Evidence-Based Practice- A Key to Quality Patient Care

 

Ms. Sharika Ratish

Assistant Professor, Jabalpur Institute of Nursing Sciences and Research, Jabalpur (M.P)

 

ABSTRACT:

In all parts of the world, nursing has experienced a profound culture change over the past few decades. Nurses are increasingly expected to understand and conduct research, and to base their professional practice on emerging evidence from research – that is to adopt an Evidence Based Practice (EBP). Evidence-based practice is a conscientious, problem-solving approach to clinical practice that incorporates the best evidence from well-designed studies, patient values and preferences, and a clinician's expertise in making decisions about a patient's care. EBP implements the most up to date methods of providing care, which have been proven through appraisal of high quality studies and statistically significant research findings. The seven steps of EBP are - Cultivate Spirit of Inquiry, Ask Clinical Question, search for and collect relevant evidence, critically appraise the evidence, integrate the evidence, evaluate the outcome and disseminate the outcome. CINHAL, MEDLINE (PubMed), evidence based abstraction journals ect are few resources to avail best evidences for practice. After appraising the evidence, it is necessary to integrate it with the provider's expertise and patient's preferences. The patient is encouraged to practice autonomy and participate in the decision-making process. Adequate knowledge, attitude, skill and support are key to apply Evidence in to practice. There are so many professional and individual barriers which are needed to be overcome in order to implement EBP in clinical setting in order to achieve quality of nursing care.

 

 

INTRODUCTION:

In all parts of the world, nursing has experienced a profound culture change over the past few decades. Nurses are increasingly expected to understand and conduct research, and to base their professional practice on emerging evidence from research – that is to adopt an Evidence Based Practice (EBP)¹. Involving all disciplines, EBP is an approach to clinical practice that's been gaining ground since its formal introduction in 1992. Starting in medicine, it then spread to other fields, such as nursing, psychology, and education.

 

 

Currently, 55% of all nursing practices are based on research findings. The ANA predicts that by 2020, 90% of all nursing practice will be based on EBP research findings. To meet the 2020 goal, nurses must become proficient in evaluating various types of EBP research because they provide effective, proven rationales for nursing actions. As you incorporate this new knowledge into your clinical practice and work areas, you become a role model and a positive change agent.² Nancy Dickenson-Hazard states, "Nurses have the capacity to serve as caregivers and change agents in creating and implementing community and population-focused health systems. When delivered in a context of caring and in a supportive organizational culture, the highest quality of care and best patient outcomes can be achieved.

 

What is Evidence based practice?

Evidence-based practice is a conscientious, problem-solving approach to clinical practice that incorporates the best evidence from well-designed studies, patient values and preferences, and a clinician's expertise in making decisions about a patient's care. EBP implements the most up to date methods of providing care, which have been proven through appraisal of high quality studies and statistically significant research findings. The goal of EBP is to improve the health and safety of patients while also providing care in a cost-effective manner to improve the outcomes for both the patient and the healthcare system. EBP is a process founded on the collection, interpretation, appraisal, and integration of valid, clinically significant, and applicable research.¹

 

Key Components of EBP:

Decisions about care are based on (Institute of Medicine, 2003):

A.    Research evidence: Randomized controlled trials, Laboratory experiments, clinical trials, epidemiological research, outcome research, qualitative research.

B.    Clinical expertise: Knowledge gained from practice over time, Inductive reasoning

C.    Patient values and circumstances: Unique preferences, concerns, expectations, financial resources and social supports.⁶

 

Figure- 1: Key Components of EBP⁶

The 7 Steps of Evidence Based Practice:

1. Cultivate Spirit of Inquiry:

A spirit of inquiry refers to an attitude in which questions are encouraged to be asked about existing practices.³

 

Key questions to ask when considering EBP:

·         Why have we done it this way?

·         Is the practice based on evidence rationale or tradition??

·         Is there a better (more effective, faster, safer, less expensive, more comfortable) method?

·         What are patient’s preferences?

·         What do experts in this speciality recommend?

·         What methods are used by leading/benchmark, organization?

·         Do the research findings suggest an alternative method?

·         Is there a review of the research on the particular topic?

·         What are the barriers inhibiting the application of best practices in this situation?

·         Are there nationally recognized standards of care, practice guidelines, or protocols that apply?

 

2. Ask Clinical Question (PICOT):

PICOT formatted questions address the patient population (P), issue of interest or intervention (I), comparison group (C), outcome (O), and time frame (T). Asking questions in this format assists in generating a search that produces the most relevant, quality information related to a topic, while also decreasing the amount of time needed to produce these search results.³

 

Figure-2 PICOT Criteria⁵

 

3. Search for and Collect Relevant Evidence:

To begin the search for evidence, use each keyword from the PICOT question that was formed. Once results have been found on the intervention or treatment, the research can be rated to determine which provides the strongest level of evidence. There are seven levels of evidence, with a level I being of the strongest quality and a level VII being of the weakest quality:³

·         Level I: Evidence from systematic reviews or meta-analysis of randomized control trials

·         Level II: Evidence from well-designed randomized control trials

·         Level III: Evidence from well-designed control trials that are not randomized

·         Level IV: Evidence from case-control or cohort studies

·         Level V: Evidence from systematic reviews of descriptive or qualitative studies

·         Level VI: Evidence from a single descriptive or qualitative study

·         Level VII: Evidence from expert opinions

 

Key Sources to acquire evidences:

·         CINHAL

·         MEDLINE: (PubMed)

·         Evidence based Clinical Practice Guidelines

·         Agency for healthcare Research and quality sites

·         Electronic Media

·         e Journals

 

4. Critically Appraise the Evidence:

To begin the critical appraisal process, three questions need to asked to determine the relevance of evidence and if evidence applies to population being cared for. The three questions are:

i.         Are the results of the study valid?

ii.       What are the results?

iii.     Will the results be applicable in caring for patients?

 

·         Question 1 measures the validity. In order to be valid, the results of the study must be as close to the truth as possible. Also, the study must be conducted using best available research methods.

·         Question 2 measures the reliability of the study. If it is an intervention study, reliability consists of: whether the intervention worked, how large the effect was, and whether a clinician could repeat the study with similar results. If it is a qualitative study, reliability would be measured by determining if the research accomplished the purpose of the study.

·         Question 3 measures the applicability. The study may be used in practice when caring for patients if the subjects are similar to the patients being cared for, the benefit outweighs the harm, the study is feasible, and the patient desires the treatment.

 

After asking these three questions, evidence appraisal continues by creating an evidence synthesis. This synthesis compares multiple studies to see if they are in agreement with each other.³

 

5. Integrate the Evidence:

After appraising the evidence, it is necessary to integrate it with the provider's expertise and patient's preferences. The patient is encouraged to practice autonomy and participate in the decision-making process. Therefore, even if the study had successful outcomes, the patient may refuse to receive a treatment. Assessment findings and patient history may reveal further contraindications to a certain evidence-based treatment. Lastly, availability of healthcare resources may limit the implementation of a treatment even if it is found to be effective in a study.³

 

6. Evaluate Outcomes:

The next step in the evidence-based practice process is to evaluate whether the treatment was effective in terms of patient outcomes. It is important to evaluate the outcomes in a real-world clinical setting to determine the impact of the evidence-based change on healthcare quality.³

 

7. Disseminate Outcomes:

The last step is to share the information especially if positive outcomes are achieved. By sharing the results of evidence-based practice process, others may benefit. Some methods to disseminate the information include presentations at conferences, rounds within one's own institution, and journal publications.³

 

 

Figure-3 Five A’s of EBP

 

Implementation and Sustainability:

The Iowa Model is used to promote quality of care. It is a guideline for nurses in their decision making process. The decision making can include clinical and administration practices. These practices affect patient outcomes. The model is based on problem-solving steps at are a part of the scientific process.⁴

 

Key components of using the Iowa Model:

·         Identify "triggers"

·         Clinical applications

·         Organizational priorities

·         Forming a team

·         Piloting a practice change

·         Evaluating the pilot

·         Evaluate change and share results

 

Figure-4 The Iowa Model of Evidence-Based Practice to Promote Quality Care. ⁷

 

Barriers for EBP in nursing Practice:

·         lack of time during their shift is the primary challenge to researching and applying EBP

·         lack of practitioner's ability to critically appraise research

·         workload pressures

·         nurses' and other professional practitioners' lack of knowledge of research methods

·         lack of support from professional colleagues and organizations

·          resistance to changing tried and true conventional methods of practice

·          lack of continuing education programs

·         Lack of access to computer, library and other research materials.

·         Lack of understanding of electronic databases.

 

CONCLUSION:

Evidence based practice is the need of the hour to help bridge the research practice gap by strengthening the evidence base so that we know what works and what doesn’t work in providing patients with the best outcomes and standardizing evidence across fields to reach the best outcome for the patient.

 

REFERENCES:

1.        Polit and beck (2008) Nursing Research: Generating and assessing Evidence for nursing Practice. Philadelphia: Lippincott Willams and Wilkins.

2.        Chrisman, J., Jordan, R., Davis, C., and Williams, W. (2014). Exploring evidence-based practice research. Nursing Made Incredibly Easy, 12(4).

3.        Melnyk, B.M. (2011). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia, PA: Lippincott Williams and Wilkins. pp. 3–7.

4.        Melnyk, B.M. and Fineout-Overholt, E. (2015). Evidence-based practice in nursing and healthcare: A guide to best practice (3rd ed.). Philadelphia, PA: Wolters Kluwer Health. pp. 10–16.

5.        Cyrus, J. (n.d.). Research Guides: Rapid Review Protocol: Steps: Rapid Review.

6.        Evidence_Based_Practice_Module_I.pdf. (n.d.). Retrieved from https://www.amsn.org/sites/default/files/documents/practice-resources/evidence-based-practice/Evidence_Based_Practice_Module_I.pdf

7.        The Iowa Model of Evidence-Based Practice to Promote Quality Care Scientific Diagram. (n.d.). Retrieved July 3, 2019, from https://www.researchgate.net/figure/The-Iowa-Model-of-Evidence-Based-Practice-to-Promote-Quality-Care-Reprinted-with_fig4_8346940

8.        https://www.nurse.com/evidence-based-practice

 

 

 

 

Received on 03.07.2019          Modified on 21.07.2019

Accepted on 08.08.2019     © A&V Publications all right reserved