7. Prepare and enable nurses to lead change to
advance health
8. Build an infrastructure for the collection and
analysis of interprofessional health care
workforce data

…IN CONCLUSION
 We must commit to take action on
recommendations from IOM report
 Affirm that this is about access to
access to patient-centered care and
health care reform
 Essential that nurses mobilize
 Not just to support nursing, but
more importantly – to support the
public www.drjayeshpatidar.blogspot.in

THANK YOU

Evidence based practice & future nursing

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