Introduction to evidence-based practice in a magnetic world

1. Introduction to evidence-based practice in a magnetic world Sheila Snow-Croft Outreach Education Coordinator NN/LM SE/A

2. objectives • By the end of this class, attendees will be able to: • define the levels of evidence, • formulate literature searches to find such evidence, • use acquired skills to critique search results, and • articulate the library’s role in the Magnet Recognition Program.

3. Agenda • Introduction • Theory of Evidence Based Practice (EBP) • Critical Appraisal • Null Hypothesis and P Value • Critical Appraisal Tools • Literature Searching • Magnet Recognition: Partnership between Libraries and Nurses • Standards you can impact • Discussion Practice Exercise

4. Theory of EBP

5. Definitions Evidence-based nursing is an approach to health care practice that enables nurses to provide the highest quality care based on the best evidence available to meet the needs of their patients. Melnyk & Fineout-Overholt, 2005 The integration of the best research evidence with clinical expertise and patient values. Sackett, Straus, Richardson, Rosenberg & Haynes, 2000 Evidence-based medicine: how to practice and teach EBM 2d ed. London, UK: Churchill Livingstone

6. Terminology • Evidence-Based Practice (EBP) • Evidence-Based Health Care (EBHC) • Evidence-Based Nursing (EBN) • Evidence-Based Medicine (EBM) Sackett’s definition refers to all of these; EBP and EBHC are more universally used.

7. Research Utilization • Traditional nursing practice • Using research to support data collection, interventions, and evaluation in patient care • Sometimes involves choosing studies to support current practice

8. Evidence-Based Nursing • Analyzes ALL research data • Compliments local experts’ experience • Emphasizes skills to make independent assessments • Uses active learning model

9. Why Practice EBN? • Standard of Care: EBNER recommendations • Assures patient receives most up-to-date care possible • Assists practitioner in dealing with increasing volume of medical literature • Allows patient and practitioner to work together to make informed decisions

10. Challenges of EBN • New, Unfamiliar • Need to develop good search strategies • Must identify best databases • Need to do critical appraisals • Should be implemented from the top down, with nursing faculty learning first • Much of relevant research is qualitative; need more systematic reviews of qualitative research

11. Misconception EBN is not a collection of statistical summaries, ignoring patient preferences and clinical expertise.

12. Salmond S. Advancing Evidence-Based Practice: A Primer Orthopaedic NursingMarch/April 2007  Volume 26 Number 2 Pages 114 - 123 What is Evidence-based practice?

13. EBN Steps: • Problem Identification • Discovery • Critique • Summary • Translation • Evaluation

14. Step 1: • Problem Identification: Converting information needs into an answerable question • PICO • Patient or Problem • Intervention • Comparison Intervention • Outcomes

15. Step 2: • Discovery: Finding, with maximum efficiency, the best evidence with which to answer the question

16. Step 3: • Critique: Determining the merit, feasibility and utility of evidence. • The process of systematically examining research evidence to assess its validity, results, and relevance before using it to inform a decision. (http://www.evidence-based-medicine.co.uk)

17. Step 4: • Summary: Combining findings from all evidence to make a practice recommendation

18. Step 5: • Translation: Placing evidence into context, incorporating recommendation into a clinical setting or organization

19. Step 6: • Evaluation: Determining and measuring the effectiveness of the practice change over time

20. Critical Appraisal

21. Critical Appraisal terminology • Null Hypothesis • P-value • Confidence intervals • Relative vs Absolute Risk Reduction

22. Null hypothesis • States that there is no relationship between the variables being studied. • Opposite of what you are trying to find out. • Tylenol is better than Advil for headaches • Exercising 30 minutes a day is good for your health • Lefthanders are prone to accidents

23. P-value • Probability that the outcomes are due to chance • Accepted reference point is .05 • Less than .05 is statistically significant • Small p-value dismiss chance • Large p-value means that anything is possible (chance, actual effect, or confounding factors)

24. Confidence intervals • The ranges of values within which a researcher can be confident that the population value falls. • A 95% confidence interval (CI 95) means that one can be 95% confident that the population value falls within a certain range • Example: A study states that 40% of a sample of 1000 people are smokers with a CI of 95% +/- 3% means the frequency of smoking is between 37% and 43%.

25. Risk RR (Relative Risk) is the risk for achieving an outcome in the treatment group relative to that in the control group RRR (Relative Risk Reduction) is the increase in outcome with the treatment compared to the control (often expressed as a percentage) ARR (Absolute Risk Reduction) is the difference in outcome rates for two groups, usually treatment and control

26. Relative Risk Reduction • Not a good way to compare outcomes • Amplifies small differences and makes insignificant findings appear significant • Does not reflect the baseline risk of the outcome event • Can make weak results look good • Making weak results look good makes them popular, thus they are reported in many journal articles • RRR can mislead – DO NOT USE

27. Absolute Risk Reduction • A better statistic to evaluate outcome • Does not amplify small differences, but shows the true difference between the experimental and control interventions

28. Critical Appraisal Questions • Are the results of the study valid? • What were the results? • Will the results help me in caring for my patients?

29. Practice exercises

30. What is Evidence? • Primary Studies: • Clinical Trials • Randomized Controlled Trials • Multicenter studies • Secondary Studies • Reviews • Meta-analyses

31. Levels of Evidence

33. Establishing Validity • What are the results of the study? • Are the results valid? • How do the results affect the patient?

34. Literature Searching

35. ResourcesPubMed/Medline • Citations and Abstracts • Includes over 4600 journals worldwide • More than 17 million citations • Approximately 1/3 full text articles available • Uses MeSH controlled vocabulary • Updated daily • Available anywhere, anytime • Searching help available • Must do one’s own quality filtering • Must learn how to search the database

36. ResourcesCINAHL • Dates back to 1981 • Contains more than a million records • Indexes almost 3,000 journals • Searchable cited references for more than 1,200 journals • Full text for 71 journals • Covers nursing, biomedicine, health science librarianship, alternative/complementary medicine, consumer health and 17 allied health disciplines • Now features Clinical Query Functionality

37. ResourcesThe Cochrane Library To scan many types of information pre-filtered for quality • Includes the Cochrane Database of Systematice Reviews (Cochrane Reviews), Database of Abstracts of Reviews of Effectiveness (DARE), Cochrane Controlled Trials Register (Clinical Trials) and others • Systematic reviews aggregate randomized controlled trials • Review process is labor intensive, so not all topics are covered • Small database

38. ResourcesCritical Appraisal Critical reviews of published studies • ACP Journal Club • InfoPOEMS • Clinical Inquiries • High quality evidence with commentary • High specificity • Abstracts accompanied by commentary • Incomplete coverage of literature • Small databases

39. ResourcesPoint Of Care with Evidence Quick answers to clinical questions with evidence based analysis embedded in resource • ACP Pier • FIRSTConsult • Natural Medicines Comprehensive Database • UpToDate • Grades rate quality of evidence • Grades different for each source • Rating criteria sometimes difficult to locate

40. Information Aggregator Resources To scan many types of information pre-filtered for quality • The Cochrane Library • Includes the Cochrane Database of Systematic Reviews (Cochrane Reviews), Database of Abstracts of Reviews of Effectiveness (DARE) ,Cochrane Controlled Trials Register (Clinical Trials) and others • Systematic reviews aggregate randomized controlled trials • Review process is labor intensive, so not all topics are covered • Small database

41. Other Resources that Support EBP • Clinical Practice Guidelines • National Guideline Clearinghouse • http://www.guidelines.gov • Health Services/Technology Assessment Text (HSTAT) • http://text.nlm.nih.gov • Specialized Journals • ACP Journal Club • Evidence Based Medicine • Evidence Based Nursing

42. For More Information • Centre for Evidence-Based Medicine • http://cebm.jr2.ox.ac.uk/ • Health Information Research Unit Evidence-Based Health Informatics • http://hiru.mcmaster.ca/

43. Magnet Recognition Partnerships between Libraries and Nurses

44. Magnet Recognition: Librarian and Nurse Partnership • What is the Magnet Recognition Program • Standards you can impact • Discussion Practice Exercise

45. What is the magnet recognition program? The Magnet Recognition Program® was developed by the American Nurses Credentialing Center (ANCC) to recognize health care organizations that provide nursing excellence.

46. Why is it important? • Nursing Recruitment and Retention • Better patient outcomes

47. Cost of Magnet Recognition Program is about 51 thousand dollars Cost to recruit one registered nurse can be up to 60 thousand dollars

48. Magnet Hospitals • 2003 – 97 magnet hospitals • 2006 – 231 magnet hospitals • 2007 – 281 magnet hospitals

49. Forces of Magnetism • Quality of nursing leadership • Organization structure • Management style • Personnel policies and progress • Professional models of care • Quality of care • Quality improvement • Consultation and resources • Autonomy • Community and the hospital • Nurses as teachers • Images of nursing • Interdisciplinary relationships and • Professional development

50. Highlighted Forces Part 1 • (5) Professional models of care – Give nurses the responsibility and authority for the provision of direct patient care. Nurses are accountable for their own practices, as well as for the coordination of care. • (7) Quality Improvement – Educational process: staff nurses participate in the process and view it as one that improves the quality of care delivered. • (8) Consultation and resources – Adequate consultation and human resources are available. Knowledgeable experts, including APNs, are available and used. Peer support is given within and outside the nursing division.