Evidence Based Practice–A Core Concept to Achieve Quality of Nursing Care

 

S. K. Mohanasundari¹, Dr. A. Padmaja²

¹PhD Scholar, Tutor/Clinical Instructor (Nursing), AIIMS, Jodhpur.

²Vice-Principal/Professor, College of Nursing, SVIMS, Tirupati. AP

 

ABSTRACT:

Nursing has a rich history of using research in practice, pioneered by Florence Nightingale.Although during the early and mid-1900s, few nurses contributed to this foundation initiated by Nightingale, the nursing profession has more recently provided major leadership for improving care through application of best clinical research evidences in practice. Evidence-based practice (EBP) is the conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions. Expansion of Scientific knowledge, highly educated consumers, and nurses in clinical settings, aggressive pursuit of cost-effectiveness and accreditation expectation etc contributing to emphasis EBP. The steps of implementing EBP is Ask, Acquire, Appraise, Apply and Assess/Re Assess. CINAHL, MEDLINE: (PubMed) and Evidence based clinical practice guidelines etc are few resources to avail best evidences for practice. Best evidence includes empirical evidence from meta analysis, randomized controlled trials; evidence from other scientific methods such as descriptive and qualitative research; as well as use of information from case reports, scientific principles, and expert opinion. When enough research evidence is available, the practice should be guided by research evidence in conjunction with clinical expertise and patient values. Adequate knowledge, attitude, skill and support are key to apply Evidence in to practice. There is so many professional and individual barrier need to be overcome in order to implement EBP in clinical setting to achieve quality of nursing care.

 

 

INTRODUCTION:

Nursing has a rich history of using research in practice, pioneered by Florence Nightingale.Although during the early and mid-1900s, few nurses contributed to this foundation initiated by Nightingale, the nursing profession has more recently provided major leadership for improving care through application of best clinical research evidences in practice. ^(1-6)

 

Nursing has a strong tradition of focusing on the best ways to provide excellent patient care, yet one of the greatest challenges facing nurses today is incorporating evidence-based research into an organization’s policies and procedures to improve patient outcomes. Nursing care in every health care department is typically need evidence based practice in order to achieve standard and quality of nursing service.  But “Much of nursing lags incorporating evidence-based practice because many nurses lack the time and the knowledge of how to obtain EBP research, and often they lack education on how to fully understand research articles,” it is necessary to know what Is the difference in EBP, research and quality improvement.^1-3

 

 

 

Evidence-based practice (EBP) – utilizes the best clinical evidence in making patient care decisions typically from research. EBP translates knowledge into practice. There are several definitions that could be considered. The most commonly cited is that EBP is “the conscientious, explicit, and judicious use of current best evidence in making clinical decisions. ^4-5

 

Research (R)- applies a methodology whether quantitative or qualitative to develop, uncover, create, find, add new nursing knowledge4

 

Quality improvement (QI) - utilizes a system to monitor and evaluate the quality and appropriateness of care (outcomes) based on EBP and research

 

Key components of EBP:

Integration of best following components in making decisions about the care of individual patients. ^6-7

 

 

Figure-1: key components of EBP

 

A. Research evidence:

·      Randomized controlled tirals

·      Laboratory experiments

·      Clinical trials

·      Epidemiological research

·      Outcomes research

·      Qualitative research

 

 

B. Clinical expertise:

·        Knowledge gained from practice over time

·        Inductive reasoning

C. Patient values, circumstances:

·        Unique preferences

·        Concerns

·        Expectations

·        Financial resources

·        Social supports

 

Factors Contributing to Emphasis on Evidence-Based Nursing Practice:

—  Scientific knowledge expansion

—  Knowledge availability -- The Internet

—  Highly educated nurses in clinical settings- E.g. APNs – focusing on evidence-based clinical problem-solving, Clinical Nurse Researchers

—  Aggressive pursuit of cost-effectiveness

—  Focus on quality of care, Risk and error reduction

—  Highly educated consumers

—  JCAHO/Accreditation expectations

—  Increased attention to institutional image -Magnet hospital movement⁸

 

Importance of Evidenece based practice:

—  Health care delivery is filled with uncertainty and many questions arise in every day practice…

—  Changing patient demographics require new approaches to care.

—  The evidence base for practice is rapidly expanding and growing in complexity for nursing and other disciplines.

—  How to search, evaluate, and apply evidence in practice is unknown by many or inconsistently used.

—  There continues to be a mismatch between what we know to be quality care and the quality of care that is delivered.

—  Quality problems occur even in the hands of dedicated, conscientious professionals.¹⁰

 

 

Figure-2: Steps or processes of EBP

 

 

1.      Key Questions to Ask When Considering EBP:

—  Why have we always done “it” this way?

—  Do we have evidence-based rationale?

—  Or, is this practice merely based on tradition?

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

—  What approach does the patient (or the target group) prefer?

—  What do experts in this specialty recommend?

—  What methods are used by leading/benchmark, organizations?

—  Do the findings of recent research suggest an alternative method?

—  Are organizational barriers inhibiting the application of best practices in this situation?

—  Is there a review of the research on this topic?

—  Are there nationally recognized standards of care, practice guidelines, or protocols that apply? ¹¹

 

 

 

Box-1: Five A’s of EBP

 

Box-2: PICO questions

 

 

2.      Key source to acquire evidences:

·      CINAHL

·      MEDLINE: (PubMed)

·      Evidence based clinical practice guidelines

·      National Guidelines Clearinghouse:

http://www.guideline.gov

·      Agency for Healthcare Research and Quality: www.ahrq.gov/clinic/cpgsix.htm

·      National Institute of Nursing: http://ninr.nih.gov/ninr

·      Evidence based abstraction journals

·      Original articles published journals ⁹

 

3.      Key to analyze level the strength of evidence:

—  I Evidence - meta-analysis, Systematic reviews, RCTs, EB clinical practice guidelines based on RCTs

—  II Evidence - One well designed RCT

—  III Evidence - CTs without randomization

—  IV Evidence - Well-designed case control or cohort studies

—  V Evidence - Systematic reviews of descriptive or qualitative studies

—  VI Evidence - Single descriptive or qualitative study

—  VII Evidence – Opinions of authorities, reports of experts¹¹

 

4.      Key to apply evidence to practice:

·        Knowledge adequate of knowledge/awareness. familiar with guidelines and guideline accessibility

·        Attitudes Adequate confidence in the guideline developer, adequate motivation to perform the guideline recommendations

·        Skill Ability to incorporate patient preferences into the clinical decision making process

·        Support-A managerial and organisational culture that facilitate the implementation of research into clinical practice.¹⁰

 

5.      Key to assess and reassess the outcome of evidence:

—  Have you ever tried to change a practice at your work site?

—  What worked?

—  What didn’t?

—  What was the final outcome?

—  What would you do differently?

—  Do facts (evidence) change behavior?⁹

—   

 

Box-3: barrier for EBP1^{7, 12,13}

 

 Box-4: Research: When Evidence is Not There/Not Sufficient:

 

CONCLUSION:

Although the science of translating research into practice is fairly new, there is some guiding evidence of what implementation interventions to use in promoting patient safety practices. However, there is no magic bullet for translating what is known from research into practice. To move evidence-based interventions into practice, several strategies may be needed. Additionally, what works in one context of care may or may not work in another setting, thereby suggesting that context variables matter in implementation of EBP.

 

REFERENCES:

1.       Nightingale F. Notes on hospitals. London: Longman, Green, Roberts, and Green; 1863.

2.       Titler MG. Critical analysis of research utilization (RU): An historical perspective. Am J Crit Care. 1993;2(3):264.

3.       Kirchhoff KT. State of the science of translational research: from demonstration projects to intervention testing. Worldviews Evid Based Nurs. 2004;1(S1):S6–12.

4.       Burns and Grove (2005). The Practice of Nursing Research (5^th ed).St. Louis: Elsevier Saunders

5.       Polit and Beck (2008). Nursing Research: Generating and Assessing Evidence for Nursing Practice. Philadelphia: Lippincott Williams and Wilkins

6.       Melnyk and Fine-Overholt (2005). Evidence-Based Practice in Nursing and Health Care.

7.       Philadelphia: Lippincott Williams and Wilkins

8.       Roberts and Bourke (1989). Nursing Research: A Quantitative and Qualitative Approach. Boston: Jones and Bartlett

9.       NONPF

10.     ACE Star Model: http://www.acestar.uthscsa.edu/Learn_model.htm

11.     Deming Model: http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/

12.     Vasantha .K, Mohanasundari SK. Mata Analysis on “Symptoms, Suffering And Palliative Care At The End Of Life In Children With Cancer”. IJPN.2016 4(1): 13-18

13.     Mohanasundari SK. Mata synthesis on Psychosocial, Psychomotor and Neurocognitive challenge of chronically ill children and their parents and siblings. AJNER. 2017: 7(4)

 

 

 

 

Received on 04.01.2018           Modified on 29.03.2018

Accepted on 21.04.2018     © A&V Publications all right reserved