IMPROVING QUALITY OF HEALTHCARE THROUGH EVIDENCE-BASED PRACTICE : IMPROVING QUALITY OF HEALTHCARE THROUGH EVIDENCE-BASED PRACTICE
Bernadette Mazurek Melnyk, PhD, RN, CPNP/NPP, FAAN
Dean and Distinguished Foundation Professor in Nursing
Arizona State University
College of Nursing and Healthcare Innovation
Associate Editor
Worldviews on Evidence-Based Nursing
Slide2 :
In God We Trust,
Everyone Else Must
Bring Data!
Slide3 : Evidence-based practice (EBP) is a problem solving approach to clinical practice that integrates the conscientious use of best evidence in combination with a clinician’s expertise as well as patient preferences and values to make decisions about the type of care that is provided. Existing resources must also be considered in the clinical decision-making process. Evidence-Based Practice
Slide4 : The Merging of Science and Art: EBP within a Context of Caring Results in the Highest Quality of Patient Care Clinical Decision-making Quality
Patient
Outcomes Research Evidence & Evidence-based Theories Clinical Expertise and Evidence from assessment of the patient’s history and condition as well as healthcare resources Patient
Preferences
and Values Context of Caring © Melnyk & Fineout-Overholt, 2005
An Example of When Patient Preferences “Trump” the Best Evidence : An Example of When Patient Preferences “Trump” the Best Evidence A New York Times article entitled
“When Doctors Say Don’t and the
Patient Says Do”
(Siegel, October 29, 2002).
Slide6 : Patient Outcomes With and Without Evidence-Based Practice
Slide7 :
Despite an aggressive research movement, the majority of findings from research often are not integrated into practice.
It takes approximately 17 years to translate research findings into practice (Balas & Boren, 2000).
Why Must We Accelerate Evidence-Based Practice?
Slide8 :
COPE: An Evidence-Based Program to Improve Outcomes in Critically Ill/Hospitalized Young Children, LBW Premature Infants & Parents
Slide9 : Why Must We Accelerate Evidence-Based Practice? The Slippery Slope Knowledge of Best Current Care for Hypertensive Patients Years since Medical School Graduation From: Shin et al (1993), CMAJ, 969-976 r=-.54
p<.001
Slide10 :
A high JASPA score
(Journal of Associated Score of Personal Angst)
J: Are you ambivalent about renewing your Journal subscriptions?
A: Do you feel Anger toward prolific authors?
Why Must We Accelerate Evidence-Based Practice?
Slide11 :
S: Do you ever use journals to help you Sleep?
P: Are you surrounded by piles of Periodicals?
A: Do you feel Anxious when your journals arrive?
Modified from BMJ (1995), 311, 166-1668 Why Must We Accelerate Evidence-Based Practice?
Slide12 :
Practices routed in tradition are often outdated and do not lead to the best patient outcomes
Daily changing of IV dressings
Use of a nebulizer instead of a MDI with spacer to deliver albuteral to asthmatic children in the ED
Mayonnaise for head lice
Why Must We Accelerate Evidence-Based Practice?
Slide13 :
A recent survey with a random sample of 1097 registered nurses in the U.S. indicated that:
34.5 percent of the sample felt they needed information only seldomly or occasionally
almost half were not familiar with the term “evidence-based practice”
more than half do not believe that their colleagues use research findings in practice Why Must We Accelerate Evidence-Based Practice?
Slide14 :
A recent survey with a random sample of 1097 registered nurses in the U.S. indicated that:
most do not search information resources to gather practice information
only 27% had any instruction in using electronic data bases
besides time, the greatest personal barrier in using information in practice was “lack of value for research”
Source: Pravikoff, Pierce, & Tanner (2005).
Nursing Outlook, 53 (1), 49-50.
Why Must We Accelerate Evidence-Based Practice?
Conclusion from the AAN Expert Panel Study : Conclusion from the AAN Expert Panel Study “RNs in the United States aren’t ready for evidence-based practice because of the gaps in their information literacy and computer skills, their limited access to high quality information resources, and above all, the attitudes toward research”
Pravikoff, Tanner & Pierce, 2005, p. 50
Slide16 :
1. Ask the burning clinical question in PICO format
Patient population
Intervention or interest
Comparison intervention or group
Outcome
The Five Steps of EBP In teens (P), is cognitive-behavior skills building (I) or yoga (C) more effective in reducing anxiety (O)?
Slide17 :
2. Collect the best evidence. Search first for systematic reviews (e.g., the Cochrane Database of Systematic Reviews) and evidence-based clinical practice guidelines (www.guideline.gov) The Five Steps of EBP
Slide18 : 3. Critically appraise the evidence
a. Are the results valid (as close to the truth as possible)?
b. What were the results of the study (including magnitude [effect size, NNT, NNH, ARR, RRR] and precision [confidence intervals])?
c. Are the findings clinically relevant to my patient(s)?
The Five Steps of EBP
Slide19 : The Five Steps of EBP 4. Integrate evidence, clinical expertise, and patient factors/preferences to implement a decision
5. Evaluate the outcome
Slide20 :
Individual knowledge and skills in EBP
Beliefs that EBP improves care and outcomes
Beliefs in the ability to implement EBP
Mentors/teachers who are skilled in EBP
Administrative/organizational support
Journal clubs
Evidence Supported Facilitators of EBP
The ARCC (Advancing Research and Clinical practice through close Collaboration) Model : The ARCC (Advancing Research and Clinical practice through close Collaboration) Model Potential Strengths
Philosophy of EBP
Presence of EBP Mentors & Champions
Administrative Support Nurses’ Beliefs about the Value of EPB & Ability to Implement the EBP Process* Nurse Satisfaction
Cohesion
Intent to Leave
Turnover Assessment of Organizational Culture & Readiness for EBP* Identification of Strengths & Major Barriers to EBP Implementation Implementation of ARCC Strategies EBP Implementation* Decreased Hospital Costs Improved Patient Outcomes Potential Barriers
Inadequate EBP Knowledge & Skills
Lack of EBP Valuing
Lack of EBP Mentors & Champions Interactive EBP Skills Building Workshops EBP Rounds & Journal Clubs Development & Use of EBP Mentors * Scale Developed © Melnyk & Fineout-Overholt
2005
Control Theory as a Guide for ARCC Intervention Strategies : Control Theory as a Guide for ARCC Intervention Strategies Current State of EBP Ideal State/Goal: System-wide EBP Nurse Behaviors to Advance EBP Barriers
Inadequate EBP Knowledge & Skills
Lack of Value for EBP
Lack of EBP Mentors ARCC
Strategies © Melnyk & Fineout-Overholt
2005
Data from the 2006 Arizona Governor's Task Force Survey on the Nursing Shortage: Vacancy Rate by Advanced Practice Nurses Serving as an EBP Mentor : Data from the 2006 Arizona Governor's Task Force Survey on the Nursing Shortage: Vacancy Rate by Advanced Practice Nurses Serving as an EBP Mentor
Creating a Vision and Motivating a Change to Evidence-Based Practice in Healthcare Settings : Creating a Vision and Motivating a Change to Evidence-Based Practice in Healthcare Settings
SHOCK! “You are now asking me to integrate EBP on top of everything else that I do?” : SHOCK! “You are now asking me to integrate EBP on top of everything else that I do?”
Key Ingredients for Organizational Change : Key Ingredients for Organizational Change A vision with well defined strategic plan and goals
Strong belief about its accomplishment
Clear communication of that vision & plan
Strategies to overcome barriers
Champions and EBP mentors
Knowledge & skills building workshops
Resources, including computers at point of care
Persistence through the “character-building” times
Recognition and rewards
Slide27 : Knowing what to expect as part of the change process will enhance success!
Slide28 : Clinicians must ask themselves the following questions
To what extent is the care that I deliver evidence-based?
How much do I believe that implementing and teaching EBP will lead to the highest quality of care for patients and their families?
How much knowledge of the EBP process do I possess? Recommendations for Igniting EBP in Healthcare Settings
Slide29 :
Assess Environmental Readiness
Does the philosophy and mission of the institution support EBP?
What is the personal commitment to EBP among administrators and educators?
Are there mentors who have strong knowledge and skills related to EBP? Recommendations for Advancing EBP
Slide30 :
Assess Environmental Readiness
Do advanced practice nurses and educators model EBP?
Do learners have access to quality computers in educational settings and at the point of care?
Are there librarians who have knowledge of EBP who can assist with EBP? Recommendations for Advancing EBP
Slide31 :
Champions in the environment at all levels (ie., Administrators, Teachers, Learners)
Resources (eg., Committed and Skilled EBP Mentors, Computers, Access to Quality Databases and the Internet) Recommendations for Advancing EBP
Slide32 :
Skills Building Workshops (Basic and On-Going)
EBP Rounds
Online EBP Modules and Discussion Groups
Journal Clubs
EBP Implementation and Outcomes Management Projects
EBP Poster Presentation Events Practical Strategies for Advancing EBP in Healthcare Settings
Integrating EBP throughout Academic Curriculum Across All Levels : Integrating EBP throughout Academic Curriculum Across All Levels
The recent Health Professions Education Summit defined core competencies for all healthcare professionals, one of which is
evidence-based decision making and another is interdisciplinary education (Greiner & Knebel, 2003)
A Key Message for Teaching EBP : A Key Message for Teaching EBP Role Modeling is the Most Powerful Variable in Success
What is experienced and seen in the clinical area is what will most likely predict future behavior
-Bob Berenson
The Generation of High Quality Evidence is Absolutely Necessary for EBP to Advance : The Generation of High Quality Evidence is Absolutely Necessary for EBP to Advance We Must Become an
“Evidence-Seeking” Profession
-D. Rothenberger
We must generate practice based
evidence!
Slide36 :
Arizona State University College of Nursing
Center for the Advancement of EBP
http://nursing.asu.edu/; click on evidence-based practice
-Ongoing 5 day immersion EBP mentorship
workshops throughout the year
-Annual national EBP conference (Phoenix, February 22-23, 2007)
-17 credit graduate/post-master’s certificate in EBP EBP Resources: Conferences and Workshops
Slide37 :
Worldviews on Evidence-Based Nursing: Blackwell Publishing and Sigma Theta Tau International
www.blackwellpublishing.com/journal.asp?=1545-102xsite=1
Evidence-Based Nursing: BMJ Publishing Group
http://ebn.bmjjournals.com/ EBP Resources: Journals
Slide38 :
Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice.
Melnyk & Fineout-Overholt (Editors) (2005): Lippincott Williams & Wilkins
How to Teach and Learn Evidence-based Practice: A Guide for Educators. Levin & Feldman (Editors) (2005): Springer EBP Resources: Books
Slide39 :
RESEARCH
PRACTICE
EBP Advancing and Teaching EBP calls for a paradigm shift in educational programs and the fusion of clinical practice and research Copyright, Fineout-Overholt, 2004
“…because we’ve always done it that way.” : “…because we’ve always done it that way.” Anonymous ? ? ? ? ? ? ? ? ? ? ? ? ?
Slide41 : Belief at the beginning of an endeavor is the one thing that will ensure success -William James Failure is Not an Option!
-Gene Krantz
Slide42 : Contact Information Bernadette Melnyk 602-496-2200 Bernadette.Melnyk@asu.edu