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Chapter 5
Evidence-Based Practice
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
A Case for Evidence

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A response to societal forces
A problem-solving approach to practice
Challenge to obtain:



The very best information
The most current information
Information at the right time, when you need it for
patient care
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Evidence-Based Decision Making
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Steps to Evidence-Based Practice
(EBP)

Six steps provide a systematic approach to
rational clinical decision making:
1. Ask the clinical question.
2. Collect the best evidence.
3. Critique the evidence.
(cont’d)
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Steps to Evidence-Based Practice
(EBP) (cont’d)
4. Integrate the evidence.
5. Evaluate the practice decision or change.
6. Share the outcomes of EBP changes with others.
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PICOT

Developing a PICOT question:
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P = Patient population of interest
I = Intervention of interest
C = Comparison of interest
O = Outcome
T = Time
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Gathering Evidence

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The more focused a PICOT question is, the
easier it will become to search for evidence in the
scientific literature.
Expert clinicians are a rich source of evidence
because they use it frequently to build their own
practice and to solve clinical problems.
The critique or evaluation of evidence includes
determining the value, feasibility, and usefulness
of evidence in making a practice change.
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Hierarchy of Evidence
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Reviewing Studies
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Evidence-based articles include the following:
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Abstract
Introduction
Literature review or background
Narrative (clinical or research)
• Purpose
• Methods or design
Results and/or conclusion
• Clinical implications
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Analysis of Evidence

After critiquing all articles for a PICOT
question,
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Synthesize or combine the findings
Consider the scientific rigor of the evidence and
Whether it has application in practice
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Integration of Evidence

When you decide to apply evidence,
consider:
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The setting
Whether support is provided from staff and
available resources
Evaluate the change.
Share the information.
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Nursing Research


A way to identify new knowledge, improve
professional education and practice, and use
resources effectively
The International Council of Nurses (ICN)
supports the need for nursing research as a
means of improving the health and welfare of
people.
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Case Study

Shana and Eric are nurses
who work in the surgical
intensive care unit (ICU).
They belong to their unit
practice committee, which
meets monthly to discuss
practice issues. They have
received a copy of the
monthly report on quality
indicators.
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Case Study (cont’d)

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Shana notes that the incidence of catheterrelated bloodstream infections (SR-BSIs) has
steadily increased during the last 3 months.
Patients with central venous catheters, used
to deliver fluids and medications over
extended periods of time, are becoming
infected, but why?
Is there a problem with the type of dressing
placed over the catheter or the way the site is
cleansed before insertion?
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Outcomes Management
Research
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Designed to assess and document the
effectiveness of health care services and
interventions
A response of the health care industry to
demands from policy makers, insurers, and
the public
Outcomes must be observable or
measurable.
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Quick Quiz!
1. Which of the following is the first step of the
research process?
A. Analyze data.
B. Identify problem.
C. Conduct study.
D. Use the findings.
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Scientific Method

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The foundation of research
The most reliable and objective means of
acquiring and conducting research and
gaining knowledge.
A step-by-step process to ensure that findings
from a study are valid, reliable, and
generalizable to a similar group of subjects
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Nursing and the Scientific Approach

Nursing research provides a way for nursing
questions and problems to be studied in
broader context.
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Quantitative
Qualitative
Quantitative types: historical, exploratory,
evaluation, descriptive, experimental,
correlational
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Research Process
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An orderly series of steps that allows a
researcher to find the answer to a question
Consists of five steps:
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Identify problem.
Design study.
Conduct study.
Analyze data.
Use the findings.
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Human Research Terminology
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Institutional Review Board (IRB)
Informed consent means
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Participants receive full and complete information
They can understand the information
They have free choice to participate
They understand how their confidentiality will be
kept
Confidentiality
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Case Study (cont’d)
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Shana and Eric volunteer as part of their
committee responsibilities to implement an
EBP project.
Their first step will be to develop a clinical
question and then search the scientific
literature.
Their aim is to determine what evidence is
available so that they can make an informed
decision about the best approaches for
reducing CR-BSIs among their patients.
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Quality and Performance
Improvement
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Every health care organization gathers data
on health outcome measures as a way to
gauge the quality of care.
Quality improvement
Performance improvement
A thorough analysis of QI data leads
clinicians to understand work processes and
the need to change practice.
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Quick Quiz!
2. Every health care organization gathers data
on health outcomes. Examples of data
include
A. Discharges.
B. Medications administered.
C. Healthy births.
D. Infection rates.
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Example: QI Program
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Plan—Review available data to understand
existing practice conditions or problems to
identify the need for change.
Do—Select an intervention on the basis of the
data reviewed and implement the change.
Study—Study (evaluate) the results of the
change.
Act—If the process change is successful with
positive outcomes, act on these practices by
incorporating them into daily unit performance.
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Chapter 6
Health and Wellness
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Healthy People Documents
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Healthy People: The Surgeon General’s
Report on Health Promotion and Disease
Prevention, 1979
Healthy People 2000: National Health
Promotion and Disease Prevention
Objectives
Healthy People 2010
Healthy People 2020
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Healthy People 2020 Goals
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Attain high-quality, longer lives free of
preventable disease, disability, injury, and
premature death
Achieve health equity, eliminate disparities,
and improve the health of all groups
Create social and physical environments that
promote good health for all
Promote quality of life, healthy development,
and healthy behaviors across all life stages.
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Case Study
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Jack is a 59-year-old man with a history of
type 2 diabetes, hypertension, and obesity.
He is married and works 50 to 60 hours per
week in a computer technology position.
His wife works the same number of hours,
although she tends to travel more with her job
and sometimes works the night shift.
Therefore, both Jack and his wife have a hard
time fitting exercise into their daily routine,
and they often eat in restaurants.
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Definition of Health
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Health is more than the absence of disease!
A state of complete physical, mental, and
social well-being, not merely the absence of
disease or infirmity (WHO, 1947)
A state of being that people define in relation
to their own values, personality, and lifestyle
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Models of Health and Illness
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Health Belief Model
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Addresses the relationship between a person’s
beliefs and behaviors
Health Promotion Model
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Directed at increasing a patient’s level of wellbeing
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Models of Health and Illness (cont’d)
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Basic Human Needs Model
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Attempts to meet the patient’s basic needs
Holistic Health Model
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Attempts to create conditions that promote optimal
health
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Case Study (cont’d)
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Jack comes to the clinic today for routine
follow-up for his diabetes. Jack’s laboratory
data reveal that his blood glucose level is
consistently running high. His blood pressure
is on the high side of normal.
Sally, the diabetes nurse educator, is working
with Jack for the second time. Sally knows
she wants to find a way to get Jack’s blood
glucose levels down to avoid the long-term
complications of diabetes.
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Maslow’s Hierarchy of Needs
Self-actualization
Self-esteem
Love and Belonging
Safety and Security
Physiological
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Variables Influencing Health
and Health Beliefs and Practices
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Variables influence how a person thinks and
acts.
Health beliefs can negatively or positively
influence health behavior or health practices.
Health beliefs and practices are influenced by
internal and external variables and should be
considered when planning care.
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Quick Quiz!
1. According to Maslow’s hierarchy of needs,
which of these needs would the patient seek
to meet first?
A. Self-actualization
B. Psychological security
C. Shelter
D. Love and belonging
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Internal Variables
Developmental Stage
Intellectual Background
Perception of Functioning
Emotional Factors
Spiritual Factors
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External Variables
Family Practices
Socioeconomic Factors
Cultural Background
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Case Study (cont’d)
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Because Jack occasionally exercises, Sally
decides to focus her teaching on the
importance of routine exercise to improve
Jack’s health and help with the management
of diabetes.
Sally finds out that 6 months ago, Jack was
using his treadmill for 20 minutes on most
mornings. Since then, he has gotten out of
the habit because he now tries to arrive at
work 30 minutes earlier.
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Quick Quiz!
2. After evaluating a patient’s external variables,
the nurse concludes that health beliefs and
practices can be influenced by
A. Emotional factors.
B. Intellectual background.
C. Developmental stage.
D. Socioeconomic factors.
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Health Promotion, Wellness,
and Illness Prevention
1. Immunization Programs
2. Routine Exercise, Good Exercise
3. Physical Awareness, Stress Management,
Self-Responsibility
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Levels of Prevention
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Primary
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Secondary
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True prevention that lowers the chances that a
disease will develop
Focuses on those who have a disease or are at
risk to develop a disease
Tertiary
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Occurs when a defect or disability is permanent or
irreversible
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Quick Quiz!
3. You will use the concept of primary
prevention when instructing a patient to
A. Get a flu shot every year.
B. Take a blood pressure reading every day.
C. Explore hiring a patient with a known
disability.
D. Undergo physical therapy following a
cerebrovascular accident.
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Risk Factors
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Variables that increase the vulnerability of an
individual or a group to an illness or accident
Risk factors include:
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Genetic and physiological factors
Age
Environment
Lifestyle
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Risk Factor Modification and
Changing Health Behaviors
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Precontemplation
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Contemplation
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Not intending to make changes within the next 6
months
Considering a change within the next 6 months
Preparation

Making small changes in preparation for a change
in the next month
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Case Study (cont’d)
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Sally wants to apply the stages of behavior
change with Jack. By using this model, she will
work with Jack regarding what he is ready to do
rather than simply telling Jack to be more active.
To do this, she first asks Jack how he feels about
exercise and what his plans are. Jack states, “I
know that exercise would be good for me and I
should probably work on it.”
This tells Sally that Jack is at the contemplation
stage.
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Risk Factor Modification and
Changing Health Behaviors (cont’d)
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Improvement in health may involve a change
in health behaviors.
Action
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Actively engaged in strategies to change behavior;
lasts up to 6 months
Maintenance stage
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Sustained change over time; begins 6 months
after action has started and continues indefinitely
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47
Illness
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A state in which a person’s physical,
emotional, intellectual, social, developmental,
or spiritual functioning is diminished or
impaired
Acute Illness
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Short duration and severe
Chronic Illness

Persists longer than 6 months
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Quick Quiz!
4. Sally has decided to set aside 30 minutes a
day to walk after work next week. Sally is in
what stage of risk factor modification?
A. Precontemplation
B. Contemplation
C. Preparation
D. Action
E. Maintenance
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Illness Behavior

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Involves how people monitor their bodies and
define and interpret their symptoms
Influenced by many variables and must be
considered by the nurse when planning care
Internal variables
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
Perception of illness and nature of illness
External variables

Visibility of symptoms, social group, cultural
background, economics, and accessibility to
health care
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50
Impact of Illness on the Patient and
Family
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Behavioral and emotional changes
Impact on body image
Impact on self-concept
Impact on family roles
Impact on family dynamics
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51
Patient Teaching: Lifestyle Changes

Objective
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Patient will reduce health risks related to poor
lifestyle habits through behavior change.
Teaching strategies

Provide active listening, ask about perceived
barriers, assist the patient in establishing goals,
and reinforce the process of change.
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Case Study (cont’d)

Teaching strategies:
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

Practice active listening and determine what Jack
understands regarding health risks related to poor
lifestyle.
Ask Jack what barriers and benefits he perceives
with the planned lifestyle change of consistently
exercising.
Help Jack set achievable goals for change.
Work with Jack to establish realistic time lines for
modification of exercise habits.
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Case Study (cont’d)

At the next appointment,
Jack says, “I saw there
was a sale on walking
shoes. If I’m going to
start walking, do you
think I need to get new
shoes? Next week, I am
taking a week of
vacation, just doing
things around the house,
and I thought this would
be a good time to start.”
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Patient Teaching: Lifestyle Changes
(cont’d)

Evaluation

Have the patient maintain an exercise and eating
calendar to track adherence, and provide positive
reinforcement.
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Case Study (cont’d)

Evaluation strategies
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
Have Jack maintain an exercise log to track
adherence, and provide positive reinforcement.
Ask Jack to discuss his success with lifestyle
changes, such as minutes spent in activity.
Have Jack identify community resources used in
making a change.
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56
Chapter 25
Patient Education
Copyright © 2013, 2009, 2005 by Mosby, an imprint of Elsevier Inc.
Standards for Patient Education



The Joint Commission sets standards for
patient and family education.
Successful accomplishment of standards
requires collaboration among health care
professionals.
All state Nurse Practice Acts recognize that
patient teaching falls within the scope of
nursing practice.
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Purposes of Patient Education


To help individuals, families, or communities
achieve optimal levels of health
Patient education includes:



Maintenance and promotion of health and illness
prevention
Restoration of health
Coping with impaired functioning
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59
Teaching and Learning

Teaching
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An interactive process that promotes learning
Learning

The purposeful acquisition of knowledge, skills,
behaviors, and attitudes
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60
Role of the Nurse in
Teaching and Learning
Teach information that
the patient and the family need to make
informed decisions regarding their care.
Determine what patients need to know.
Identify when patients are ready to learn.
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TJC’s Speak Up Tips
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Speak up if you have questions or concerns.
Pay attention to the care you get.
Educate yourself about your illness.
Ask a trusted family member or friend to be
your advocate.
Know which medicines you take and why.
Use a health care organization that has been
carefully evaluated.
Participate in all decisions about your
treatment.
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Teaching as Communication

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Closely parallels the communication process
Depends partly on effective interpersonal
communication
The learning objective describes what the
learner will be able to accomplish after
instruction is given.
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Domains of Learning
Cognitive
Includes all intellectual behaviors
and requires thinking
Affective
Deals with expression of feelings
and acceptance of attitudes,
opinions, or values
Psychomotor Involves acquiring skills that
require integration of mental and
muscular activity
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64
Quick Quiz!
1. A patient newly diagnosed with diabetes
needs to learn how to use a glucometer. Use of
a glucometer constitutes
A. Affective learning.
B. Cognitive learning.
C. Motivational learning.
D. Psychomotor learning.
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Domains of Learning
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Different teaching methods are appropriate
for each domain of learning.
Cognitive: discussion (one-on-one or group),
lecture, question-and-answer session, role
play, discovery, independent project, field
experience
Affective: role play, discussion (one-on-one or
group)
Psychomotor: demonstration, practice, return
demonstration, independent projects, games
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Basic Learning Principles
Motivation to learn
Ability to learn
Learning
environment
Addresses the patient’s
desire or willingness to
learn
Depends on physical and
cognitive abilities,
developmental level,
physical wellness, thought
processes
Allows a person to attend to
instruction
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67 67
Slide
Motivation to Learn
•
•
Attentional set: the mental state that allows
the learner to focus on and comprehend a
learning activity
Motivation: a force that acts on or within a
person (e.g., idea, emotion, physical need) to
cause the person to behave in a particular
way
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Motivation to Learn (cont’d)


Use of theory to enhance motivation and
learning
Self-efficacy: refers to a person’s perceived
ability to successfully complete a task.
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Motivation to Learn (cont’d)

Psychosocial adaptation to illness
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
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Difficult for patients to accept
Need to grieve
Learning occurs in the acceptance stage.
Active participation

Learning occurs when the patient is actively
involved in the educational session.
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Ability to Learn

Developmental
capability



Cognitive
development
Prior
knowledge
Learning in
children

Developmental
stage
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Ability to Learn (cont’d)

Adult learning



Self-directed
Patient-centered
Physical capability



Level of personal development
Physical health
Fatigue
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Learning Environment
Well lit
Good ventilation
Appropriate
furniture
Comfortable
temperature
Quiet
Private
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Integrating the Nursing
and Teaching Processes




The nursing process and the teaching
process are not the same.
The nursing process focuses on the patient’s
total health care needs.
The teaching process focuses on the
patient’s learning needs and ability to learn.
When education becomes part of the care
plan, the teaching process begins.
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Chapter 1
Overview
Purpose and Goal of Health
Education
• Purpose: To promote, retain, and restore
health
• Goals: To encourage positive, informed
changes in lifestyle.
Client Education Model
Components
• Nurse as Educator
• Client as Learner
• Nurse/Client Relationship
• Client Education Outcomes
Nurse as Educator
• Health Care Institutions
• Public Health
• Health Education Programs
Client as Learner
• Individuals
• Families
• Groups/Communities
• Health Team Members
Nurse/Client Relationship
• Nursing Process
• Teaching and Learning Process
• Clinical Judgment
• Evidence-based Nursing Practice
Nursing Process/Teaching and
Learning Process
• Assessment
• Analysis
• Planning
• Implementing
• Evaluation
Clinical Judgment
• Noticing
• Interpreting
• Responding
• Reflecting
Evidence-based Nursing
Practice
•
•
•
•
•
•
•
•
•
•
Meta-analysis
Systematic Review
Randomized Controlled Trial
Observational Study
Case Study
Descriptive Study
Cohort Study
Case Controlled Study
Expert Opinion
Qualitative Study
Client Education Outcomes:
Formative Evaluation
• Evaluation of the teaching plan.
• Evaluation of the learning environment.
• Evaluation of the nurse/client interaction.
Client Education Outcomes:
Summative Evaluation
• Evaluation of client learning.
• Evaluation of program effectiveness.
• Evaluation of integration of learning into
daily living.
Definitions
• Health education
• Health
• Illness
• Wellness/Illness Functional Continuum
Health Belief Model:
Perceptions
• Need for care.
• Seriousness and consequences of condition.
• Value of health intervention.
• Effectiveness, cost, and barriers of treatment.
Context for Health Education
• National importance of health education.
• Living in an interactive and interdependent
global community.
Chapter 2
Thinking and Learning
Learning
• A purposeful activity with the goal of
bringing about a necessary change.
Domains of Learning
• Cognitive domain
• Affective domain
• Psychomotor domain
Types of Thinking
•
•
•
•
•
•
•
•
Problem solving
Nursing process
Critical thinking
Clinical judgment
Creative thinking
Intuition
Reflection
Others
Promoting Thinking in Clients
and Colleagues
•
•
•
•
•
•
•
Listen carefully to what is said
Be respectful
Assess frame of mind, readiness to learn
Reinforce thinking behavior
Assess how your comments are received
Clarify information
Explicate learning expectations
Styles of Thinking and Learning
• Sternberg’s Styles
• Witkin’s Field Preference
• Kolb’s Experiential Learning Cycle
• Gardner’s Multiple Intelligences
Gardner’s Multiple Intelligences
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Linguistic Intelligence
Logical-mathematical Intelligence
Spatial Intelligence
Musical Intelligence
Bodily-kinesthetic Intelligence
Interpersonal Intelligence
Intrapersonal Intelligence
Chapter 3
Theories and Principles of
Learning
1
Reasons for Theories
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You need a theory when you:
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Confront a new situation and what you already know does not
apply to that situation.
Want to increase your understanding of something relatively
familiar.
Face a familiar situation but what you already know does not
work.
Wish to teach what you know to a colleague or client.
Question the validity of a cherished belief.
Explore new hypotheses.
Observe events for which you can find no explanation in your
present way of thinking.
1
Theories of Learning
• Behavioral Views of Learning
– Stimulus-response
– Operant conditioning
• Cognitive Views of Learning
– Gestalt/cognitive field
– Information processing
• Social Cognitive View of Learning
1
Historical Foundations of the
Nurse Educator Role
• Health education has long been
considered a standard care-giving role of
the nurse.
• Patient teaching is recognized as an
independent nursing function.
• Nursing practice has expanded to include
education in the broad concepts of health
and illness.
Historical Foundations (cont’d)
Organizations and Agencies Promulgating
Standards and Mandates:
1. NLNE (NLN)
– first observed health teaching as an
important function within the scope of
nursing practice
– responsible for identifying course content
for curriculum on principles of teaching and
learning
Historical Foundations (cont’d)
2. ANA
- responsible for establishing standards and
qualifications for practice, including patient
teaching
3. ICN
- endorses health education as an essential
component of nursing care delivery
Historical Foundations (cont’d)
4. State Nurse Practice Acts
- universally includes teaching within the scope
of nursing practice
5. JCAHO
- accreditation mandates require evidence of
patient education to improve outcomes
6. AHA
- Patient’s Bill of Rights ensures that clients
receive complete and current information
Historical Foundations (cont’d)
7. Pew Health Professions Commission
- puts forth a set of health profession
competencies for the 21st century
- over one-half of recommendations pertain to
importance of patient and staff education
Current Mandates for
Nurse as Educator
Institute of Medicine 2001
CROSSING THE QUALITY CHASM:
A NEW HEALTH SYSTEM FOR THE
21ST CENTURY
 focuses more broadly on how the health system
can be reinvented to foster innovation and improve
the delivery of care.
 Six Aims for Improvement
 Ten Rules for Redesign
Joint Commission:
Patient and Family Education
 The organization provides education that
supports patient and family participation in
care decisions and care processes.
 Education and training help meet patients’
ongoing health needs.
 Education methods consider the patient’s and
family’s values and preferences and allow
sufficient interaction among the patient,
family, and staff for learning to occur.
Current Mandates for
Nurse as Educator
Healthy People 2020 (USDHHS)
Federal initiatives outlined:
To increase the quality & years of healthy life
To eliminate health disparities among different
segments of the population
*Requires the nurse as educator to use theory
and evidenced based strategies to promote
desirable health behavior.
Trends Affecting Health Care
Social, economic, and political forces
that affect a nurse’s role in teaching:
• growth of managed care
• increased attention to health and well-being of
everyone in society
• cost containment measures to control
healthcare expenses
• concern for continuing education as vehicle to
prevent malpractice and incompetence
Trends (cont’d)
• expanding scope and depth of nurses’
practice responsibilities
• consumers demanding more knowledge and
skills for self-care
• demographic trends influencing type and
amount of health care needed
• recognition of lifestyle related diseases which
are largely preventable
• health literacy increasingly required
• advocacy for self-help groups
Purpose, Benefits, and Goals
of Patient, Staff and Student
Education
Purpose: to increase the competence and
confidence of patients to manage their
own self-care and of staff and students to
deliver high-quality care
Benefits of education to patients:
- increases consumer satisfaction
- improves quality of life
- ensures continuity of care
Purpose, Benefits and Goals
(cont’d)
- reduces incidence of illness complications
- increases compliance with treatment
- decreases anxiety
- maximizes independence
Benefits of education to staff:
- enhances job satisfaction
- improves therapeutic relationships
- increases autonomy in practice
- improves knowledge and skills
Purpose, Benefits and Goals
(cont’d)
Benefits of preceptor education for nursing
students
• prepared clinical preceptors
• continuity of teaching/learning from
classroom curriculum
• evaluation and improvement of student
clinical skills
Purpose, Benefits, and Goals
(cont’d)
Goal: to increase self-care responsibility of
clients and to improve the quality of care
delivered by nurses