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![Page 1: Onderzoek ontmoet praktijk Evidence meets practice Helen Spiby Mother and Infant Research Unit University of York, UK 11 th December 2007.](https://reader036.fdocuments.in/reader036/viewer/2022062423/56649e165503460f94b0121d/html5/thumbnails/1.jpg)
Onderzoek ontmoet praktijkEvidence meets practice
Helen Spiby
Mother and Infant Research UnitUniversity of York, UK
11th December 2007
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Where evidence meets experience
PLAN
• Overview EBP process
• Identifying research questions from midwifery practice
• Early Labour Support & Assessment trial
• Suggest ways to increase midwives’ involvement in evidence based practice
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The three elements of evidence-based health care
The professional’s
expertise, skills and judgement
The needs and preferences of patients and
clients
The best available evidence
Evidence-based healthcare
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Evidence Based Practice in Midwifery
Why?• Best possible care & outcomes• Ethical imperative• Reduce variations in practice• Efficient use of finite resources• Professional accountability• Women & families as partners
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Alternatives to Evidence Based Practice
•Opinion-based practice
•Custom
• Interventions implemented/ practice changes without a strong evidence base
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Procedures : evidence of harm/mixed effects/no clear evidence/evidence
applied inappropriately
•Supplementation with formula for breastfed babies
•Routine rupturing of membranes
•Not suturing second degree tears
•Placing babies prone to sleep
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Overview of the EBP process
• Identifying questions from practice
•Locating the evidence
•Critically appraising the evidence
•Utilisation in practice
•Evaluation & reflection
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Identifying questions from practice
Formulating the question: PICO
•Population
• Intervention/exposure
•Comparison
•Outcome
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Identifying questions from practice: PICO
•Population- description of a similar group of women/babies
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Identifying questions from practice: PICO
• Intervention– treatment– therapeutic intervention– screening– diet
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Identifying questions from practice: PICO
•Comparison– alternative option– control/current treatment
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Identifying questions from practice: PICO
•Outcome– clinical : wellbeing enhanced– organisational– economic
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Relating questions to research methods
•Effectiveness of treatment: systematic reviews/ randomised controlled trials
•Effect of environmental factors on health: cohort & case control studies
•Women’s experiences : qualitative (interviews) & quantitative (questionnaire surveys)
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Locating the evidence:Evidence Based Healthcare: Resources
•Pre-synthesized information
•E.g. systematic reviews, evidence summaries; higher quality clinical guidelines (NICE); Practice Standards (KNOV)
•Cochrane Reviews
• Individual studies
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Critical appraisal
•Was an appropriate research method used to answer that question?
• Is the research described comprehensively?
•Was the context relevant?
Resource: CASP www.phru.nhs.uk
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Critical appraisal
• Is there a clear focus to the research question?
•Appropriate allocation between groups?
•How were outcomes measured?•What is the risk of bias?•How are results presented?•Valid conclusions?
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Identifying questions from practice:some examples
•Are there midwifery practices that prevent perineal trauma ?
•What are women’s experiences of labouring in water ?
•Should women in early labour receive midwifery care at home ?
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Practices: impacts unknown & evidence required
•When should support start once women are in labour?
•What information do women need in early labour?
•What is the appropriate schedule for vaginal examinations in early labour?
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Asking questions about effectiveness
• Impacts at individual level
• Improvements in physical/ emotional wellbeing
•Consequences/ side-effects
•Uptake/ acceptability
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Identifying & measuring outcomes
•Clearly defined & interpreted consistently
•Valid & reliable methods of measurement
•Risk of bias minimised
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The Early Labour Support and Assessment trial (ELSA)
Funded by: NIHR Service Delivery & Organisation of Care programme
Conducted by: a midwifery-led multi-disciplinary research team
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•Arriving at hospital early- more intervention during labour; higher rate of instrumental & operative births
•10-33% women admitted to a delivery suite are not in labour
•97% births in UK in hospital
•Caesarean Section rate 22%: national concern
•40%-50% first babies born by CS/ instrumental birth
in Yorkshire in 2001
Background (1)
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Critical appraisal of existing research:
• Methodologically prone to bias• Settings unrepresentative of current UK maternity care• Home visits not tested as a single intervention
Background (2)
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Aim & Research design
To determine the effect of offering home visits by a midwife to nulliparous women in early labour
Using
A multi-centre randomised controlled trial with cost-effectiveness analysis
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Intervention
Offer of a home visit by a community midwife (08.00-21.00)
Advice & support, assessment of wellbeing & progress
Control Group
Standard care - telephone contact with labour & delivery suite; advice to attend for assessment
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Outcomes
Primary:• Caesarean section in labour & instrumental vaginal
birth
Secondary:• Impacts on labour: length, pain relief, procedures• Maternal & neonatal complications• Breastfeeding • Women’s emotional wellbeing & experiences of care• Health professionals’ views & experiences• Economic analysis
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Timetable & progress
•Recruitment August 2004 – July 2006
•3500 participants; 11 clinical sites in England
•Analysis in progress; Final report March 2008
•Active dissemination to all stakeholders
•Conference September 2008
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Workshops
•Please divide into 4 groups
•Work in small groups
• Identify a writer, work through the task; hand notes to facilitator
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Workshops
• Identify an issue from practice that you encounter nearly every day with your students & develop a research question-
Using the PICO framework
•Which type of research would answer that question?
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Challenges to EBP in midwifery
•Access to & quantity of evidence
•Providing women with evidence
•Changing professional practice
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Changing professional practice
Consistently effective:
•Educational outreach visits
•Manual/computerised reminders
•Multifaceted interventions
• Interactive educational meetings
Haines A. (2001) Getting research into practice. 2nd ed. London: BMJ
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Changing professional practice
Mixed effects:
•Audit & feedback
•Local opinion leaders
•Local consensus processes
•Patient-mediated interventions
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Evaluation & reflection
•Evaluation - early, under-resourced, methodologically weak
•Reflection- individual & system-based approaches
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Evidence based practice in midwifery: making it happen
•Throughout midwifery –policy, education, practice; avoid divisions
•Education & skills
•Building capacity
• Infra-structure support
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Core skills & attitudes for EBP in midwifery
•Formulating questions about practice
•Ability to locate evidence
•Skills in critical appraisal
•Ability to collaborate & lead research
• Implementation knowledge
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Evidence based practice in midwifery: making it happen
Build capacity by creating opportunities
•Secondments- clinical midwives joinresearch teams ; mentorship
• Joint appointments – shared fundingbetween academic & practice settings
•Academic midwifery practices
•How do we involve midwifery students?
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Evidence based practice in midwifery: making it happen
Build capacity by creating opportunities
•Career pathways
•Academic development funding streams
•What opportunities are there for you ?
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Opportunities- in the Early Labour trial
•Midwifery Research Fellow –PhD
•Local Midwifery Co-ordinators – 10 midwives, part –time, working in practice
•Midwives : investigators, all Trial Committees & working groups
•2 Midwives seconded into MIRU working on the trial
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Evidence based practice in midwifery: making it happen
Infrastructure support• Identify existing systems that could foster
EBP e.g. Journal clubs ; academic assessments
• Information specialists• Link activity to policy, professional &
public health priorities• Develop skills in acquiring funding • National & international collaborations
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Evidence based practice in midwifery: making it happen
• Identify support systems
•Engage stakeholders
•Set achievable goals, celebrate early success
•Evaluate & disseminate all experiences