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UNPACKING THE PIECES FOR
EVIDENCE BASED PRACTICE
LuAnn Tandy
2009
LuAnn Tandy, RN, PhD
Student
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Today’s Goal
EBP
EBP
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We went to school to be…..
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But its more like….
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7 Days Worth of Stuff
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It used to be that patients stayed in the
hospital about 7 days.
So….we taught nurses how to do 7 days
worth of stuff.
Now patients stay 2-3 days
We continue to hold nurses to providing
the same standard of care we gave
patients when their stays were 7 days.
Dr. Tim Porter-O’Grady 2007
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Evidence-based Medicine
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The Institute of Medicine defines
evidence-based practice (EBP) as “the
integration of best research, clinical
expertise, and patient values in making
decisions about the care of
individualized patients”
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Evidence-based Nursing
Practice
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Sigma Theta Tau definition:
“Integration of the best evidence
available, nursing expertise, and the
values and preferences of individuals,
families and communities who are
served”
Sigma Theta Tau International Evidence-Based Nursing Position
Statement, 2005
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What is EBNP?

EBP is a problem-solving approach to
clinical practice that incorporates the
best evidence from well-designed
studies, patient values and preferences
and a clinician’s expertise in making
decisions about patient care.
Melnyk & Fineout-Overholt, 2005
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You might be practicing EBP if you…
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question your practice
go to the literature to determine best
practice rather than a peer
Embrace change and let go of old
practices
Quit saying “because that’s the way I
was taught” (30 years ago)
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Ways to Use EBP
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Improve outcomes
Increase efficiency
Improve patient satisfaction
Improve nurse satisfaction
Improve physician satisfaction
Lower costs
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List the Following…
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Everything you have added to your
practice in the last 5 years (i.e.. VAP
protocol, two patient identifiers)
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List things you have given up in the last
five years (i.e.. Changing IV sites every
other day)
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Interdisciplinary EBP ……
different points of view
Nurse
Physician
Dietician
Patient
Therapist
Case
Manager
Administrators
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Why EBP?
THE QUALITY OF CARE LAGS
BEHIND KNOWLEDGE AND
EBP IS SEEN AS
THE SOLUTION
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So Why are We Behind?
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Knowledge Explosion
• Every 9 years the number of journals
increases by……
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Time it takes to move research into
practice?..........
Research is not always able to be translated
into practice
EBP is a way to bundle that knowledge and
put it into usable interventions
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History of EBP
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Evidence Based Practice was used by
Florence Nightingale years ago.
• Observation informed her on what worked
and what didn’t
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1990’s EBP became a viable framework
for positive clinical outcomes
Driven by cost-containment efforts that
were initiated by health administrators
and payers.
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History of EBP
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Educated health care consumers expect
their health care providers to be on the
cutting edge and they demand high
quality care and outcomes.
With the coming of the web health care
consumers do their research and they
may know the best treatment before the
physician or the nurse.
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EBP: We’ve Come A Long Way
Baby
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In 1977 the standard of care for a patient post-op
open heart surgery was to give pain medications as
needed.
In 2008 our standard of care is to schedule pain
medication with dosages based on the patient’s pain
rating.
In 1977 family visits were restricted to 5 minutes
every hour and only 2 people at a time.
In 2008 family members have unrestricted visiting
privileges
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EBP: Then and Now
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In 1977 only patients with diabetes had
their blood glucose levels monitored and
controlled
In 2008 all open-heart surgery patients
glucose levels are maintained between
80 and 110 mg/dL.
Sendelbach, S.E. (2008) Evidence Based Practice:Then and Now, AJN,
108:10, 75-76.
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UNC-Chapel Hill EBP
Process
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Evidence Based Process
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ASK
• Define the question
AQUIRE
• Find the evidence
APPRAISE
• Evaluate the evidence
APPLY
• Apply the evidence
ASSESS
• Assess the outcome
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Evidence Based Process
ASK*
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AQUIRE
APPRAISE
APPLY
ASSESS
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ASK :Questions arise out of our daily
practice and daily life.
These are a few real life examples….
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Janey’s story
•
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Sister in the hospital was febrile and
shivering
Blankets or no blankets?
Jennifer’s story
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Noticed several standards of practice in the
ICU regarding tube feedings
When should tube feedings be held?
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ASK
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Mary Ann’s story
• Heard on CNN that you no longer need to
•
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apply alcohol to a newborn’s umbilical cord
Is this true?
You need to define the question in order
to find the evidence
• PICO is one strategy
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PICO
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P is for patient for population
I is for intervention
C is for conventional treatment
O is for outcome
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Patient or Population
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How would you describe a group of
patients that are similar to yours?
• Primary problem, disease or co-existing
•
•
condition
Sex, age or race
Socio-economic situation
• Country they live in
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Intervention
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What main intervention are you
considering
What do you want to do to the patient?
What are the co-existing issues?
• Age
• Addictions
• Mobility
• Socio-economic concerns
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Comparison
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What is the main alternative to compare
with the intervention?
Is it better to instill normal saline into the
trachea before you suction or not?
You do not always need a comparison
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Outcomes
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What are you trying to measure?
What are you trying to improve?
What are you trying to do for the patient?
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Janey’s Story
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Janey’s sister was in the hospital and
had a fever and she was shivering. The
nurse wanted to take away the blankets
and Janey felt bad for her sister and
fought to keep them. After that situation
she wondered what really was the best
thing to do in that situation. What is
Janey’s PICO
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Janey’s PICO
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P = In post-op patients who are febrile
and shivering
I = is taking away the patient’s blankets
C = or allowing them to keep the
blankets
O = more effective in reducing the fever?
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Mary Ann’s Story
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Mary Ann was driving to work one day to
her job in the labor and delivery
department. On the radio she heard that
it was no longer necessary to apply
alcohol to the newborn’s umbilical cord,
you could just use soap and water.
What is Mary Ann’s PICO?
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Mary Ann’s PICO
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P = In newborn’s
I = is soap and water
C = better than alcohol
O = in preventing infection of the
umbilical cord?
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PICO
Think of your EBP question
and write it down
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Evidence Based Process according
to UNC-Chapel Hill
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ASK
AQUIRE*
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APPRAISE
APPLY
ASSESS
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ACQUIRE: Selecting the Resources
and Conducting the Search
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Locating the highest quality and relevant
information from the medical literature to
answer your question
How do you find the literature?
How do you know the literature is of the
highest quality?
• By determining the levels of evidence.
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DETERMINING THE LEVELS OF
EVIDENCE
Level I: Evidence from a systematic review
or meta-analysis of all relevant
randomized controlled trials (RCTs) or
evidence based clinical practice
guidelines based on systematic reviews
of RCTs.
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Systematic Reviews

A summary of evidence on a particular
topic that uses a rigorous process for
retrieving, critically appraising, and
synthesizing studies in order to answer a
question about a burning clinical
question
Melnyk, 2004
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Meta-analysis
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A systematic review that uses
quantitative methods to summarize the
results of multiple studies.
It produces a summary statistic
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Where to find Systematic
Reviews
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Cochrane Database
Worldviews on Evidence-Based Nursing
by Sigma Theta Tau
Peer reviewed journals
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Levels of Evidence
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Level II: Evidence obtained from at least
one well-designed RCT
• Experimental study in which subjects are
•
randomly assigned to experimental and
control groups.
Randomized trial is an opportunity for anyone
that fits the criteria for inclusion to have a
chance to be in the study.
• Pointing to names in the phone book
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Levels of Evidence
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Level III: Evidence obtained from welldesigned controlled trials without
randomization
• Without randomization you can’t assume that
subjects in the study are equal on
demographic and clinical variables.
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Levels of Evidence
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Level IV: Evidence from well-designed casecontrol and cohort studies
•
•
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Case control study compares certain characteristics of an
individual such as a person with diabetes to the
characteristics of another individual without the disease.
This type of study is used to identify variables that might
predict the condition.
A cohort study gathers two groups on individuals, one with
exposure to a disease and one without and follow them over
time to measure outcomes of the disease.
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Levels of Evidence
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Level V: Evidence from systematic
review of descriptive and qualitative
studies
•
This is similar to meta-analysis only using
qualitative studies
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Levels of Evidence
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Level VI: Evidence from a single
descriptive study
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Level VII: Evidence from the opinion of
authorities and/or reports of expert
committees
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Issues with Evidence
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Too much
Too little
Same author publishes all the studies
Only vendor research
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Interpreting the Results:
Statistics
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Sample size
Reliability
Validity
Significance
Clinical significance
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Sample Size=n
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Number of people in the study
The larger the better
Determining a good sample size
depends upon the size of the population
that is being studied.
Sometimes it’s a small sample size but if
the whole population is in the study, then
that means you sampled 100%
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Significance = p
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A good significance level is between <.01
and .05 in most cases
Significance is the risk of error we are willing
to accept and still say our results are correct
.05 means that 95 times out of 100 “IT” works
.01 means that 99 times our of 100 “IT”
works
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Reliability
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Reliability means that the tool you used to
measure results in your research study will
measure the same way every time.
You wouldn’t want to use a tape measure
that stretches.
You might stretch it more one time than you
do the next.
Look for clues that they didn’t measure things
the same way every time
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Validity
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When research is valid it means that the tool
used to measure the results measures what
it is supposed to measure.
You don’t want to use a tape measure to
weigh a baby. It measures inches not
pounds.
Look for clues that they didn’t use the right
tool to measure their results.
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Clinical Significance
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Sometimes you don’t need a .01 to a .05
significance to be clinically significant.
Sometimes a study isn’t statistically
significant, but it made something better
For example: extremely depressed people
became less depressed but the depression
scale didn’t show that it was statistically
significant. They got better, but they didn’t
get relieved of their depression to equal
normal.
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Evidence Based Process according
to UNC-Chapel Hill
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ASK
AQUIRE
APPRAISE
APPLY*
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ASSESS
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APPLY
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Application is the step where you
integrate the evidence with your clinical
expertise and the unique needs and
values of your patient/situation
• Once you have gathered your evidence and
you have determined that it is of the highest
quality you can find, you must match it to the
patient, situation, and organizational
environment.
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APPLICATION….
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APPLY
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Match the evidence to the patient or
population
• Patient’s religious beliefs
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Match the evidence to the situation
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Match the evidence to the organizational
culture
• USA versus a third world country
• Physician culture, economic issues
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Evidence Based Process according
to UNC-Chapel Hill
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ASK
AQUIRE
APPRAISE
APPLY
ASSESS*
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ASSESS
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Determine outcomes
Develop short and long term goals
Gather feedback
Monitor costs/cost savings
Determine success
Celebrate success
Share your success
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Evidence Based Process in Summary
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ASK
AQUIRE
APPRAISE
APPLY
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ASSESS
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Examples of Real Staff
Nurse Projects….
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Stories: Janey’s Story
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Janey wanted to know if it was better to
let her sister have all the blankets she
wanted or if she should take them away.
Results: vote
• Issues with the literature review
• Surveyed current standard of practice
• Implemented into organizations post-op
•
surgery protocol and fever protocol
No cost
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Jennifer’s Story
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Jennifer noticed there was a different
standard of care between nurses in
regards to when to hold a tube feeding in
the ICU.
• What is the PICO
• Issue with the literature search
• Survey of unit nurses
• Results
• Organizational climate concerns
• Interdisciplinary focus
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Mary Ann’s Story
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Heard on CNN that she no longer
needed to use alcohol on newborn
umbilical cords and no longer need to
teach mom’s to do it at home
Results? Vote
• Issues in the literature
• Application of findings
• Expertise
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Sharon’s Story
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Sharon noticed that her IV team members
were using different amounts of t-PA to clear
central line blockages.
What is the PICO?
Results: Vote
•
•
Working with peers
Cost savings
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Donna’s Story
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In Donna’s unit a physician wanted to
start using rectal tubes and she didn’t
know much about them
• What is the PICO?
• Issues with the literature
• What being knowledgeable about the
research can do for you
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Outcomes
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Increased Patient Satisfaction
Increased Nurse Satisfaction
Improved Care
Save nurses time
Standardize care
Improve nurse confidence
Reduce cost
Improved Quality
Improved efficiency
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Point to Ponder
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Traveling naked into the land of
uncertainty allows for another kind of
learning, a learning that helps us forget
what we know and discover what we
need. It is this journey that leads to the
discovery of what is needed to help us
create the future…Robert E. Quinn
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P 123 in Quantum Leadership by Porter-O’Grady & Malloch 2003
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Levels of Evidence- Melnyk, 2004
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Level I: Evidence from a systematic review or meta-analysis of
all relevant randomized controlled trials (RCTs) or evidence
based clinical practice guidelines based on systematic reviews
of RCTs.
Level II: Evidence obtained from at least one well-designed
RCT
Level III: Evidence obtained from well-designed controlled trials
without randomization
Level IV: Evidence from well-designed case-control and cohort
studies
Level V: Evidence from systematic review of descriptive and
qualitative studies
Level VI: Evidence from a single descriptive study
Level VII: Evidence from the opinion of authorities and/or
reports of expert committees
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Evidence Based Process-UNC-Chapel
Hill
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ASK
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AQUIRE
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• Define the question
•
Find the evidence
APPRAISE
•
Evaluate the evidence
APPLY
•
Apply the evidence
ASSESS
•
Assess the outcome
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PICO- UNC-Chapel Hill
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P is for patient for population
• describe a patient or group of patients that are similar to yours
I is for intervention
• What main intervention are you considering?
• What do you want to do to the patient?
C is for conventional treatment
• What is the main alternative to compare with the intervention?
• You do not always need a comparison
O is for outcome
• What are you trying to measure?
• What are you trying to improve?
• What are you trying to do for the patient?
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