EBP and its implications in Nursing.

1. OPPORTUNITIES FOR EBP
IN OPTIMIZING NURSING
AND HEALTH CARE
Dr Rajesh G Konnur
Professor
Kurji Hospital CON
Patna Bihar

2. CONCEPT OF EBP:
• The origin of EBP can be traced back to Florence Nightingale –
wrote about the importance of Statistics in her book “Notes on
Nursing”. She believed that patient morbidity and mortality can be
predicted only by comparison with other parameters.
• Prof . Archibald Cochrane, a British epidemiologist is considered
as the Father of EBP . His book “Effectiveness & Efficiency :
Random Reflections on Health Services (1972) . He advocated
RCT and other types of research to be used in patient care.
• EBP isn’t about developing new knowledge or validating existing
knowledge. It’s about translating the evidence & apply it to clinical
decision making.

3. SCIENTIFIC EVIDENCE IN
NURSING
• Oxford Dictionary (2015) defines the ‘evidence’ as “The
available body of facts or information indicating , whether a
belief or proposition is true or valid”.
In nursing science, the evidence – based practice incorporates
the best available scientific evidence rather than traditional
interventions. It not only answers the clinical questions through
research using critical appraisal but also includes a nurse’s
own clinical expertise & a patient’s values & preferences to
bring the better out-comes for the patient .(Melnyle Fineout –
Overholt , 2011).

4. DEFINITIONS AND MEANING OF
EBP:
• Sackett D et.al; (2000) defines EBP as “the integration of the best
research evidence with clinical expertise and patient values”.
• Duke University Medical Center (2012) defines EBP as the ‘
integration of clinical expertise , patient values and the best research
evidence into the decision-making process for patient care.
• Melnke & Fineout-Overholt (2015) defines EBP is a paradigm & life
long problem-solving approach to clinical decision – making that
involves the conscientious use of the best available evidence (including
a systematic search for critical appraisal of the most relevant evidence
to answer a clinical question) with one’s own clinical expertise and
patient values & preference to improve outcomes for individuals,
groups, communities and systems.
• EBP in nursing is a way of providing care that is guided by the
integration of the best available scientific knowledge with nsg expertise.
This approach requires nurses to critically assess relevant scientific
data or research evidence & to implement high quality interventions for
their nsg practice.

5. EVIDENCE – BASED CLINICAL DECISION MAKING INCORPORATES THE
CONSIDERATION OF THE PATIENT’S CLINICAL STATE , THE CLINICAL
SETTING & CLINICAL CIRCUMSTANCES.

6. COMPONENTS OF EBNP

7. OBJECTIVES OF EBP:
• The primary goal of EBN is to make practice less subjective &
increase the accountability that provides a stronger foundation
to make clinical decision.
• To replace the normal practice with outcome research
oriented.
• To induce accountability and objectivity in the health care
system.
• To identify best practices.
• Advancing Quality care, increase patient satisfaction , cost
efficient and high quality care.
• Achieve excellence in health delivery.
• Reduces the variations in nursing care and assist with efficient
& effective decision making.

8. TOOLS TO PRACTICE EBN
• EBP involves innovation in terms of finding & translating the best
evidence into clinical practice.
• To practice EBN , the stake holders of health care need the skills
and sound knowledge.
Five Essential Steps:
I) Convert information needs into answerable questions i.e. by
asking a focused question.
II) Search for the best available evidence.
III) Appraise evidence critically.
IV) Changing practice in the light of evidence.
V) Evaluation of performance.

9. STEPS IN EBP

10. • Step I : Asking a focused question.
Before seeking the best evidence , convert the information into
a tightly focused question ? Ex. “Is hot application effective for
relief of pain in Otitis media ? We need to convert this into the
answerable question : Is hot application reduce the duration of
pain symptoms when prescribed to children with Otitis Media ?
The PICO approach can be used as a framework to focus the
question. It contains four components:

11. CONT..
• Patient or Population (children under 5 Yrs).
• Intervention (Hot application).
• Comparison intervention (Placebo).
• Outcome (duration of specific symptoms or rate of
complications).
• Step II: Tracking down the evidence
Step II includes the search for best latest evidence & simple
ways to access and use it. Search research evidence in a
systematic way by using authenticated publications & journals.

12. LEVELS OF EVIDENCE:
(SCOTTISH INTERCOLLEGIATE
NETWORK)
• 1++ High quality meta-analysis , systematic reviews of RCTs or
RCTs with a very low risk of bias.
• 1+ Well conducted meta-analyses, systematic reviews or RCTs
with a low risk of bias.
• 1- Meta analysis , systematic reviews or RCTs with a high risk of
bias.
• 2++ High quality systematic reviews or RCTs with a high risk of
bias.
• 2- Case – control or cohort studies with a high risk of confounding
or bias and a significant risk that the relationship is not Causal.
• 3 Non – analytic studies , e.g. case reports , case – series.
• 4. Expert opinion

13. Hierarchy of Evidence

14. STEP III : APPRAISING THE EVIDENCE
• To determine whether we should act on the results of the
studies found in the search, we must be able critically to
appraise a range of study types. Apply epidemiological
concepts and decide the results are valid enough to change our
practice. In order to do this, a series of questions about the
study which include:
• Did the research ask a clearly focused question and carry out
the right sort of study to answer it ?
• Were the study methods robust ?

15. CONTD…
• Do the conclusions made match of the study ? (Might the
results have been due to chance ? Were they ‘big’ enough to
make a real difference?
• Can we use these results in our practice ?
• Use of checklists helps the findings to go for generalization in
our own population.

16. STEP IV : CHANGING PRACTICE IN LIGHT OF
EVIDENCE.
• Following through on the results of your appraisal
of new evidence – implementation is very difficult
task. Some change can be self- initiated and
other circumstances requires other health care
providers including top level human resources.

17. STEP V : EVALUATING THE EFFECTS OF
CHANGES IN PRACTICE .
• Effect of changes can be evaluated by the involvement
of quality improvement project / clinical or Nursing
audit. This depends on how frequently the intervention
or activity under scrutiny is performed , a review of
practice can be undertaken throughout the change
using statistical processes.

18. MODELS OF E B P
• Several models have contributed conceptually to the
implementation of EBNP.
I) Stetler Model (Stetler 2001)
II) Iowa Model (Titler 2001)
III) John Hopkins EBP Model (2007)
IV) ACE Star Model (Stevens 2004)
V) ARCC Model (1999)

19. THE STETLER MODEL OF EBNP (STETLER
2001)
• The Stetler model of research utilization helps practitioners assess how
research findings and other relevant evidence can be applied in clinical
practice. 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 model links research use, as a first step, with evidence-
informed practice.
• The Stetler model provides the relationship between research use and
evidence-informed practice.

20. • It has five steps.
• 1)

21. I) Preparation: Identification of problem / issue & validation of
the problem with evidence.
II) Validation: - Critique & synthesis of the evidence.
- Rate the level & the quality of evidence.
- Eliminate non-credible sources.
III) Comparative Evaluation/ Decision-making :
- Determine whether it is desirable to apply the summarized
findings in practice. Make a decision about what can be
used. Own research can be conducted if findings can’t be
used.

22. Translation / Application: Decide on what level of application
(individual, group ,organization) .
- Develop proposal for practice change.
- Create methods for formal dissemination & planned change.
Consider a pilot project.
V) Evaluation: Can be formal or informal. Consider costs . Include
both formative and summative evaluations of outcomes.
- Evaluate the plan in terms of goals.

23. IOWA MODEL OF EBP
• Developed by Marita G Titler , Dept of Nursing Services , Univ
of Iowa (2001) USA.
• Introduced to nurses with guidance while making decisions
about day-to-day practice.
• The Iowa model encourages clinicians to identify ‘problem’ or
‘triggers’ & solution through 7 steps.

24. 1. Select Topic.
2. Form Research Team
3. Retrieve & develop evidence
4. Grade the evidence
5. Develop an EBP to address the topic
6. Implement the EBP
7. Evaluate Outcomes

26. JOHN HOPKIN’S EBNP MODEL
• Problem solving approach to clinical decision-making.
• Main objective of JHEBPN is to meet the needs of the
clinical nurse.
• Three step process called PET : Practice Question ,
Evidence and Translation.
• The goal of the model is to ensure that the latest research
findings and best practices are quickly & appropriately
incorporated into client care.
• The model includes 3 domains of professional nursing : Nsg
Practice, Education and Research.

28. 3 Phases of EBP “PET” process. i.e. Practice question,
Evidence, & Translation.
- The first phase of ‘P’ in PET is the practice question &
involves 5 steps.
Practice question Evidence Translation
1. Identify a practice question through the use of PICO format
to identify key search terms for the evidence search.
P- Patient, Population or Problem
I – Intervention (Rx, Medications, education & diagnostic
tests)
C- Comparison with other treatments
O- Outcome

29. 2. Recruit an Interpersonal Team.
3. Define the scope of problem including agreement with the team on the
patient population , staff involved & key stakeholders.
4. Assign a team leader.
5. Schedule team meetings.
The II Phase , or ‘E’ in PET is evidence & involves another 5 steps.
a. Identify and Think – ‘terms’ for the evidence search – brainstorm-
search for evidence.
b. Conduct Search for evidence.
c. Critique the evidence by rating the strength & quality of evidence.
d. Summarize the evidence.
e. Determine the overall strength of the evidence.

30. • The III Phase / ‘T’ in PET ‘Translation’ includes 8 steps.
1.Determine the appropriateness & feasibility of translating
recommendations into the specific practice setting.
2. Create an action plan.
3. Implement the changes.
4. Evaluate the outcomes.
5. Report the results of the preliminary evaluation to the decision
makers.
6. Secure support from decision makers for implementation.
7. Identify the next steps.
8. Communicate the findings.

31. ACE STAR MODEL OF EBP
• Cycle of Knowledge transformation.
• It is a model for understanding the cycles, nature &
characteristics of knowledge that are utilized in EBP.
• It places nursing’s previous scientific work within the context of
EBP.
• The Star Model depicts various forms of knowledge in a relative
sequence, as research evidence is combined with other
knowledge & integrated into practice.

32. FIVE STAGES OF KNOWLEDGE TRANSFORMATION

33. Stage I: Knowledge Discovery :
- Knowledge generating stage.
- New knowledge is discovered through the research methodologies &
scientific inquiry.
Stage II: Evidence Synthesis:
- Evidence is synthesized by research knowledge.
- Use of various research methodologies , meta – analysis , ROL, &
scientific review.

34. Stage III: Translation:
- The transformation of evidence is translated into practice. Research
evidence is recommended in the form of clinical practice guidelines
(CPGs) , Care Standards, Clinical Pathways, Protocols & algorithms.
Stage IV: Integration :
- Knowledge of evidence is implemented through innovations.
Stage V : Evaluation:
- Evaluation of the impact of EBP on patient health outcomes , provider
and patient satisfaction ; efficacy , efficiency , economic analysis and
health status impact.
- As new knowledge is transformed through 5 stages, the final outcome is
evidence- based quality improvement of health care.

35. ARCC MODEL OF EBP
• ARCC – Advancing Research & Clinical Practice Through Close
Collaboration.
• Bernadette Melnyk -1999.
• Constructed as a strategic planning initiative.
• Constructs of ARCC model were based off Ellen Fineout
Overholt’s research on the Control Theory and Surveys.
• This model integrates control and cognitive behavioral theories
& works to build a cadre of EBP mentors to advance EBP in a
system.
• This model is for improving Quality of Care and Patient
Outcomes.
• Used to achieve “high reliability” organization.

36. ASSUMPTIONS
1) Both the barriers to & facilitators of EBP exist for individuals and
within health care systems.
2) Barriers to EBP must be removed or mitigated & facilitators put in
place in order for individuals & healthcare systems to implement
EBP as a standard of care.
3) For clinicians to change their practices to be evidence based , both
their beliefs about the value EBP & their confidence in their ability
to implement it must be strengthened .
4) An EBP culture that includes EBP mentors is necessary in order to
advance & sustain EBP in individuals and healthcare systems.

38. • Main theme : Understand organizational culture and readiness
to change; identify strengths & barriers for the implementation
of EBP in the organization, identify the professionals
specialized in the organization to assist in the implementation
of the EBP with the assistance team in the clinical units/ Depts.
; implement the evidence in the practice and evaluate the
results.
• Application of ARCC model of EBP results in higher job
satisfaction , lower turnover rate & better patient outcomes.

39. OPPORTUNITIES FOR EBP IN
NSG PRACTICE/HEALTH CARE
A) Clinical Care/ Nursing Service:
- EBP contributes to improve & maintain health care quality.
- Provides better information to practioner.
- Enhances confidence in decision making .
- Provides client focused care.
- Enable consistency of care.
- Better patient outcome.
- Contributes for Quality Assurance & QM.

40. NURSING EDUCATION
• Induces the novice nurses to become critical thinkers &
problem solvers.
• The resources of EBP offers students to connect their
emerging competencies with clinical needs.
• Applies to build best practice in nsg education.
• Training in EBP for educators aids for future development of
skills in Tg-Lg process.
• After passing out of the course , students will see great
enthusiasm for employing in today’s clinical environments.
• Bridges solidarity & cooperation b/w nsg education and
service.
• Enhances professional status & research knowledge.
• Potential of ability on clinical decision making .
• Provides direction for future development.

41. NURSING ADMINISTRATION
• EBP helps to reduce the gap b/w theory & practice.
• Implements for future of health care delivery & administration.
• EBP points out at policy making & contributes to growth of
profession.
• Clinical leaders have unprecedented opportunity to step forward to
transform healthcare from a systems perspective , focusing on EBP
for clinical effectiveness, patient engagement and patient safety.

42. NURSING RESEARCH
• EBP peeps into the nascent fields of health care research to
understand how to increase effectiveness, efficiency , safety &
timeliness of healthcare. , how to improve HCDS & how to spur
performance improvement . These emerging fields include
translational & improvement science, implementation research
and health care delivery systems science.
• EBP helps for Inter and Multidisciplinary research .

43. BARRIERS TO EBP
- Insufficient time on the job to implement new ideas.
- Limited research usage in practice (bec’z nurses rely more
on their experience rather than research evidence).
- After education nurses spend less / no time to
research and its evaluation.
- Lack of interest and research skills.
- Lazy attitude of nurse leaders and managers.
- Lack of resources (library, funds, HRs….)
- Organizational policy and culture.
- Little benefit for self.
- Unwillingness to change / try new ideas.

44. IMPLEMENTATION STRATEGIES FOR EBP
Focus on nurses “continuous Skills” development through building
research skills, providing necessary resources , access to internet
and apps & research engines can be helpful.
• Use of research & EBP as a value in recruitment.
• Continuous support, identification & encouraging early research &
EBP , adopters & clinical nurse specialists as skilled role models.
• Framing a ‘Research Cell’ in clinical area and exhibiting research
articles , posters , findings & holding research discussions.

45. SUMMARY / CONCLUSION
• For redesigning health care , cost-effective delivery , safe &
efficient care, EBP plays a credible role. No single model
suits for every set-up. Elective model application renders the
benefits to health care stakeholders.
• A sound theory of clinical knowledge & skillful practice helps
to render EBP in clinical set up and as well as in nsg
education, administration and in research.

46. REFERENCES
1. Psychiatric Mental health Nursing – Mary C Townsend .2014.
2. E B P in Nursing – Peter Ellis.
3.Advanced Nursing Practice- Rajesh Konnur
4. Research for Advanced Practice Nurses – Magdalena Mateo.
5. Best Practices – EBN Procedures. Lippincott Williams &
Welkin's .
6. Evidence Based Geriatric Nursing Protocols for Best
Practice . –Marie Boltz 2011.

47. Thank You