EBP 1

What are Clinical Practice Guidelines?

*Systematically developed statements to assist clinicians and patients in making decisions about care*; ideally, the guidelines consist of a systematic review of the literature, *in conjunction with consensus of a group of expert decision makers*, including administrators, policy makers, clinicians, and consumers who consider the evidence and make recommendations

What is a Boolean operator?

-"AND": narrows search, restrictive word, reduces number of articles cited -"OR": expands search, citations have either one or both terms

What is The AGREE instrument?

-*Appraisal of Guidelines for Research and Evaluation* -*Appraisal instrument for the National Health Services* -To formally evaluate the usefulness of a guideline appraisal instrument -The U.K National Health Services Management Executive began development of an appraisal instrument for the National Health Services in 1992; its completion was subsequently funded by the European Union -Final Development and evaluation was done by an international group of guideline developers and researchers -*Meant for use by a panel of reviews rather than for individual use*

Bias: Loss to follow up

-*Attrition could occur due to unforeseen side effects of the intervention or burdensome data collection procedures*, leading to non-comparable groups -May lead to measurement bias -The factors for why there is a loss of follow up is usually out of control, but can lead to non-comparable groups and should be noted and addressed in reports of the study

Describe Guba and Lincoln Criteria of Trustworthiness

-*Credibility*: i. Demonstrated by accuracy and validity that is assured by thorough documentation ii. Approximates to internal validity in quantitative appraisal -*Transferability*: i. Demonstrated by information that is sufficient for a research consumer to determine whether findings are meaningful to other people in similar situations ii. Approximates to external validity -*Dependability*: i. Demonstrated by a research process that is carefully documented to provide evidence of how conclusions were reached and whether, under similar conditions, a researcher might expect to obtain similar findings ii. Approximates reliability -*Confirmability*: i. Demonstrated by providing substantiation that findings and interpretations are grounded in the data ii. Approximates objectivity

Keyword search

-*First major search strategy, key words are generated from the PICOT question* -Strengths: Provides quick snapshot of resource's relevance to PICOT question, identifies records when keyword appears with and without major relevancy, included in 3 most powerful search strategies -Weaknesses: Misses studies with authors' choice of keywords differ, requires advanced search skills to quickly sort for relevancy among too many citations, required combined subject headings to search, requires all 3 strategies to achieve certainty nothing was missed

Bias: Knowing who receives which treatment

-*Occurs if subjects or those measuring the outcomes know the subject group assignment* -*Is reduced by blinding*, in which subjects and those measuring outcomes don't know the groups assigned

Subject heading search

-*Second major search strategy, an advanced searcher will utilize a standardized set of preselected terms known as subject headings in order to locate all material that is available on a particular topic* -Strengths: Provides quick snapshot of resource's relevance to PICOT question, retrieves only citations when topic is at least 25% relevant to topic, increases chances that best citations will not be missed when authors and searchers use different synonyms because of database, retrieves citations searched using related and narrower MeSH terms associated with the searcher's MeSH, increases chances that MeSH's broader terms identifying fields, environments, settings, industries, can be combined with a very specific common keyword to target relevant citations, included in the 3 most powerful search strategies -Weaknesses: Not always assigned for every keyword (e.g. cutting edge new terminology, coined phrases, etc.), may not yet be assigned MeSH or not be a successful match for auto mapping, requires combining 3 major search strategies to avoid missing something, not available across all major databases/search engines

Define the following qualitative research traditions: Ethnography

-*Studies of a social group's culture through time spent combining participant observation and in-depth interviews in the informant's natural setting* -Addresses questions about experiences *within a specific culture*, provides a better understanding of answers to specific research questions regarding: 1) Health/ illness 2) Caregiver concerns 3) Response to certain types of settings

How does bias relate to the validity of a study?

-*The validity of the study measures whether or not the results of the study are as close to the truth as possible. Certain biases can effect the validly of the information* -Did the investigators applying the intervention know which groups the subjects were assigned? -Were the instruments calibrated according to manufacture specifications? -How many subjects were lost to follow-up and what groups were they in?

Define the following qualitative research traditions: Phenomenology

-*Used to study the essences intuited or grasped through descriptions of lived experience* -Lived experience: understanding about life's meanings, which lie outside of a person's conscious awareness -*Addresses questions about how people perceive their experiences in a specified situation to achieve better understanding of the phenomenon* -*Offers perspectives shaped through ongoing intellectual dialogue rather than explicit procedures*

Define the following Qualitative research techniques: Interviews and focus groups

-*Ways in which the informants express their own thoughts, remembrances, reflections and ideas* 1) *Unstructured, open-ended* - informal conversation occurring in the natural course of participant observation 2) *Semistructured interview* - more formal conversation, using interview guides which outline the topics and questions to be covered, uses flexible questioning which allows informants to answer in their own ways 3) *Structured, open-ended* - uses a question format with little flexibility in the way the questions are asked, but allows informants to respond on their own terms 4) Focus groups are group interviews that generate data on designated topics through discussion and interaction

Define Qualitative Research

-A formal, objective, systematic process in which numerical data are used to obtain information about the world by: i. *Describing variables* ii. *Examining relationships among variables* iii. *Determining cause and effect interactions between variables*

Define Confidence Interval

-A measurement of the precision of the estimate -The 95% CI is the range of values within which we can be 95% sure that the true value lies for the whole population of patients from within the patients that were selected for the study

What is a Foreground Question?

-A question that can be answered from scientific evidence about diagnosing, treating, or assisting patients in understanding their prognosis. These questions focus on specific knowledge. -In children, how does Tylenol compared to advil affect fever? -In patients at risk for pressure ulcers, how do pressure mattresses compare to pressure overlays affect the incidence of pressure ulcers?

What is a Background Question?

-A question that need to be answered as a foundation for asking the searchable, answerable foreground question. -Ask about general information about the clinical issue. Far broader in scope. Involves 2 components: the who, what, where, when, why, and how as well as the outcome of interest. -How does the drug Tylenol work to affect fever? -How does hemodynamics differ with positioning?

List the Three Components of EBP and define each

-Best external evidence from research, evidence-based theories, opinion leaders, and expert panels. -Clinical expertise (i.e. internal evidence generated from outcomes management or QI projects, a thorough patient assessment and evaluation and use of available resources). -Patient preferences and values

List the Sources of External Evidence, in which subject heading searches would be effective

-CINAHL -Cochrane databases -EMBASE -Joanna Briggs Institute EBP database -MEDLINE -PscyINFO -Scottish Intercollegiate Guideline Network

Define each of the American College of Cardiology (ACC) and the American Hospital Association (AHA) classification of recommendations from Practice Guidelines

-Class I: conditions for which there is evidence and/ or general agreement that a given procedure or treatment is useful and effective -Class II: conditions for which there is conflicting evidence and/ or a divergence of opinion about the usefulness/ efficacy of a procedure or treatment -Class IIa: weight of evidence/ opinion is in factor of usefulness/ efficacy -Class IIb: usefulness/ efficacy is less well established by evidence/ opinion -Class III: conditions for which there is evidence or general agreement that the procedure/ treatment is not useful/ effective and in some cases may be harmful

Title search

-Final major search strategy. *Searching your P, I, and O terms in the title increases the chance of finding relevant citations*. -Strengths: Provides quick snap shot to resources' relevance to topic, increases chances that keywords appearing in title are major topics, increases chances that the P & I are related as required for PICOT question, increases chances assigned subject headings are precise and best for a subject heading search, effective in quickly targeting highly relevant articles within all search strategies, included in 3 most powerful search strategies -Weaknesses: Misses studies when author's choice of title words differ, requires all 3 major strategies to achieve certainty nothing missed, not available across all search engines/databases

What are Evidence-Based Practice Guidelines (EBPG)?

-Guidelines intended to optimize patient care and outcomes that include recommendations for practice based on a systematic review of evidence that includes the benefits and harms of interventions -Benefits: i. Based on previously appraised evidence ii. Allow flexibility in application to patients who fall outside the guideline's scope or who have significant comorbidities not adequately addressed in the guideline -Issues: i. Reporting of the rigor of the evidence search used for guideline development varies significantly ii. Reporting on how the evidence was appraised and the level of evidence finally used for guideline formulation varies significantly (since we aren't appraising the guideline we want to know how they appraised it) iii. A guideline search may yield guidelines with conflicting recommendations iv. Guidelines may be written in ways that are difficult to implement

Define the following Qualitative research techniques: Data management and analysis

-In appraising qualitative studies, it is important to understand how data are managed and analyzed. *Qualitative studies generate large amounts of narrative data that need to be managed and manipulated*. -Personal computers and word processing software facilitate data management including: 1) Data entry 2) Cleaning or editing 3) Storage and retrieval -*Qualitative data management: the act of designing systems to organize, catalog, code, store, and retrieve data*. (System design influences, in turn, how the researcher approaches the task of analysis) -Computer: assisted qualitative data analysis - an area of technological innovation that in qualitative research has resulted in uses of word processing and software packages to support data management -Qualitative data analysis: *a variety of techniques that are used to move back and forth between data and ideas throughout the course of research*

Define the following Qualitative research techniques: Mixing methods

-Inquiry that combines two or more methods -*Typically crossing qualitative and quantitative methods*

What does Magnitude of the Effect mean and how does it relate to the reliability of a study?

-It is a statistical determination to *decide whether or not the findings are reliable* -An increased number of subjects in a study are more likely to make the study more reliable

Define the following qualitative research traditions: Hermeneutics

-Method of *interpretation* of experiences through the interpreter's dialogical engagement -Example of a study of the meaning of comfort care for hospice nurses 1) Comfort 2) Relief 3) Peace and ease 4) Spirituality and meaning -Also associated with phenomenology as in hermeneutic phenomenology to denote summarizations as *interpretative* rather than descriptive

Define the following Qualitative research techniques: Narrative and content analysis

-Narrative analysis: a specific way to *generate, interpret and understand stories* about life experiences *from textual data* -Content analysis: most commonly used in qualitative reports, procedures involving *breaking down data* though coding, comparing, contrasting, and categorization, *then reconstituting it in some new form*, such as description, interpretation, or theory

List the Sources of External Evidence, which are free to users

-National Guideline Clearing House -MEDLINE - free via PubMed -National Institute for Health and Care Excellence -Registered Nurses Association of Ontario -Scottish Intercollegiate Guideline Network -Trip

List four evidenced-based practice guidelines (EBPG)/clinical practice guidelines web sites

-National Guideline Clearinghouse (NGC) -Canadian Medical Association -Registered Nurses' Association of Ontario -United States Preventive Services Task Force (USPSTF)

Define the following Qualitative research techniques: Observation and fieldnotes

-Observation: takes on difference dimensions 1) *Complete observer* 2) *Observer as participant* 3) *Participant as observer* 4) *Complete participant* -Fieldnotes: *self-designed, highly detailed records of observational protocols* for recoding notes about filed observations 1) Analytic notes are written by researchers about ideas for analysis, issues to pursue, people to contact, questions, personal emotions, and point of view understandings

Measurement bias

-Occurs if instruments are incorrectly calibrated (which will create higher or lower measurements) or if data collectors deviate from established data collection protocols, especially if observation is being used or psychological variables are being measured -*Can be reduced by making sure the tools used to measure the data are accurate*

Information bias

-Occurs in longitudinal cohort studies *if participants know the subject of the study and "act differently"* if they know that they are in the group that has been "exposed" to the condition being studied -Occurs when researchers record different information from interviews of patient records. *The risk of such information bias is higher when researchers know which participants are in the case group and which are controlled*

Bias: Gatekeepers

-Occurs when a well-intentioned person acts as a gate keeper in studies involving vulnerable populations, resulting in a sample not representative of the vunerable population -This introduces bias as healthier patients may respond differently to the intervention, creating a different outcome than if a more representative sample (larger number of vulnerable people) was included in the bias

Selection bias

-Occurs when participants are selectively assigned to groups -*Is reduced when researchers randomly assign participants to groups*

Recall bias

-Occurs when subjects are asked to recall past actions or events. Subjects may *give answers that are "socially acceptable" or that they "think" is what happened* -This can be a challenge with case-control studies in that people may not remember things correctly

What is Hierarchy of Evidence?

-Organization of levels of evidence -*Provides guidance about the type of research studies that are most likely to provide relevant and reliable answers to a specific clinical question* -There are different levels to the hierarchy, the level that is the most appropriate varies based on the clinical question being asked -*The higher the evidence ranks on the hierarchy, the more likely the results accurately represent the actual situation and the more confidence clinicians can have that the intervention will produce the same health outcomes in similar patients*

Define the following Qualitative research techniques: Sampling strategies

-Purposeful/ purposive sampling: intentional selection of people or events in accordance with the needs of the study -Nominated/ snowball sampling: recruitment of participants with the help of informants already enrolled in the study -Volunteer/ convenience sampling: sample obtained by solicitation or advertising for participants who meet study criteria -Theoretical sampling: in grounded theory, purposeful sampling used in specific ways to build theory

What are examples of Quantitative study designs?

-Research that *collects data in numeric form and emphasizes precise measurement of variables*; often conducted in the form of rigorously controlled studies -Randomized controlled trials (RCTs) -Appraising systematic reviews (SRs) -Case studies -Case-control studies -Cohort studies

What are the six AGREE areas of appraisal?

-Scope and purpose -Stakeholder involvement -Rigor of development -Clarity and presentation -Application -Editorial independence

What makes a study applicable? What is Applicability?

-The ability for the study outcomes to be applied and helpful to patients -Will the results help me in caring for my patients?

Define the following qualitative research traditions: Grounded Theory

-Used to generate theory, which is grounded in empirical data -Addresses questions about how people deal with life situations by describing processes by which they move through experience over time -May describe the process in terms such as phases or stages (ex: stages of grief)

What is the Goal of the National Guideline Clearinghouse (NGC)?

-Was developed by Agency for Healthcare Research and Quality (AHRQ) in partnership with the American Medical Association (AMA) and the American Association of Health Plans *-Goal: to create a comprehensive database of up-to-date English language EBPGs*

List the Steps of EBP

0 - Cultivate a spirit of inquiry within the environment -Without this spirit of inquiry the next steps of the EBP process are not likely to happen. 1 - Ask the burning clinical question in PICOT format -One of the fundamental skills required for EBP is the asking of well-built clinical questions. By formulating an answerable question you to focus your efforts specifically on what matters. These questions are usually triggered by patient encounters which generate questions about the diagnosis, therapy, prognosis or etiology. 2- Search for and collect the most relevant best evidence -The second step is to find the relevant evidence. This step involves identifying search terms which will be found in your carefully constructed question from step one; selecting resources in which to perform your search such as PubMed and Cochrane Library; and formulating an effective search strategy using a combination of MESH terms and limitations of the results. Use the PICOT question elements in your research. 3- Critically appraise the evidence (i.e. rapid critical appraisal, evaluation, and synthesis) -It is important to be skilled in critical appraisal so that you can further filter out studies that may seem interesting but are weak. Use a simple critical appraisal method that will answer these questions: What question did the study address? Were the methods valid? What are the results? How do the results apply to your practice? 4- Integrate the best evidence with one's clinical expertise and patient preferences and values in making a practice decision or change -Individual clinical decisions can then be made by combining the best available evidence with the your clinical expertise and your patients values. These clinical decisions should then be implemented into your clinical practice which can then be justified as evidence based. 5- Evaluate the outcomes of the change -Evaluate the effectiveness and efficacy of your decision in direct relation to your patient. Was the application of the new information effective? Should this new information continue to be applied to practice? How could any of the 5 processes involved in the clinical decision making process be improved the next time a question is asked? 6- Disseminate the outcomes of the evidence-based change -Clinicians can achieve wonderful outcomes for their patients through EBP, but they often fail to share their experiences with colleagues and their own or other health care organizations. This leads to needless duplication of effort, and perpetuates clinical approaches that are not evidence based. Among ways to disseminate successful initiatives are EBP rounds in your institution, presentations at local, regional, and national conferences, reports in peer-reviewed journals or professional newsletters and publications for general audiences

What are the seven critical steps to implementation of EBPG into practice?

1) Processes and structures that facilitate the use of EBP, including ongoing administrative support 2) A positive milieu with structures and processes that foster EBPG use 3) Interactive education with skills building practice and attention to patient education 4) Use of reminders 5) Electronic systems offering easy access to guideline and real-time outcome feedback 6) Organization structures and processes that alert staff to EBPG initiation and revision 7) EBP champions and mentors at all levels of the organization

List the three domains to grading the strength of a body of evidence:

1) Quality: the extent to which a study's design, conduct, and analysis have minimized selection, measurement, and confounding biases (internal validity) 2) Quantity: the number of studies that have evaluated the clinical issue, overall sample size across all studies, magnitude of the treatment effect, and strength from causality assessment for interventions such as relative risk or odds ratio 3) Consistency: whether or not investigations with both similar and different study deigns report similar findings

What is Clinical Inquiry?

A process in which clinicians gather data together using narrowly defined clinical parameters to appraise the available choices of treatment for the purpose of finding the most appropriate choice of action.

List government agencies which ensure quality practice for care

Agency for Healthcare Research and Quality (ARHQ): creates the National Health Care Quality Report which tracks the state of healthcare quality for the nation on an annual basis. It is the most extensive ongoing examination of quality of care in the United States as well as every industrialized country world wide.

Define the following qualitative research traditions: Fieldwork

All research activities carried out in the field (informant's natural settings)

How do you know if the result of a study is valid? What is Validity?

Are the results as close to the truth as possible? Did the researchers conduct the study using the best research method possible? (were study subjects randomly assigned or control groups and whether they were equal on key characteristics prior to treatment?)

What makes the results of a study reliable? What is Reliability?

Can clinicians expect similar results if they were to perform this intervention in their own clinical practice? Whether or not the intervention(s) worked and how large a treatment effect was obtained.

Define each of the following Steps for Developing EBPGs: Develop an analytic framework or causal pathway

Diagrams should provide a precise description of the target population, setting of care, interventions, and any intermediate as well as final health outcomes

Define each of the following Steps for Developing EBPGs: Develop recommendations based on the strength of the evidence:

Each question identified in the analytic framework should be addressed. If evidence is lacking for a specific recommendation and expert opinion used, this should be stated

What is External evidence?

It is generated through rigorous research (i.e. RCTs or cohort studies) and is intended to be generalized and used in other settings

Describe MeSH

Medical subject headings, which are a set of terms used by the NLM to describe the content of articles indexed in MEDLINE. If the MeSH term "acquired immunodeficiency syndrome" was searched, all of the articles would contain information about acquired immunodeficiency syndrome regardless of what terms the authors decided to use when writing, including HIV, HIV-positive, AIDS, STI, and STD.

Define each of the following Steps for Developing EBPGs: Identify the guideline panel

Members should be able to address relevant interventions, meaningful outcomes, benefits, and harms. Experts who bring the different perspectives of research, clinical practice, administration, education, policy, and feasibility should be included

Contamination

Occurs if intervention and control *groups have interaction and information is shared*, especially if the intervention is educational in nature

Define the components of the PICOT format:

P: Patient/population/problem I: Intervention (variable) C: Comparison O: Outcome T: Time

Define each of the following Steps for Developing EBPGs: Perform a formal search and review of the literature

Self explanatory?

Define each of the following Steps for Developing EBPGs: use a formal and explicit process

The process should be detailed enough that it could be replicated

Define each of the following Steps for Developing EBPGs: Perform peer review

This step will help to identify any omissions or misinterpretations of the guideline

What is Internal evidence?

Typically generated through practice initiatives, such as outcomes management or quality improvement projects that use internal evidence from patient data in an organization to improve clinical care.