Critical Inquiry Quiz 3

Nursing Organizations that incorporate EBP into standards/expectations of leadership

- ANA - AONE - ANCC

Phase 1 of OMM

- Define clinical problem incl structure/process contributors and descriptive and confounding variables - identify desired outcomes and related measures - build database - measure baseline

Research is

- Directional - based on theory - generalizable - high reliability

Levels of data measurement

- Nominal - Ordinal - Interval - Ratio

QI techniques and models used

- PDCA - DMAIC - six sigma - TQM - lean process - dashboards and scorecards

QI process is

- about fixing problems - based on internal data - process focus - not generalizable - limited reliability

Authentic leadership 4 central behaviors

- balanced processing - internalized moral perspective - relational transparency - self-awareness

Factors influencing EBP implementation

- beliefs and attitudes - knowledge - organizational commitment - organizational support - organizational culture responsive to change - support of ideas/initiatives

Phase 4 of OMM

- close first data collection cycle - analyze results and disseminate to stakeholders - identify opportunities for further improvement - return to phase 2 to begin refinement of improvement

Phase 2 of OMM

- compare appraised evidence with traditional practice - engage stakeholders - negotiate adoption of new practice - develop methods to support new practice - adopt new standard

Phase 3 OMM

- educate all stakeholders - assure that role models and resources are available for troubleshooting - monitor reliability and stability of measures and refine as needed - finalize the refined process and measurement methods - begin data collection

Interventions vital to consistent implementation of EBP

- education combined with active repetitive skills building - mentorship and support - culture and environment supportive - leaders and managers who support and role model - strategies that overcome system barriers

Basic principles supporting outcomes management

- emphasizing practice standards that providers can use to select interventions - measuring patient functional status, well-being, and disease-specific clinical outcomes - pooling outcome data on a massive scale - analyzing and disseminating outcomes, in relation to the interventions used, to appropriate decision makers and stakeholders

EBP integration

- est formal implementation teams - build excitement while implementing EBP - disseminate evidence - develop clinical tools - pilot test EBP change - preserve energy sources - allow enough time for success - celebrate success

Competencies of the innovative leader

- focuses on the essence of the innovator - possessed knowledge and experience in concepts and processes of innovation - possesses an understanding of their own personal strengths and limitations - demonstrates effective collaboration based on listening, encouraging feedback, openness, and conflicting resolution - manages considerable amounts of data and info and quickly evaluates the evidence, its value, and potential outcomes - collects related info when gaps are identified - evaluates new technology from the perspective of enhancing the organization - coaches others in the principles of innovation, adult learning, and change

10 key visions for guideline development and use

- globalize the evidence - focus on relevant Qs - undertake relevant collaborative evidence reviews - use a common assessment metric - consider comorbidities - identify ways that help guideline consumers - deal with conflicts of interest - support development of decision aids - maintain international collaboration - examine collaborative models

Implementing EBP guidelines into daily clinical practice requires

- individual skills - developing a supportive culture and context - providing mentors - administrative support

Leadership theories for contemporary nursing and healthcare leadership

- innovation leadership - transformational leadership - servant leadership - authentic leadership

Foundational characteristics central to servant leadership

- intent and careful listening to others - seeking to understand and empathize with those they lead - healing relationships by helping others to solve problems and conflicts, thus supporting and promoting personal growth in others - self-awareness that allows a better understanding of issues surrounding ethics, power, and values - ability to build consensus among others and a reliance on persuasion rather than power to influence - seeing beyond the day-to-day and focusing on long term goals - learning from the past to understand the present consequences of decisions - belief that serving the needs of others is an obligation - commitment to the personal, professional, and spiritual growth and development of each individual - desire to develop a true community among businesses served

GRADE strong recommendation

- intervention outweigh its undesirable effects - implies that most or all individuals will be best served by the recommended course of action - not necessarily high priority recommendations because that will depend on importance of outcome

QI process

- monitor EBP practice change and outcomes continuously - modify practice based on results - generate internal evidence - improve care

EBP questions are

- not directional - based on clinical inquiry - outcomes focus - not generalizable - varied reliability

Evaluating EBP clinical outcomes

- outcome measures - quality care improvement - patient centered quality care - efficiency of processes - environmental changes - professional expertise

Sources of internal data for EBQI

- quality management dept - finance dept - HR - clinical systems - administration - EHR

challenges of clinical practice guidelines

- recommendations largely developed from lower levels of evidence or expert opinion - guidelines with conflicting recommendations - guidelines may be difficult to implement

2 methods of presenting data in an understandable way

- scorecards (table w/operational, quality, and satisfaction reporting) - dashboards (graph)

Research process

- search literature to determine gap - ask a research question or test a hypothesis - generate new knowledge - disseminate findings

EBP process

- search/appraise internal and external evidence - implement practice change based on best evidence - measure outcomes of practice change - disseminate findings

GRADE provides a framework for

- specifying healthcare questions - choosing outcomes of interest and rating their importance - evaluating the available evidence - bringing together the evidence with consideration for values and preferences of patients and society

GRADE weak recommendation

- undesirable effects probably outweigh the desirable effects, but appreciable uncertainty exists - implies that not all individuals will be best served by the recommended course of action - consider more carefully individual patient's circumstances, preferences, and values; allocate more time to shared decision making

Cronbach's alpha

.80+ indicates that an instrument should perform reliably each time that it's used

Steps to implementing evidence in clinical settings

0. Cultivate a spirit of inquiry 1. Ask the PICOT question 2. Search for the best evidence 3. Critically appraise the evidence 4. integrate the evidence with your clinical expertise and patient preferences to make the best clinical decision 5. evaluate the outcomes of the EBP practice change 6. disseminate the outcomes

GRADE 3 categories of outcomes according to importance for decision making

1. Critical 2. important but not critical 3. limited importance

4 dimensions of transformational leadership

1. Idealized influence 2. Inspirational motivation 3. Intellectual stimulation 4. Individualized consideration

7 Ethical principles as applied to research, EBP, and EBQI

1. social or scientific value 2. scientific validity 3. fair subject selection 4. favorable risk-benefit ratio 5. independent review 6. respect for potential and enrolled subject 7. informed consent

outcomes management (OM) is

A technology of patient experience designed to help patients, payers, and providers make rational medical care-related choices based on better insight into the effect of these choices on patient life

Ex of national organization guideline

Am heart Ass Am Cancer society

AGREE stands for

Appraisal of Guidelines for Research and Evaluation

EBP Q

Are we doing the best thing? focus on implementing

Reliability asks

Does the instrument measure the construct consistently every time it is used?

Clinical management includes

EBP

A vision for EBP

EBP mentors preparation and planning promoting small changes over time creating a motivating image for change sharing the vision

Research, EBP, or QI? A PT reads a clinical practice guideline about the benefits of yoga for individuals with low back pain and decides she would like to incorporate yoga practices into her her client's care. She shares info about yoga practices with her clients. If clients agree to add yoga to their plan of care, she asks them to complete a pre- and post - survey at the start and end of therapy to evaluate the effectiveness of this approach. She shares her findings in a poster presentation at a local symposium.

EBP project - change in practice based on evidence - all/most clients included - results may be disseminates as long as this is described as an EBP project

Interval ex

Fahrenheit temp scale

T or F? The Health outcomes institute's outcomes management model provides a four step process for the critical appraisal of evidence

False - it delineates a process that can be used to guide measurement of the impact of new interventions on improving healthcare outcomes

Health Outcomes Institute's Outcomes Management Model

First model to provide steps to guide measurement of the impact of new interventions on improving healthcare outcomes

GRADE stands for

Grading of Recommendations Assessment, Development, and Evaluation - quality of evidence and strength graded

Ratio ex

Kelvin temp scale

EBP techniques

PICOT ARCC PARIHS Stetler, Rosswurm & Larrabee, Iowa, Hopkins

Research, EBP, or QI? An NP working in an acute care setting notices a rise in the incidence of central line infections among his pts. He develops a protocol for RNs to use when caring for pts with central lines, educates nurses on its use, and implements protocol. He monitors institutional data before and after implementation to determine how this affects infection rates throughout the hospital. He shares his findings in the institution's newsletter and gives a presentation on his findings to hospital staff and administrators.

QI - change in process based on institutional data - universal implementation in facility - results may be disseminates as long as they are described as quality improvement

Research techniques and models used

Quantitative research methodologies Qualitative research methodologies

Research, EBP, or QI? An SLP notices that many of her pts with childhood apraxia or speech also show symptoms of learning disability and wonders if there is an association between these conditions. She decides to survey parents of children with apraxia to measure sx of learning disability in this population. She shares her findings in a presentation at a local conference.

Research - hypothesis testing - specific target population - results are disseminated with intent to add to generalized knowledge

Research Q

What is the best thing to do? Utilizing focus

Authentic Leader

a composite of other leadership types; these leaders are confident, hopeful, optimistic, resilient, transparent, self-aware, and possess high moral character ensure their communication is transparent and comprehended as intended

UVM IRB definition of research

a systematic investigation, including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge

Select all of the barriers that still have impact on building and sustaining and environment favorable to EBP: a. organizational support and commitment b. resistance to EBP implementation c. attitude about the importance of EBP d. knowledge about EBP processes

a, b, d attitude toward importance of EBP to clinical practice has improved

balanced processing

ability to objectively analyze data to formulate decisions while soliciting views that may challenge ideas without being self-protective

HIPAA regulations require IRB approval of

all studies involving personal healthcare info

QI Q

are we doing the best thing right, and continuously? focus on conducting

Inspirational Motivation

articulates a clear vision that inspires and motivates others to accomplish great achievements

Promoting engagement

assessing & eliminating barriers prioritizing clinical issues evaluate the infrastructure develop experts in the EBP process

AGREE instrument is used for

assessing guidelines

GRADE instrument is used for

assessing guidelines

Which of the following 2 sources would be the most likely to house the data needed to measure patient outcomes related to a proposed change in the nursing skills mix at a hospital? a. finance and administration b. HR and quality management c. clinical systems and EHR d. Administration and quality management

b. HR and quality management HR is key source of data related to nursing skills mix & quality management collects data on pt outcomes through incident reports, pt satisfaction scores, and data collection for regulatory or accreditation bodies

A rating scale asks pts to rate their nausea by describing it as "no nausea" "slight nausea" "significant nausea" or "severe nausea". What is the highest level of data measurement that this scale provides? a. nominal b. ordinal c. interval d. ratio

b. ordinal In likert-type scales, data can be ranked in order, but the absolute difference between each interval is not equal. It is not possible to calculate a mean or standard deviation

Ex local guidelines

care protocols agreed upon by dept, local institution, local hospital

Ex of central level guideline

clinical practice guidelines developed by federal/national govt

At UVM EBP projects and QI projects generally do not

constitute "research" and do not require IRB approval

Not all clinical practice guidelines have the same rigour, so

critical appraisal is needed before adopting them for implementation in clinical practice settings

Ordinal

data can be ranked in order, but the absolute difference between each level is not equal

Nominal

data sorted into categories; any numbers assigned to categories used only for labeling

Research purpose

discovering new knowledge that can be generalized to large groups of ppl

intellectual stimulation

encourages innovation and creativity by empowering others to explore new ways of doing things and approaching problems using the EBP process

IRB for EBP

for protection of data and publication

IRB use for research

for protection of human subjects

IRB for QI

for publication

Nominal examples

gender presence or absence of quality (disease)

QI purpose

generating internal evidence about process and outcomes in the setting/environment that generated it

EBP purpose

implementing knowledge through practice change in narrow population and measuring outcomes

Validity asks

is the instrument measuring what it is supposed to measure?

Servant leader

leadership based on the essential elements of trust, empathy, caring, and focused on others

Ordinal ex

likert scales

Even if no IRB approval is required, you are responsible for

maintaining ethical implementation - protection of confidentiality/privacy - risk-benefit ratio

Interval

numeric data with equal and consistent mathematical values separating each discrete measurement point, however, lack an absolute zero

Leader

one who provides a vision and motive and is an inspiration to others

In review Qs, it is essential to have

precise description of target population, setting of care, interventions, intermediate, and health outcomes

How guidelines are developed

processes and panels review Qs lit search and review evidence based recommendations peer review & dissemination

clinical practice guidelines are statements that include

recommendations for practice based on a systematic review of evidence along with the benefits and harm of interventions intended to optimize patient care and outcomes

Clinical practice guidelines that are rigorously developed

reduce variations in care and enhance healthcare quality and pt outcomes

If it is possible that knowledge might be shared outside of the specific QI initiative or institute, then IRB approval is

required PRIOR to initiation of the project

Idealized Influence

role models with a focus on doing things right rather than ensuring that others do the right things

Ratio

same data characteristics as interval-level data, but also has an absolute zero value

How to access guidelines

search by adding the clinical areas or interventions of interest searching citation databases for EBPGs can present challenges not all guidelines are published in indexed journals or books, making it difficult to locate

Staff and stakeholders to engage in all levels

staff clinicians leadership team members advanced practice RNs stakeholders of all disciplines directly affected physicians family advisory board allied health professionals doctorally prepared nurse researchers EBP mentors

robust and realistic research Qs will guide the literature review and

subsequent recommendations

individualized consideration

supports and encourages others by offering reward and recognition for unique contributions

EBQI is

systematic and continuous actions that lead to improvement in health services and the health status or health outcomes of targeted patient groups

Content validity

the minimum demonstration of validity needed; often reflected through a panel of experts reviewing the instrument

AGREE evaluates

the process of practice guideline development and the quality of reporting - 7 point scale from 1-7 (1 being strongly disagree to 7 strongly agree) depending on completeness and quality of reporting - recommends 4 appraisers for each guideline

What is most important is not how the study or project is classified but

whether the activity is ethically appropriate