Chapter 27

Strategies for Promoting Evidence-Based Nursing Practice

Evidence-Based Practice
Definition: conscientious integration of best research evidence with clinical expertise and patient values and needs in the delivery of quality, cost-effective health care

Elsevier items and derived items 2009, 2005, 2001, 1997 by Saunders, an imprint of Elsevier Inc.

Criticisms of Evidence-Based Practice in Nursing

Nursing lacks the research evidence. Evidence generated based on populations is applied to individual patients. Contributions of qualitative research are still evolving. Guidelines can lead to cookbook nursing. Administrators do not provide resources needed.

Elsevier items and derived items 2009, 2005, 2001, 1997 by Saunders, an imprint of Elsevier Inc.

Benefits of Evidence-Based Practice in Nursing

Improved outcomes for patients, providers, and health care agencies Cost and quality Magnet Status Program

Elsevier items and derived items 2009, 2005, 2001, 1997 by Saunders, an imprint of Elsevier Inc.

Guidelines for Synthesizing Research Evidence

Systematic review Meta-analysis Integrative reviews Metasummary and metasynthesis (qualitative)

Elsevier items and derived items 2009, 2005, 2001, 1997 by Saunders, an imprint of Elsevier Inc.

Stetler Model of Research Utilization to Facilitate Evidence-Based Practice

Elsevier items and derived items 2009, 2005, 2001, 1997 by Saunders, an imprint of Elsevier Inc.

Phases of Stetler Model

Phase I: Preparation Phase II: Validation Phase III: Comparative evaluation/decision making Phase IV: Translation/application Phase V: Evaluation

Elsevier items and derived items 2009, 2005, 2001, 1997 by Saunders, an imprint of Elsevier Inc.

Phase I: Preparation
Identify a need for knowledge related to a specific nursing practice situation. Conduct a review of published research related to the topic of concern.

Elsevier items and derived items 2009, 2005, 2001, 1997 by Saunders, an imprint of Elsevier Inc.

Phase II: Validation

Synthesis of knowledge If research knowledge base is strong, a judgment is made about the applicability or usefulness for your agency

Elsevier items and derived items 2009, 2005, 2001, 1997 by Saunders, an imprint of Elsevier Inc.

Phase III: Comparative Evaluation/Decision Making

Includes four parts
Substantiating evidence Fit of setting Feasibility Current practice

Elsevier items and derived items 2009, 2005, 2001, 1997 by Saunders, an imprint of Elsevier Inc.

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Decision Making
Three types of decisions
Use the findings Consider using the findings Reject or not use the findings

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Phase IV: Translation/Application

Steps of change
Assess the situation to be changed Develop a plan for change: protocol, algorithm Implement the plan

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Cognitive Application
Research modifies your way of thinking or perception by:
Improving understanding of a situation Allowing analysis of practice dynamics Expanding problem-solving skills for clinical problems

Elsevier items and derived items 2009, 2005, 2001, 1997 by Saunders, an imprint of Elsevier Inc.

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Instrumental Application
Develop a protocol, guideline, or algorithm based on research to change practice. Create a poster to document steps for changing practice.

Elsevier items and derived items 2009, 2005, 2001, 1997 by Saunders, an imprint of Elsevier Inc.

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Symbolic Utilization
Research is used to:
Revise a policy Develop a new role Legitimize a position Implement a new health delivery system

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Phase V: Evaluation
Formal evaluation
Case studies Audits, surveys Quality assurance projects

Informal evaluation
Self-monitoring Discussions with patients, families, peers, and other professionals

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Iowa Model of Evidence-Based Practice

Assemble, critically analyze, and synthesize research for use in practice. Evaluate the sufficiency of the research base. Pilot change in practice. Institute the change in practice. Monitor outcomes.

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Grove Model for Implementing Evidence-Based Guidelines in Practice

To facilitate the use of evidence-based guidelines in practice

Elsevier items and derived items 2009, 2005, 2001, 1997 by Saunders, an imprint of Elsevier Inc.

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Implementing Evidence-Based Guidelines in Practice

Development of Evidence-Based Guidelines Evidence-Based Practice Centers

Elsevier items and derived items 2009, 2005, 2001, 1997 by Saunders, an imprint of Elsevier Inc.

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Grove Model
Search for best evidence for practice problem Use existing evidence-based guideline Assess quality and cost-benefit ratio of guideline Use guideline in practice Monitor outcomes from use of guideline Extend use of guideline to other practice settings

Elsevier items and derived items 2009, 2005, 2001, 1997 by Saunders, an imprint of Elsevier Inc.

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Introduction
Identify practice problem Link practice problem with evidence-based guideline Interest in guideline in practice

Elsevier items and derived items 2009, 2005, 2001, 1997 by Saunders, an imprint of Elsevier Inc.

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Evidence-Based Guideline
Guideline development
Author of guideline Significance of health care problem Strength of research evidence Link to national standards Cost-effectiveness analysis

Elsevier items and derived items 2009, 2005, 2001, 1997 by Saunders, an imprint of Elsevier Inc.

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Cost-Benefit Ratio
Discuss setting for using guideline Fit within this setting and/or change required Benefits of using evidence-based guideline Cost or risks associated with guideline Support to use guideline

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Decision to Use Evidence-Based Practice (EBP) Guideline

Who is involved in decision? What steps have been taken to implement guideline and results? Probable decision regarding implementation?

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Implementation of EBP
How will the intervention be used by an individual, group, or agency?

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Use of Evidence-Based Guidelines in Practice

Who will implement guideline? Final form of guideline Communication process related to guideline Support of health care professionals for guideline

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Implementation
Protocol Algorithm Policy

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Evaluation
The individual, nursing unit, clinic, or agency evaluates the effectiveness of the EBP guideline and decides whether to continue.

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Evaluation (contd)
Anticipated outcomes for agency, provider, and/or patient Specific outcomes to be examined Process for evaluating these outcomes Action related to evaluation

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Evaluation (contd)
Formal evaluation
Case studies Audits, surveys Quality assurance projects

Informal evaluation
Self-monitoring Discussions with patients, families, peers, and other professionals

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Project Outcomes
Patient outcomes
Clinical end points (symptoms and signs, status of disease) Functional status Psychological status Satisfaction with care: access, convenience, financial coverage, quality

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Project Outcomes (contd)

Provider outcomes
Number of patients cared for Revenue generated Status of patient: repeat hospitalizations, emergency department visits Patient satisfaction with care

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Project Outcomes (contd)

Agency outcomes
Length of stay of patients Revenue generated Health status of patient Quality assurance, such as infection rate Patient and provider satisfaction Access to care

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Project Outcomes (contd)

What is to be measured? How will it be measured? Analysis of results Use of the results to maintain or change practice

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