Second Step in Implementation of Evidencebased Practice Includes Systemic Review

1: Systematic Review as a Basis for Evidence-Based Practice

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DOI:

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Abstruse

Objectives

At the end of this chapter, the reader volition be able to:

• Differentiate betwixt expert-driven health care and bear witness-based health care (EBHC)

• Define the components of EBHC

• Discern the process of EBHC and the value of systematic reviews (SRs) as a quality source of evidence

• Ascertain filtered show and unfiltered evidence

Affiliate Highlights

• Loftier-quality evidence provides a solid foundation for clinical practice and health care decisions.

• The testify-based care prototype calls for the integration of best inquiry evidence along with clinical expertise and the opinions and values of patients and their families as a component in clinical decision making.

• The evidence-based procedure includes asking a question, acquiring evidence to support the question, appraising the evidence, applying the evidence to a patient or grouping, acting to put the evidence to use for patients/groups, and assessing whether the show leads to desired patient outcomes.

• SRs are at the top of the prove hierarchy, as they provide a summary of research findings that are available on a particular topic or clinical question.

• As they use an explicit, rigorous process to comprehensively identify, critically appraise, and synthesize relevant studies, findings from an SR have greater validity than those from a single research study.

The shift in health care from skilful-driven practice to EBHC is growing. Expert-driven do is a hierarchical arrangement grounded in skilful stance and clinical skills. The rituals and traditions of this paradigm (see Box ane.ane) view the experienced practitioner every bit the source of noesis and, as such, expert opinion and intuition, tradition, experience, and pathophysiologic rationale are the principal influencers of exercise and clinical conclusion making (Swanson, Schmitz, & Chung, 2010). EBHC, on the other mitt, is grounded in the premise that although practitioners may exist skillful in the art of their discipline, the explosion of scientific information, the demands of a more educated health care consumer, and spiraling health care costs have created a situation where one's cognition of the scientific discipline of the subject is often either not electric current or non enough.

BOX 1.one

WHAT IS A PARADIGM?

A paradigm is a traditional way of thinking, a traditional theory or model that guides behavior or practice. Paradigms are non static, simply they change and suit over time. On occasion, meaning agents of change drive new ways of thinking, which are not pocket-size changes but stand for major shifts in perception, knowledge, and ways of behaving. The coexistence of the old and the new prototype creates tension if the paradigms are incommensurable.

Acknowledging the lag between discovery and actual practice and the significant variation in care and care outcomes, Iain Chalmers, editor of the James Lind Library, wrote, "Although scientific discipline is cumulative, scientists rarely cumulate scientifically" (as cited in Swanson et al., 2010, p. 287). The show-based paradigm calls for the integration of the best inquiry bear witness along with clinical expertise and the opinions and values of patients and their families as a component in clinical decision making. The aim of EBHC is to meliorate patient outcomes by using a systematic approach to identifying and promoting practices that work and past eliminating those that are ineffective or harmful (Akobeng, 2005).

This chapter presents an overview of the emergence of EBHC as the driving epitome of health care today, highlighting the new cognition and skill that are required to be successful. Through this overview, the central office of systematic reviews (SRs) every bit a valuable source of testify that contributes to clinical conclusion making will be apparent.

Prove-Based Health Care

EBHC is the utilise of current best evidence in making decisions well-nigh the intendance of individual patients or the delivery of health services. Best evidence is current, upwardly to appointment, relevant, valid, and grounded in inquiry near the effects of a treatment, the potential for harm from exposure to particular agents, the accuracy of diagnostic tests, and the predictive power of prognostic factors (Cochrane, 1972). Although Archie Cochrane wrote this definition almost 50 years agone, it remains relevant to the practise of EBHC. Point-of-care clinicians and other decision makers are in demand of authentic, high-quality information to make important decisions.

Another afterward definition of prove-based medicine provided by Dr. David Sackett and colleagues from McMaster Medical School involved the conscientious, explicit, and judicious use of current all-time evidence in making decisions nearly the care of an private or groups of patients (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). This definition was later on expanded with clarifications that best prove must be integrated with private clinical expertise, patient/family preferences and values, and the clinical context, and it was referred to as show-based practice (EBP). EBP reflects a trouble-solving arroyo to the commitment of wellness care that crosses all disciplines (Melnyk, Fineout-Overholt, Stilwell, & Williamson, 2009). Currently, these processes are referred to as EBHC and include attending to quality outcomes and price of care. Effigy i.1 illustrates that EBHC is a dynamic process that combines the four components of clinical conclusion making with the aim of improving patient outcomes. Understanding the components of the process and the constant interaction of the components is of import. There is no rule for what is the most important; rather, the weight given to each component varies according to the clinical situation (Melnyk et al., 2009), every bit evidence, expertise, context, preferences, and values inform each other in positive and different ways (Kitson, 2002).

FIGURE ane.ane

Components of evidence-based health care.

Components of EBHC

Evidence

Use of the prove-based paradigm emphasizes the need for practitioners to make clinical decisions that are grounded in quality information. Quality or best evidence refers to timely, useful evidence from research-based literature that is both clinically important and cost-effective (Gilliam & Siriwardena, 2014). Research is the written report of phenomena to reach new or expanded findings. It is made upwards of data, which are pieces of private information, sometimes in the form of statistics or patient-reported preferences. Best enquiry evidence for use in clinical decision making uses both research studies and data to depict conclusions.

New skills are needed for this to happen. Practitioners need skills to search for best evidence, as research evidence is constantly evolving. Clinicians practicing from an show-based epitome need to know what are the best research designs to reply a specific clinical question equally well as to possess the skills to critically assess published research for its rigor and trustworthiness. Awareness of the strength and the rigor of the actual study guides determination making as to whether the evidence should exist incorporated into the clinical plan.

And so what counts as best evidence? Definitions of best evidence have been debated, but near agree that show is extremely important for researchers, practitioners, and policy makers who are tasked with making decisions (Institute of Medicine [IOM], 2001). Although research evidence, particularly in the form of randomized controlled trials (RCTs), is widely believed to be the best evidence, in that location are two other types of evidence worth noting:

• Experiential evidence is based on the clinical do insight, skill, and expertise of the health intendance provider and is ofttimes referred to equally intuitive, craft, or tacit knowledge.

• Contextual testify is based on factors that are specific to a particular community or setting and helps make up one's mind the feasibility of a specific intervention.

Published manufactures may reverberate the predispositions of their authors, journals tend to take articles with only positive findings (known as publication bias), and books appointment speedily; hence, there is the need for an SR that looks at all findings on a item topic and incorporates them to the best extent possible into enquiry and experiential and contextual evidence. SRs at the apex of the evidentiary hierarchy can be interventional, observational, or qualitative, that is, giving context and pregnant to the topic.

Research Evidence

Enquiry is a systematic inquiry into a question for which the respond is non completely known. Enquiry findings aggrandize what is known well-nigh a topic, add new contributions to that agreement, or test the theory underlying the topic. The findings of a inquiry study are but as reliable as the sources used to assemble and analyze the data. Best research evidence includes empirical prove from RCTs, descriptive and qualitative research; equally well as utilise of information from instance reports, scientific principles, and expert stance.

Clinical Expertise

Best testify past itself, however, is insufficient to directly practice. Clinical expertise is also a necessary element. Clinical expertise is the "quality of an individual professional who practices methodologically and is not misled by unfound pathophysiological inferences" (Timmermans & Berg, 2003, p. 89). Knowledge gained through clinical practice is too a necessary component. This knowledge is referred to as practical knowledge, professional-craft knowledge, or practical "know how" (Rycroft-Malone et al., 2004) and includes the proficiency and judgment acquired through clinical feel and clinical exercise (Sackett, 1998). A practitioner uses his or her professional-craft knowledge, the proficiency and judgment acquired through clinical experience, to determine whether best testify applies to a patient or a group and whether the evidence should be integrated into the clinical decision. This tacit, unspoken knowledge is used to assess the course and effects of implemented interventions. By using clinical skills and by feel, the expert clinician quickly identifies "each patient'southward unique health country and diagnosis, their individual risks and benefits of potential interventions, and their personal circumstances and expectations" (Straus et al., 2000, p. 1).

Once new practices based on best evidence are implemented, the clinician assesses the course and effects of the intervention and uses his or her clinical acumen to make necessary adjustments (Shah & Chung, 2009). This dynamic rest between show and expertise is captured by Sackett and colleagues as they describe the dangers in do guided only by clinical expertise or only by all-time bear witness: Without clinical expertise, do risks condign tyrannized past evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. Without current best bear witness, practice risks becoming rapidly out of date, to the detriment of patients (Sackett et al., 1996). As this text focuses on the SR process, information technology will consequently emphasize all-time practice using empirical enquiry; however, it is essential to recognize that the tacit knowledge of clinical expertise is a valuable component of EBP.

Patient/Family Preferences and Values

It is also insufficient to merely blend expertise and testify, for at the heart of EBHC is the patient. Practicing from an bear witness-based perspective requires the clinician to recognize the uniqueness of the patient and family and to value the client as a co–conclusion maker in selection of interventions or approaches for his or her improved wellness. Best evidence on treatments should be adapted for congruence with the distinct needs of the patient and family unit. Needs are influenced by many factors, including patient values and beliefs, and the social, emotional, and physical environment. Making the patient central to the decision-making process involves:

1. Developing a relationship with the patient

2. Listening to the patient'southward expectations, concerns, and beliefs

3. Learning about the patient'southward experiences in managing his or her illness or treatment regimen

4. Discussing with the patient both the bear witness and one's clinical assessment/judgment regarding that evidence

5. Explicitly incorporating patient preferences into clinical decision making (Rycroft-Malone et al., 2004)

When patients recollect about handling options, not merely do they consider recommendations from their health intendance providers simply also whether they are willing to have the benefits and harms associated with these options (Heidenreich, 2011). Treatment pick discussions are of import in helping patients understand their care plans and in allowing them to participate in their own care. These discussions should be a shared partnership among the clinician, patient, and family in which each person works collaboratively to develop a care programme based on the patient's values, clinical circumstances, and available handling options (Rex, Vocal, & Quill, 2013). This is an important consideration in working from an EBHC paradigm, as many patients have reported being uncomfortable receiving expert-endorsed recommendations (Anderson, Cimino, & Lo, 2013).

Regulatory bodies as well are increasingly seeking input from patients about their opinions of the meaningfulness and importance of wellness outcomes as role of a process to enhance patient centeredness in the regulatory procedure. This input spans all stages of a research study from the generation of a focused clinical question to the interpretation of findings and decisions on how and in what form dissemination of findings will occur. In fact, the Patient-Centered Outcomes Research Institute (PCORI) is mandated to ameliorate the quality and relevance of evidence bachelor to help patients, caregivers, clinicians, employers, insurers, and policy makers to make informed health decisions (world wide web.pcori.org). To see this mandate, PCORI involves patients, caregivers, clinicians, and other wellness intendance stakeholders, including payers and researchers, throughout the process.

Clinical Context

Context is whatever circumstance in which something happens. McCormack et al. (2002) use the term context to refer to the physical setting in which patient services are provided. Clinical care takes place within many differing contexts that dictate their nature and the testify available to aid in decision making (Dieppe, Rafferty, & Kitson, 2002). Sources of testify in the clinical context may include: audit and functioning data, patient stories and narratives, knowledge about the culture of the organization and the individuals inside it, social and professional person networks, information from stakeholder evaluation, and local and national policies (Rycroft-Malone et al., 2004). These sources of data tin can be used to inform practice decisions, do changes, and inform about the need for research-based prove.

EBHC Process

Figure 1.2 links the procedure to the "A" Steps model adult by Sackett, Straus, Richardson, Rosenberg, and Haynes (2000) and by Straus, Richardson, Glasziou, and Haynes (2000). The process and its components (enquire, learn, assess, apply, human action, and assess) are divers here and are explained in depth.

Practicing from an testify-based prototype calls for clinicians to prefer a mindset of informed skepticism. Instead of only accepting tradition, hierarchy, and expert opinion, the EBHC clinician questions "why" things are being done as they are, "whether" at that place is a better way to do them, and "what" the evidence suggests may be best in the specific clinical situation (Salmond, 2007). This clinical inquiry stance along with concerns generated from bear witness at the practice level (clinical expertise, patient values, and contextual problems) leads the clinician to recognize the need to ask for farther data. A lifelong, self-directed learning process of clinical questioning, searching for and appraising information, and incorporating relevant data into daily practise is central to EBHC (Akobeng, 2005).

FIGURE 1.two

Evidence-based wellness care process: The "A" Steps Model.

Enquire

There is both an art and a science to asking clinical questions to efficiently obtain needed information for informed clinical decisions regarding patients. Information needs from practice are converted into focused, structured, and searchable questions that are relevant to the clinical outcome by using the PICO (population, intervention, comparison, outcome) mnemonic or similar approaches that are described in farther detail in Chapter 3, "Organizing and Planning a Systematic Review," and Chapter four, "Developing Clinical Questions for Systematic Review." PICO provides a systematic style to identify the components of the clinical issue and structures the question in a manner that will guide the search for testify (Stillwell, Fineout-Overholt, Melnyk, & Williamson, 2010). These four components of a expert clinical question can exist thought of equally data fields that will help in the search for evidence and answers. How the question is framed or whether the question volition include all components of PICO, such as a "C" or a comparison, will depend on the type of question. For case, a PICO for a prognosis question type usually has no "C" or comparison.

Larn

Afterwards the question is framed, the next pace in the process is to learn the evidence. Practitioners should first search sites where enquiry has already been critically reviewed and summarized and deemed of sufficient quality to guide clinical practice. These resources are sometimes referred to as filtered resources. Filtered resources feature the latest evidence-based literature on a clinical question. Filtered resources containing EBP information can exist part of clinical data systems (CISs) at a health care facility for utilize by health professionals, which collect and synthesize show from a multifariousness of sources, and typically offer some interpretation and appraisal. Other sources with filtered information include websites such as Best Evidence and Bandolier, journals such equally Evidence-Based Nursing, and repositories in institutions and organizations where one can find critically appraised topics (CATs) or summaries of the best available evidence, all of which provide readily accessible evidence. One skillful site for CATs is the Centre for Evidence Medicine in Toronto, which is available through the Knowledge Translation (KT) Clearinghouse website that is funded by the Canadian Institute of Health Research (ktclearinghouse.ca/cebm/resources/web). Bold one is drawing from a trustworthy source, the value of this type of evidence is that the work of appraisal has been done and the practitioner can move directly toward examining applicability in the context and congruency with patient preference.

In the absence of data from sites that accept pre-appraised the research, searches using individual bibliographic databases are the next activity. To begin, start at the top of the testify hierarchy, searching for SRs and evidence-based guidelines—both of which are preprocessed evidence, thus making it easier for practitioners to utilise. Clinical guidelines generally promulgated by professional groups, regime agencies, and local practices gather, appraise, and combine evidence of varying levels. They include practice recommendations that are designed to assist the practitioner in making patient decisions. Sources for evidence-based clinical guidelines include the National Guideline Clearinghouse (NGC; www.guideline.gov), the Agency for Healthcare Research and Quality (AHRQ; world wide web.ahrq.gov), and the U.S. Preventive Services Task Force recommendations (USPTF; http://www.ahrq.gov/professionals/prevention-chronic-care/decision/uspstf/index.html).

SRs are searched for offset, because they provide a summary of research findings that are bachelor on a particular topic or clinical question. Using an explicit, rigorous procedure to comprehensively identify, critically appraise, and synthesize relevant studies, findings from a systematic review take greater validity than a single enquiry report. The search for systematic reviews should initially concentrate on sites that focus on this type of evidence. This includes Cochrane Collaboration (www.cochrane.org), Campbell Collaboration (world wide web.campbellcollaboration.org), and Joanna Briggs Institute (JBI, www.joannabriggs.edu.au). One tin also search for systematic reviews on PubMed by using the search features PubMed Clinical Queries or Special Queries.

If systematic reviews are not nowadays on the topic of interest/clinical question, retrieval of private studies is the next source. Both systematic reviews and individual studies will need to be critically appraised by the practitioner. In searching, the components of the PICO question can be used as search terms. One can further limit the search by stipulating the preferred research design for the question being asked. Knowing the preferred enquiry design (the strongest evidence), i can begin the search past stipulating the research approach, thus narrowing to the "all-time" available evidence.

Appraise

One time relevant prove has been acquired, the next step in ensuring that "best" show informs practice is to subject each study to scrutiny, to appraise the retrieved systematic reviews or individual studies for quality and conviction in the trustworthiness of the data and their clinical usefulness. The new paradigm of EBHC requires developing the skill set to examine a research study for its fit to clinical practice. The appraisement process differs depending on the blazon of enquiry design used. Both primary studies and secondary reviews must be appraised for their quality. More information nearly critical appraisal is presented in Chapter 7, "Critical Appraisal," too as in the specific chapters on an SR of observational, experimental, qualitative, and economic evidence.

Apply

After high-quality studies have been selected from the appraisal process, the next step is to decide whether in that location is applicability to ane'south own context and patient population. The decision to apply results in existent-time clinical practice is based on the magnitude of the findings, their applicability to different populations, and the strength of the evidence.

In because the magnitude of the findings or the clinical significance, the practitioner must ask, "Is the size of the benefit (event size) likely to aid my patient?" This requires understanding between the patient and the practitioner on the outcome that is important to the patient. The practitioner can provide the testify to the patient every bit to the likelihood of benefit or harm that is specific to the intervention, comparison interventions, and the desired outcome in plain linguistic communication so that the patient can make an informed decision.

In research that examines whether interventions work or not, such as RCTs, the intervention is often tested in a advisedly defined population nether tightly controlled situations that do non simulate real-world settings. The practitioner must make up one's mind whether the settings and patient populations from the studies or the SR are like to their ain routine practice and whether the interventions used can exist duplicated and are acceptable to patients. Thus, in the application phase, ane is questioning the ability to apply the findings to one'south own context and 1'due south ain patient population. Information technology is important to recognize that although the data may be objective, the meanings have intrinsically subjective values that are dependent on the audience and may differ amidst nurses, physicians, patients, and administrators (Manchikanti, Boswell, & Giordano, 2007).

A last factor to consider in examining applicability is the strength of the show. It is not unusual for studies to be of poor quality and frequently the recommendations of SRs emphasize the need for more than high-quality trials. Ane has to only consider the progression of recommendations for bedrest in the presence of low back hurting. Recommendations from "experience" called for bedrest in episodes of acute back pain and sciatica. Early recommendations from lower levels and lower quality of evidence found bedrest to be effective in alleviating depression back pain. Subsequent higher quality clinical trials found dissimilar results. In a 2010 systematic review on whether to propose patients to balance in bed versus stay active for acute low back hurting and sciatica, the moderate-quality testify showed that patients with acute low back hurting may experience small benefits in pain relief and functional comeback when brash to stay agile as compared with recommendations for bedrest. In that location was trivial or no difference between the two approaches in patients with sciatica (Dahm, Brurberg, Jamtvedt, & Hagen, 2010). In other words, action was recommended. All the same, information technology must be pointed out that the hierarchy of evidence is non accented. It may be that observational studies with sufficiently large and consistent treatment effects are more compelling than small RCTs (Manchikanti et al., 2007).

Human action and Appraise

If the practitioner identifies that the evidence can be practical to practice, the final steps are to human activity (put information technology into practice) and to assess whether the expected outcomes are achieved. This ongoing monitoring and review provide ongoing practice-based data on efficacy and effectiveness.

Summary

This chapter highlighted the new skills that nurses need in low-cal of the paradigm shift to EBP. The components of EBP require all-time evidence to exist integrated with patient values, the clinical context, and clinical judgment/expertise. The process for incorporating the new image requires an ongoing sense of research in which the practitioner "asks" or challenges the way things are and whether practise is based on best do, has the skills to "acquire" and "assess" the testify, makes decisions well-nigh whether to "employ" the evidence, and finally "acts" past implementing the new practice and assessing the outcomes of the change.

Exercise Activities

1. Think virtually an aspect of your professional practice that you routinely undertake (e.g., depression screening, vital signs every 4 hours). What is the evidence base of operations for this aspect of your practice? If you do not know, practice you know where y'all could notice an bear witness base for this attribute of your practice?

2. Identify whatever areas of intendance in your electric current practice situation that you feel would benefit from more robust bear witness. Ask those you lot work with to do the aforementioned. Are there any areas of commonality?

3. Wait at the policy or procedure of a routine in which you are oft engaged. What were the sources of evidence used to develop the policy or process? How old are they? Is the policy still relevant, up to engagement, and valid?

Suggested Reading

1. Anderson, West., Cimino, J., & Lo, B. (2013). Patient perception, preference and participation: Seriously ill hospitalized patients' perspectives on the benefits and harms of two models of hospital CPR discussions. Patient Instruction and Counseling , 93 (3), 633–640.

2. Evans, D., & Pearson, A. (2001). Systematic reviews: Gatekeepers of nursing knowledge. Journal of Clinical Nursing , x (five), 593–599.

3. Male monarch, K., Song, S., & Quill, T. (2013). Goals-of-intendance discussions for seriously ill hospitalized patients. Hospital Medicine Clinics , 2 (iv), e574–e586.

4. Pang, T., Pablos-Mendex, A., & Usselmuiden, C. (2004). From Bangkok to Mexico: Towards a framework for turning cognition into action to improve health systems. Bulletin of the World Wellness Organisation , 82 (x), 720–722.

5. Rycroft-Malone, J., Seers, K., Titchen, A., Harvey, M., Kitson, A., & McCormack, B. (2004). What counts as evidence in evidence-based practise?. Periodical of Advanced Nursing , 47 (1), 81–90.

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