EVIDENCE – BASED

PRACTICE

SHARON A. DENHAM, PHD, RN, CNE

SDENHAM@TWU.EDU
 OBJECTIVES
AT THE END OF THE SESSION, PARTICIPANTS WILL BE ABLE TO:
• DESCRIBE PURPOSES OF EVIDENCE-BASED NURSING PRACTICE.
• IDENTIFY WHY EVIDENCE BASED PRACTICE IS CRITICAL TO CLINICAL PRACTICE.
• DESCRIBE BARRIERS TO EVIDENCE-BASED PRACTICE.
• IDENTIFY WAYS TO SEARCH FOR THE BEST EVIDENCE.
• ASK SEARCHABLE QUESTIONS AND KNOW HOW TO LOCATE EVIDENCE.
• DISSEMINATE FINDINGS FROM SYSTEMATIC EVIDENCE-BASED REVIEWS.
EVIDENCE-BASED PRACTICE IS NOT
• QUALITY IMPROVEMENT
• PERFORMANCE IMPROVEMENT
• RESEARCH
 QUALITY IMPROVEMENT

• A PROCESS TO IMPROVE HEALTHCARE SERVICES, SYSTEMS, AND PROCESSES

WITH THE INTENT IMPROVE OUTCOMES.
• THE PROCESS GENERALLY HAS A METHOD TO MEASURE PARTICULAR
OUTCOMES, MAKING CHANGES TO IMPROVE PRACTICE, AND MONITOR
PERFORMANCE ON AN ONGOING BASIS.
• FOR EXAMPLE: DECREASE CATHETER INFECTIONS, DECREASE ED WAIT TIMES,
DECREASE FALLS, DECREASE USE OF RESTRAINTS.
 PERFORMANCE IMPROVEMENT
• MEASURING THE OUTPUT OF A PARTICULAR BUSINESS PROCESS — THEN
MODIFYING THE PROCESS OR PROCEDURE TO INCREASE OUTPUT OR
INCREASE EFFECTIVENESS.
• CAN BE APPLIED TO INDIVIDUAL OR ORGANIZATIONAL PERFORMANCE.
• AT THE ORGANIZATIONAL LEVEL IT MAY BE A MEASURE OF PATIENT
SATISFACTION.
 RESEARCH
• A SYSTEMATIC EVALUATION (E.G., QUANTITATIVE, QUALITATIVE, MIXED
METHODS) DESIGNED TO DEVELOP, UNCOVER, CREATE OR CONTRIBUTE TO
NEW KNOWLEDGE THAT CAN BE GENERALIZED FOR BROADER
APPLICATION.
• RESEARCH INVOLVES APPROVAL BY AN INSTITUTIONAL REVIEW BOARD.
• EXAMPLES:COMMUNICATION AMONG CAREGIVERS, PAIN AT THE END OF
LIFE, POST-STROKE MEMORY FUNCTION.
 QUANTITATIVE STUDIES
(HARD SCIENCE – NARROW FOCUS)

• USE OBJECTIVE QUANTIFIABLE DATA

• RANDOM CONTROL TRIALS, EXPERIMENTAL DESIGNS, QUASI-
EXPERIMENTAL DESIGNS, DESCRIPTIVE, CORRELATIONAL
• USE SURVEY INSTRUMENTS (MEASURE: KNOWLEDGE, BELIEFS,
ATTITUDES, EXPERIENCES)

Test Relationships
 QUALITATIVE STUDIES
(SOFT SCIENCE – BROAD FOCUS)

• PURPOSE; UNDERSTAND A PARTICULAR PHENOMENA

• INTERVIEWS, OBSERVATIONS - RIGOR
• ETHNOGRAPHY, PHENOMENOLOGY, GROUNDED THEORY,
HISTORICAL, CASE STUDY
• NARRATIVE ANALYSES

Gain Insights
 EVIDENCE-BASED PRACTICE
• CONSCIENTIOUS PROBLEM-SOLVING APPROACH TO CAREGIVING
• INCORPORATES: (A) BEST RESEARCH EVIDENCE; (B) INDIVIDUAL’S
VALUES AND PREFERENCES; (C) CLINICIANS’ EXPERTISE
• NOT “THIS IS THE WAY WE HAVE ALWAYS DONE IT” --- INSTEAD,
PROVIDE HIGH QUALITY CARE BASED ON RESEARCH AND KNOWLEDGE
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 EVIDENCE-BASED NURSING PRACTICE
• ABILITY TO ACCESS, SUMMARIZE, AND APPLY INFORMATION TO
ADDRESS EVERY-DAY CLINICAL PROBLEMS
• EVIDENCE-BASED PRACTICE REQUIRES EMPHASIS ON SYSTEMATIC
OBSERVATION AND EXPERIENCE AND KNOWLEDGE OF THE RESEARCH
LITERATURE TO SUBSTANTIATE CLINICAL DECISIONS
 CLINICAL GUIDELINES
• AGENCY FOR HEALTHCARE RESEARCH AND QUALITY (AHRQ)
HTTPS://WWW.AHRQ.GOV/PROFESSIONALS/CLINICIANS-PROVIDERS/GUIDELINES-
RECOMMENDATIONS/INDEX.HTML
• COCHRANE LIBRARY
HTTP://WWW.COCHRANELIBRARY.COM/COCHRANE-DATABASE-OF-SYSTEMATIC-
REVIEWS/TABLE-OF-CONTENTS/CURRENT-ISSUE.HTML
• SPECIALTY ORGANIZATIONS: AMERICAN ASSOCIATION OF
NEUROSCIENCE NURSES
HTTP://AANN.ORG/PUBLICATIONS/CLINICAL-PRACTICE-GUIDELINES
 EVIDENCE-BASED PRACTICE
• RESULTS: BETTER CARE DELIVERY & DECISIONS
• CONTRIBUTES TO SCIENCE OF NURSING
• CURRENT AND RELEVANT PRACTICE
 BARRIERS TO
EVIDENCE-BASED PRACTICE
• DO NOT VALUE RESEARCH IN PRACTICE
• LACK TIME TO READ RESEARCH
• RESEARCH REPORTS TOO COMPLEX
• DIFFICULT TO CHANGE PRACTICE
• LACK OF ADMINISTRATIVE SUPPORT OR KNOWLEDGEABLE MENTORS
• PROCESS SEEMS OVERWHELMING - LACK EDUCATION/UNDERSTANDING
ABOUT THE RESEARCH PROCESS & EVIDENCE-BASED PRACTICE
 EVIDENCE BASED PRACTICE AND
CLINICAL NURSING PRACTICE
• RELIANCE ON TEXTBOOKS DOES NOT PROMOTE THE NEEDED CRITICAL
THINKING
• MANAGE THE EXPLOSION OF RESEARCH FINDINGS THAT MAY IMPROVE
CLINICAL OUTCOMES
• ENHANCE ABILITY TO MAKE QUALITY DECISIONS USING THE MOST
CURRENT & RELEVANT EXPERTISE/KNOWLEDGE
 HIERARCHY OF EVIDENCE
LEVEL A:
• GOLD STANDARD: RANDOMIZED CONTROLLED TRIALS (RCT)
• SYSTEMATIC REVIEW OR META-ANALYSIS OF RELEVANT RCT
• CLINICAL PRACTICE GUIDELINES

LEVEL B:
• WELL-DESIGNED STUDIES (NOT RCT)
• CASE-CONTROLLED STUDIES
• UNCONTROLLED STUDIES (CONVENIENCE SAMPLES)
• EPIDEMIOLOGICAL STUDIES
• QUALITATIVE/QUANTITATIVE STUDIES (DESCRIPTIVE, CORRELATIONAL)
 HIERARCHY OF EVIDENCE
LEVEL C:
• CONSENSUS VIEWPOINT AND EXPERT OPINION (USE WHEN NO QUANTITATIVE
OR QUALITATIVE STUDIES IN THE AREA OF INTEREST)
• META-SYNTHESIS (SYSTEMATIC REVIEW THAT SYNTHESIZES FINDINGS FROM
QUALITATIVE STUDIES
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 ASKING YOUR QUESTION
PICO IS A MNEMONIC - DESCRIBES 4 ELEMENTS OF CLINICAL QUESTIONS:
• P = POPULATION/PROBLEM - HOW DO YOU DESCRIBE THE PROBLEM OR
A GROUP OF SIMILAR PATIENTS?
• I = INTERVENTION - WHAT MAIN INTERVENTION, PROGNOSTIC FACTOR
OR EXPOSURE IS TO BE CONSIDERED?
• C = COMPARISON - IS THERE AN ALTERNATIVE TO COMPARE WITH THE
INTERVENTION?
• O = OUTCOME - WHAT DO YOU HOPE TO ACCOMPLISH, MEASURE,
IMPROVE OR AFFECT?
Sample Footer Text 8/9/2018 28
SYSTEMATIC LITERATURE REVIEWS

• ANSWER THE PICO QUESTION….

• SYNTHESIZE THE LITERATURE IN A FIELD
• IDENTIFY GAPS IN THE LITERATURE
• EVALUATE THE STRENGTH OF THE LITERATURE
Where will you find
the evidence?
 SEARCH FOR EVIDENCE
• IDENTIFY SEARCH TERMS
• IDENTIFY DATABASES TO BE USED FOR SEARCH
• INCLUSION CRITERIA
• EXCLUSION CRITERIA
 COMPLETING THE SEARCH
• SYSTEMATIC SEARCH OF RESEARCH
• GET A SMALL NOTEBOOK
• WHAT ARE YOU LOOKING FOR DURING THE SEARCH???
• KEEP LISTS OF SEARCH CHAINS AND DATABASES USED – NUMBERS/NAMES
OF REFERENCES FOUND
• CAREFULLY READ STUDIES – IDENTIFY THE PERTINENT ONES
❑ WHAT SPECIFIC CRITERIA ARE YOU LOOKING FOR
❑ WHY STUDIES ARE NOT INCLUDED
 SKILLS NEEDED
• NOTE TAKING SKILLS
• SYNTHESIS SKILLS - SEE RELATIONSHIPS AND PATTERNS
• SUMMARY SKILLS
• EVALUATION SKILLS
 NOTE-TAKING SKILLS

• SPREADSHEET: CITATION, MAIN ARGUMENTS & FINDINGS, STUDY

RELATIONSHIPS
• NOTES: KEY QUOTES & CITATIONS, RESPONSE TO QUOTES, CONNECTIONS
OR CONFLICTS SEEN AMONG KEY POINTS, THEMES IDENTIFIED
• BUCKETS: BASE ON DATABASES, SEARCH TERMS USED - BREAK DOWN THE
WRITING PROCESS INTO USEFUL SECTIONS
 SYNTHESIS
• STUDY QUESTIONS
• WHEN/WHERE WAS STUDY CONDUCTED
• WHO OR WHAT WAS STUDIED
• SAMPLE SIZE (TRAITS/CHARACTERISTICS)
• STUDY TYPE/METHODS
• FINDINGS
 SYNTHESIS
• MAKE RESPONSIBLE OBSERVATIONS OR GENERALIZATIONS ABOUT A SET OF TEXTS
• MAKE ASSERTIONS OR ARGUMENTS ABOUT THE AVAILABLE LITERATURE
• ARTICULATE CONSENSUS POSITIONS
• IDENTIFY TRENDS AND/OR CONTROVERSIES
• SUMMARIZE THE EXISTING BODY OF LITERATURE
SYNTHESIZE EVIDENCE
CREATE TABLES
• AUTHORS/PUBLICATION YEAR
• TYPE OF RESEARCH STUDY
• SUBJECTS
• INTERVENTION(S)
• KEY STUDY FINDINGS
• CONCLUSIONS
• OTHER INFORMATION
 CREATE TABLES
Authors Key Study Categories Themes of Other
(year) Findings of Findings Findings Findings/Comments

Author Research Subject Participant Intervention Location of Level of

s/year Design Descriptors Numbers Study (Yes/No) the Study Research
 WRITING OF SYNTHESIS
• ONE STUDY WAS FOUND THAT DESCRIBES…..
• ANOTHER STUDY ADDRESSES…..
• THE NEXT STUDY IDENTIFIES…..

• Discuss common findings

• Describe contrasting opinions
• Identify the state of research studies
• Draw conclusions
• Recommendations
 FIVE A’S –EVIDENCE –BASED PROCESS
• ASK: INFORMATION NEEDS FROM PRACTICE ARE CONVERTED INTO
FOCUSED, STRUCTURED QUESTIONS.
• ACQUIRE: THE FOCUSED QUESTIONS ARE USED AS A BASIS FOR LITERATURE
SEARCHING IN ORDER TO IDENTIFY RELEVANT EXTERNAL EVIDENCE FROM
RESEARCH.
• APPRAISE: THE RESEARCH EVIDENCE IS CRITICALLY APPRAISED FOR
VALIDITY.
• APPLY: THE BEST AVAILABLE EVIDENCE IS USED ALONGSIDE CLINICAL
EXPERTISE AND THE PATIENT'S PERSPECTIVE TO PLAN CARE.
• ASSESS: PERFORMANCE IS EVALUATED THROUGH A PROCESS OF SELF
REFLECTION, AUDIT, OR PEER ASSESSMENT.
Disseminate
 RESOURCES
• AGENCY FOR HEALTHCARE RESEARCH AND QUALITY EVIDENCE-BASED PRACTICE
CENTERS: HTTPS://WWW.AHRQ.GOV/PROFESSIONALS/CLINICIANS-
PROVIDERS/GUIDELINES-RECOMMENDATIONS/INDEX.HTML
• THE COCHRANE COLLABORATION:
• COCHRANE REVIEWS: HTTP://WWW.COCHRANE.ORG/WHAT-IS-COCHRANE-
EVIDENCE
• EVIDENCE-BASED HEALTHCARE: HTTP://WWW.COCHRANE.ORG/WHAT-IS-
COCHRANE-EVIDENCE
• NATIONAL GUIDELINE CLEARINGHOUSE: HTTPS://WWW.GUIDELINE.GOV/
• EBSCO NURSING REFERENCE CENTER:
HTTPS://WWW.EBSCOHOST.COM/NURSING/PRODUCTS/NURSING-REFERENCE-
CENTER/NURSING-REFERENCE-CENTER-CONTENT