St.

Paul University Philippines

MASTER OF SCIENCE IN NURSING
Tuguegarao City, Cagayan 3500

MSN 201
CLINICAL REASONING AND
TEACHING

Maria Girlie D. Jordan,

MSN
 TABLE OF CONTENTS
ntroduction >Definition
> The Process of Knowing > Null Hypothesis
> Kerlinger Ways of Knowing Method > P-value
Evidence-based Practice (EPB) Confidence intervals
> Dr. Archie Cochrane > Relative vs. Absolute Risk >
> Evidence-based Practice (EPB) Reduction
Key Steps of Evidence-based Practice (EPB) 3 Key Questions
1. What were the results study?
Collect the most relevant Ask the burning 2. Are the results valid?
clinical question. 3. Will the results help me in
> PICO format caring for my patients?
> Example of Clinical Scenario and 4. Integrate all evidence with ones clinical
answering using PICO format and best expertise, patient preferences,
values in making a practice decision
evidence.
or change.
Evidence Support
3 Domains of Data Gathering
> Systematic Review 5. Evaluate the practice decision or
> Meta-Analyses Review change.
Critically appraise the evidence. VI. Sources
I. Introduction
Healthcare is filled with uncertainty in situations
such as:
Which treatment is most effective to produce
the best patient outcome?
How are patients experiencing their illness?
What will be the outcome of a diagnosis if left
untreated?
On a daily basis, nurse practitioners, nurses,
physicians, and other health care providers
are faced with an array of important clinical
decisions?
 As Each clinical decision
made or action taken is

Nurs
based on knowledge.
This knowledge derives
from a variety of

es,
sources, such as
research, theories,
experience, tradition,
trial and error, authority,

how or logical reasoning.

do
 The Process of Knowing
The process of knowing are common and
fundamental human activities.
What people know is the outcome of these
everyday experiences.
Although various ways of knowing have been
acknowledged and described in western
societies, Science has acquired the status of a
superior way for a group to develop
knowledge.
 The Process of Knowing
Using Kerlinger (1986), ways of knowing method
that are inferior to science:
If asked how you know this is so?
SITTING IN A DRAFT CAUSES A COLD?
It just is TENACITY truth is believed simply
because it has always been thought to be true.
Parents said so AUTHORITY is a belief
about what is true because an
authoritative sources or person says it is
true.
 The Process of Knowing
It stands for a reason A PRIORI depends on
reason and is not necessarily consistent with
experience.
These forms of knowing can all lead to the same
conclusion and may even be thought of as
Factual.
The difference between them
is how someone knows.
 The Process of Knowing
Knowledge about how a cold is transmitted may
also be learned from the method of science.
That is, EMPIRIC (EXPERIENTIAL OR
SENSORY) OBSERVATION OR EVIDENCE.
The method of science were developed as a
way to eliminate errors in judging what is
factual or true by repeated tests of hypotheses
or examination of research questions on the
basis of empiric reality.
 f E v id e nc e -
y S t e ps o
III. Ke
ed Pr a c tic e
Ba s
 Evidence-Based Practice
Founded by Dr. Archie Cochrane, a British
epidemiologist.
Who struggled with the efficacy of healthcare and
challenged the public to pay only for care that had
been empirically supported as effective (Enkin, 1992).
Cochrane was a strong proponent
of using evidence from randomized
clinical trials because he believed
that this was the strongest
evidence on which to base clinical
decisions.
 Evidence-Based Practice

In an exemplar case, Cochrane noted that

thousands of low-birth-weight premature infants
died needlessly.
He emphasized that the results of several
randomized clinical trials supporting the
effectiveness of corticosteroids therapy halt
premature labor in high-risk women.
A systematic review showed that corticosteroid
therapy reduced the odds of premature infant
death from 50% to 30% (Cochrane
Collaboration, 2001).
 Evidence-Based Practice
Definition
Is the conscientious use of current best
evidence in making decisions about patient
care.
Is an approach that enables clinicians to
provide the highest quality care in meeting the
multifaceted needs of their patients and families
(Sackett, Straus, Richardson, Rosenberg, &
Haynes, 2000).
 Evidence-Based Practice
Definition
Evidence-based nursing is an approach to health
care practice that enables nurses to provide the
highest quality care based on the best evidence
available to meet the needs of their patients.
Melnyk & Fineout-Overholt, 2005

The integration of the best research evidence with

clinical expertise and patient values.
Sackett, Straus, Richardson, Rosenberg & Haynes, 2000
Evidence-based medicine: how to practice and teach EBM
2d ed. London, UK: Churchill Livingstone
 Evidence-Based Practice
Terminology
Evidence-Based Practice (EBP)
Evidence-Based Health Care (EBHC)
Evidence-Based Nursing (EBN)
Evidence-Based Medicine (EBM)

Sacketts definition refers to all of these;

EBP and EBHC are more universally used.
 Evidence-Based Practice
It is a problem-solving approach to clinical
practice that integrates:

A systematic search for and critical

appraisal of the most relevant evidence to
answer a burning clinical question.
Ones own clinical expertise.
Patient preference and values.
 Evidence-Based Practice
Evidence from Research-
Evidence-Based Theories,
and Opinion
Leaders/Experts Panels

Evidence from
Assessment of the
Patients History & Evidenced-Based Clinical
Physical Exam, and Decision-Making
Availability of Healthcare
Resources

Clinical Expertise

Information about Patient

Preferences and Values
Figure 1.1 The components of Evidence-based practice.
 Evidence-Based Practice

Challenges of EBP
New, Unfamiliar
Need to develop good search strategies
Must identify best databases
Need to do critical appraisals
Should be implemented from the top down, with
nursing faculty learning first
Much of relevant research is qualitative; need
more systematic reviews of qualitative research
 Evidence-Based Practice

Practice on evidence can decrease the

uncertainty that patients and clinicians
experience in a complex healthcare
system.
Evidence indicates that patients who
receive care based on the best and latest
evidence from well designed studies
experience 28% better outcomes (Heater,
Becker, & Olson, 1988).
 Evidence-Based Practice
There are some health care providers who
have difficulty believing that EBP is necessary
for the delivery of quality patient care.
However, when asked specific questions about
the care they personally want to deliver or
receive, it is likely that these providers, whether
they are in the clinician, family, or patient role,
would choose EPB over care that is steeped in
tradition alone.
 Evidence-Based Practice
e.g.,

If you were diagnosed with cancer today and

were faced with the decision about which type of
chemotherapy to choose, would you want to
know the evidence regarding the risks and
benefits of each therapeutic agent as generated
prior clinical trials with other similar cancer
patients?
 f E v id e n ce -
S t e p s o
III. Key
d P r a c ti ce
Base
 Evidence-Based Practice
Key Steps of Evidence-Based Practice
1. Ask the burning clinical question.
2. Collect the most relevant and best
evidence.
3. Critically appraise the evidence.
4. Integrate all evidence with ones clinical
expertise, patient preferences, values in
making a practice decision or change.
5. Evaluate the practice decision or change.
 Key Steps of Evidence-Based Practice
Step 1: Formulate the Burning Clinical Question
Clinical questions should be asked in the
format that will yield the most relevant and best
evidence using the PICO format (i.e., patient
population, intervention of interest, comparison
intervention or status, and outcome).

P for the patient or problem

I for the intervention of interest
C for comparison, and
O for outcome.
 Key Steps of Evidence-Based Practice
Step 1: Formulate the Burning Clinical Question
e.g.,
In teenagers (the patient population), how
effective is Depo-Provera (the intervention)
versus oral contraceptives (the comparison
intervention) in the prevention of pregnancy
(the outcome).
When a clinical
problem generates
multiple clinical
questions, prioritize!
 Key Steps of Evidence-Based Practice

The next series of slides will present you with

clinical scenarios and ask you to identify for each:
What is your clinical question in PICO format?
What type of clinical question is this?
What is the best study design to answer this type
of clinical question?

Before advancing slides after each clinical

scenario, take a few moments to see if you can
answer the questions on your own
 Key Steps of Evidence-Based Practice

Clinical Scenario #1
On morning rounds in the Hem/Onc unit, a first
year resident turns to you for consultation. She
wants to discuss options for managing moderate
nausea and vomiting that result following
chemotherapy. She shares an experience a
relative had taking ginger when prochlorperazine
didnt provide effective relief and asks for your
input.
 Key Steps of Evidence-Based Practice
Answerable Clinical Question
PICO:
P In patients receiving chemotherapy who are
experiencing moderate nausea and vomiting
I is the use of ginger
C as effective as prochlorperazine
O in reducing nausea and vomiting?

Type of Question: Therapy/Treatment

Type of Study/Methodology: Double-Blind Randomized

Controlled Trial; Systematic Review/Meta Analysis of
RCT
 Key Steps of Evidence-Based Practice

Clinical Scenario #2
Traditionally, clinicians have used a conservative
approach to the diagnostic evaluation of head-
injured infants, arguing that infants are at increased
risk of intracranial injury (ICI) and that symptoms or
signs of brain injury may not be reliably present in
those with ICI. A number of previous studies have
reported that a significant fraction of ICIs in infants
occur in patients with a normal neurological status
and with no signs or symptoms of brain injury. You
want to see how well clinical features predict ICI in
infants.
 Key Steps of Evidence-Based Practice
Answerable Clinical Question
PICO:
P Among children with minor head injury
I does the use of CT scan
C versus other clinical findings
O affect identification and diagnosis of intracranial
hemorrhage?

Type of Question: Diagnosis

Type of Study/Methodology: Controlled Studies;

Systematic Review/Meta Analysis of Controlled Studies
 Key Steps of Evidence-Based Practice
Step 1: Formulate the Burning Clinical Question

Limits of PICO

This model works best for Therapy/Treatment &

Diagnosis questions.
Remember, PICO is a model, not a rigid structure.
 Key Steps of Evidence-Based Practice
Step 2: Search for Best Evidence
First begin with, systematic or meta-analyses
and evidence-based clinical practice
guidelines, which are regarded as the
strongest level of evidence on which to base
practice decisions (Guyatt & Rennie, 2002).