Transforming Nursing Practice through Evidence: The Joanna Briggs Institute Approach

1. Transforming Nursing Practice through Evidence: The Joanna Briggs Institute Approach

2. Course Objectives Describe the history of and trends in evidence-based health care (EBHC). 1.Apply techniques for moving evidence into practice. 2.Outline the steps to systematical and critical review of evidence. 3.Evaluate the clinical audit and feedback process.

3. Introduction The Fundamentals of Evidence-Based Nursing Purpose/Goal: This program is designed to educate nurses in the fundamentals of the Joanna Briggs Institute’s (JBI’s) evidence-based nursing (EBN) process. To be useful in practice, evidence must first be presented in an applicable, user- friendly format. The transfer of this evidence remains one of the greatest challenges still facing the evidence-based practice (EBP) movement and its success requires a multi-dimensional approach. Nurses are at the front line of this change and are the key facilitators of applying research findings into routine patient care.

4. Module 1History and Origins of Evidence-Based Health Care Introduction The art of medicine, or health care as it is often called, has been practiced formally for centuries. However, health care practices used today have benefited from the influence of several historical figures. Over time, these early pioneers determined that the process of healing and the effectiveness in practices could be greatly improved. This module discusses the evolution of practice and how our understanding of searching for and utilizing scientific research has changed over time. Learner Objectives Upon completion of this module the learner will: 1.   Understand the need for evidence in health care practice. 2.   Describe how the concept of evidence is not new. 3.   Name several pioneers credited with first applying evidence to their practice. 4.   Explain the evolution of evidence-based health care as we know it today.

5. Module 2 The Evidence-Based Health Care Debate Introduction Much of the debate that encompasses evidence-based health care (EBHC) focuses on a handful of core issues that appear consistently in the literature questioning the merits of EBHC. Listed below are the five main areas of criticism. 1.Evidence-based health care is like “cookbook” practice with no allowance for individual patient care or clinical expertise. 2.Evidence-based health care isn’t new at all; nurses are already doing it. 3.There is too much weight and consideration given to randomized controlled trials (RCTs) and systematic reviews at the expense of more common observational research and expertise. 4.Oftentimes, there is no evidence. 5.Theory is more important than evidence to guide practice. Learner Objectives Upon completion of this module the learner will: 1.Discuss the criticisms of evidence-based health care. 2.Explain the merits and drawbacks of evidence-based health care. 3.Describe the evolution of evidence-based health care.

6. Module 3 Understanding the Generation of Health Care Evidence Introduction The basis of evidence-based practice is evidence! So the generation of evidence is fundamental in terms of making sure the process moves forward. Evidence for health care is generated through research, experience and the formulation of opinion. Where evidence represents our “knowledge” or “truth,” research represents our search for it. Learner Objectives Upon completion of this module the learner will: 1.Utilize the appropriate research technique to generate new “knowledge” for health care, dependent on the question that is asked. 2. Describe what a research paradigm is. 3. Explain how most evidence for health care today is a product of research undertaken using the positivist paradigm. 4. Demonstrate how, for some research questions, other paradigms of knowledge generation (including interpretive and critical) are equally appropriate.

7. Module 4 Clinical Wisdom and the Use of Evidence Introduction The use of “clinical wisdom” or “judgment” is a clearly acknowledged aspect of mainstream evidence-based health care (EBHC). What is not understood is the extent to which research-derived evidence outweighs clinical wisdom in everyday clinical decision making. Patients value a technical, scientifically informed practitioner who is also clinically wise. Health professionals acknowledge that using evidence without clinical wisdom (which they often refer to as “clinical judgment,” “clinical reasoning” or “critical thinking”) falls far short of best practice. Learner Objectives Upon completion of this module the learner will: 1.Define clinical wisdom and its recognition, acquisition and transmission to the clinical setting. 2.Identify ways of supporting and evaluating clinical wisdom in practice. 3.Describe the relationship between clinical evidence and clinical wisdom within EBHC.

8. Module 5 What is Evidence for Practice? Introduction Nurses make numerous clinical decisions each and every day. In making such decisions, the nurse draws on a wide range of knowledge. This knowledge involves the basic sciences, assessment of the context and of the individual patient. Also taken into consideration is a nurse's own experience and understanding of research reports. When you combine this knowledge to make a decision, this is referred to as evidence and an answer to the question, “Exactly what counts as evidence?” Learner Objectives Upon completion of this module the learner will: 1.Understand what constitutes “evidence for practice.” 2.Explain why evidence is more than just results from controlled trials. 3.Describe how EBHC strives to discover the “best available evidence.” 4.List how the “best available evidence” may take many forms beyond experiments.

9. Module 6 Searching for the Evidence Introduction To be able to incorporate evidence in practice, it is essential to be able to find the evidence! The aptitude to search for evidence is essential for any evidence-based practitioner. The sheer volume of medical literature available is an important obstacle. To streamline access to relevant and good quality evidence, the systematic review was developed and has been used successfully to inform clinical practice (More about this in Module 11). To make accessing this information more user-friendly, summaries of the best available evidence are available. They are easy to identify and use. Learner Objectives Upon completion of this module the learner will: 1.   Refine a research question so that it can inform a database search. 2.   Formulate search questions using PICO. 3.   Perform a search using several health databases. 4.   Demonstrate how to use the 6S pyramid for searching.

10. Module 7 Critically Appraising Quantitative Research Evidence Introduction Critical appraisal is the careful assessment of research by reviewing its relevance, validity, value, results and its trustworthiness in a situation. Appraisal enables you to quickly exclude papers that are of inadequate quality and to pull out the key points of those papers that you do want. First, you need to understand the essential components of quantitative studies and design in order to assess quantitative research. This module discusses that process and takes you through it step by step. Let’s begin by exploring the benefits of critical appraisal. Learner Objectives Upon completion of this module the learner will: 1.   Conduct a critical appraisal of quantitative research papers using RAPid. 2.   Assess the relevance of published research and its applicability. 3.   Critically appraise published research and judge its validity and reliability.

11. Module 8 Critically Appraising Qualitative Research Evidence Introduction To date, there is no commonly accepted statement of what should be reported in papers of qualitative research. Critical appraisal checklists provide researchers with the main criteria with which their reports are evaluated. This makes them a useful tool to be considered at that stage. Critical appraisal is “the process of systematically examining research evidence to assess its validity, results and relevance before using it to inform a decision” (Hill & Spittlehouse, 2003). Qualitative research is subject to the same appraisal criteria as quantitative research, which includes validity, reliability and generalizability. Learner Objectives Upon completion of this module the learner will: 1.Demonstrate how to conduct critical appraisal of qualitative research papers using RAPid. 2.Assess the relevance of published research in practice. 3.Critically appraise published research and judge its validity.

12. Module 9 Summarizing Evidence Introduction Evidence-based health care practice focuses on the need for all health professionals to use the most up-to-date evidence or knowledge available. The evidence-based approach acknowledges the difficulties faced by busy practitioners in keeping up with the ever growing amount of literature and providing them with condensed information. Perhaps what is needed in health care is not more research but proper communication of existing evidence and the means of making sense of the vast amounts of data which have already been accumulated (Hunter, Schmidt and Jackson, 1982). Learner Objectives Upon completion of this module the learner will: 1.   Discuss the need for summarizing evidence through the synthesis of research. 2.   Outline the steps involved in the process of meta-analysis and meta-synthesis. 3.   Describe which forms of synthesis are appropriate for various sources of evidence.

13. Module 10 Understanding Levels of Evidence Introduction Generally speaking, the better the evidence, the higher it is ranked. How good the evidence is depends on the study design and the methodology used to establish the evidence. Those study designs that minimize bias, such as a RCT, will be ranked higher than an observational study design, such as a case-control study. Levels of evidence is a method for ranking research evidence. This is also called evidence hierarchy. Learner Objectives Upon completion of this module the learner will: 1.Explain why EBP recommendations are assigned a level of evidence. 2.Describe the term level of evidence. 3.Outline how a level of evidence is assigned. 4.Describe what is meant by effectiveness, feasibility, appropriateness and meaningfulness.

14. Module 11 Understanding Systematic Reviews Introduction The need for evidence to support practice is paramount. The knowledge on which clinical nursing practice is based is changing rapidly. A great deal of what is taught to nursing students during their graduate studies may become rapidly irrelevant as understandings of mechanisms of disease advance and new improved methods of treatment and management are developed. Nurses need to keep up-to-date with research evidence. This is easier said than done! Learner Objectives Upon completion of this module the learner will: 1. Explain why systematic reviews are fundamental to EBHC. 2. Describe how to outline a systematic review. 3. List the differences between a systematic review and a traditional literature review. 4. Explain the steps used in developing a systematic review to answer a clinical question.

15. Module 12 Using Evidence-Based Guidelines Introduction Throughout history without referencing research evidence, practitioners have developed clinical practice guidelines. However, with the advent of evidence-based practice, development of guidelines includes scientific research evidence to support expert clinicians’ recommendations. The Institute of Medicine defines a clinical practice guideline as a “systematically developed statement to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” (IOM, 1992). Evidence-based guidelines are a series of recommendations on clinical care, supported by the best available evidence in the clinical literature. Learner Objectives Upon completion of this module the learner will: 1. Describe the purposes and principles of evidence-based guidelines. 2. List the skills necessary to use evidence-based guidelines in practice. 3. Assess the potential benefits and harms/limitations in using evidence-based guidelines.

16. Module 13 Using Evidence Introduction As nurses engage in practice they make numerous clinical decisions on a daily basis. We have learned through the previous modules the role that evidence plays in clinical decision making. The JBI model of evidence-based health care recognizes that evidence-based practice occurs when clinical decision-making considers the best available evidence in the specific context in which care is delivered. JBI believes in incorporating both the professional judgment of the health professional and individual client preference (Pearson et al., 2005). Inherent in this model is evidence utilization. Learner Objectives Upon completion of this module the learner will: 1. Explain the importance of using evidence in practice. 2. Describe the different methods of evidence utilization. 3. Outline the barriers to the implementation of evidence in clinical practice. 4. Evaluate strategies which can be used to promote implementation of evidence in practice.

17. Module 14 Clinical Audit Introduction Once we have evidence to guide practice, it is imperative that we modify our practice and put the evidence to use! Clinical audit is one evidence utilization tool that is used to achieve practice change. Clinical audit is an internal mechanism for nurses to use for quality improvement and a formal process to help get evidence into practice (evidence utilization). Audit is commonly used internationally to improve quality of care. It is a process that allows nurses to examine care practices and compare the results with clinical guidelines or best practice statements (Pearson et al., 2007). In short, it’s an effective means to measure the extent of a change in practice and it supports further action to improve practice. Learner Objectives Upon completion of this module the learner will: 1. Define what clinical audit is and what its goals are. 2. Describe the importance of evidence-based clinical audit.

18. Module 15 Conducting a Clinical Audit Introduction Clinical audit is an effective evidence utilization strategy to improve professional practice. When conducting a clinical audit it is important to follow the strategic process in the correct order to save time and effort. Learner Objectives Upon completion of this module the learner will: 1. Demonstrate the steps required to perform a clinical audit. 2. Design a clinical audit for a specific environment.

19. Module 16 Consumer Influence on EBHC Introduction Consumers of health care assume that the treatment they receive is the latest, cutting edge treatment and the best available for their condition. In countries like the United States and Australia, consumers assume that the millions of dollars the government spends on scientific research and health directly benefit them. Unfortunately, this is not always the case. Over recent years the move towards EBHC has had a significant impact on consumers of health care. A change has occurred in Western medicine, where instead of being a submissive recipient of treatment, patients now play a role in the decisions of their care by giving informed consent or deciding on their own therapy. Patients have changed from the “passive recipient of health-care to a consumer who demands autonomy” (Gatson & Mitchell, 2005). Learner Objectives Upon completion of this module the learner will: 1. Describe the important role which consumers play in health care. 2. Recognize the ways that consumers have embraced EBP. 3. Discuss the benefits of consumer involvement in EBHC.

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