Evidence based practice

EVIDENCE BASED PRACTICE PRESENTER:

INTRODUCTION
• During 1980s the term “evidence-based medicine” emerged to describe the approach that
used scientific evidence to determine the best practice. Evidence based practice movement
started in England in the early 1990s
• Evidence-based medicine (EBM) or evidence based practice (EBP), is the judicious use of
the best current evidence in making decisions about the care of the individual patient.
• Evidence-based practice represents both an ideology and a method. The ideology springs
from the ethical principle that clients deserve to be provided with the most effective
interventions possible. The method of EBP is the way we go about finding and then
implementing those interventions.
•
DEFINITIONS
o Evidence: It is something that furnishes proof or testimony or something legally submitted to
ascertain in the truth of matter. Evidence based practice: It is systemic inter connecting of
scientifically generated evidence with the tacit knowledge of the expert practitioner to
achieve a change in a particular practice for the benefit of a well- defined client / patient
group. (French 1999).
o Evidence based nursing- it is a process by which nurses make clinical decisions using the best
available research evidence, their clinical expertise and patient preferences (mulhall, 1998).
o Evidence based medicine or practice- The conscientious, explicit and judicious use of current
best evidence in making decision about the care of individual patient. (Dr. David Sackett,
Rosenberg, 1996)
o EBP in nursing is a way of providing nursing care that is guided by the integration of the best
available scientific knowledge with nursing expertise. This approach requires nurses to
critically assess relevant scientific data or research evidence and to implement high quality
interventions for their nursing practice. (NLM PubMed)

NEED FOR EBP

 For making sure that each client get the best possible services.
 Update knowledge and is essential for lifelong learning.
 Provide clinical judgement.
 Improvement care provided and save lives.

GOAL OF EBP
o Provide practicing nurse the evidence based data to deliver effective care.
o Resolve problem in clinical setting.
o Achieve excellence in care delivery.
o Reduces the variations in nursing care and assist with efficient and effective decision making.
  STEPS IN EBP

SORCES OF EVIDENCE
 Research evidence has assumed priority over other sources of evidence in the
delivery of evidence based health care.
 It includes
 Filtered resources- Clinical experts and subject specialist pose a question and
then synthesise evidence to state conclusion based on available research. These sources
are helpful because the literature has been searched and results evaluated to provide
an answer to clinical question.
 Unfiltered resources (Primary literature)- It provides most recent information.
E.g MEDLINE, CINHAL etc provides primary and secondary literature for medicine.
 Clinical experiences- Knowledge through professional practice and life experiences
makes up the second part in the evidenced based , person-centered care.
 Knowledge from patients- Evidence delivered from pt’s knowledge of
themselves, their bodies and social lives.
 Knowledge from local context- Audit and performance data Patient stories and
narratives Knowledge about the culture of the organization & individuals within it. Social
& professional networks. Information from feedback Local & national policy.
Hierarchy of Evidence

MODELS OF EBP
• John Hopkins nursing EBP Model- Used as a framework to guide the synthesis and
translation of evidence into practice. (Newhouse, Dearholt, Poe, Pugh, & White, 2007).
• There are three phases to the JHNEBP model
a. The identification of an answerable question.
b. A systematic review and synthesis of both research and non-research evidence.
c. Translation includes implementation of the practice change as a pilot study, measurement of
outcomes, and dissemination of findings.

JOHN HOPKINS NURSING EBP MODEL

IOWA model
• The Iowa model focuses on organization and collaboration incorporating conduct and use of
research, along with other types of evidence. (Titler et al, 2001). It was originated in 1994.
The star point in the model can either be
• A knowledge focused trigger (that emerges from awareness of innovative research findings
• A problem- focused trigger (that has its root in a clinical or organizational problem)

The IOWAModel of EBP to Promote Quality Care The Stetler Model

• This model examines how to use evidence to create formal change within organizations, as well how
individual practitioners can use research on an informal basis as part of critical thinking and reflective
practice. The Stetler model of evidence-based practice based on the following
1. Use may be instrumental, conceptual and/or symbolic/strategic.
2. Other types of evidence and/or non-research- related information are likely to be combined with
research findings to facilitate decision making or problem solving.
3. Internal or external factors can influence an individual's or group's review and use of evidence.
4. Research and evaluation provide probabilistic information, not absolutes. 5. Lack of knowledge
and skills pertaining to research use and evidence-informed practice can inhibit appropriate and
effective use.
This model consists of five phases. Each phase is designed to
• facilitate critical thinking about the practical application of research findings
• result in the use of evidence in the context of daily practice
• Mitigate some of the human errors made in decision making.
Barriers in EBP
o Lack of value for research in practice
o Difficulty in bringing change
o Lack of administrative support
o Lack of knowledge mentors
o Lack of time for research
o Lack of knowledge about research
o Research reports not easily available
o Complexity of research reports
o Lack of knowledge about EBP

Advantages of EBP
• Provide better information to practitioner
• Enable consistency of care
• Better patient outcome
• Provide client focused care
• Structured process
• Increases confidence in decision-making
• Generalize information
• Contribute to science of nursing
• Provide guidelines for further research
• Helps nurses to provide high quality patient care

Disadvantages of EBP
• Not enough evidence for EBP
• Time consuming
• Reduced client choice
• Reduced professional judgement/ autonomy
• Supress creativity
• Influence legal proceedings
• Publication bias
 Research abstract Translating research into practice:
case study of a community- based dementia caregiver intervention. (Mittelman MS, Bartels SJ.) Evidence
from randomized clinical trials has demonstrated the effectiveness of providing psychosocial
interventions for caregivers to lessen their burden. This case study describes outcomes of the
implementation of an evidence-based intervention in a multisite program in Minnesota. Consistent with
the original randomized clinical trial of the intervention, assessments of this program showed decreased
depression and distress among caregivers. Some of the challenges in the community setting included
having caregivers complete the full six counseling sessions and acquiring complete outcome data. Given
the challenges faced in the community setting, web-based training for providers may be a cost-effective
way to realize the maximum benefits of the intervention for vulnerable adults with dementia and their
families.

CONCLUSION
Evidence-based nursing care is a lifelong approach to clinical decision making and excellence in practice.
Evidence-based nursing care is informed by research findings, clinical expertise, and patients' values, and
its use can improve patients' outcomes. Use of research evidence in clinical practice is an expected
standard of practice for nurses and health care organizations, but numerous barriers exist that create a gap
between new knowledge and implementation of that knowledge to improve patient care. Using the levels
of evidence, nurses can determine the strength of research studies, assess the findings, and evaluate the
evidence for potential implementation into best practice.

Innovations in nursing
 The fast development of health care sector
 healthcare personnel have new challenges
 worldwide nurses are engaged in innovative activities on a daily basis to improve patient
care outcomes and to reduce cost to healthcare system.
 Resulted in significant improvement in health of patients, Community and healthcare systems.
 Nursing research are the new role of nurses

DEFINITION
“ Innovation is anything that creates new resources , processes , or values , or improves a company’s
existing resources , processes , or values .” - Christiansen et al.
Innovation is central to maintaining and improving quality of care . And nurses innovate to find new
information and better ways of promoting health , preventing disease and better ways of care and cure.

Innovation - A dynamic, systematic process that envisions new approaches to nursing education.
Innovation refers to developing and adopting new approaches, technologies, products and ways of
functioning.
 In nursing, it means finding new information and better ways of promoting health, preventing disease
and better patient care.
Innovation is act of constructive thinking, grouping knowledge, skill, attitude in to new original and
rational ideas like…critical thinking – Imagination – plan – Action – Achieve – Objectives.
By Luecke & Katz : Innovation is generally understood as the successful introduction of a new thing
or method.

Innovation is new way of doing something.

 Innovation is a process that brings creativity to measurable outcomes, actions, products, or
processes “innovation is something different that has impact. The often unspoken goal is
to solve a problem” .
Most of us are capable of being creative. Yet many of us don’t recognize our own creativity, whether
it is in the artistry of one’s cooking or the way in which we plan and deliver care to elderly residents
in a long-term care facility. Some innovation methods, such as non-judgmental brainstorming,
prototype building, and story- telling that are discussed below, are designed to restore this sense of
playfulness and creativity

 Creative people frequently solve problems with a process called divergent thinking. This
thought process, which is the most commonly accepted indicator of creative capacity,
involves the ability to make mental connections between unrelated matters. Divergent
thinking is not as valued in healthcare as convergent thinking. Convergent thinkers,
sometimes known as “linear thinkers,” like data and puzzles. They value getting the
correct or conventional answers. Healthcare disciplines generally socialize their members
to be excellent convergent thinkers.

 The context within which innovation and creativity thrives, or conversely withers, is the
environment. In the quality-driven, yet risk-averse healthcare field, a field with unrelenting
operational pressure, it is difficult to encourage creativity and innovation. There is no down-
time, no break from the paramount focus on patient care. Yet, creative insights do emerge
from this pressure and providers’ concern for patients.
 Innovation, by its nature, often involves a process of trial-and-error in which mistakes are
frequent and from which much is learned. Some organizations create protective
environments, such as incubators, insulating innovation teams from operational pressures;
others create permissive “learning environments” within mainstream structures.
 To maintain the quality of care
 To improve the quality of care
 To find new information
 To find new way of promoting health
 To find new way of promoting illness
 To find better way of care & cure
 To conform to the regulation
 To reduce the energy consumption

◻By the Hand out

  Innovation is to analyze the opportunities or sources
 Innovation is both conceptual and perceptual
 It should be simple and focused
 Effective innovation start small and they aim to do one specific thing
 Successful innovation aim at being the best from the very beginning
 Maintenance of quality health services
 Meeting the increasing demands of healthcare field
 Compete the global workforce shortage
 Increasing advance in the healthcare field
 Emerging clinical/nursing specialities

We can broadly classify these into the following :

 Innovation in nursing practice
 I0nnovation in nursing education
 Innovation in nursing care
 Innovation in nursing management
 Innovation in the clinical practice occur across the continuum of care. Clinical practice demanding new
skills and techniques as well as the new ways of working. Similarly changes in the availability and
effectiveness of drug-based treatments have also brought about significant shifts in the clinical practice.
 Innovations are a way we approach care through new collaborative partnerships with Other organizations
and healthcare providers , community groups and with consumers of health services, their families and
carers.
 There are number of stages in the diffusion process: like…Knowledge, persuasion, decision,
implementation and confirmation.
 This process begins with the involved knowledge becoming aware of the innovation and then forming a view
about it Decision is made about whether it should be pursued The innovation is implemented and experimented
with. In a confirmation stage new method become part daily activity or practice, replacing the former approach.

◻Varies innovations are there in clinical practice:

 Computer Assistance
 Wireless Technology
 Evidence Based Practice
 Procedure Manual
 Emergency Medical Services
 Job Description
 Management and Leadership
 Infection control
 Triage
 Ethics
 Forensic Nursing Speciality
 Community Based Nursing Role
 Nurse Educator
 Nurse Anaesthetist
 Tele Nursing
  Variations in Traditional Role

 Hospice Nurse
 Informatics nurse specialist
 Occupational health opportunity
 Quality manager
 Case manager
 Flight nurse
 Telephone triage nurse
 Travel nurse
 Nurse practitioner
 Certified nurse midwife
 Clinical nurse specialist
 Nurse administrator

◻Maintenance of health records

 Health security card
 Use of ROBOTS
 Reduce error and give certitude to the clinical planning process
 Nurse have immediate telephone contact with employees and with patient
 Direct and accurate communication between Nurse and Physician
 E.g.. In south Africa nurses uses their mobile phone to support people living with HIV/AIDS
 It is combination of professional expertise with available evidence to produce practice that lead a
positive outcome for client
◻Steps:
 Identify a knowledge need and formulate an answerable clinical question
 Locate the best available evidence
 Critically evaluate the evidence
 Integrate the evidence with patient’s unique biology, preferences and values
 evaluate
a. Procedure manual has become mandatory.
b. To disseminate information about emergency medical services, pre hospital care & emergency
department care, as well as to share ideas, problem solving & develop relationships among many
emergency departments within the country.
c. By doing this kind of networking will enhance pre hospital and emergency care in our country.
d. These are written according to specific practice area and level of responsibility.
e. Nurses are also given format of the standards for performance.

Nursing leaders and managers are exposed to different management principles relevant
to nursing practice. They are as follow :
o Management theory & leadership principles
o Time management
o Decision making & problem solving
o Teaching & performance strategies
o Identifying and achieving patient goals
 o Documentation as an instrument
o Performance evaluation
o Quality assurance
o To identify available resources which in the Hospital while maintaining good patient care.
o Infection control has become Paramount importance.
o Segregation of waste has become mandatory in all the hospitals.
o Every hospital need to have Hospital infection control committee & policy.
o Triage has become mandatory in the accident and emergency and thereby they are able
to prioritize the patients those who come to causality and are able to treat the sick and
vulnerable one as early as possible.
o This is to increase more awareness among nurses that they will be able to apply
ethics principles while caring for patients.
o It significantly increase their knowledge about ethics and improves patient satisfaction and
the litigation rates.
  Many hospitals encourages nurses to attend such conferences and
workshops.
o Forensic psychiatric nurse work with mentally ill offenders and with victims of crime
o It is the management of crime victims from trauma to trial
o People in communities in partnership with health care professionals will define the
health needs to be met and maintain control of strategies for meeting those needs
o They are the leaders and developers of nursing program of the future
o Diabetic nurse educator
o Asthma educator
o Nurse anesthetist is a registered nurse who got specialization in anesthesia and is
responsible for monitoring , administering anesthesia, to detect equipment fault
o Tele nursing is nursing practice that occurs through the utilization of telecommunication
and includes the use of nursing knowledge, skills and abilities; the application of critical
thinking and nursing judgment and provision of nursing direction or care in specific
client situation

 HOSPICE NURSE
The nurse works holistically with clients and family.

 INFORMATICS NURSE SPECIALIST Nursing specialty whose activities center

or management and processing of health care information

 OCCUPATIONAL HEALTH OPPORTUNITIES Nurse designs and implement a

program of health promotion and disease prevention for employees

 QUALITY MANAGER Quality management nurses research and describe findings and look
for opportunities to improve care

 CASE MANAGER: Case manager co-ordinate resources to achieve health care outcomes
based on quality, access and cost.
◻FLIGHT NURSE: Military and civilian flight nurse

 TELEPHONE TRIAGE NURSE The practice nurse interacts with clients on telephone
to assess needs, intervene and evaluate

◻TRAVEL NURSE Assignment usually for a minimum time. Extra allowance will be provided

 NURSE PRACTITIONER Nurse serves as a primary care provider and consultant

for individuals, families or communities

 CERTIFIED NURSE MIDWIFE Independent management of women’s health care.

should pass the national certification examination conducted.

 CLINICAL NURSE SPECIALIST Clinical expertise in a defined area of nursing practice for
a selected client population or clinical setting.eg- OT nurse, ICU nurse, Dialysis nurse,etc.

 NURSE ADMINISTRATOR Nurse administrator unites the leadership perspective of

professional nursing with various aspects of business and health administration

INNOVATION IN NURSING EDUCATION

Development of computer-assisted thinking: in order to enhance students active thinking, faculty
members at international University Of Health and Welfare developed the CAT( Computer Assisted
Thinking) program. The CAT program is different from CAI (Computer Assisted Instruction),which
mainly ask the users to choose correct answer.
There are two functions in the CAT programme:
 One is to keep the students action log each time they use programme
 The other is to serve as medical dictionary. An analysis comes that the students
demonstrated little skill in inferential thinking. Their observations were very
concrete. Its helps the students to develop their abstract thinking.
 Substantive innovation in nursing education:

Task group develop four strategies.

 Distribute an online survey that asks faculty to share their perceptions about the current
state of innovation in nursing education.
 Formulate specific questions, shared with deans ,directors and chairpersons of
nursing programmes, that are designed to thoughtful dialogue at any forum where
faculty engage in conversations about thinking and learning, such as faculty meetings
and retreats.
 Develop an electronic community where educators can share innovative practices and
engage in ongoing dialogue.
 The fourth strategy: The purpose of this to gather baseline data about how nurse
educators are beginning to frame ideas surrounding innovation and strategic reform in
nursing education.
  These strategies might be embedded in individual courses or used as an organizing framework
for the entire academic programme, such include:  Creative use of technology, including CD-
ROMs, personal digital assistants (PDAs), computer assisted instruction.  Use concept mapping
to promote higher level thinking skills.  Integrate educational theories, including learning styles,
multiple intelligences into our educational practices.  Use gaming in classroom and clinical
settings.  Employ integrative exercises and tests as teaching tools.

  All the ideas were recorded and the information was analysed
later.Such as:

◻HANDHELD COMPUTERS IN NURSING EDUCATION

 First personal digital assistant in 1996
 According to ANA (2001) all nurses need to use nursing informatics

◻VIDEOCONFERENCING AND WEB BASED CONFERENCING

 Connects students and educators across distance
 Connects diverse student groups
E-LEARNING
 Adaptation of different distance learning technologies
 Self directed, active learning
 Refocusing from educator to the subject

◻SERVICE-LEARNING
 Structured learning experience that combines community service with preparation and reflection
 Achieves a balance between service and learning objectiv

HIGH FIDELITY PATIENT SIMULATOR

 Help student practice decision making and problem solving skill and to develop human interaction
 Simulation is the third leg in the stool of education and science

◻TELE TEACHING
 Online model of education-learner directly interacts with tutor
 Learner oriented learning
 Promotes discovery learning MICRO TEACHING
 Miniature classroom teaching
 Small duration
 Paying full attention to a particular unit and skill
 Content reduced to one unit with a single concept

◻NURSING INFORMATICS
 Integrates nursing science, computer science and information science in identifying, collecting,
processing and managing data and information to support nursing practice, administration, education,
research
NURSING MOBILE LIBRARY
 Access to health care information for nurses working in remote area
 To reduce the gap between the desperate need for nursing information and its availability

 STAFF AND STUDENT RECRUITMENT

 Objective because examiner use a checklist for evaluating the trainee
 Structured, because every trainee sees the same problem and performs the same task in same
time frame
 Clinical, because the task are representative of those faced in real clinical situation

o This literature review focuses on substitution related innovation in nursing care of

patients in six industrialized countries.
o Difference between primary and secondary care oriented countries in the kind of
innovation implanted are discussed.
o Health care systems are increasingly being opposed with chronic patients who
need complex interventions tailored to their individual needs.
o However today’shealth care professionals,organizations and budgets are not
sufficiently prepared to provide this kind of care.as a results ,health care policy
reduce the health care cost and the improve the quality of care.
o Care is provided by health personnel at the lowest cost level, giving advance
nursing practice,hospital-at-home care and integrated care.eg…DOTS therapy

◻Examples:
 They used adhesive towel hooks and covered rubber bands to mark daily progress for each patient
in hallways.This information is documented in their charts for future references.
 This is an example of the wonderful care this team provides to our patients and to each other.

 There are many changes occurring in national Health Services at this time, not
just to economic and finding policies, but also at the very heart of nursing care
delivery.

◻USE OF COMPUTER
o Computerized physician order entry (CPOE)
o Clinical decision support system (CDSS)

ELECTRONIC MEDICAL RECORDS

 Affordable & integrated.
 For improving patient care.
 Powerful practice management system for practices of any size.
 Fast, flexible, Easy to use schedule for increasing productivity.
 Clinical desktop for improving enterprise work flow.
 Integrated, Internet – based solution that securely connects clinics and patients.
 Electronic document management system for eliminating paper charts.

◻ LEADERSHIP FOR CHANGE

  It is an action learning programme to develop nurses as effective leaders and managers

 OUTSOURCING
 outsourcing is subcontracting a process to a third party company
 it helps to provide core job-care giving
 transcription  electronic medical record
 medical billing and coding services
 entry level recruitment, security, house keeping, nursing assistance

o STAFFING STRUCTURE
 Benchmarking: Organization has varying levels of support in place at the unit level for the
nurse.eg.
Nursing unit that has dietary aides
 JCAHO: Surveys hospitals for the quality of care provided. sees for the right number of
competent staff to meet the need of patient
 Skill mix: It is the percentage of RN staff to other direct care staff, LPNs and unlicensed
assistive personnel

o PERSONAL MANAGEMENT
 Use of computer in recording staff files, biodata, accounts

The Role of NaTioNal NuRsiNg associaTioNs :

National Nursing Association (NNAs) represents fostering and supporting innovation. The
NNAs provide the leadership by:
 Promoting nursing is a profession with supporting innovative approaches to health care and
nurse’s innovative achievements.
 Supportive innovative cultures in the workplace, collaboration with high readiness for
change and innovative ideas can be openly discussed.


READINESS TO CHANGE
 Some individuals and organizations are more ready to affect changes than others.
 This depends often on the degree of felt security.
 In turn, it depends on the knowledge
 skill
 attitude
 self confidence
 tolerance to stress
 motivation of the individuals It also depends on the security to change. If there is
optimal feeling of security , then the acceptance of change will be possible. Change is
crucial.
Change is a must for progress.
 Providing a space for exchange and discussion of innovations
 Recognizing nurse innovators.
◻DISSEMINATION
Planned, formal communication of information about the innovation, through formal channels
 Every nurse can play a role in ensuring that innovations are effectively implemented
and adopted.
 Through their professional conduct and relationship with colleagues, nurses can play
in creating a working environment.
 In their leadership positions, nurses are well placed to disseminate information about
innovations.
 In leadership roles, is encouraged and supported among peers and more junior staff.
 Everyday nurse are developing new and innovative approaches to improve
healthcare services and healthcare outcome for local people.
 Florence Nightingale’s work provides a great example of leadership in innovation.
 She was also an innovator in the collection , tabulation, interpretation and
graphical display of descriptive statistics.
 In 1860, Florence Nightingale become the first woman to be elected as fellow of
the statistical society.
 Poor leadership
 Poor communication
 Poor knowledge management
 Poor participation in team
 Poor access to information
 Poor organization
 Poor empowerment
 Poor goal definition
 Poor monitoring of results

o INTRODUCTION OF INNOVATION IN NURSING

o DEFINITION OF INNOVATION IN NURSING
o SOURCES OF INNOVATION IN NURSING
o GOALS OF INNOVATION IN NURSING
o CHARACTERISTICS OF INNOVATION IN NURSING
o PRINCIPLES OF INNOVATION IN NURSING
o NEEDS OF INNOVATION IN NURSING
o INNOVATION IN NURSING
o ROLE OF NURSING ASSOCIATION
o NURSE IN WORKPLACE AS- INNOVATORS
o NURSE AS INNOVATORS – FLORENCE NIGHTINGALE
o REASON FOR FAILURE OF INNOVATION

After the end of this topic students will be able to know about the definition of
the innovation in nursing, sources of innovation, goals, principles, innovations in nursing care, role of
national nursing association, nurse in the workplace innovator, nurse as a innovator- Florence
nightingale, reason for failure if innovation.
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