Evidence-based Practice

Outcomes management typically uses a four-step process What are these 4 steps?

(1) define a clinical problem and outcome that need to be improved (e.g., falls, hospital readmissions); (2) establish how the outcome will be measured; (3) identify practices supported by evidence that need to be implemented to improve the outcome; (4) measure the impact of implementing the best practice on the targeted outcome

Support and Strategy 3: Mastering Database Searching Searchers should use three major search strategies across multiple bibliographic databases to increase the certainty that best evidence is not missed. These major strategies are?

(1) keyword searching (2) subject heading searching (3) title searching Because each of the three major search strategies has strengths and weaknesses, all three should be used in combination to provide high levels of certainty that best evidence is not missed.

IMPLEMENTING EVIDENCE-BASED GUIDELINES Critical elements that assist in uptake and translation of evidence into day-to-day practice include

(a) facilitating staff to use best practice guidelines (b) creating a positive milieu and securing structures and processes that inspire EBP (c) interactive education with skills building practice sessions and attention to patient education ; (d) use of reminders (e) electronic gathering and dissemination systems offering real-time feedback and access to guidelines (Davies et al., 2008; Doran et al., 2009); (f) a checklist with interventions linked to times (g) changing organizational policies and procedures to reflect best clinical practices and making staff aware of these changes (h) prioritizing interventions when care bundles are used (i) integrating evidence-based guidelines into care pathways when comorbid conditions exist (j) organizational and unit-based champions or EBP mentors, teamwork and collaboration, professional association's support, interorganizational collaboration, networks, and administrative leadership

Support and Strategy 2: Gathering the Right Evidence From the Right Source the first step in finding answers to their clinical questions is to search for evidence in synthesized, preappraised sources----what are they?

(e.g., Cochrane Database of Systematic Reviews [CDSR], American College of Physicians [ACP] Journal Club, and the journal, Evidence-Based Nursing [EBN For point-of-care decisions, clinicians may choose to consult one of the preappraised summaries or synopsized sources listed earlier. However, when making practice changes, it is important to either find a synthesis that has conducted an exhaustive search (i.e., found all that we know on the topic) or get as close to that as possible by searching multiple databases to try to ensure that studies are not missed

PICOT format

(i.e., patient population, intervention or issue of interest, comparison intervention or group, outcome, and time frame) to yield the most relevant and best evidence from a search of the existing literature In teenagers (the patient population), how does cognitive behavioral skills building (the experimental intervention) compared with yoga (the comparison intervention) affect anxiety (the outcome) after 6 weeks of treatment (the time taken for the interventions to achieve the outcome)

What is the meaning of, evidence? How is evidence generated? Hierarchy of Evidence? What does the acronym, FAME, stand for?

- Evidence is a collection of facts that are believed to be true. - Internal: within an institution External: RCT, other research, case-control studies - 1. Regular research (RCT) 2. Meta-analysis, systematic reviews (2+ peers), 3. Clinical decision support (tools that HCP use, must read the evidence and put into practice immediately) - Feasibility Appropriateness Meaningfulness Effectiveness

Ethnography Research Terms

--Culture: Shared knowledge and behavior of people who interact within distinct social settings and subsystems. --Participant observation: The active engagement (i.e., observation and participation) of the researcher in settings and activities of people being studied (i.e., everyday activities in study of informants' natural settings). --Fieldwork: All research activities carried out in and in relation to the field (informants' natural settings). These activities include the many social and personal skills required when gaining entry to the field, maintaining field relationships, collecting and analyzing data, resolving political and ethical issues, and leaving the field --Key informant: A select informant/assistant with extensive or specialized knowledge of his/her own culture. --Emic and etic: Contrasting "insider" (emic) views of informants and the researcher's "outsider" (etic) views.

What is the purpose of RESEARCH question? What evidence is provided for this type of question? Example?

--P: To generate new knowledge/external evidence --External evidence --What is the effect of a health coach on kidney transplant patients' satisfaction with hospitalization? What is the effect of health coaching on kidney transplant patients' readmission rates?

What is the purpose of a Clinical Question? What evidence is provided for this type of question? Example?

--P: To guide the systematic search for evidence to determine the best intervention to affect the outcome --Best available evidence --In postoperative kidney transplant patients (P), how does a health coach (I) compared with no health coaching (i.e., current practice) (C) affect hospital readmission rates (O1) and patient satisfaction (O2) within 90 days of discharge (T)? PICOT FORMAT REQUIRED

What is the purpose of a QI question? What evidence is provided for this type of question? Example?

--P: To identify and fix the processes leading to a problem that is internal to the clinical setting --Internal evidence --Why is the hospital readmission rate in our post-kidney transplant patient population so high? Why are our patient satisfaction scores not meeting benchmarks for our kidney transplant patients?

When combining subject headings or keywords, the _________________ AND or OR are used

--When combining subject headings or keywords, the Boolean connectors AND or OR are used a) The AND connector is useful when attempting to link different concepts together. Using AND is appropriate when clinicians wish to narrow their search by having both of the combined terms required in the retrieved articles. Because AND is a restrictive word (i.e., both words must appear in the article), it will reduce the number of articles retrieved, which serves well with a finely honed PICOT question. b) Conversely, the OR Boolean connector is generally used to expand a search because either one or both of the search terms will be included in the results list. When concepts using synonyms are searched for, OR should be used.

CRITICAL APPRAISAL OF CASE-CONTROL STUDIES

-A case-control study investigates why certain people develop a specific illness, have an adverse event with a particular treatment, or behave in a particular way -The case-control method selects individuals who have an outcome (disease, adverse event, behavior) and retrospectively looks back to identify possible conditions that may be associated with the outcome -The characteristics of these individuals (the cases) are compared with those of other individuals who do not have the outcome (the controls). ((An example of a clinical question for which a case-control study could be the appropriate design to provide an answer would be, In patients who have a family history of obesity (body mass index [BMI] > 30) (P), how does dietary carbohydrate intake (I) influence healthy weight maintenance (BMI < 25) (O) over 6 months (T)?))

CRITICAL APPRAISAL OF SYSTEMATIC REVIEWS

-A systematic review is a compilation of similar studies that address a specific clinical question -The researchers determine beforehand what inclusion and exclusion criteria will be used to select identified studies. -TOP for EVIDENCE -A compilation of like studies to address a specific clinical question using a detailed, comprehensive search strategy and rigorous appraisal methods for the purpose of summarizing, appraising, and communicating the results and implications of all the research available on a clinical question. A systematic review is the most rigorous approach to minimization of bias in summarizing research

CRITICAL APPRAISAL OF RCTS

-An RCT compares the effectiveness of different interventions. This can involve one group that gets the intervention under investigation (intervention group) and another group that gets one of four comparative options (comparison group) to determine whether the intervention or comparison is better at producing the outcome. The four options for the comparison group include (1) no intervention (i.e., a true control group), (2) a placebo, (3) another treatment (i.e., comparison intervention), or (4) the current standard of care. -RCTs are the most appropriate research design to answer questions of efficacy and effectiveness of interventions because their methodology provides confidence in establishing cause and effect (i.e., increased confidence that a given intervention leads to a particular outcome) - As INDIVIDUAL STUDIES-----rank as Level II evidence in this hierarchy of evidence because a well-conducted study should have a low risk of bias -A synthesis of RCTs is considered Level I evidence for answering questions about interventions for the same reason

conditions have been found to enhance EBP:

-Support and encouragement from leadership/administration that foster an EBP culture with expectations for EBP -Alignment of stakeholders -Time to critically appraise studies and implement their findings -Clearly written research reports -EBP mentors with excellent EBP skills as well as knowledge and proficiency in individual and organizational change strategies -Proper tools to assist with EBP at the point of care (e.g., computers dedicated to EBP; computer-based educational programs) -Integrating EBP into health professions curricula -Clinical promotion systems and performance evaluations that incorporate the EBP competencies -Evidence-based clinical practice policies and procedures -EBP models that can guide implementation and sustainability of EBP -Journal clubs and EBP rounds -A certification credential and high level of education

Grounded Theory Research Terms

-Symbolic interaction: Theoretical perspective on how social reality is created by human interaction through ongoing, taken-for-granted processes of symbolic communication. -Pragmatism: Theoretical perspective that problems of truth and meaning need to be arrived at inductively; understood in terms of their utility and consequences; and modified to fit the circumstances of time, place, and the advent of new knowledge. -Constant comparison: A systematic approach to analysis that is a search for patterns in data as they are coded, sorted into categories, and examined in different contexts. -Theoretical sampling: Decision making, while concurrently collecting and analyzing data, about the data and data sources that are needed further to develop the emerging theory. -Saturation: The point at which categories of data are full and data collection ceases to provide new information. -Core variable: A theoretical summarization of a process or pattern that people go through in specified life experiences.

CRITICAL APPRAISAL OF COHORT STUDIES

-The cohort study design is especially suitable for investigating the course of a disease or the unintended consequences of a treatment -A cohort refers to a study population sharing a characteristic or group of characteristics. -Can be conducted with and without a control group. Without a control group, researchers identify a cohort exposed to the characteristic of interest and monitor them over time to describe various outcomes. (For example, a cohort could be adolescents experiencing their first episode of psychosis. The study could follow the cohort over time and report on what was observed and measured.)

CRITICAL APPRAISAL OF CASE STUDIES

-played an important role in identifying new issues in healthcare. -historically ranked lower in the hierarchy of evidence for intervention questions because of their lack of objectivity -Publication bias is an important factor because most case studies found in the literature have positive outcomes.

The Steps of the Evidence-Based Practice Process

0.Cultivate a spirit of inquiry within an evidence-based practice (EBP) culture and environment. 1.Ask the burning clinical question in PICOT format. 2.Search for and collect the most relevant best evidence. 3.Critically appraise the evidence (i.e., rapid critical appraisal, evaluation, and synthesis). 4.Integrate the best evidence with one's clinical expertise and patient/family preferences and values in making a practice decision or change. 5.Evaluate outcomes of the practice decision or change based on evidence. 6.Disseminate the outcomes of the EBP decision or change.

major barriers to EBP ?

1) -Nurse leader/manager resistance! Over 50% of nurse leaders reporting that they were uncertain about how to measure the outcomes of care being delivered in their hospitals. Most chief nurses also reported that they did not have a critical mass of nurses in their hospital who were skilled in EBP and that they only invested 0% to 10% of their budgets in equipping their staff with EBP knowledge, skills, and resources. 2) -Lack of EBP knowledge and skills -Cultures steeped in tradition -Misperceptions or negative attitudes about research and evidence-based care -Lack of belief that EBP will result in more positive outcomes than traditional care -Voluminous amounts of information in professional journals -Lack of time and resources to search for and critically appraise evidence -Overwhelming patient loads -Organizational constraints, such as lack of administrative support or incentives -Lack of EBP mentors -Demands from patients for a certain type of treatment -Peer pressure to continue with practices steeped in tradition -Resistance to change -Lack of consequences for not implementing EBP -Lack of autonomy and power to change practice -Inadequate EBP content and behavioral skills building in educational programs along with the continued teaching of how to conduct rigorous research in baccalaureate and master's programs instead of teaching an evidence-based approach to care

Support and Strategy 1: Sources of External Evidence

1) -Textbooks- can consult a good textbook to refresh or gain new knowledge. This background information may be all that is necessary in certain situations. At other times, consulting a textbook may help clinicians better understand the context for the PICOT question they are asking 2) -Journals (foreground question, if one is to be found.) Clinicians first go to look for answers to their clinical questions. Includes systematic reviews, article synopses, research articles, narrative reviews, discussion articles, news items, editorials, and letters to the editor 3) -Consolidated sources (pyramid framework) The pyramid is a hierarchy in which the most useful, easily accessible evidence is at the top. a. ORIGNINAL STUDY--> (The pyramid's base reflects original research articles that form the foundation on which the rest of the pyramid is built. Databases where these original research articles are indexed (e.g., MEDLINE or CINAHL) are the gateways for finding a body of evidence.) b. REVIEW OF EVIDENCE( designed to answer both background and foreground questions. These sources can contain many types of evidence, ranging from systematic reviews, clinical practice guidelines, health topic summaries, to article synopses.)----> c. DECISION SUPPORT IN MEDICAL FIELD (data on a specific patient are automatically linked to the current best evidence available in the system that matches that patient's specific circumstances. Upon matching the evidence with patient data, the clinical decision support system assists clinicians with evidence-based interventions for that patient.)

critical appraisal process

1. Are the results of the study valid? (Validity) 2. What are the results? (Reliability) 3. Will the results help me in caring for my patients? (Applicability This process provides clinicians with the means to interpret the quality of studies and determine the applicability of the synthesis of multiple studies' results to their particular patients Study validity and reliability are determined by the quality of the study methodology

Formatting Foreground Questions to Drive the Search

1. Intervention questions that ask what intervention most effectively leads to an outcome 2. Prognosis/prediction questions that ask what indicators are most predictive of or carry the most associated risk for an outcome 3. Diagnosis questions that ask what mechanism or test most accurately diagnoses an outcome 4. Etiology questions that ask to what extent a factor, process, or condition is highly associated with an outcome, usually undesirable 5. Meaning questions that ask how an experience influences an outcome, the scope of a phenomenon, or perhaps the influence of culture on healthcare.

CERTAINTY AND KNOWLEDGE SOURCES knowledge sources for care:

1. Valid research evidence as the primary basis of clinical decisions (i.e., external evidence); 2. Clinical expertise to best use research by filling in gaps and combining it with PBE (i.e., internal evidence) to tailor clinical actions to individual patient context. In clinical decisions, the key criterion for quality of underlying knowledge is certainty. Certainty is the level of sureness that the clinical action will produce the intended or desired outcome. To appraise certainty, the practitioner must first uncover the source of knowledge underlying the contemplated clinical action and then appraise the quality of that knowledge. Patient choices and concerns for determining the acceptability of evidence-based care to the individual patient.

Critical appraisal of different research designs 1. 3 nonexperimental categories of study designs? 2. Pre-experimental designs? 3. True experimental designs? 4. Systematic review

1. case, case-control, and cohort studies 2. quasi-experimental, in which there is an intervention expected to have an impact on the outcome/nonrandomized studies because the participants are not randomly assigned to these groups 3. the intervention is randomly assigned to some participants and not to others. (RCTs) 4. systematic reviews should include the body of evidence (i.e., all that we know) that best answers the clinical question.

Research questions usually have _____________________________ (i.e., improved or reduced) and bring with them a sense of expectation of what will be found in the literature Clinical questions come with no expectations of what will be found in the literature. These questions ask about how an issue or_______________________________, which includes answers from studies that may be positive, negative, or neutral (i.e., no effect) A QI question is formulated when a _________or_____________ is exposed and processes are evaluated to establish steps in a plan that is rapidly implemented and evaluated

1. directional outcomes 2. intervention affects an outcome 3. concern or problem

Which two methods yield the strongest level of evidence which are based on practice decisions What if these two methods are not available? What can be used to supplement?

1. systematic reviews and meta-analyses yield the strongest level of evidence on which to base practice decisions 2. MEDLINE, Cumulative Index of Nursing and Allied Health Literature, Research Tested Intervention Programs (RTIPs) If RCTs are not available, the search process should then include other types of studies that generate evidence to guide clinical decision making (e.g., nonrandomized, descriptive, or qualitative studies) to determine the best available body of evidence

Key elements of an EBP culture and environment include the following:

A spirit of inquiry where all health professionals are encouraged to question their current practices; A philosophy, mission, clinical promotion system, and evaluation process that incorporate EBP and the EBP competencies; A cadre of EBP mentors, who have in-depth knowledge and skills in EBP, mentor others, and overcome barriers to individual and organizational change; An infrastructure that provides tools to enhance EBP (e.g., computers for searching at the point of care, access to key databases and librarians, ongoing EBP educational and skills-building sessions, EBP rounds and journal clubs); Administrative support and leadership that values and models EBP as well as provides the needed resources to sustain it; Regular recognition of individuals and groups who consistently implement EBP

Distinguishing Between PICOT, Research, and Quality Improvement Questions Research The EBP team is frustrated with this pulmonary complication and is wondering how to reduce it. They wonder if they would need to do a research study. Select the relevant research question: a)Does oral care with chlorhexidine improve ventilator-associated pneumonia rates in patients receiving mechanical ventilation? b)Why are ventilator-associated pneumonia rates so high in our trauma patients? c)In trauma patients who are mechanically ventilated, how do probiotics compared with no probiotics affect ventilator-associated pneumonia development while on the ventilator?

A.

Distinguishing Between PICOT, Research, and Quality Improvement Questions Select the relevant QI question: a)Does oral care with chlorhexidine reduce ventilator-associated pneumonia in patients receiving mechanical ventilation? b)Why are ventilator-associated pneumonia rates so high in our trauma patients? c)In trauma patients who are mechanically ventilated, how do chlorhexidine mouthwashes compared with probiotics affect ventilator-associated pneumonia development?

B

Distinguishing Between PICOT, Research, and Quality Improvement Questions Intervention Clinical Question a)Why are ventilator-associated pneumonia rates so high in our trauma patients? b)Which is more effective in reducing ventilator-associated pneumonia in patients receiving mechanical ventilation, chlorhexidine, or probiotics? c)In trauma patients who are mechanically ventilated, how do chlorhexidine mouthwashes compared with probiotics affect ventilator-associated pneumonia development while on the ventilator?

C.

Support and Strategy 4: Choosing the Right Database Common research databases used?

Cochrane Databases MEDLINE Trip CINAHL Embase PsycINFO ***MEDLINE and CINAHL are among the best-known comprehensive databases that contain much of the scientific knowledge base in healthcare.

_____________________is the accuracy and validity assured through documentation of researcher actions, opinions, and biases; negative case analysis; appropriateness of data; adequacy of the database; verification/corroboration by multiple data sources; validation of data and findings by informants and colleague consultation.

Creditability

Phenomenology/Hermeneutics Research Terms

Essences: Internal meaning structures of a phenomenon grasped through the study of human lived experience. Lived experience: Everyday experience, not as it is conceptualized, but as it is lived (i.e., how it feels or what it is like). Introspection: A process of recognizing and examining one's own inner state or feelings. Bracketing: Identifying and suspending previously acquired knowledge, beliefs, and opinions about a phenomenon. Phenomenological reduction: An intellectual process involving reflection, imagination, and intuition. Hermeneutics: Philosophy, theories, and practices of interpretation.

Background and foreground questions What is the difference? Examples?

Foreground questions are those that can be answered from scientific evidence about diagnosing, treating, or assisting patients in understanding their prognosis or their health experience. These questions focus on specific knowledge. EXAMPLE: a) "In children, how does acetaminophen affect fever within 30 minutes of administration compared with ibuprofen?" Analysis: The first question builds on the background knowledge of how acetaminophen works but can be answered only by a group of studies (i.e., body of evidence) that compare the two listed medications. b) "In patients with acute respiratory distress syndrome, how does the prone position compared with the supine position affect heart rate, cardiac output, oxygen saturation, and blood pressure after position change?" Analysis: The second question requires the knowledge of how positioning changes hemodynamics (i.e., the background question) and in particular the outcomes listed, but the two types of positioning must be compared in a body of evidence focused on a specific population of patients to best answer it. The foreground question generated from the third background question example could be as follows: In patients at high risk for pressure ulcers, how do pressure mattresses compared with pressure overlays affect the incidence of pressure ulcers within a week of application? The answer provided by the body of evidence would indicate whether pressure mattresses or overlays are more effective in preventing pressure ulcers in the high-risk population.

Plan-Do-Study-Act (PDSA)

In PDSA, a particular change is planned and implemented, results are observed (studied), and action is taken on what is learned. The cycle tests an idea by putting a planned change into effect on a temporary and small-trial basis and then learning from its impact

Question Templates for Asking PICOT Questions

Intervention In __________ (P), how does __________ (I) compared with __________ (C) affect __________ (O) within __________ (T)? Prognosis/Prediction In __________ (P), how does __________ (I) compared with __________ (C) influence/predict __________ (O) over __________ (T)? Diagnosis or Diagnostic Test In __________ (P) are/is __________ (I) compared with __________ (C) more accurate in diagnosing __________ (O)? Etiology Are __________ (P), who have __________ (I) compared with those without __________ (C) at __________ risk for/of __________ (O) over __________ (T)? Meaning How do __________ (P) with __________ (I) perceive __________ (O) during __________ (T)?

nformation to help clinicians with principles and queries for appraising of qualitative evidence for clinical decision making, including the following

Language and concepts that will be encountered in the qualitative literature; Aspects of qualitative research known to have raised concerns for readers less familiar with different qualitative methods; Issues surrounding the use of evaluative criteria that, if not understood, could lead to their misuse in the appraisal of studies and subsequent erroneous conclusions.

What is a meta analysis study

Many systematic reviews incorporate quantitative methods to compare the results from multiple studies. These reviews are called meta-analyses. A meta-analysis generates an overall summary statistic that represents the effect of the intervention across multiple studies.

Narrative review Integrative review

Narrative review A research review that includes published papers that support an author's particular point of view and usually serves as a general background discussion of a particular issue. An explicit and systematic approach to searching for and evaluating papers is usually not used Integrative review A systematic review that does not have a summary statistic because of limitations in the studies found (usually because of heterogeneous studies or samples)

Four Stages of the Plan-Do-Study-Act (PDSA) Cycle

PLAN: Plan the change and observation. DO: Try out the change on a small scale. STUDY: Analyze the data and determine what was learned. ACT: Refine the change, based on what was learned, and repeat the testing.

PICOT: Components

Patient population/disease The patient population or disease of interest, for example: • Age • Gender • Ethnicity • With certain disorder (e.g., hepatitis) Intervention or Issue of interest The intervention or range of issues of interest: • Therapy • Exposure to disease • Prognostic factor A • Risk behavior (e.g., smoking) Comparison intervention or issue of interest What you want to compare the intervention or issue against: • Alternative therapy, placebo, or no intervention/therapy • No disease • Prognostic factor B • Absence of risk factor (e.g., nonsmoking) Outcome Outcome of interest: • Outcome expected from therapy (e.g., pressure ulcers) • Risk of disease • Accuracy of diagnosis • Rate of occurrence of adverse outcome (e.g., death) Time The time involved to demonstrate an outcome: • The time it takes for the intervention to achieve the outcome • The time over which populations are observed for the outcome (e.g., quality of life) to occur, given a certain condition (e.g., prostate cancer)

Phenomenology.

Phenomenology is the study of essences intuited or grasped through descriptions of lived experience.

Search Strategy: Subject heading search Strengths? Weaknesses?

S: Subject headings are used to help searchers find information on a particular topic, no matter what words the author may use to refer to a concept in the article. Using subject headings, searchers can broaden their searches without having to consider every synonym for the chosen keyword. -Provides a quick snapshot of evidence's relevance to the PICOT question -Retrieves only citations when the topic is deemed by reviewers as at least 25% relevant to the topic is being searched -Increases chances that best citations will not be missed when authors and searchers use different synonyms because of database -Maps all synonyms to one assigned subject heading -Retrieves citations searched using related and narrower MeSH terms associated with searchers' 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 three most powerful search strategies W: -Not always assigned for every keyword (i.e., new cutting edge terminology, coined phrases, acronyms) may not yet be assigned MeSH or be a successful match for auto mapping -Requires combining three major search strategies to avoid missing something -Not available across all major databases, search engines

Search Strategy: Title search Strengths? Weaknesses?

S: The TITLE search is the final major search strategy. Searching your P, I, and O terms in the title increases the chance of finding relevant citations, and it can help you identify relevant subject headings -Provides quick snapshot to evidence's relevance to a topic -Increases chances that keywords appearing in the 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 the three most powerful search strategies W: -Misses studies when the author's choices of title words differ -Requires all three major strategies to achieve certainty nothing missed -Not available across all major databases, search engines. Note: Google Scholar provides title search mode

Support and Strategy 3: Mastering Database Searching Search Strategy: Keyword search Strengths? Weaknesses?

S: -Provides a quick snapshot of resource's relevance to PICOT question -Identifies records when the keyword appears with and without major relevance -Included in the three most powerful search strategies -Truncation uses special symbols to locate additional letters beyond the root that is identified. Truncation is indicated by using an asterisk (*) or other symbol immediately after a word or part of a word. For example, in PubMed and CINAHL, adolescen* would retrieve adolescent, adolescents, or adolescence W: -Misses studies when authors' choices of keywords differ -Requires advanced search skills to quickly sort for relevance among too many citations -Requires combined subject headings search -Requires all three strategies to achieve certainty that nothing was missed

Define the Terms What are: -Study limitations? -Directness? -Precision? -Reporting bias?

Study limitations: The likelihood of studies included in the synthesis are adequately protected against bias by the study design and how the study was conducted • Directness: Two criteria include whether (a) evidence demonstrates the association of interventions to specific outcomes, and (b) comparisons studies are head-to-head • Precision: The extent to which certainty surrounds the effect estimate and if the sufficiency of sample size and number of events assumptions are met • Reporting bias: The bias inherent in selectively publishing or reporting only research findings that are in the desired direction or magnitude of the effect

Support and Strategy 3 The primary goal of disseminating evidence?

The primary goal of disseminating evidence, whatever the channel or tool as described in this chapter, is to facilitate the transfer and adoption of research findings into clinical practice or to disseminate evidence-based quality improvement projects

The teaching of EBP can and should be accomplished with multiple strategies, including...?

The teaching of EBP can and should be accomplished with multiple strategies, including: continuing education conferences with skills-building activities; interactive workshops; and dissemination of educational materials, such as journal articles, textbooks, and informational handouts.

_______________is providing information sufficient for clinicians to determine whether the study findings are meaningful to other people in similar situations, often using thick description.

Transferability

Support and Strategy 3: Mastering Database Searching Searching Databases: What do clinicians need to be aware/mindful of? Three things

Understanding the structure and content of a particular information source before attempting to search it is critical. Without this background, the search terms and strategies used may not yield the desired information, or the chosen database may not contain the information sought. It is important to note the fundamental difference between licensed databases (1) Is the evidence current? (2) Will subject headings and/or keywords be more effective in getting to the best evidence quickly? (3) How frequently is the database updated?

Change to EBP within an organization or practice requires

a clear vision, a written strategic plan, a culture and environment in which EBP is valued and expected, and persistence to make it happen.

What is EBP?

a lifelong problem-solving approach to clinical practice --- a) Search for and critical appraisal of the most relevant and best research (i.e., external evidence) to answer a burning clinical question; b) One's own clinical expertise, including use of internal evidence generated from outcomes management or evidence-based quality improvement projects, a thorough patient assessment, and evaluation and use of available resources necessary to achieve desired patient outcomes; c) Patient/family preferences and values

basic social process (BSP) is

basis for theory generation

most important reasons for consistently implementing EBP?

leads to the highest quality of care and the best patient outcomes reduces healthcare costs and geographic variation in the delivery of care

priority should be given to those questions with

priority should be given to those questions with the most important consequences or those that occur most frequently (i.e., those clinical problems that occur in high volume and/or those that carry high risk for negative outcomes to the patient). example -For example, nurses and physicians on a surgical unit routinely encounter the question, "In postoperative adult patients, how does morphine compared with hydromorphone affect pain relief within the first half hour after administration?" "In postoperative mobile patients, how does daily walking compared with no daily walking prevent pressure sores during hospitalization?" The clinical priority would be answering the question of pain relief first because pain is a daily occurrence in this population, versus prioritizing seeking an answer to the second question because pressure ulcers rarely occur in postoperative adult patients.

Step 3 in EBP Rapid critical appraisal

rapid critical appraisal process in which studies are evaluated for their validity, reliability, and applicability to answer the posed clinical question 1. Are the results as close to the truth as possible? Did the researchers conduct the study using the best research methods possible? 2. (a) whether the intervention worked; (b) how large a treatment effect was obtained; and (c) whether clinicians could expect similar results if they implemented the intervention in their own clinical practice setting (i.e., the preciseness of the intervention effect) 3. This third rapid critical appraisal question includes asking whether: (a) the subjects in the study are similar to the patients for whom care is being delivered; (b) the benefits are greater than the risks of treatment (i.e., the potential for harm); (c) the treatment is feasible to implement in the practice setting; and (d) the patient desires the treatment ****The answers to these questions ensure relevance and transferability of the evidence to the specific population for whom the clinician provides care

Support and Strategy 4: Choosing the Right Database Cochrane Databases

represents the efforts of a global network of dedicated volunteer researchers, healthcare professionals, and consumers who prepare, maintain, and promote access to the Cochrane Library's five current databases: (1) CDSR, (2) Cochrane Central Register of Controlled Trials (CENTRAL), (3) Cochrane Methodology Register, (4) Health Technology Assessment, and (5) NHS Economic Evaluation Database The Cochrane Library's gold standard database is the CDSR. full-text systematic reviews and should be searched first to answer intervention questions. contains a few thousand citations and is limited to a single publication type—systematic reviews—including meta-analyses

Ethnography.

study of a social group's culture through time spent combining participant observation, in-depth interviews, and the collection of artifacts (i.e., material evidence of culture) in the informants' natural setting. This appreciation of culture—drawing on anthropologic (i.e., human development) theory and practice—provides the context for a better understanding of answers to specific research questions.

Grounded Theory

theory about how people deal with life situations grounded in empirical data and that describes the processes by which they move through experiences over time. Movement is often expressed in terms of stages or phases (e.g., stages/phases of living with a chronic illness, adjusting to a new situation, or coping with challenging circumstances).

Quality Quantity Consistency

• Quality: the extent to which a study's design, conduct, and analysis have minimized selection, measurement, and confounding biases (internal validity) • Quantity: the number of studies that have evaluated the clinical issue, overall sample size across all studies, the magnitude of the treatment effect, and strength from causality assessment for interventions, such as relative risk or odds ratio • Consistency: whether investigations with both similar and different study designs report similar findings (requires numerous studies)