Evidence Based Practice

1. We believe that Nursing is united by:
• A personal commitment to caring
• A dynamic search for professional
excellence
• A team spirit of courage, joy and hope in our
interaction with
mankind
The Key Components Of Our Practice
• Caring and Compassionate Environment
• Professional excellence
• Continuum of Care
• Mind, Body and Spirit approach to Health
and Wellness
• Evidence-based Practice
• Sensitivity for Customer Service, Outcomes
and Cost
• Advocacy
• Collaboration across disciplines
• Autonomy

2. 1.What's Evidence Based Nursing (EBN)?
Evidence Based Nursing is the process by which nurses
make clinical decisions using the best available research
evidence, their clinical expertise and patient preferences.
Three areas of research competence are: interpreting and
using research, evaluating practice, and conducting
research. These three competencies are important to EBN.
2.Evidence-based practice (EBP) involves complex and
conscientious decision-making which is based not only on
the available evidence but also on patient characteristics,
situations, and preferences. It recognizes that care is
individualized and ever changing and involves
uncertainties and probabilities.

3. The movement of evidence-based healthcare has evolved over time.
Dominant themes for the decades of 1970-1980 were "doing things
cheaper" (efficiency) and "doing things better" (quality improvement).
These two themes together were considered "doing things right.
" During 1980-1990, "doing the right things" (increasing effectiveness)
was the major theme and this, in combination with "doing things right"
was considered "doing right things right" in the 21st century (Gray,
1997).
These days, practitioners have come to expect evidences for their
interventions, some to the point of saying, "In God we trust: All others
bring data" (Cornelia Beck, as cited in Tanner, 1999).
The history of evidence-based nursing is closely related to the evolution
of evidence-based health practice and evidence-based medicine.

4. (Florence Nightingale 1860/1969)
- the Mother who gave birth to Professional Nursing -
by publishing her Notes on Nursing
-demonstrating evidence of its efficacy by statistics
- recognized the potential of combining sound
logical reflection and empirical research in the
development of scientific knowledge about nursing
and the application of its principles in professional
nursing.

5. Virginia Henderson(1960)
 Second Pragmatic Visionary Nurse
 Defined the function of nursing
 Because of its conceptual clarity, this description of
nursing was accepted by the ICN.
 This description structured Henderson's meticulous
search for empirical evidence already generated by
the physical, biological, and social sciences
foundational to nursing

6. (Henderson & Nite, 1978),
 collected the wealth of empirical evidence in
Principles and Practice of Nursing .
 This description also structured her identification of
research questions with great relevance for
professional nursing practice.
 last 40 years – efforts to generate evidence-based
practice have intensified and expanded.
 Nurse theorists - Orem, Rogers, Leininger, Roy,
King, Parse, Newman, and Benner in the US Roper,
Juchi, Bienstein, van der Bruggen, and Norberg in
Europe

7. • Nursing research began to focus on clinical issues in
the mid 80's (Stevens & Cassidy, 1999).
• The National Institute for Nursing Research (NINR) was
formed in 1986, greatly increasing the visibility and
funding opportunities for nursing research.
• Many new journals emphasize nursing research
• In recent years the International Society for Nursing
Research, Sigma Theta Tau, has greatly increased its
capacity to support and disseminate nursing scholarships
• McMaster University in Ontario, Canada has developed
extensive resources in teaching and implementing
evidence-based practice in nursing and other disciplines

8. Factors to be considered
to carry out EBN
-sufficient research
must have been
published on the
specific topic
-the nurse must have
skill in accessing and
critically analyzing
research
-the nurse's practice
must allow her/him to
implement changes
based on EBN

9. DEFINITIONS
Sackett (1996) Evidence Based Medicine
• "Integrating clinical expertise and the best available evidence from
systematic research
Stetler (1998) Evidence Based Nursing
• "De-emphasizes ritual and isolated unsystematic clinical experience,
ungrounded opinions and traditions
• "Emphasizes research, findings from QI data and other operational and
evaluation data, consensus of experts, affirmed experiences.
Evidence-based practice refers to a decision-making approach based on
integrating clinical expertise with the best available evidence from systematic
research. This is in contrast to opinion-based decision-making that is based
primarily on values and resources (Gray, 1997).
Ingersoll (2000) proposed the following definition. "Evidence-based nursing
practice is the conscientious, explicit and judicious use of theory-derived,
research based information in making decisions about care delivery to
individuals or groups of patients and in consideration of individual needs and
preferences“

10. Evidence-based Nursing Practice: solves problems
encountered by nurses by carrying out four steps:
I. Clearly identify the issue or problem based on accurate
analysis of current nursing knowledge and practice
II. Search the literature for relevant research
III. Evaluate the research evidence using established
criteria regarding scientific merit
IV. Choose interventions and justify the selection with the
most valid evidence

11.  (1) The Conduct and Utilization of Research in Nursing (CURN)
project.
The CURN Project was designed to develop and test a model for using
research-based knowledge in clinical practice settings. Research
utilization is viewed as an organizational process. Planned change is
integrated throughout the research utilization process. Systems change
is essential to establishing research-based practice on a large scale.
 (2) The Stetler Model of Research Utilization
The Stetler Model of Research Utilization applies research findings at
the individual practitioner level. The model has six phases: (1)
preparation, (2) validation, (3) comparative evaluation, (4) decision
making, (5) translation and application, and (6) evaluation. Critical
thinking and decision making are emphasized.
 (3) Iowa Model for Research in Practice
The Iowa Model of Research in Practice infuses research into practice to
improve the quality of care , and is an outgrowth of the Quality Assurance
Model Using Research (QAMUR). Research utilization is seen as an
organizational process. Planned change principles are used to integrate
research and practice. The model integrates evidence-based healthcare
acknowledges and uses a multidisciplinary team approach.

12.  The Star Model of Knowledge
Transformation is a model for
understanding the cycles,
nature, and characteristics of
knowledge that are utilized in
various aspects of evidence-
based practice (EBP). The Star
Model organizes both old and
new concepts of improving
care into a whole and provides
a framework with which to
organize EBP processes and
approaches.

13.  The Star Model depicts various forms of knowledge in a relative
sequence, as research evidence is moved through several cycles,
combined with other knowledge and integrated into practice. The ACE
Star Model provides a framework for systematically putting evidence-
based practice processes into operation.
 Definition of Knowledge Transformation--the conversion of
research findings from primary research results, through a series of
stages and forms, to impact on health outcomes by way of EB care.
STAGES OF KNOWLEDGE TRANSFORMATION
1. Discover y
2 . Evidence Summar y
3. Translation
4. Integration
5. Evaluation

14. 1. Discovery
This is a knowledge generating stage. In this
stage, new knowledge is discovered through the
traditional research methodologies and
scientific inquiry. Research results are
generated through the conduct of a single
study. This may be called a primary research
study and research designs range from
descriptive to correlational to causal; and from
randomized control trials to qualitative. This
stage builds the corpus of research about
clinical actions.

15. 2. Evidence Summary
Evidence summary is the first unique step in EBP—
the task is to synthesize the corpus of research
knowledge into a single, meaningful statement of
the state of the knowledge
 This stage is also considered a knowledge
generating stage, which occurs simultaneously with
the summarization. Evidence summary produces
new knowledge by combining findings from all
studies to identify bias and limit chance effects in
the conclusions. The systematic methodology also
increases reliability and reproducibility of results

16. 3.Translation
 The transformation of evidence summaries into actual practice
requires two stages: translation of evidence into practice
recommendations and integration into practice.
The aim of translation is to provide a useful and relevant package of
summarized evidence to clinicians and clients in a form that suits the time,
cost, and care standard. Recommendations are generically termed clinical
practice guidelines (CPGs) and may be represented or embedded in care
standards, clinical pathways, protocols, and algorithms.
Summarized research evidence is interpreted and combined with other
sources of knowledge (such as clinical expertise and theoretical guides) and
then contextualized to the specific client population and setting. Evidence-
based CPGs explicitly articulate the link between the clinical
recommendation and the strength of supporting evidence and/or strength
of recommendation.

17. 4. Integration
Integration is perhaps the most familiar stage in
healthcare because of society’s long-standing
expectation that healthcare be based on most
current knowledge, thus, requiring implementation
of innovations. This step involves changing both
individual and organizational practices through
formal and informal channels. Major factors
addressed in this stage are those that affect
individual and organizational rate of adoption of
innovation and integration of the change into
sustainable systems.

18. 5. Evaluation
The final stage in knowledge transformation is
evaluation. In EBP, a broad array of endpoints
and outcomes are evaluated. These include
evaluation of the impact of EBP on patient
health outcomes, provider and patient
satisfaction, efficacy, efficiency, economic
analysis, and health status impact.
As new knowledge is transformed through the
five stages, the final outcome is evidence-based
quality improvement of health care.

19. (Voda et al. 1971) the research-practice gap was the result of
1. Failure to directly involve clinical nurses in research projects;
2. Researchers not directly being involved with patient care and;
3. Nurses failing to read research.
4. (Smith 1986 & Miller et al., 1997) insufficient time for nurses to participate
in research activities.
5. Practicing clinicians do not understand the importance of research.
6. Cruickshank (1996), Walsh & Ford (1986:2) 'nursing tends to be in-
situation driven rather than research driven and actions have become
rituals.‘
7. Akinsanya (1993:174) research as a minute and difficult component" of
undergraduate nursing programs

20. Strategies to reduce the research-
practice gap:
1.Further development of leadership skills
amongst nurses
2.The development of research teams
3.An increase in the research components in
undergraduate and post graduate courses
and an improvement of nursing research
skills amongst nursing lecturers.

21. HYDRATION MANAGEMENT
Nursing Standard of Practice Protocol: Oral Hydration
Management
Goal
 To minimize episodes of dehydration in older adults.
Overview
 Maintaining adequate fluid balance is an essential component
of health across the life span; older adults are more vulnerable
to shifts in water balance, both over-hydration and dehydration,
because of age-related changes and increased likelihood that
they have several medical conditions. Dehydration is the more
frequently occurring problem.

22. A. Definitions
 1. Hydration management is the promotion of adequate fluid
balance that prevents complications resulting from abnormal or
undesired fluid levels. (See Resources: Dochterman & Bulechek, 2004).
2. Dehydration is depletion in TBW content due to pathologic fluid
losses, diminished water intake, or a combination of both. It results in
hypernatremia (>145mEq/L) in the extracellular fluid compartment,
which draws water from the intracellular fluids. The water loss is shared
by all body fluid compartments and relatively little reduction in
extracellular fluids occurs. Thus, circulation is not compromised unless
the loss is very large. This is also known as intracellular dehydration or
hypernatremic dehydration (Na > 145mE/L).
3. Volume depletion is the loss of both sodium and water with
greater losses of sodium resulting in extracellular fluid loss and a
reduction in intravascular volume, 1 also called hypotonic dehydration.

23. B. Etiologic factors associated with dehydration
 1. Age-related changes in body composition with resulting decrease in
TBW.
2. Decreasing renal function.
3. Lack of thirst.
C. Risk Factors
 1. Individuals older than 85.
2. Individuals who are institutionalized.
3. Individuals with ADL dependencies, specifically feeding and eating.
4. Individuals with a diagnosis of dementia.
5. Individuals with infections.
6. Individuals who have had prior episodes of dehydration.

24. A. Health history C. Laboratory Tests
1. Specific disease states:  1. Urine specific gravity.
dementia, congestive heart failure,
chronic renal disease, malnutrition, 2. Urine color.
and psychiatric disorders such as
depression. 3. BUN/creatinine ratio
2. Presence of co morbidities: more 4. Serum sodium
than four chronic health conditions.
5. Serum osmolality
3. Prescription drugs: number and
types. D. Individual fluid intake
4. Past history of dehydration,
behaviors.
repeated infections
B. Physical Assessments
 1. Vital signs
2. Height and weight
3. BMI

25. A. Risk Identification
 1. Identify acute situations: vomiting, diarrhea, or febrile episodes
2. Use a tool to evaluate risk: Dehydration Appraisal Checklist
B. Acute Hydration Management
 1. Monitor input and output.
2. Provide additional fluids as tolerated.
3. Minimize fasting times for diagnostic and surgical procedures.
C. Ongoing Hydration Management
 1. Calculate a daily fluid goal.
2. Compare current intake to fluid goal.
3. Provide fluids consistently throughout the day.

26. 4. Plan for at-risk individuals
 a. Fluid rounds.
b. Provide two 8-oz. glasses of fluid, one in the morning and the other
in the evening.
c. "Happy Hours" to promote increased intake.
d. "Tea time" to increase fluid intake.
e. Of fer a variety of fluids throughout the day.
5. Fluid regulation and documentation
 a. Teach able individuals to use a urine color char t to monitor
hydration status.
b. Document a complete intake recording including hydration habits.

c. now volumes of fluid containers to accurately calculate fluid
consumption.

27. Evaluation and Expected Outcomes
 A. Decreased infections, especially urinary tract infections.
 B. Improvement in urinary incontinence.
 C. Normal urinary pH.
 D. Decreased constipation.
 E. Decreased acute confusion
Follow-up Monitoring of Condition
 A. Urine color chart monitoring in residents with better renal function.
 B. Urine specific-gravity checks.
 C. 24-hour intake recording.
Relevant Practice Guidelines
 A. Hydration-Management Evidence-Based Protocol