Evidence Based Maternity Care

EVIDENCE BASED MIDWIFERY PRACTICE INTRODUCTION

Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. (Fineout-Overholt E, 2010). Health care that is evidence-based and conducted in a caring context leads to better clinical decisions and patient outcomes. Gaining knowledge and skills in the EBP process provides nurses and other clinicians the tools needed to take ownership of their practices and transform health care. Evidence-based maternity care uses the best available research on the safety and effectiveness of specific practices to help guide maternity care decisions and to facilitate optimal outcomes in mothers and newborns. Although the field of pregnancy and childbirth pioneered evidence-based practice, resulting in a wealth of clear guidance for evidence-based maternity care, there remains a widespread and continuing underuse of beneficial practices, overuse of harmful or ineffective practices, and uncertainty about effects of inadequately assessed practices. Effective maternity care with least harm is optimal for childbearing women and newborns. KEY WORDS

Evidence: 

‘Knowledge derived from a variety of sources sources that has been been found to be be credible’ (Higgs

& Jones 2000) 

Evidence refers to a particular form of research

Research: 

Research is defined as a systematic and objective analysis and recording of controlled observation that may lead to the development of generalization of principles, theories, resulting in prediction and possible ultimate control of events (J.W. Best).

Titles you can't find anywhere else

Try Scribd FREE for 30 days to access over 125 million titles without ads or interruptions! Start Free Trial Cancel Anytime.















Research in its broadest sense is an attempt to gain solutions to problems; more precisely it is the collection of data in a rigorously- controlled situation for the purpose of prediction or explanation (Treece & Treece).

Nursing: 

ICN defines nursing as the unique function of nurse that is to assist the individual sick or well in the performance of those activities contributing to health or its recovery (or a peaceful death) that he would perform if he had the necessary strength, will or knowledge.



Professional nursing is a devoted occupation with ethical components that are devoted to the promotion of human and social welfare. The services are based on specialized knowledge and skills that have been developed in a scientific manner (Sr. Stephaine).

Nursing research: 

Nursing research refers to the use of systematic, controlled, empirical, and critical investigation in attempting to discover dis cover or confirm facts that relate to specific problem or question about the practice of nursing (Walls & Bauzell, 1981).



Nursing research is a way to identify new knowledge, improve professional education and practices and use of resources effectively (International council of nurses, 1986).

Practice: 

A repeated exercise in an activity requiring the development of skill (oxford dictionary).

Decision: 

A conclusion or resolution reached after consideration (oxford dictionary) .















DEFINITION

Evidence based medicine: 

The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. It is conscientious, explicit and judicious use of current evidence in making decision about the care of individual patients.

Evidence based nursing: 

Sharma (2011) defines evidence based nursing as a process of identifying the solid research findings and implementing them in nursing practice, in order to increase the quality of patient care.



Evidence based nursing is a type of evidence based practice in nursing. It involves identifying solid research findings and implementing them in nursing practices, in order to increase the quality of patient care.



Evidence based nursing is a process founded on the collection, interpretation, and integration of valid, important, and applicable research.

Evidence based practice: 

Sackett etal (1996) define EBP as ‘the conscientious, explicit and judicious use of current best evidence in making nursing decisions about the care of individual patients.’



Carnwell defines EBP as ‘the systematic search for, and appraisal of, best evidence in

order to make clinical decisions that might require changes in current practice, while taking into account the individual needs of the patient.’ 

Benefield defines evidence based practices as using the best evidence available to guide clinical decision making.















Evidence based decision making: 

"Evidence-based decision-making is a continuous interactive process involving the explicit, conscientious and judicious consideration of the best available evidence to provide care."-Position Statement by Canadian Nurses'

ORIGIN

Evidence based practice was founded by Dr. Archie Cochrane, a Scottish epidemiologist. Cochrane was a strong proponent of using evidence from randomized clinical trials because he believed that this was the strongest evidence on which clinical practice division is to be based. In the early 1970s, Archie Cochrane recognized the need to collate research data from randomized controlled trials (RCTs), critique it and conclude what was effective care, so that limited resources could be used wisely (Cochrane 1972 cited in Reynolds 2000). This led to the systematic review. The work of Iain Chalmers and like-minded colleagues led the way in healthcare, providing professionals within the maternity services with a register of RCTs and a database of what care options were effective, not effective, or of unknown value based on systematic reviews of RCTs on each topic (Chalmers et al 1989). Prof. Archie Cochrane through his book “Effectiveness and efficacy: random reflections of health services”. The publication of these two volumes provided an accessible and essential

reference text. After the demise Dr. Archie Cochrane in 1988, the Cochrane centre was launched in oxford, England, in 1992. The major purpose of the centre is to assist individuals in making well informed decision about health care with international collaboration by developing, maintaining and updating systematic review of healthcare intervention and ensures that these reviews are accessible to the public. Technological advances in worldwide















EVIDENCE BASED NURSING AIMS: 

To provide the highest quality and most cost-efficient nursing care possible.



To advance quality of care provided by nurses.



To increases satisfaction of patients



To focus on nursing practice away from habits and tradition to evidence and research

COMPONENTS

OF

EVIDENCE-BASED

NURSING PRACTICE 



Key elements of a best practice culture are 

EBP mentors



Partnerships between academic and clinical settings



EBP champions



Clearly written research



Time and resources



Administrative support ( Fineout - Overholt E, 2005)

When delivered in a context of caring and in a supportive organizational culture, evidence based practice can help to achieve the highest quality of care and best patient outcomes (Baumann SL, 2010).

PURPOSE

The aim of EBP is to do the right thing, at the right time, for the right person, in other words ensure quality care for the individual client. This is achieved by evaluating ideas, practices and previous events and applying the learning achieved to future practice. 

Evidence based is an approach which tries to specify the way in which professionals or other decision makers should make decisions by identifying such evidence that there

















EBP has contributed a lot towards better patient outcome. Heater and colleagues reported that patients who receive research based nursing care make sizeable gains” in

behavioral knowledge, and physiological and psychological outcomes compared with those receiving routine nursing care. 

The ultimate goal of EBP is to provide the highest quality and most cost efficient nursing care.



The purpose or utility of evidence based practice in nursing is mainly to improve the quality of nursing care.

Levels of EBP

Gabby and le May (2004) explored how professionals used formal evidence sources such as research, and describe a pyramid with four levels of EBP. 

The foundation layer is described as a social movement, but could be considered as representing the underpinning philosophy on which everything is based.



The second layer refers to national and local EBP policies and/or guidelines. This is the EBP process, the practical interpretation of the concepts.



The third layer represents the practitioners who utilize the concepts and processes. The clients receiving care based on the current best evidence, which is related to their individual circumstances, complete the layers.

These four layers, however, do not consider how the philosophy is converted into policies, or how practitioners adopt the policies and make EBP information and care available to clients.

















Professionals may use policies/guidelines without subscribing to, or understanding the EBP philosophy, while clients may receive the best care, without anyone having considered EBP. The pyramid could also be turned upside down as it could be argued that it is consumers that are contributing to the upsurge of EBP. Clients increasingly demand high-quality care, with expectations increasing each year (Department of Health 2004). There is increased emphasis on partnership, working with clients in the provision of a service that is responsive to their needs (Department of Health 2003). Therefore a circular relationship between clients, practitioners and evidence may be a useful representation of the interaction of each within an overall philosophy of EBP. This is congruent with the principles of effective and high-quality care, in which midwives, and all practitioners, strive to provide the very best care to each individual.















As Sackett etal (2000) emphasize, EBP is more than just the best evidence, it is the integration of best evidence with high-quality clinical skills, such as communication and assessment, as well as the application of evidence to the particular belief systems, values and context of the client’s life. Evidence is forever changing in the light of new research, new technology, new

ideas, as well as old ideas and options put together in new ways. This is challenging as it means best practice cannot conclusively and finally be established. The onus/ responsibility is on each practitioner to establish the evidence for each case. An important feature of EBP is the way it is dynamic and open to reviewing, its purpose to be a way of constantly updating practice. Therefore all midwives need to develop the skills required for EBP practice. These skills are the same skills that midwives need for midwifery care, some of which are listed below. Characteristics needed for EBP 

Clinical competence, knowledge and skills



Observant and sensitive and thus able to identify the needs of individual women



Empathic to the needs women may not be able to articulate



Effective communication, to enable women to be equal partners in their care



Reflective practitioner, and therefore able to develop clinical expertise based on















BASIC

PRINCIPLES

DETERMINING

BEST

FOR

AVAILABLE

EVIDENCE

• Question common assumptions.

Maternity care practices based on the opinions of experts or the general public or on tradition are unreliable guides for decision making. These views and patterns of care have been shaped by many factors and often do not reflect the best current research. They may lead to inadequate care, poor outcomes, and wasted resources. It is important to demand to be shown the best evidence. • Know that many studies of interventions are unreliable guides for decision making. Careful evaluation of the quality of research using “critical appraisal” skills is essential. Many

studies are flawed or limited in scope and do not provide valid answers to key questions. One newly reported study rarely offers the best, most definitive answer, and commercial interests influence many studies. It is important to ask what is already known about a particular question on the basis of the best available research, r esearch, and what, if anything, anyth ing, a new study adds. • Look for the “gold standard.”

When available, well-designed and well-conducted systematic reviews of research should















WHAT IS THE “GOLD STANDARD” FOR KNOWLEDGE ABOUT EFFECTS OF MATERNITY CARE?

A rigorous and transparent systematic review of original studies that has been conducted according to established guidelines and with discernment regarding both methodology and topic (Cochrane Methodology Register 2008; Moher et al. 2007; Sheikh et al. 2007) is a powerful tool for understanding the weight of the best available evidence. Such a review gives the most trustworthy knowledge about beneficial and harmful effects of specific health interventions. Systematic review procedures help limit investigator bias and error that can easily distort results of single studies and of more conventional and haphazard research reviews. A systematic review establishes the scope and other basic review parameters at the outset as a guide for conducting the review. It involves a thorough search for all the studies that meet explicit criteria for inclusion. Using criteria for assessing methodological rigor, researchers include only better quality studies in the review. When possible, researchers reach a conclusion by pooling data from the included studies using statistical techniques of meta-analysis. Systematic reviews should be updated over time to incorporate new relevant high-quality research and to refine and strengthen the original analysis when possible. A recent Milbank Report describes the history, methodology, and uses of systematic reviews (Moynihan 2004), and another highlights the use of systematic reviews in policymaking (Sweet and Moynihan 2007). The earliest systematic reviews were carried out more than twenty-five years ago to evaluate pregnancy and childbirth care. This pioneering work led to the formation of the Cochrane Collaboration to continue the pregnancy and childbirth research and to develop and update systematic reviews across all clinical and public health fields (Chalmers 1993). Many hundreds of systematic reviews are now available to guide maternity policy and practice from the highly regarded Cochrane Pregnancy and Childbirth Group and many other entities and individuals throughout the world. These invaluable tools for providing high-quality maternity care and obtaining good value have been grossly underutilized in the United States (see, for example, Chauhan et al. 2006). Among individual studies, randomized controlled trials (or RCTs) can provide especially trustworthy results about many effects of specific interventions. In this type of research, participants are randomly assigned to receive one or another form of care. Those receiving usual care (or placebo treatment such as a sugar pill) are in the control group. Those receiving the type of care that is being studied are in the treatment or experimental group. Random assignment helps ensure that the groups being compared are truly similar and that any differences in outcomes are due to the treatment under study rather than some other difference between the groups. RCTs are not the best study design for answering many important questions. For example, due to the great















•Make informed decisions that consider evidence about safety and effectiveness and the values and circumstances of individual childbearing women.

When making maternity care decisions, it is crucial to consider the best available evidence as well as values, preferences, and individual circumstances of childbearing women who have been supported to understand this evidence. It is also important to consider the options within specific care settings, such as the skills of caregivers and available forms of care. • Beware of misleading claims.

With growing recognition of the value of evidence-based policy and practice, it is important to describe “evidence-based” products and services and of deeply flawed execution that may not in fact reflect these principles. LEVELS OF EVIDENCE HIERARCHY

Primary sources of evidence are considered superior to other forms of evidence and the most important primary source is research findings. However, not all research is valued to the same degree. This led to the development of a hierarchy of evidence, with an expectation that practitioners will base their practice on the best evidence as described by a hierarchy of evidence. Best evidence includes empirical evidence from randomized controlled trials evidence from other scientific methods such as descriptive and qualitative research; as well as use of information from case reports, scientific principles, and expert opinion. One of the most

















5. Case control studies 6. Cross-sectional studies 7. Case reports

LEVEL-I

SYSTEMATIC REVIEW OF ALL RELEVANT RCT LEVEL-II

SINGLE RCT LEVEL-III

SYSTEMATIC REVIEW OF CORRELATIONAL / OBSERVATIONAL STUDIES LEVEL-IV

SINGLE COORELATIONAL / OBSERVATIONAL STUDY















3) Evaluating and analyzing the strengths and weaknesses of that evidence in terms of validity and generalisability 4) Implementing useful findings in clinical practice based on valid evidence; evidence is used alongside clinical expertise and the patients perspective to plan care 5) Evaluating efficacy and performance of evidences through a process of self reflection, audit, or peer assessment

FORMULATING A CLEAR QUESTION BASED ON A CLINICAL PROBLEM

LITERATURE REVIEW TO SEARCH BEST AVAILABLE EVIDENCE















1) Formulating a clear question based on a clinical problem The first step is to formulate a clear question based on clinical problems. Ideas come from different sources but are categorized in two areas.

PROBLEM FOCUSED TRIGGERS

KNOWLEDGE FOCUSED TRIGGERS

Problem focused triggers: are identified by health care staff through quality improvement, risk















be considered because providing proof of the research. This will increase staffs willingness to implement into nursing practice. The most challenging issue in using EBP in the clinical setting is learning how to adequately frame a clinical question so that an appropriate literature review can be performed. An acronym used to remember this is called the PICO model;

P

= Who is the patient population?

I

= What is the potential intervention or area of interest?

C

= Is there a comparison intervention or control group?

O

= What is the desired outcome?

The importance of asking the right question is highlighted by Bastin (2004). Evidence on the administration of bromocriptine to suppress lactation suggested effectiveness, but later it was discovered that it increased mortality and morbidity. Perhaps the EBP process to establish the















Examples of EBP questions for a topic Example one: Topic is water immersion in labour

Question 1: Does immersion in water during the first stage of labour reduce the use of pharmacological analgesia? P = women in labour I = immersion in water C = not in water O = analgesia used Question 2: Is birth in water safe for the fetus/neonate? P = neonates born of women who birthed in water I = immersion in water C = not in water O = wellbeing – e.g. APGAR score, or cord gases

















2) Literature review to search for the best available evidence Having defined the question, the next step is to locate all the evidence that may be pertinent. This can be very time-consuming, and can require lateral thinking, imagination, ingenuity and perseverance, but with practice it does get easier. Once the topic is selected the research relevant to the topic must be reviewed in addition to other literature. It is important that clinical studies, integrative literature reviews, meta-analysis and well known and reliable existing EBP guidelines are accessed in the literature retrieval process.

















Secondary literature includes systematic reviews, reviews, guidelines/policies, editorials, opinions, critiques, and any information that is a reconsideration of primary data.



Some types of literature can be either primary or secondary.



Published letters, for example, may be commenting on a previously published study, or provide original data from another unit supporting or refuting a study, or even highlighting a completely new point.



It is also important to remember that people are a vital resource.



Speaking to experts on a topic, networking within the area of interest may provide contacts and links to invaluable sources of evidence. This additional time investment is















5) Evaluating efficacy and performance of evidences through a process of self reflection, audit, or peer assessment Finally after the implementation of the useful findings for the clinical practices, efficacy and performance is evaluated through processes of self reflection, internal or external audit or peer assessment.

MODELS

FOR

EVIDENCE

BASED

–

PRACTICE

A number of models of research utilization have been developed by nurse















STETLER MODEL OF RESEARCH RE SEARCH UTILIZATION

This model was first developed in 1976 and refined in 1994 and was designed with the assumption that the research utilization could be undertaken not only by the organizations but also by individual clinicians and managers. It was a model designed to promote and facilitate critical thinking about the application of research findings in practice. It involves 5 phases A) Preparation: 

Nurse would define the underlying purpose of the project.















E) Evaluation: In this final phase application would be evaluated. Although this model was designed as a tool for individual practitioners, it has also been the basis of formal research utilization and evidence based practice projects by group of nurses. IOWA MODEL

IOWA model of evidence based practice is an organizational, collaborative model developed by the university of IOWA hospital and University of IOWA College of nursing. This model was































IOWA model has 4 phases

Evidence triggered.



Evidence supported















According to this model EBP involves 6 steps: 

Assess the need for change.



Define the problem identified.















• Lack of a set of robust maternity performance measures with buy-in of key stakeholders to

use them for measuring, reporting, rewarding, and improving performance • Perverse incentives of payment systems

















EBP guidelines, enabling consistency of care across professional boundaries



Client-focused care pathways



Structured processes for dissemination of the best evidence



Explicit and transparent ways of working with less scope for misinterpretation





































































































Evidence Based Maternity Care

Recommend Documents