PERT Program: Tip of the Month

PERT Program

Tip of the Month: February 2005

EVIDENCE-BASED PRACTICE

Evidence-based Practice: What is It?

Have you noticed your colleagues, facility administrators, or other therapists at your facility using the phrase "evidence-based practice" increasingly in the workplace? Have you come across journal articles on this topic? Maybe evidence-based practice has surfaced in discussions about facility policies and procedures. The purpose of this month's tip is to help you understand what evidence-based practice (EBP) is and learn how to incorporate EBP into the care provided at your facility.

EBP is defined as the "integration of best evidence with clinical experience and patient values. It involves obtaining research evidence and combining the evidence with clinical experiences, available resources, and patient preferences to determine the best care for the patient."¹ EBP began as an educational approach, called evidence-based medicine, to teaching Canadian medical students, and has developed over the last 30 years. Nursing adopted the approach, and initially described it as research utilization.²

EBP forms the basis for clinical practice guidelines, care pathways (also called critical pathways or clinical pathways), care protocols, and standards of care. This means that the care that is delivered in your facility is standardized (that is, consistent across residents, care providers, and units) and is based on research findings. When asked why nursing staff do things a certain way, it's no longer acceptable to answer, "Because that's the way we've always done it." Of course, we don't always have the research base to guide nursing practice. For many elements of nursing practice, the evidence is fairly weak. Nonetheless, we need to develop and implement nursing care plans that are based on the best information available. And, because nursing care is both an art and a science, the research base needs to guide but not dictate care. Thus, the aim of EBP isn't to provide "cookbook care." However, EBP is one vital component in clinical decision-making.

Integrating EBP into Nursing Care

EBP sounds like a good idea, but you may be wondering how to incorporate it into the care provided in your facility. Rosswurm and Larrabee³ developed a model for integrating EBP into nursing care. Their model proposes six steps:

Assess need for change in practice

Link problem with interventions and outcomes

Synthesize best evidence

Design a change in practice

Implement and evaluate the practice change

Integrate and maintain the practice change

As you can see, these steps are similar to quality improvement methods. The piece that is emphasized here is step 3: synthesizing best practice. To do this, you need to review the research on a particular topic.

For example, Let's say you know from resident and family satisfaction surveys, care conferences, and your MDS quality indicators that your facility could do better managing your residents' arthritis pain (step 1: assess a need for change in practice). Your goal is to decrease the percentage of residents with moderate to severe pain — in other words, you want to improve your pain quality indicators. The committee working on this project decides that several potentially effective nondrug pain management strategies aren't being used consistently. These include hot/cold applications, massage, and exercise (step 2: link problem with interventions and outcomes). You know from textbooks and clinical experience that these approaches should be effective, but you want an evidence-based policy and procedure for managing pain. The next step (step 3) is to evaluate and synthesize the evidence.

Evaluating the Evidence

To evaluate the research evidence for using these nondrug pain therapies, you might ask someone on your staff to do a library search or check various books and journals for information about these therapies. The process might take weeks, perhaps months, given limited staff time. In addition, the staff may not have the necessary research background to evaluate the evidence. Fortunately, help is available. The EBP movement has resulted in the creation of several resources to help clinicians interpret research studies and evaluate the evidence.

Groups that develop clinical practice guidelines and critical reviews on specific topics examine the evidence using a framework that is similar to the one below. This particular framework was used by the committee that wrote the American Geriatrics Society Clinical Practice Guideline on Managing Persistent Pain in Older Adults.⁴

Evaluating Strength of Evidence

Quality of evidence
I.	Strong evidence from at least one properly designed, randomized controlled trial (RCT) of appropriate size.
II.	Evidence from at least one well-designed trial without randomization, from cohort or case-controlled analytic studies, from multiple time series studies, or dramatic results in uncontrolled experiments.
III.	Evidence from respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
Strength of evidence
A.	Good evidence to support the use of a recommendation; clinicians "should do this all the time."
B.	Moderate evidence to support the use of a recommendation; clinicians "should do this most of the time."
C.	Poor evidence either to support or reject the use of a recommendation; clinicians "may or may not follow the recommendation."
D.	Moderate evidence against the use of a recommendation; clinicians "should not do this."
E.	Good evidence against the use of the recommendation, which is therefore "contraindicated."

A randomized controlled trial (RCT) is the "gold standard" of research. Drug companies and manufacturers of new medical and surgical devices must conduct RCTs before they can get FDA approval for their product. An RCT refers to a study in which one group of research subjects receives the treatment (for example, a particular drug or therapy) and the other group gets no treatment (also know as placebo, control group, or usual care) or some other treatment. The people participating in these studies don't get to choose the treatment they want. Instead, they are randomly assigned to a treatment or control group, usually through a specialized computer program. Randomization is often explained as being similar to flipping a coin to determine which treatment the person receives. Another feature of RCTs is that they usually involve large enough groups of subjects so that the researchers have a good chance of detecting differences in outcomes between the treatment and control groups. Without a sufficient sample size, one treatment may be better than another or superior to a placebo or control, but there isn't enough "statistical power" to detect those differences using standard statistical tests. For this reason, it's difficult to draw firm conclusions from studies involving small samples. Sometimes, researchers pool results from several smaller studies, which increases their confidence in drawing conclusions about the effectiveness of certain therapies; this technique of pooling studies is called meta-analysis.

When there haven't been any RCTs conducted for a particular therapy, researchers rely on "weaker" forms of evidence, such as those from nonrandomized trials or even simply the experience and opinions of expert clinicians.

If you're thinking that analyzing the evidence on your own seems daunting, the following are some resources for finding "ready-made" reviews and guidelines.

The National Guideline Clearinghouse (Available at http://www.guideline.gov/) is a free, web-based resource for locating evidence-based clinical practice guidelines. It is supported by several government agencies (including the Agency for Healthcare Research and Quality [AHRQ], and private organzations, inlcuding the American Medical Association [AMA] and America's Health Insurance Plans [AHIP]). The site has a search engine that allows you to look for your topics of interest. Abstracts are available on the site for no cost. Contact information for obtaining the full guideline also is available as well as guideline publication or release date, status of updates, and availability of companion documents such as staff and patient/family teaching tools.

The Gerontological Nursing Interventions Research Center (GNIRC) at the University of Iowa College of Nursing is funded to develop and disseminate evidence-based protocols on various topics in gerontology. Some of the evidence-based protocols available from their website (http://www.nursing.uiowa.edu/centers/gnirc/protocols.htm.) include:

Advance Directives with Quick Reference Guide and Consumer Information Sheet
Family Bereavement Support Before and After the Death of a Nursing Home Resident
Individualized Music with Quick Reference Guide and Consumer Information Sheet
Music Therapy Programming for Individuals with Alzheimer's Disease and Related Disorders
Management of Constipation with Consumer Information Sheet
Acute Pain Management in the Elderly: Clinical Practice Guideline and Course

For further information about the University of Iowa guidelines and protocols, contact them directly at (319) 384-4429, or by email at research-dissemination-core@uiowa.edu.

The Cochrane Database of Systematic Reviews (http://www.cochrane.org/) is the "grandfather" of online EBP reviews. It began in the late 1980s and publishes systematic reviews of many types of healthcare interventions. They summarize the literature but do not include practice guidelines. The site, however, is a great source of information, particularly because it covers a huge range of topics and is updated regularly. As of 2003, the database is no longer free, but is available at most university and medical center libraries.

The Oxford Center for Evidence-based Medicine, which is available at http://www.cebm.net/ contains educational materials about evidence-based practice. It doesn't include specific protocols but provides a nice overview of EBP.

The Next Step: Incorporating Research into Your Facility's Policies and Procedures

After you review the evidence, either by doing your own research or evaluating available reviews and guidelines, you need to incorporate the best evidence into your facility's standards of care, measure the outcomes, and if favorable, maintain the changes in practice (Steps 4, 5, and 6 of Rosswurm and Larrabee's³ model). Although an in-depth discussion of these steps is beyond the scope of this tip, you know that no change in practice is possible without staff education, systems-level changes (e.g., updating policies and chart forms), and accountability. It's a lot of work, but the bottom line is better care of your residents as documented in improved outcomes. And that's the essence of EBP.

This month's tip was prepared by Mary Ersek, PhD, RN. If you have questions or comments about this article, you can reach us via the PERT Program contact page.

References

Sigma Theta Tau International: Position Statement on Evidence-based Nursing. 2003. Available at: http://www.nursingsociety.org/research/main.html#ebp (Accessed Feb 12, 2005)
Hospice and Palliative Nurses Association: Position Statement on Evidence-Based Practice. 2004. Available at: http://www.hpna.org/pdf/Evidenced_Based_Practice_Position_Statement_PDF.pdf. (Accessed Feb 8, 2005)
Rosswurm MA, Larrabee JH. Model for change to evidence-based practice. Image: Journal of Nursing Scholarship. 1999;31:317-22.
American Geriatrics Society: The management of persistent pain in older persons. (Clinical Practice Guideline), 2002. Available at: http://www.americangeriatrics.org/products/positionpapers/persistent_pain_guide.shtml. (Accessed Feb 12, 2005).