實證護理概念

國立陽明大學 穆佩芬 教授

2012

發生了什麼事？為什麼？

如何改變？

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Department of Health, Taiwan

Nursing Policy

Three Action Projects Anticipated Challenges Core Functions

Quality education & training： EBN Model

Satisfactory workplace： The consensus of a promising

nursing career

Quality care & practice： Nursing Leadership Development

Competent health workforce

Adequate & satisfied health workforce

Productive health workforce

Highest standards of practice for health workforce

Management of health workforce & information systems

Evidence based practice

Advocacy & pluralism 4 partnership with nursing groups & stakeholders

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1. DEFINITION OF EVIDENCE-

BASED NURSING

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DEFINITION OF EVIDENCE-BASED NURSING

Joanna Briggs Institute (1996) Cochrane nursing care field (2009) The integration of the best research evidence with

clinical expertise and patient values (Sackett, Straus, Richardson, Rosenberg & Haynes, 2000)

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實證護理 認識論 研究者如何理解社會生活？如何去理解這個世界？了解的方式是什麼？也可以說是研究者自己在想些什麼？到底想知道什麼？

本體論 研究者的終極關懷與為何要進行學術研究？是呈現各種生命情調互相激盪的存在論。

技藝 以人為本之實證照護

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(1)實踐哲學的知識論

知識形成方式 它的思考方式為何

成立的可能性 它的知識成立的條件為何

知識的客觀性、適用性、檢證性及選擇性

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1.1.實踐哲學的架構

宇宙論 現象存在問題的知識

本體論 價值命題 人生追求的理想目標

工夫論 價值意義的心理修養工夫 或是 身體能力的鍛鍊

境界論 主體達到理想的狀態

此四架構能進行 討論概念定義 以及這些概念之間的關係 此為存有論

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1.2. Three forms of knowledge

Aristotle (400BC) Episteme (科學): scientific knowledge, theoretical

knowledge Techne (技藝): the kind of knowledge we need for

producing and creating and for manufacturing various products

Phronesis (實踐智): practical knowledge or wisdom, and is the knowledge used in the processes of social interaction

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Episteme (科學) 實證基礎

Techne (技藝): 實證操作

Phronesis (實踐智): 實證操作

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1.1. Evidence generation

Evidence: the basis of belief, the substantiation or confirmation that is needed in order for us to believe that something is true (Miller & Fredericks, 2003)

Make a decision: the type of evidence

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FAME

Evidence of feasibility: activity is practical and practibable

Evidence of appropriateness: an intervention or activity fits with or is apt in a situation

Evidence of meaningfulness: an intervention or activity is positively experienced by the patient

Evidence of effectiveness: an intervention, when used appropriately achieves the intended effect

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1.2. Evidence synthesis

The synthesis of the results of quantitative research (meta-analysis)

The synthesis of the results of qualitative research (meta-synthesis)

The synthesis of evidence arising out of expert opinion and text (expert opinion)

The synthesis of evidence arising out of economic analyses (economic analysis)

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1.3. Evidence (knowledge) transfer

Developing understandable and actionable knowledge

Accommodating the context of a target audience’s information needs

Delivering messages in cost-effective ways (including information technology, print materials, meetings, workshops and training programmes)

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1.4. Evidence utilization

Practice change

Embedding evidence through system/organization change

Evaluating the impact of the utilization of evidence on the health system, the process of care and health outcomes.

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Evidence Pyramid

Meta-Analysis

Meta-synthesis

Systematic Review

Randomized Controlled Trial Qualitative Research Method

Cohort studies

Case Control studies

Case Series/Case Reports

Animal research

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Unsound

Research

Sound

Research

Systems (bottomline± ref)

Synopses (user summary of research)

Systematic Reviews and CATs (search; appraisal; synthesis)

Aware Accepted Applicable Able Acted on Agreed Adhered to

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文獻

摘要

精要

從知識到實踐的管道

注意到→接收到→可行→有能力作→開始做→認同→養成習慣

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2. A PARADIGM SHIFT

Thomas Kuhn (1970): scientific paradigms as ways of looking at the world which define both the problems which can legitimately be addressed and the range of admissible evidence which may bear on their solution.

量性 PICO

P: 問題 I: 護理措施 C: 其他護理處置 O: 結果

質性 PICO P: 問題 I：護理現象 Co：護理脈絡

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DEFINITION OF EVIDENCE-BASED PRACTICE (SIGMA THETA TAU INTERNATIONAL POSITION)

EBP is the process of shared decision-making between practitioner, patient, and others significant to them based on research evidence, the patient’s experiences and preferences, clinical expertise or know-how, and other available robust sources of information (Rycroft-Malone et al. 2004)

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Nursing paradigm vs. medical model

What kinds of competence in evidence-based

nursing in undergraduate program, graduate

program, PGY, and ANP

How do we design EBN into nursing teaching and

learning environment or activities into curriculum?

What kind of preparation of teachers?

The possibilities in nursing knowledge development

in EBP

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3. SIX STEPS OF EVIDENCE-BASED NURSING IMPLEMENTATION

Question A clinical problem Recurrent problem

Search** Appraisal** Synthesis the findings** Practice** Assessment and Evaluation

(Flemming, 1998) 32

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背景問題 vs 前瞻問題

Background question (背景問題) 希望獲得處理病患的specific knowledge 預期有答案 Searchable answers 能比較各項選擇的優劣 Focus on evidence 決定行動方向 Decision-making oriented Foreground question (前瞻問題)

PICO (Pubmed, JBI, Cochrane review) Patient character or Problem Intervention Comparison intervention Clinical Outcome

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Concept map

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Different types of questions are best answered by different types of studies.

1. Intervention or Therapy Randomised Controlled Trial

2. Diagnosis/Screening 2.1. To assess the accuracy of the test

Cohort study where all subjects receive both the study test and gold standard reference test

2.2. To assess effect of test on health outcomes: Randomised Controlled Trial

3. Prognosis Longitudinal cohort

4. Aetiology/Risk factors Randomised controlled trial Cohort for rare exposure with common outcome Case-control for rare outcome with common exposure

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4. Search: 資料庫種類與方式

系統文獻查證

實徵資料

臨床指引

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(1) Evidence-based Medicine resources 實證醫學文獻資料庫

Uptodate Cochrane Lib Cinahl information systems ACP journal club

醫學期刊, 電子期刊, 電子資料庫 Medline, Medscape PubMed Evidence based nursing journal Center for evidence-based nursing, University of

York JBI web journal Ovid PsycINFO MEDLINEPlus

教課書, 電子書

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Evidence-based practice resources Uptodate

PubMed

Cochrane Library

Abstract of Cochrane reviews

Evidence-based practice centers

Joanna Briggs Institute

Clinical evidence

Evidence-based Medicine Resources Center: Clinical Practice Guideline

http://www.ebmny.org/thecentr.html

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Joanna Briggs Institute

網址: www.joannabriggs.edu.au

Taiwan Joanna Briggs Collaborating Center

(TJBCC)

網址: http://www.joannabriggs.edu.au/collab_ctrs/taiwan.p

hp

Cochrane Nursing Care Network

http://www.joannabriggs.edu.au/cncn/index.php

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5. APPRAISAL 文章評析 Meta-Analysis Systematic Review Randomized Controlled Trial Cohort Study Case Control Study Case series or Case Report Editorials, Letters, Opinions 44

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Yes No Unclear

1 The participants were randomised to study groups.

2 Allocation to treatment groups was concealed from allocator.

3 Other than the intervention, participants were treated the same.

4 The groups were comparable at entry.

5 The outcomes were measured in the same manner for all

participants.

6 Those assessing outcome were blinded to treatment allocation (if

outcome not objective such as survival or length of hospitalisation).

7 Outcomes were measured in a reliable manner.

8 The statistical analysis used was appropriate for the data

presented.

9 There was adequate follow up of participants.

In reflecting upon my critical appraisal I believe that this paper is

-- --

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Critical Appraisal for Intervention Study

2889Please chooseNextform1

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TJBCC 2008 46

6. EVIDENCE SYNTHESIS

The synthesis of the results of quantitative research (meta-analysis)

The synthesis of the results of qualitative research (meta-synthesis)

The synthesis of evidence arising out of expert opinion and text (expert opinion)

The synthesis of evidence arising out of economic analyses (economic analysis)

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TJBCC 2008 47

META-ANALYSIS

Uses various statistical methods to combine the results of multiple different studies to produce a stronger conclusion than can be derived from any one of the studies on its own.

Effectiveness or Therapy 治療性問題

Diagnosis 診斷性問題

Prognosis 預後性問題

Harm 傷害性問題

Economic analysis

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TJBCC 2008 48

The procedure of meta-analysis Identification of a clinical problem Develop a review protocol Locate studies Select relevant studies Appraise the quality of the research Collect data from individual studies Synthesize and summaries the findings of studies Document method in review report

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TJBCC 2008 49

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LEVELS OF EVIDENCE

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Meta-synthesis

1.Meta-data-analysis : research findings

2. Meta-method: research method

3. Meta-theory: theoretical and analytical

framework

4. Experts’ opinion

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Clinical Practice Guidelines:

Best Practice Guidelines (Registered Nurses Association of Ontario)

AGREE (Appraisal of Guidelines

Research & Evaluation) Recommended Clinical Practice

Guidelines (Guideline Advisory

Committee (GAC)) CMA Infobase: clinical practice

guidelines -- Canadian Medical Association

Clinical Practice Guidelines -- Alberta Medical Association

National Guideline Clearinghouse (United States)

Joanna Briggs Institute -- (TJBCC)

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7. EBP example

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Suction strategies of adult patients with tracheal

Domain of the

phenomeon

Suc

tion

care

Physica

l st

rate

gies

Position

str

ate

gies

Research method

Meta

-ana

lysis

Meta

-sy

nthesis

Foc

us g

roup

Sur

vey

Clinical guideline development: Suction strategies of adult patients

with tracheal

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FIVE STEPS

(1)Systematic review of the suction strategies of adult with tracheal

(2)Meta-analysis of the experience of adult with ventilator

(3) Focus group : the suction strategies of adult with tracheal

(4) Protocol of clinical guidelines

(5) Conduct a survey to investigate the appropriateness and usefulness of the protocol of clinical guidelines

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(1) Systematic review of the suction strategies of adult

with tracheal

Abstract 1. Background 2. Methods (1) searching literature 1.1. inclusive criteria 1.2. exclusive criteria 1.3. searching process 1.4. appraisal 3. Findings 3.1 Systematic review 3.2 Clinical Guideline 4. Results Each evidence: abstract, findings, clinical implications 5. Synthesis：Integrating the findings

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(2) META-SYNTHESIS： THE EXPERIENCE OF ADULT PATIENTS WITH VENTILATOR

Abstract Background Objective Inclusive criteria

Types of studies Types of participants Types of phenomenon of

interest Types of outcomes

Exclusive criteria Search Strategy

Software

The initial search terms included: Key words: Phenomenon Population Methods

Critical appraisal Data collection Data Synthesis Findings Discussion Clinical Guideline

suggestions

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(3) FOCUS GROUP: SUCTION STRATEGIES OF ADULT PATIENTS WITH TRACHEAL

1 Research purpose: what are the strategies of clinical experts in caring of adult patients with tracheal?

2 Research methods: focus group 3 Process： (1) Participants (2) Data collections Semi-structure interview (3) Data analysis

4 Findings 59

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(4) PROTOCOL OF CLINICAL GUIDELINE

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(5) Conduct a survey to investigate the appropriateness and usefulness of the protocol of clinical guidelines

1. Purpose

(1) Degrees of agreement of each item

(2) Factors affects on the degrees of agreement of each item

2. Research method

(1) data collections

(2) Subjects

3. Findings

(1) Experts opinion

12 experts to validate the items

(2) Survey 400 clinical nurses and RTS

(3) The correlations between the answers from experts and clinical nurses and RTS

4. Discussion

5. Findings

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THANKS FOR YOUR ATTENTION !!