Evidence Based Practice In Health Care

Health Care and Evidence Based Practice

 Evidence Based Practice,Historical Overview,Efforts Leads to Evidence Based Practice,Evaluation Evidence Based Practices,Evaluation Models.

Evidence Based Practice

    Evidence-based practice (EBP) refers to nursing practice that uses research findings as the foundation for nurses' decisions, activities, and interactions with clients. Another term which is often used synonymously but is slightly different is the term "research utilization." 

    Research utilization specifically refers to the practical utilization of findings from one or more scientific studies and is a predecessor of EBP. EBP is broadly conceptualized as a continuum of synthesized information used to improve practice and patient outcomes (Bakken, 2001). 

    These two terms encompass the burgeoning interest in developing a practice in which there is solid evidence from scientific research that explicit nursing actions are clinically relevant, cost effective, and result in positive quality outcomes for clients. 

    The focus of EBP is its emphasis on integrating the best available research evidence within the clinical, patient, and organizational context of an institution to attain high-quality and cost-effective care. 

    According to Hewitt-Taylor (2002), evidence-based practice is a process that entails six elements: 

(a) selecting an area of practice that requires an evidence base.

(b) making decisions about what constitutes evidence.

(c) conducting a systematic search for evidence.

(d) evaluating individual pieces of evidence.

(e) synthesizing the findings of these sources into a cohesive whole.

(f) applying this evidence appropriately to patient care situations.

Historical Overview

    The desire to explore the path and timing of research to practice began in the 1960s and 1970s. N. Caplan and Rich (1975) coined the terms instrumental utilization (changing practice based on empirical evidence) and conceptual utilization (inability to change behavior based on the results, but a new awareness during caregiving). 

The slow evolution of practice change was called knowledge creep and decision accretion by C. Weiss (1980). Practice changes occur slowly over time as nurses and other health care providers repeatedly come into contact with new knowledge during readings, discussions, and at local and national meetings. 

    Estabrooks (1999) reported three types of research utilization: indirect (changes in nurses' thinking), direct (incorporating findings into patient care), and persuasive (using findings to change decision makers' behaviors and beliefs).

Efforts Leads to Evidence Based Practice

    Two formal efforts undertaken in the 1970s to bridge the gap between nursing research and nursing practice were the Western Interstate Commission for Higher Education (WICHE) Regional Program and the Conduct and Utilization of Research in Nursing (CURN) projects. 

    In the WICHE project, although nurses were successful in increasing research utilization, they noted a dearth of scientifically sound nursing research with identifiable nursing implications. 

    The goal of the CURN project was to increase the use of research results in daily practice by disseminating current findings, encouraging collab orative research with relevance to nursing issues, and enhancing administrative and organizational change supportive of implementing new evidence. 

    The Cochrane Collaboration, which was founded in the United Kingdom in the 1970s, was a foundation of the evidence-based practice movement. British epidemiologist Archie Cochrane, noting the paucity of evidence supporting care, advocated for the availability of clinical summaries upon which health care providers could base their decisions. 

    This led to the formation of the Cochrane Collaboration (www.cochrane.org), whose aim is the preparation and dissemination of systematic reviews of the results of health care interventions. As the Cochrane movement was going on, Dr. David Sackett pioneered evidence-based medicine (EBM) at McMaster Medical School. 

    She has conceptualized EBM as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of EBM means integrating individual clinical expertise with the best available external evidence from systematic research" (Sackett , Rosenberg, Muir Gray, Haynes, & Richardson, 1996, p. 71).

Evaluation Evidence Based Practices

    Rigorous rating systems for evaluating evidence have been developed by Sackett and others (1996), Stetler and others (1998), as well as the AHCPR (2003) (now Agency for Healthcare Research and Quality (AHQR)].

    In general, the rating systems order the types of evidence in the following manner: meta analyses of randomized, controlled trials (RCT) (strongest evidence); (or RCT); quasi experimental studies (time series, nonequivalent control group) or matched case control studies; nonexperimental studies (correlational, descriptive); and program evaluations, quality improvement projects, case reports, authoritative opinions (weakest evidence).

Evaluation Models

    Two models ( Stetler Model, Iowa Model) that were originally designed for research utilization have been adapted for use in EBP projects. These models have been the inspiration for the following steps to change practice: 

(a) identify a clinical problem.

(b) collect the evidence about clinical issue (literature review, integrative review).

(c) review, evaluate, and synthesize available evidence.

(d) plan the EBP change.

(e) design, implement, and evaluate a pilot EBP project.

(f) design, implement, and evaluate a larger EBP project; and finally. 

(g) disseminate the results (Polit & Beck, 2004).

    Currently, informatics has become a key contributor to EBP and the promotion of quality patient care (Bakken, Cimino, & Hripesak , 2004). Although this is not yet the standard, the methodology exists and presents an opportunity to impact quality of care through using up-to-date evidence about best practice tailor made for an individual patient. 

    For example, a patient is admitted for a specific operating procedure; Reminders are sent to the physician and nurses regarding type of antibiotics, changes in care and testing based on laboratory functions, and best educational methodologies for the patient based on his demographics. 

    These care processes are changed based on the most current and best evidence for care and treatment. Computer based reminders have been demonstrated to decrease errors of omission and enhance adherence to clinical practice guidelines ( Overhage , Tierney, Zhou, & McDonald, 1997).

    There is some concern by practitioners that the systematic reviews used by clinicians are a watered-down version of the scientific method and raw data. 

    Although Cochrane reviews, summarizations, and meta syntheses of data are used by clinicians in the formation of guidelines, nurses continue to appreciate the scholarly merit of single study or a series of studies excellently formulated and conducted. 

    In this author's experience, since the nature of nursing problems do not always fit the structure of a randomly controlled trial, evidence in one or a series of studies is evaluated and considered for their scientific soundness and clinical significance.

    Polit and Beck (2004) recommend eight strategies for promoting the use of research findings in current practice. 

    Researchers should collaborate with staff nurses to: identify current clinical problems, use rigorous designs, replicate findings, write clear research reports and share the information, report findings that are conducive to meta analysis, present clinical implications of the research, disseminate findings energetically in multiple media (journals, conferences), and finally, prepare integrative and critical research reviews and make them available to busy practicing nurses.

    Polit and Beck (2004) also identify nursing and organizational barriers to the utilization of evidence by practicing nurses. Bedside nurses may not be prepared to critically appraise the evidence. 

Nurses may not only lack the motivation to make changes, but be resistant to making changes that impact their comfortable practice. For organizations, administrators can foster a climate conducive to innovation. 

They can offer emotional, moral, and instrumental support for innovation, and can reward nurses for innovative and evidence based practice at the bedside as well as support organizational initiatives.