chapter 2 nursing research

BUILDING AN EVIDENCE-BASED

NURSING PRACTICE

By: ELVIE A. IMASON-RAMOS, MAN, RN

Chap 2: BUILDING AN EVIDENCE-BASED

NURSING PRACTICE

At the end of the chapter, the

learner should be able to:

Define evidence-based

practice

List source of evidence for

nursing practice

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Learning Outcomes:


NURSING PRACTICE

Identify barriers to the

adoption of EBP and pinpoint

strategies to overcome them.

Explain how the process of

diffusion facilitates moving

evidence into nursing

practice

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Learning Outcomes:


NURSING PRACTICE

Facts are stubborn

things; and whatever

may be our wishes, our

inclinations, or the

dictates of our

passions, they cannot

alter the state of

facts and evidence. - John Adams

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NURSING PRACTICE

Started in the field of medicine

Dr. Archie Cochrane (1971)

was concerned that evidence

was not being critically

examined. He stressed that

random clinical trials are the

gold standard for generating reliable and valid evidence.

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Evidence-based Practice


NURSING PRACTICE

Evidence from clinical

research should be used over

intuition, unsystematic clinical

experience, and

pathophysiology (Cullum, et.

al., 2008)

An important approach to

provide the best quality care

to patients and their families.

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NURSING PRACTICE

Maintained that practice

based on evidence can help

decrease uncertainty

commonly experienced by

both patients and health care

professionals particularly

nurses in todays complex health care system (Mylnek &

Finecout-Overholt, 2004)

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NURSING PRACTICE

Research has shown that

patients who receive care

based on evidence from

well designed studies

experience better

outcomes and early

recovery.

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NURSING PRACTICE

Simply the integration of the

best possible research

evidence with clinical

expertise and with patients

needs (Porter-OGrady, 2006)

Three Factors Merge.doc

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NURSING PRACTICE

1. Formulation of a clinical

question;

2. Gathering the best evidence to

answer the clinical question;

3. Critical appraisal of the best

evidence or research based

information;

4. Integration of the evidence with

the nurse own expertise, eaimason74

Evidence-based Practice: Five (5) Key Steps


NURSING PRACTICE

assessment of patients

condition, available resources

and patients preferences and values to implement a clinical

decision;

5. Evaluation of the practice

change, as a result of

implementing the evidence.

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Evidence-based Practice: Five (5) Key Steps


NURSING PRACTICE

Introduced by Melynk &

Finecout-Overholt (2004)

advocate asking clinical

questions in the PICOT

Format:

P patient population

I intervention of interest

C comparison intervention

O outcome

T time target

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PICOT Format


NURSING PRACTICE

It is necessary to have a

clear description of the

patient population and

setting retrieve the most

relevant evidence;

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P Patient Population


NURSING PRACTICE

This may include, but is not

limited to any treatment,

patient perception, exposure

or diagnostic test.

The more defined the

intervention, the more

focused the search for

evidence will be;

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I Intervention of Interest


NURSING PRACTICE

The standard of care is

compared to a new

treatment or procedure.

The comparison can be

a true control such as

placebo;

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C Comparison Intervention


NURSING PRACTICE

Specific identification of

the outcome variable

facilitates the search for

evidence that has

investigated the same

outcome;

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O - Outcome


NURSING PRACTICE

Specific time for the

intervention to achieve the

best outcome.

The authors maintained that asking

the questions in this format will

yield the most relevant and best

evidence.

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T Time Target


NURSING PRACTICE

Remember: it is common

for nurses to implement

change fail to evaluate the

effectiveness based on

evidence but of that

change.

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NURSING PRACTICE

Evaluation of practice

change is paramount in

order to determine how a

particular treatment worked

or the effectiveness of

clinical decision.

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NURSING PRACTICE

Problem solving approach,

EBP therefore incorporates

research based information,

nurses clinical expertise and research skills, patients reference, values and

expectations within the

context of caring to generate

the best patient outcome.

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NURSING PRACTICE

Combined the three nature

of EBNP.

Level I: Evidence obtained from at least one properly

designed randomized

controlled trials;

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NURSING PRACTICE

Level II: Evidence obtained from well designed

controlled trials without

randomization, well

designed case control

analytic studies or multiple

time series with or without

intervention; and

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NURSING PRACTICE

Opinions of respected authorities based on clinical

experiences, descriptive

studies or report of experts.

Nature of EBN Practice 2.doc

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NURSING PRACTICE

The nurse clinical decision

required for evidence-based

health care. It is informed by

factors such as valid, relevant

research findings or best

evidence, client preferences,

sound judgment, skills and

expertise of the nurse as well as

the resources available to the

nurse and the client.

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The of Evidence-based Nursing Practice


NURSING PRACTICE

Is about providing care that is

supported by research and

clinical trials.

Not all practice can be

evidence based, nurses must

used the best available

information on which to base

their interventions.

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NURSING PRACTICE

To incorporate research findings into practice is essential in

developing a science based

practice.

Evidence for research studies

encourage nurse practitioners to

adopt the practices that have been

found useful and to abandon those

usefulness has not been

supported by evidence.

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NURSING PRACTICE

Nurses should discriminate

between those that studies have

been characterized as:

Beneficial forms of care

Care that are likely beneficial

Care with trade off between beneficial and adverse effects

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NURSING PRACTICE

Care with unknown effectiveness

Care that are unlikely beneficial, and

Care that are likely to be ineffective or harmful.

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NURSING PRACTICE

To justify the worth of

evidence:

Systematic review of

randomized controlled trials

are conducted to determine

biased or consistent findings.

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NURSING PRACTICE

Latest protocol guideline

issued by WHO through

DOH issued A.O. 2009-

0025 Essential Newborn

Care (ENC) under the

umbrella of the Unang Yakap

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NURSING PRACTICE

Issued by DOH,

mandating all hospital to

implement the four (4)

steps of newborn care

time-bound intervention to

lessen neonatal deaths.

WHO-DOH.doc

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NURSING PRACTICE

As a result of systematic

reviews, the best practice

and better ways to achieve

nursing goals in its

operational, clinical and

financial perspective can

be improved.

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NURSING PRACTICE

Nurses have now the

resources with which to

identify successful

practices and use them as

standards for safe

practice.

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NURSING PRACTICE

Similar to benchmarking

which supports and

promotes continual quality

improvement and helps

nurses remain steadfast

and competitive in the

health care market.

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NURSING PRACTICE

Evidenced based research

also uses collaborative

benchmarking which

involves sharing of strategies

and outcomes.

Evidence was arranged in a

hierarchy according to level

of credibility (Ferguson &

Day, 2005) Pyramid of evidence.doc

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NURSING PRACTICE

Each sources of evidence is

necessary within the context

on which type of evidence

are suggested.

The primary challenge for

nurses is the establishment

of criteria for assessing and

determining acceptable

evidence.

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NURSING PRACTICE

EBP is a problem solving

approach to nursing

practice that involve the

conscientious use of

current best evidence in

making decisions about

patient care.

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Characteristics Evidence-based Practice in Nursing


NURSING PRACTICE

It is also consider the nurse

expertise and patients

values and expectations.

The nurse capacity to

identify each patients unique health status and

diagnosis, potential risks,

and benefits of nursing

interventions.

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NURSING PRACTICE

It can come up with best

available evidence by using

research in combination with

theory. Research and theory

allows for accuracy of the

nursing care plans, diagnostic

tests, prognosis, and safety

of therapeutic and preventive

interventions.

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NURSING PRACTICE

It allows client preferences

and values to be heard. As

nurses and clients interact,

the preferences, concerns,

and expectations of each

client are all integrated into

making clinical decisions.

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NURSING PRACTICE

RU is the process of

synthesizing, disseminating,

and using research-generated

knowledge into the nurse

clinical practice.

RU facilitates the transfer of

innovation and purposive

application of research findings

to the current nursing practice (Polit & Beck, 2008)

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Research Utilization (RU) & Evidence-based Practice


NURSING PRACTICE

RU is often used

interchangeably with

evidence-based practice

since research utilization is

but a part of evidence-based

practice

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NURSING PRACTICE

DISSEMINATION is a part of RU, is the process

of knowledge transfer. It

includes consideration of

what, when, and how of

moving ideas and

information from the

source(s).

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NURSING PRACTICE

e.g. researchers to intended

recipient(s) such as client or

patients.

Research findings remain

out of the reach for their

intended users such as

health workers and patients.

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NURSING PRACTICE

Knowledge and

interventions produced by

nursing research remain

untapped due to

researchers limited resources and lack of

identified utilization goals

and targets.

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NURSING PRACTICE

Purpose of research is to

confirm current practice or to

change it.

The process of

understanding and applying

research findings into

practice usually takes years,

decades, or even

generations.

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NURSING PRACTICE

It is necessary to move

carefully, new research output

needs to evaluated, replicated

and refined.

The change process is

evaluated, not by a rigorous

review and refinement, but the

gap between the research

community and the standard of

practice.

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NURSING PRACTICE

e.g. it took some time, 264 years, from the discovery of

citrus juice as preventive

measure for scurvy and its

use on British ship before it

was widely accepted.

(Glaser, Abelson, &

Garrison, 1993, cited by

Houser, 2008)

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NURSING PRACTICE

First Asia Pacific

Conference in Nursing

Research held in 2008

sought to address the issue

and proposed measures to

bridge the gap between

research and its utilization in

the Philippines.

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NURSING PRACTICE

Gathering and accounting

for research outcomes and

analyzing them for viability

requires considerable

financial resources.

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NURSING PRACTICE

Seven (7) models

Stetler, Iowa and Rogers Theory of Diffusion of

Innovations has gained the

general acceptance.

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Guide to Evidence-based Practice in Nursing


NURSING PRACTICE

Common elements of

these models which

include: synthesis of

evidence, implementation,

evaluation of impact on

patient care, and

consideration of the

context/setting in which

evidence is implemented.

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NURSING PRACTICE

Stetler Model of Research

Utilization (Stetler, 2001)

Iowa Model of Research in

Practice (Titler et. al., 2001)

Rogers Theory of Diffusion of innovations (1995)

Ottawa Model of Research

Use (Logan & Graham, 1998)

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NURSING PRACTICE

Evidence-based

Multidisciplinary Practice Model

(Goode & Peidalue, 1999)

Model for Change to Evidence-

based Practice (Rosswurm &

Larrabee, 1999)

Center for Advanced Nursing

Practice Model (Soukup, 2000)

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NURSING PRACTICE

Presents a structure for using

the research outcomes and

suggests a vehicle for changing

policies and procedures.

Nurse practitioner, educators,

and policymakers, make a

summary of research done and

use it to influence educational

programs, make practice

decision, and policies.

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STETLER MODEL


NURSING PRACTICE

Encompasses several steps:

Preparation

Validation

Comparative Evaluation

Decision Making

Translation/Application

Evaluation

(Burns & Grove, 2007)

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STETLER MODEL


NURSING PRACTICE

Involves identifying the

purpose and focus of the

literature review

Research literature may be

reviewed to solve a difficult

clinical, managerial, or

educational problem

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STETLER MODEL: Preparation


NURSING PRACTICE

To provide the basis for

policy, standard or protocol

To prepare for an in-service

program or other type of

professional presentation

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STETLER MODEL: Preparation


NURSING PRACTICE

A key consideration in

validation is to determine

whether the information is

applicable and relevant to

the current needs and

problems of the nursing

profession.

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STETLER MODEL: Validation


NURSING PRACTICE

A review of findings of

similar studies.

The end result of the

comparative evaluation is to

make a decision about using

the study findings for

practical purposes

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STETLER MODEL: Comparative Evaluation


NURSING PRACTICE

The researcher chooses

from four possible options:

To use; To consider use;

To delay use; Reject the

findings altogether

If the decision is negative, no

further steps are necessary

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STETLER MODEL: Decision Making


NURSING PRACTICE

The preparation for the

actual implementation of the

findings in the practice.

The main question here is

how research knowledge should be applied? keeping in mind always the beneficial

effects to all consumers of

health care.

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STETLER MODEL: Translation/Application


NURSING PRACTICE

Final stage which

determines the impact of

research findings on

practice, policy, and

patient care

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STETLER MODEL: Evaluation


NURSING PRACTICE

Identifying validated

research findings and

utilizing the model,

possible administrative

policies could be

designed to address the

needs and problems of

the nurse practitioner.

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STETLER MODEL: Evaluation


NURSING PRACTICE

Provides direction for the

development of evidence-

based practice in clinical

agency

Initially developed by Titler

and colleagues in 1994,

revised in 2001.

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IOWA MODEL


NURSING PRACTICE

The health agency, there are

triggers that initiate the need

for change, which is best

made based on research

evidence.

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IOWA MODEL


NURSING PRACTICE

The pressure to change can

be generated by a heightened

awareness of new research

findings derived from journal

readings, participation in

scientific conferences, and

exposure to EBP guidelines

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IOWA MODEL: Knowledge-focused triggers


NURSING PRACTICE

e.g. pain management,

prevention of skin breakdown,

assessing placement NGT or

nasogastro-intestinal tube

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IOWA MODEL: Knowledge-focused triggers


NURSING PRACTICE

It has its roots in a clinical or

organizational problem.

Discovery of these problems

are usually by-products of

quality improvement activities,

risk surveillance, data

benchmarking, review of

financial performance among

others.

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IOWA MODEL: Problem-focused triggers


NURSING PRACTICE

1. The problem is a sufficient

priority for the organization

exploring possible changes;

2. There is a sufficient research

base; and

3. The change is appropriate

for adoption in practice

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IOWA MODEL: Three Critical Decision Points


NURSING PRACTICE

Is a theory of How, Why, and

At What rate new ideas and

technology spread through

cultures

Concept was first studied by

(French) Gabriel Tarde and

by (German) Friedrich Ratzel

or Leo Frobenius (1890)

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Rogers Theory of Diffusion Model


NURSING PRACTICE

Everette Rogers (1995) first

discussed this theory in his

textbook

Rogers defines diffusion as the process by which an innovation is communicated

through certain channels over

time among members of a

social system

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NURSING PRACTICE

Diffusion of Innovations

theory by Rogers includes five

stage process:

1. Knowledge Stage

2. Persuasion Stage

3. Decision Stage

4. Implementation Stage

5. Confirmation Stage

K-P DIC Process

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NURSING PRACTICE

These consists of the

initial awareness of the

existence of an innovation

or a new idea for use in

practice

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Rogers Theory of Diffusion Model: Knowledge Stage


NURSING PRACTICE

The nurse develop

an attitude toward the

innovation

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Rogers Theory of Diffusion Model: Persuasion Stage


NURSING PRACTICE

A choice is made to

adopt or reject the

innovation

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Rogers Theory of Diffusion Model: Decision Stage


NURSING PRACTICE

This involves using

the new idea to

change the current

practice.

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Rogers Theory of Diffusion Model: Implementation Stage


NURSING PRACTICE

Nurses seeks

reinforcement of their

decision leading to either

a continuance of the

adoption of the evidence

or its rejection.

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Rogers Theory of Diffusion Model: Confirmation Stage


NURSING PRACTICE

Rogers model could serve as useful guide

during the early stages of

research and can provide

direction in implementing

research-based

intervention in nursing

practice.

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NURSING PRACTICE

The use of strategies to

apply innovations into

practice such as the use of

evidence and other research

findings to practice

environment (Logan &

Geraham, 1999)

There six components of

this model.

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NURSING PRACTICE

1. Practice environment

2. Potential research use

3. Evidenced based

innovations

4. Strategies to apply

innovations

5. Use of evidence

6. Health and other

outcomes

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NURSING PRACTICE

Similar to Rogers theory of diffusion of innovation

Involves comprehensive

information on certain

issues and weighing

pieces of evidence in

relation to literature

reviewed as basis to draw

conclusion

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Evidence Based Model


NURSING PRACTICE

Nurses to get the best from

research findings, they must

take into account much of

the evidences possible,

organized and synthesized

in a rigorous manner geared

towards making accurate

decisions for safe and

effective patient care.

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Evidence Based Model


NURSING PRACTICE

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chapter 2 nursing research

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