EBM101-EBN2024

What is EBN?

Evidence based nursing, or EBN, is a form of clinical practice that relies on research findings to manage the health problems of a patient. It involves several processes that can contribute to a better understanding of a patient’s condition as well as the effectiveness of a certain treatment method. Evidence based nursing usually begins with the formulation of a question concerning a patient’s medical condition, and then, research is performed to find answers to the question. The relevancy of the research has to be proven and alternative forms of medical care have to be considered before evidence based practice is implemented. (http://www.nursegroups.com )
國際護理榮譽學會（Sigma Theta Tau International, 2004）的定義：
實證護理為涵蓋現有之最佳證據及護理實務經驗，並重視個人及所屬家庭及社區之價值及偏好的護理照護。

Wikipedia, the free encyclopedia ：
Evidence-Based Nursing or EBN is a type of evidence-based healthcare, drawing on some of the traditions of evidence-based medicine. It involves identifying solid research findings and implementing them in nursing practices, in order to increase the quality of patient care. The goal of EBN is to provide the highest quality and most cost-efficient nursing care possible. EBN is a process founded on the collection, interpretation, and integration of valid, important, and applicable research. Some define EBN tightly, considering only the application of the findings of randomized clinical trials, while others also include the use of case reports and expert opinions.^[1] In order to practice evidence based nursing, practitioners must understand the concept of research and know how to accurately evaluate this research. These skills are taught in modern nursing education and also as part of professional training....More (http://en.wikipedia.org/wiki/Evidence-based_nursing)
(1)LoBiondo-Wood, G., & Haber, J. (2006). Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice. St. Louis, Missouri:
Mosby Elsevier.

實證護理的目的（Closs & Cheater, 1999 ; Rycroft-Malone, Bucknall & Melnyk, 2004）：
1 提供最佳的照顧方式
2 維護病人的安全及最大利益
3 降低成本

三個〔E〕的整合，以提供病人最安全及能符合期望的一種臨床工作方式及態度。
　

＊最佳文獻證據（Evidence）
　

•＊醫護人員的經驗（Experience）
　

＊病人的期望（Expectations）

The Steps in the EBN Process

1	Formulating a searchable question→ PICO	(領導護理 2005;6(1):p.8-15)
	整理出一個可以回答的問題
2	Searching the literature efficiently
	找出最佳文獻證據
3	Appraising the literature critically
	嚴格判讀文獻→信效度、可推廣性
4	Applying the result to clinical practice or patient
	整理文獻證據，應用於病人身上（臨床實務）
5	Evaluating the outcomes of the applied evidence in your practice or patient
	針對以上步驟，進行臨床稽核（評估效果）

證據分級系統：

一般常用的證據分類系統如下：
Scottish Intercollegiate Guidelines Network
American College of Chest Physicians
Oxford Centre for Evidence-based Medicine
Australian National Health and Medical Research Council
US Task Force on Community Preventive Services
（如何撰寫臨床指引/林菁華,蔡伶觀, p.61-63）

* Oxford Classification （Center for Evidence-Based Medicine, 2001）（www.cebm.net)
以臨床問題類型為主的證據等級
　

Grade of Recommendation 建議分級	Level of Evidence 證據等級	Therapy/Prevention 治療或措施
〔A〕	1a	Systemic review of RCTs 隨機控制試驗的系統性文獻回顧
	1b	Single RCT 單一隨機控制試驗
	1c	All-or-none 有一致性結果的個案報告
〔B〕	2a	Systemic review of cohort studies 世代性研究的系統性文獻回顧
	2b	Cohort study or poor RCT 世代性研究或較不嚴謹的隨機控制試驗
	2c	Outcomes research 成效研究
	3a	Systemic review of case-control studies 病歷對照研究系統性文獻回顧
	3b	Case-control study 病歷對照研究
〔C〕	4	Case series 個案報告
〔D〕	5	Expert opinion, physiology, bench research 綜論

* Melnyk和Fineout-Overholt (2005)

證據等級	治療或措施
Level I	隨機控制試驗的系統性文獻回顧、統合分析或以隨機控制試驗的系統性文獻回顧為基礎發展的實證臨床照護指引
Level II	證據來源至少有一個為設計良好的隨機控制試驗
Level III	證據來源非隨機化但設計良好的控制試驗
Level IV	設計良好的個案控制研究及世代研究之證據
Level V	描述性及質性研究的系統性文獻回顧之證據
Level VI	單一描述性研究或質性研究之證據
Level VII	專家報告或專家意見

* 中央健康保險局 (2004)
SIGN和NICE⁴所採用以研究設計類型為主的證據等級，證據等級的分類如下：

等級	實證類別
1++	高品質之整合分析（meta analysis），系統性文獻回顧（systematic reviews）之隨機控制試驗（RCTs），或該隨機控制試驗之設計誤差（bias）極低．
1+	執行良好之整合分析（meta analysis），系統性文獻回顧（systematic reviews）之隨機對照試驗（RCTs），或該隨機控制試驗之設計誤差（bias）極低．
1-	整合分析（meta analysis）系統性文獻回顧（systematic reviews）之隨機對照試驗（RCTs），或該隨機控制試驗之設計誤差（bias）偏高．
2++	1. 經過病例對照研究（case-control study）或世代研究（cohort study）之高品質系統性文獻回顧． 2. 高品質的病例對照研究法及世代研究法可降低干擾、誤差及機率，並且具有高度的因果相關．
2+	經過病例對照研究（case-control study）或世代研究（cohort study）之設計良好的系統性文獻回顧．
2-	研究誤差（bias）較高之病例對照研究或世代研究．
3	非分析性之研究，例如：個案報告．
4	專家意見
	SIGN：Scottish Intercollegiate Guidelines Network NICE：National Institute for Health and Clinical Excellence

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Evidence-Based Nursing （EBN）〔實證護理〕