In this video, I'm going to talk about what evidence-based practice is.
When it comes to evidence-based practice, many people become intimidated, but really
look at it in this manner: it is trying to make the best decision with the best evidence.
That's what you do in your daily lives when you go to buy a car, or make any other purchases, or to make a major decision in life.
The same thing is true when it comes to evidence-based practice except what you're talking about
here is the patient: what is best for your patient?
Now in saying that, there are three parts when it comes to evidence-based practice - or three legs to the chair, so to speak.
One part of the chair, or one part of evidence-based practice, is the clinical data or knowledge
which is simply put, what does your experience tell you - and what does your colleagues experience
tell you - about what the best route, or what the best thing is to do, in order to care for a patient with a particular condition?
The second step is the research evidence.
What does the research say is the best thing to do here?
And lastly are the patient's values, preferences, or expectations.
As you know, no care can be carried forward unless a patient is willing or wants to go along with it.
In all three of these things what they do is, they come together to give us an optimal decision.
Now when it comes to evidence-based practices, I said the major focus is trying to provide the best care for patients.
In doing that, you're going to have to go through an inquiry process.
It's really the search strategy or the steps of a good search for information except for it could take a couple routes.
What you'll notice here is one way of looking at it.
This is based upon the Johns Hopkins model of evidence-based practice.
And what you'll notice is, is that anytime you're doing this you're going to have a question.
When you get that question just keep in mind you're not alone.
Find some resources on your unit, and carry it forward from there.
When it comes to your literature search, don't hesitate to ask a librarian or someone with
lots of skill in doing searches to help because the research evidence is going to be very
important in informing what you're able to do.
And then as you appraise the literature, you're going to have to make a determination as to
whether or not there's adequate evidence.
If you feel based on your searching and your inquiry that there is evidence that is adequate,
then it becomes an evidence-based practice project.
If not, it becomes more of a research project in which you're going through and you're trying
to answer a brand new question and come to some sort of determination.
In any case, the main thing to do at the very end is be able to disseminate the information
and get it out there to improve patient care.
Now as you're doing that, one of the major things that you're going to have to do is
look at evidence; what is the evidence telling you?
And you're going to come across something that looks like this, which is the evidence pyramid.
What it shows you is the level of evidence.
When it comes to level of evidence, it starts at the bottom with background information
or expert opinion, and it works its way up.
As it works its way up what you'll notice is, you get a lot of primary research like
randomized control trials, and cohort studies, and cased control studies, etc.
And it continues to go up till you get to things like systematic reviews, meta-analyses,
and evidence-based practice guidelines.
Now when you're shooting to do a good literature search, what you want to do is you want to
aim for the top of the pyramid.
The problem is, as you move towards the top of the pyramid the level of evidence gets
better, or stronger, but the number of articles, or the number of studies, decreases.
Therefore many times, your search will start on a trajectory of aiming for the top, but
you will usually fall short of that and be looking for primary studies.
I just like to make sure that people understand that because everybody would love to have
a systematic review or evidence-based practice guideline, but many times what you're looking
at are-- you're looking at a series of primary studies in order to make a decision which
means that it's very important that you know how to appraise them.
Now as it comes to that, there are a couple things that you need to know when it comes
to these different types of evidence.
With practice guidelines - as you can see here - they have a couple of advantages.
One, it's a guideline that's created by a panel of experts and is based upon professional published literature.
And that's very important whereas an expert opinion is many times-- it may have some literature
base, but mainly it's based upon that person's experience.
But there are some disadvantages as well.
One, once they're done, they're slow to change or be updated.
They're not always available, especially on controversial topics, so there's not very
many of them, and many times the recommendations might be affected by the type of organization
creating the guideline, meaning it may help them with an agenda of some sort.
Now when looking for them, there are a couple places they can be found.
One is in PubMed.
Another is CINAHL and of course the National Clearinghouse.
All of them are good sources to find this kind of information, but keep in mind when
you do find them that there are drawbacks as well as advantages.
As you're working down the pyramid, you'll also come to the review articles.
The review articles are very important because what they will do is take a series of primary
studies and put them together, and they will filter through and make the decision for you,
or they'll give you a suggestion.
You'll see here you have review articles, which are very low when it comes to the pyramid,
and then you'll see the two here at the top: systematic reviews and meta-analyses.
Each one of them, their intention is to be very transparent, and the methods they use
are there for you to look at because they're there to eliminate bias.
Bias tends to show up in many review articles because you can think of them as articles
in which somebody is trying to say, "Hey, this is the decision we're going to make."
And there are times when they may not include studies that refute what they're looking for
- or what they're trying to argue for, or they're trying to advocate for - but you won't
be aware of that because they won't share that type of information with you.
As you come to a systematic review, it's very clear as to how they came to a decision and
why they're making the suggestions they are.
It'll have a clear methods section.
It'll tell you why articles weren't included, and it will give you a list of those articles.
A meta-analysis is very nice in that you go from having a qualitative type of study to
make a decision from, to one in which statistics are done, and it becomes more quantitative in nature.
Depending upon what you're doing, you may find articles that address your topic that
are review articles, systematic reviews, and meta-analyses.
You may find all of them, or you may only find a systematic review.
It just largely depends upon what others in the field have done as far as research.
Lastly, you can come to the bottom of the pyramid, and what you'll notice is, you'll
have your primary research here.
Many times this is the research that's being done that helps to generate the information
and to create new knowledge.
When it comes to these studies, the randomized control trial is very important to you because,
when it comes to randomized control trials they're the only studies that will give you cause and effect.
What that means is, when you're looking at treatments for a patient, and you're saying, "If I do "this", will "this" happen?"
Those conclusions can only be drawn through cause and effect, through a randomized control trial.
In other cases there may be correlational evidence.
Like there may be a correlation if you do "this", then "this" happens.
But largely you can't prove cause and effect unless you have some sort of randomized control
trial where you have a control group, and an experimental group, and you're going through the entire process.
The other two types of studies, depending upon what you're looking for, can also be useful.
All of them are types of primary studies.
They are all used to answer different types of questions.
Because when it comes to randomized control trials, you can't always ethically go out
and do a trial like that - like say for accidental falls.
You can't have, say, a sitter in one room and no sitter in the other room when both
patients may be at risk at falling, just to watch one patient fall and get hurt in order
to prove the point that really having a sitter in the room is the best practice in order to ensure that no one gets hurt.
It just largely depends upon your question.
The reason I bring up why it depends upon your question is, as you're going through
these studies remember that your biggest thing is that you're going to want to aim for the top of the pyramid.
When you can't find the top of the pyramid though, the type of question you ask is going
to be very important because every type of question is best answered by different types of studies.
As you'll notice here on the chart on the left side, I'm telling you what the types of questions are.
On the right, these are the types of studies that are best used to answer those questions.
This is important as you're doing literature searches because if you cannot find the top
of the pyramid, this at least allows you some focus to your searches as far as the limits
you might place on a search to find the studies that are best going to answer your question,
therefore taking lest time to do the literature search and allowing you to be more efficient
in coming to that decision.
Now as you get into this, keep in mind that as you go up the pyramid the quality of the
evidence goes up but the numbers go down.
As you're looking for this evidence, there's going to be a lot of different places you can look.
As you see here, one of the things I have provided are some of the important databases,
especially when doing nursing research that could be useful to you as well as a link to
the VCU Libraries nursing research guide, which will be a very good guide in order to
guide you to the right resources to find the appropriate studies in order to conduct a
good literature search when it comes to evidence-based practice, where not only is your knowledge
important but the patient's values and wants are important and lastly that the literature
and what the science is telling you is important.
And therefore when it comes to evidence-based practice, remember that you're trying to take
what's in the clinical setting and you're trying to move it to the bedside.
And that is what evidence based practice is and how you might want to think about it.