EBP Exam 1

Steps of EBP

0. Cultivate a spirit of inquiry. 1. Ask a clinical question in PICOT format. 2. Search for the most relevant evidence. 3. Critically appraise evidence 4. Integrate best evidence with one's clinical expertise and patient preferences and values 5. Evaluate the outcomes of the change 6. Disseminate outcomes w/ others

Hierarchy of evidence

1) Systematic Reviews or meta analyses of RCTs 2) Single RCTs 3) Controlled trials w/o randomization 4) Case-control or cohort studies 5) systematic reviews of descriptive/qualitative studies 6) Single descriptive or qualitative studies 7) Opinion of authorities, expert committees/panels

A group of nurses are interested in techniques to promote better nutrition among clients who are recovering from septic shock. Which potential resource should they prioritize? A. Cochrane Database of Systematic Reviews (CDSR) B. Cochrane Central Register of Controlled Trials (CENTRAL) C. Cochrane Methodology Register D. Health Technology Assessment (HTA) Database

A

A nurse has called into question the unit protocol around the regular flushing of percutaneous endoscopic gastrostomy (PEG) tubes to prevent occlusion. Which factor should guide the nurse's reconsideration of the evidence around PEG tube flushing? A. Certainty that a new protocol will reliably prevent occlusion B. Expressions of client preference during a designated period of study C. The rigor and reliability o a chosen research study D. The combination of expertise and internal evidence

A

A nurse has observed that reorienting demented clients as frequently as possible tends to minimize the clients' level of agitation in the evening. The nurse has shared this observation with a colleague, who is skeptical, stating, "It's best to stick to evidence-based practice." Which is the best response to this colleague? A."EBP can include clinician's personal expertise." B."Personal experience is often more sound than formal EBP." C."Traditional practice and EBP are usually shown to be the same. D. "My years of experience can be just as valuable as any literature review or randomized trial."

A

The question that best addresses study reliability is: A.How big is the magnitude of the effect? B.Did the investigator(s) applying the intervention know to which groups subjects were assigned? C.Were the instruments calibrated according to manufacturer specifications? D.How many subjects were lost to follow-up and what groups were they in?

A

The question that does not address study validity is: A.How big is the magnitude of the effect? B.Were the study results obtained by sound scientific methods? C.Was there any biases that influenced study results? D.Were there any confounding factors that influenced study results?

A

Which of the following involves bringing the body of evidence together with clinical expertise and patient preferences and values to identify best practice? A.Evidence-based practice B.Research C.Translational research D.Research utilization E.Evidence-based quality improvement

A

Which of the following is not a primary consideration when considering how well an EBPG or CPG is done? A.Do the developers focus on outcomes that are meaningful to providers? B.Do the developers address how often interventions or screenings should occur to achieve optimal outcomes? C.Do the recommendations address clinically relevant actions? D.Did the developers identify a rating scheme or similar method used to determine the quality and strength of the studies included?

A

Govt agencies which ensure quality practice for care

Agency for Healthcare research and Quality National Quality Forum National Database of Nursing Quality Indicators

Fieldwork: qualitative research tradition

All research activities carried out in study setting

Loss to follow up bias

Attrition occurs d/t unforeseen SE of intervention or burdensome data collection procedures, leading to non-comparable groups

Focus groups are ideally suited to research question about? A. Individual experiences B. People's opinions and values C. Highly emotive topics D. Developing friendships

B

One of the most common types of sampling used in Qualitative research is: A. Random sampling B. Purposive sampling C. Stratified sampling D.Maximum heterogeneity sampling

B

Which measure is most likely to ensure baseline equivalency in a randomized controlled trial (RCT) that will test the efficacy of a new bandaging system for chronic venous leg ulcers? A. Ensuring that clinicians are unaware of whether the bandage they are applying is the experimental or control product B. Randomly assigning participants to the "new bandage" group and the "old bandage" group C. Rigorously screening potential participants to ensure they have as many characteristics in common as possible D. Setting strict criteria around the character and severity of ulcers that will be treated

B

Which of the following sources of external evidence are examples of bibliographic databases? A.Cochrane Database of Systematic Reviews B.Cumulative Index for Nursing and Allied Health Literature (CINAHL) C.BMJ Clinical Evidence Google Scholar

B

A nursing supervisor is encouraging the increased use of EBP and is requesting appropriate reports to reference. Which component of EBP does the nurse prioritize? A. Patient preference B. Internal evidence C.External evidence D.Research utilization

C

A researcher conducts a study in which the participants are asked to describe the lived experience of being a caregiver of a parent with Alzheimer's disease. Which type of qualitative study does this represent? A.Grounded Theory B.Ethnography C.Phenomenology D.Case Study

C

The statement that best describes GAO is: A.GAO stands for General Appraisal Ordering B.GAO and critical appraisal are different names for the same thing C.GAO is a working form that allows clinicians the opportunity to document their thinking about a study D.Appraisers do a GAO after they are done doing their critical appraisal

C

Subject Heading Searches sources

CINAHL Cochrane EMBASE Joanna Briggs Institute EBP Database MEDLINE PsycINFO Scottish Intercollegiate Guideline Network

Foreground Question

Can be answered from scientific evidence Focus on specific knowledge Asks for specific, scientific evidence about diagnosing, treating, educating pts PICOT questions

American College of Cardiology and American Hospital Association classification of recommendations from Practice Guidelines

Class I: interv is useful and effective Class II: conflicting evidence and/or divergence of opinion about usefulness of interv Class IIa: wt of evidence/opinion is in favor of interv Class IIb: usefulness/efficacy not well est Class III: evidence that interv is not useful/effective and may be harmful

Sources of external evidence

Cochrane MEDLINE National Guideline Clearing House National Institute of Health and Care Excellence Registered Nurses Association of Ontario Scottish Intercollegiate Guideline network Trip

Qualitative Research

Collection of data in a nonnumeric form, such as personal interviews, describing phenomenon or experience Exploratory research: data is narrative, reflective, anecdotal Answers "why" Used to gain understanding of underlying reasons, opinions, motivations Placed near bottom of hierarchy, but provides strongest evidence in addressing human responses and meaning Helps answers questions r/t EBP components of pt preferences and values

Reliability

Consistency; can be repeated and produce same results

What is goal of National Guideline Clearinghouse?

Create a comprehensive database of up to date EBPGs

Guba and Lincoln criteria of trustworthiness

Credibility: assured by thorough documentation; internal validity Transferability: findings are meaningful to other people in similar situations; external validity Dependability: how conclusions were reached and whether they expect to obtain similar findings; reliability Confirmability: findings and interpretations are grounded in data; objectivity

A community health nurse wants to research for methods to encourage mammograms. Which would be an appropriate type of foreground question to develop? A. "Which cultural influence is preventing women from getting mammograms?" B. "Is there an environmental issue contributing to low mammogram adherence?" C. "Which common misconception is influencing low mammogram adherence?" D. "Which method has proven successful in other similar communities to encourage mammogram compliance?"

D

A researcher explores the phenomenon of how nurses make decisions about when to discuss end-of-life issues with clients. From this research, a model is developed to explain the decision-making process. Which type of research does this represent? A.Ethnography B.Case Study C.Phenomenology D.Grounded Theory

D

After reading several case studies, the nurse determines that more research is warranted. Which factor is the nurse prioritizing to make that decision? A. The participants were from similar geographic location. B. The results were consistent in the majority of the studies. C. The survey questions were similar in each study. D. The ages of the participants were too varied.

D

Scenario: EBP is identified as a core value in our organization's new strategic plan. This plan includes making sure all policies are supported by evidence within 3 years. In order to accomplish this, units begin hosting unit-based journal clubs from noon until 1 p.m. once a week to teach advanced critical appraisal skills. Staff are permitted to attend if census and staffing ratios allow. Which of the following is the barrier in the scenario above A.Having a new strategic plan B.The plan goal of making sure all policies and procedures are supported by evidence within the 3 years. C.Hosting unit-based journal clubs D.The timing and stipulations for attendance of the unit-based journal clubs

D

The certified nurse educator on a postsurgical unit has recently completed a client chart review after the implementation of a pilot program aimed at promoting early ambulation following surgery. Which component of EBP is the nurse employing? A. Patient Preferences B. Research Utilization C. Experience D. Internal Evidence

D

When writing up a research project, the researcher describes in detail how biases, assumptions, and personal perspectives were identified and set aside. Which criteria for reliability and validity was met? A.Credibility B.Transferability C.Dependability D.Confirmability

D

Which of the following factors has the greatest impact on the success of EBPG implementation? A.The strength of the evidence that underlies the guideline B.The validity of the process that was used to develop the guideline C.The education level of the nurses who will implement the guideline D.The commitment of the healthcare team members who will put the guideline into practice

D

Which of the following sources of knowledge would be the primary basis for clinical decision making when determining the turning schedule for an immobilized patient? A.The traditional practice on the unit B.The nurse's knowledge of skin breakdown from experience C.The preferences of the patient and the patient's family D.An evidence-based clinical practice guideline for preventing skin breakdown

D

EBP

Decision making process Evidence that has been ID, critically appraised, synthesized Generates new knowledge Not generalizable, but transferrable Clinical inquiry Formulate PICOT Conduct systematic research Critically appraise evidence Synthesize best external evidence w/ clinical expertise and pt preferences/values Eval outcomes Disseminate

Magnitude of Effect

Degree of difference in effect bt study groups

Confidence Interval

Describes range in which true effect lies with given degree of certainty Provides range of values in which they can be reasonably confident and that they will find a result when implementing study findings

T/F: According to Melnyk & Fineout-Overholt, there are six steps to the evidence-based practice process.

F

T/F: All recommendations within an EBPG or CPG are based on evidence and therefore are safe to implement.

F

T/F: Although organizational culture and context are important, they are not necessary for evidence-based practice to be implemented and sustained in the organization.

F

T/F: Evidence-based practice entails beginning with clinical inquiry, defining a conceptual framework and purpose for the project, creating a PICOT questions, searching for the best evidence, critiquing and synthesizing the body of evidence, and making a recommendation based on the evidence.

F

T/F: Foreground questions can often be answered by consulting an up-to-date nursing or science textbook.

F

T/F: The main difference between an evaluation table and a synthesis table is that evaluation tables are used to compare and contrast studies that are included in a systematic review.

F

T/F: When well done, CPGs are a valid guide to practice because they encompass not only research evidence, but also patient preferences and clinical expertise.

F

T/F: Your PICOT question defines your project.

F

Critical steps to implementation of EBPG into practice

Facilitate use of BEP including ongoing admin support Positive milieu w/ structures and processes that foster EBPG use Interactive education w/ skills building practice and attention to pt education Use of reminders Electronic systems offering easy access to guidelines and real time outcome feedback Organizational structures and processes that alert staff to EBPG initiation EBP champions and mentors at ALL LEVELS

Background Question

Foundational question: constantly questioning, asks general info Broader in scope Leads to foreground 2 components: starting place and outcome of interest

External evidence

Generated through rigorous research and is intended to be generalized and used in other settings to answer clinical question Systematic search as well as critical appraisal and synthesis of most relevant and best research

Applicability

If repeated, would I get same results in my pop? Will results help me in caring for my patients?

What are Evidence Based Practice Guidelines?

Intended to optimize pt care and outcomes that include recommendations for practice based on systematic review of evidence that includes benefits and harms of interventions Benefits: based on previously appraised evidence, allow flexibility in application to pts Issues: conflicting recommendations, difficult to implement, variation in rigor of evidence search, variation in how evidence was appraised

Hermeneutics: qualitative research tradition

Interpretation of lived experience

Contamination bias

Intervention and control groups have interaction and info is shared

Subject Heading search

Locate articles based on standardized set of preselected terms Strength: broadened w/o considering synonyms, decreases irrelevant hits Weakness: may not be linked in database, may yield fewer hits

Data management and analysis: qualitative research technique

Management: designing systems to organize, catalog, code, store and retrieve data Computer assisted data analysis: use of word processing and software to support management Qual Data Analysis

AGREE instrument

Meant for use by a panel of reviewers rather than indiv use

Validity

Measured what it is meant to measure Are results as close to truth as possible? Did researcher conduct study using best research methods possible?

Narrative and content analysis: qualitative research technique

Narrative analysis: specific way to generating, interpreting, and understanding stories about life experiences Content analysis: breaking down data through coding, comparing, contrasting, categorization, reconstitution Codes: organizing and categorizing data

4 EBPG websites

National guideline clearinghouse Canadian medical association RN's association of ontario US Preventative Services Task Force

Measurement bias

Occurs if instruments are incorrectly calibrated or if data collectors deviate from est data collection protocols

Selection bias

Occurs if participants are selectively assigned to groups Researchers are manipulating how they are selecting participants to make their study look better

Knowing who receives which tx bias

Occurs if subj or those measuring outcomes know subj group assignment Reduced by BLINDING; primary investigator is only one that knows but isn't collecting data

Info bias

Occurs in longitudinal cohort studies if participants know the subj of the study and act differently if they know that they are in a group that has been exposed to condition being studied

Internal evidence

One's own clinical expertise Includes evidence generated from outcomes or quality improvement projects, thorough patient assessment/eval, and use of available resources

Mixing methods: qualitative research technique

Paradigm: world view/set of beliefs that guide all types of research by ID where researcher stands, relationship of researcher to researched, roles of value, use of language, and process Method: how certain type of research should be carrier out Techniques: tools/procedures used to generate/analyze data

Boolean operator

Placing several concepts from PICOT question in one search allows simultaneous search And: narrows Or: expands

PICOT

Population of interest Intervention/issue Comparison of interest Outcome expected Time

Clinical inquiry

Process in which clinicians gather data together using narrowly defined clinical parameters Allows for an appraisal of available choices of tx for purpose of finding the most appropriate choice of action Includes problem ID and clinical judgement across time 4 aspects: making qualitative distinctions, engaging in detective work, recognizing changing relevance, and developing clinical knowledge about specific pt populations

3 Domains to grading strength of body of evidence

Quality: extent to which study's design/conduct/analysis have minimized selection, measurement, and confounding biases Quantity: number of studies that evaluated clinical issue Consistency: report similar findings

Ex of quantitative study designs

RCTs Systematic Reviews Case Studies Case-control Cohort studies

Characteristics of experimental design

Randomization: every subj has equal chance of being assigned Comparison: effects of interv compared to control group Interv: new type of method must be tested to determine which is effective for evoking specific outcome

How does bias relate to validity of study?

Refers to whether results of study are obtained using sound scientific methods Bias may compromise validity by: way they obtained samples, analyzed data, not addressing missing data

3 components of of EBP

Research evidence and EBP Clinical expertise Pt preferences, values, concerns

6 AGREE areas of appraisal

Scope and purpose Stakeholder involvement Rigor of dev Clarity and presentation Application Editorial appearance

Medical Subject Headings (MeSH)

Set of terms used by National Library of Medicine to describe contents of articles indexed in MEDLINE

Keyword search

Strength: provides quick snapshot of resource's relevance to PICOT Weakness: may miss studies that don't exactly match choices, may find irrelevant studies

Ethnography: qualitative research tradition

Study of a social group's culture through combining participant observation, in depth interviews, and collecting artifacts Addresses questions about experiences w/in a culture

Quality improvement

Systematic process to address issues Look at structures/processes to ID issues that impede quality/safety Use internal evidence Not generalizable PLAN: change and observe DO: try out change on sm scale STUDY: analyze data and determine what was learned ACT: refine change based on what was learned and repeat testing

What are clinical practice guidelines?

Systematically developed statements to assist clinicians and pts in making decisions about care

T/F: A well-formulated PICOT question should specify the measurable patient outcomes that need to addressed.

T

T/F: Determining the validity, reliability, and applicability to practice are central to critical appraisal of a study.

T

T/F: Finding a quasi-experimental research study that tests a protocol for the frequency of turning for immobile patients published in a peer-reviewed journal is an example of external evidence.

T

T/F: Subject headings searching (also known as controlled vocabulary searches) may yield fewer hits than a keyword search, but these hits are more likely to be relevant to the clinical question.

T

Research

Tests hypothesis, generates new knowledge, results are generalizable, requires review Ask research question Define purpose of study Search for and review relevant literature Define conceptual framework Dev research objs, hypothesis, variables, study design Test hypothesis Collect/analyze study data; draw conclusions Disseminate

Which of the following components of a PICOT question is absent from the following clinical question? "Among patients with dementia, how does the use of reorientation therapy compared with regular, supervised mobility affect patient agitation?"

Time

Steps for developing EBPGs

Use formal and explicit process ID guideline panel Develop an analytic framework or casual pathway Perform a formal search and review of literature Dev recommendations based on strength of evidence Peer review

Grounded theory: qualitative research tradition

Used to generate theory, which is grounded in empirical data; used when no theories or limited theories exist Describing processes by which they move through experiences over time May describe PROCESS in terms of phases/stages

Title search

Uses words generated by P, O, and T Most narrow search Strength: increase chances of article being relevant to PICOT Weakness: misses studies that don't contain keywords

Interviews and focus groups: qualitative research technique

Ways in which informants express own thoughts Unstructured, open ended: informal convo Semistructured: flexible questioning, answer in own way Structured, open ended: questions formed, but allows them to respond in own terms Focus group: group interviews

Gatekeeper bias

Well-intentioned person acts as _____ in studies involving vulnerable populations resulting in sample not representative of pop Can occur in convenience sampling, when pts may be chosen because they are more likely to volunteer... resulting in sample not representative of target pop

Unfiltered information

indiv studies

sampling strategies: qualitative research technique

involve choices about study sites and people who will be able to provide info on study topic Purposeful: intentional selection in accordance of needs of study Nominated/snowball: recruitment of participants w/ help of informants already enrolled Volunteer/convenience: sample obtained by solicitation or advertising for those who meet study criteria Theoretical: purposeful sampling used in specific ways to build theory

Confidence interval

measure of precision

Correlation

mutual statistical relationship or connection

Observation and fieldnotes: qualitative research technique

observation: takes on different dimensions Fieldnotes: highly detailed records of observational protocols

Data saturation

point at which categories of data are full and data collection ceases to provide new info

Power analysis

procedure used for determining the sample size needed for a study

Meta analysis

process of using quantitative methods to summarize results from multiple studies Summary statistic that represents effect of an interv across multiple studies

Effect size

quantitative measurement of magnitude of phenomenon

Relative Risk

strength of association and is the risk of outcome

Phenomenology: qualitative research tradition

study the essences intuited or grasped through descriptions of lived experience Lived experience: understanding life's meaning How people perceive their experiences

Recall bias

subjs are asked to recall past actions/events Subjs give answers that are socially acceptable or what they think happened

Systematic analysis

summary of evidence by an expert/panel on particular topic; used to answer specific clinical question and draw conclusions about data gathered

Filtered/pre-appraised information

systematic reviews and meta analysis; meta syntheses, integrative reviews, synopses/critiques of single studies Ex: cochrane, BMJ clinical evidence, Databases of Review of Effects, National Guideline Clearinghouse