Evidence-Based Practice and Quality Improvement Processes
Level IV
Evidence from well-designed case-control and cohort studies the 3 cs
C
so what are you going to compare it to (was it before something was implemented, maybe use one floor that gets the bundle and one that does not)
O
so what do you want to achieve (decrease in falls)
Statistical hypothesis
•Also known as null hypothesis •States there is NO relationship between X (independent) and Y (dependent) variables
Evidence-Based Practice
•collection, interpretation, and integration of valid research evidence (Collection of facts that we believe to be true) •combined with clinical expertise •understanding of patient and family values and preferences to inform clinical decision making.
what we should be as nurses
"Knowledgeable consumers" of research •Appraise research evidence •Use existing standards to determine the merit and readiness of research for use in clinical practice
Good Hypothesis
A declarative statement that identifies a predicted relationship between X and Y
What is the clinical problem
Clearly states the population, problem, and setting 2-3 sentences Often 'introduces' and/or summarizes what will be your background and significance
brainstorming
Colleagues, research team, start developing research question
Research Critique
Critical appraisal Objectively and critically evaluates a research report's content for scientific merit and application to practice. Reader will need: •General knowledge of the subject matter •Knowledge of how to critically read •Use critiquing criteria
Level I
Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs), or evidence-based clinical practice guidelines based on systematic reviews of RCTs or more RCTs of good quality that have similar results Takes randomized control trials cause it is the golden standard - it is the best research you can do - systematic review takes multiple of those trials and puts them together and synthesizes their findings and puts out new findings - uses best studies
Level II
Evidence obtained from at least one well-designed RCT Randomized control study
Level III
Evidence obtained from well-designed controlled trials without randomization Still high level study but the groups aren't randomized
summary vs synthesis
Have to summarize before you can synthesize - summary just describes the literature but synthesis makes it descriptive and combines them
Identify Variables
Independent, dependent
evidence from a systematic review or meta-analysis of all relevant RCTs (randomized controlled trial) or evidence based clinical practive guidelines based on systematic reviews RCTs or three or more RCTs of good quality that have similar results
Level i
Clinical questions have four components
PICO(T)
Critical Reading
Preliminary - •Familiarize yourself with the content (skim the article) Comprehensive - •Understand the author's purpose or intent Analysis - •Understand the parts of the study Synthesis - •Understand the whole article and each step of the research process
Formulate Question
Specific Question
Systematic Review
Summation and assessment of multiple research studies set out to test a research question
research
Systematic, rigorous, critical investigation to generate NEW knowledge Aims to answer questions about nursing phenomena
Consistency
The degree to which other studies, investigating the same research question report similar findings If you have 15 studies all saying the same thing but one study says something else then you'll probably go with the 15 studies that say same thing
independent variable
The experimental factor that is manipulated; the variable whose effect is being studied.
Quality
The extent to which a study's design, implementation, and analysis minimizes bias How well was the study conducted
Quantity
The number of studies that have evaluated the research question How many studies have been down to prove this
dependent variable
The outcome factor; the variable that may change in response to manipulations of the independent variable.
what levels are qualitative
V, VI, VII
literature review
What has been done, where are the gaps
Associative relationship
X and Y are systematically related
Causal relationship
X causes a change in Y
Critical reading
actively, intellectually engaging where you as a reader participates in an inner dialogue Actively engage in what you are doing with the research article or study
Evidence-Based Practice Process Steps
ask > gather > assess appraise . act > evaluate
Evidence-based QI is focused on
both internal and external evidence in decision making about a practice change to be implemented to improve an important clinical outcome
idea
clinical practice, theory
Theory base hypothesis
consistent with existing theory and research findings
goal of quality improvement
continuously improve the quality and safety of health care systems
Quality Improvement
done in the clinical setting •Systematic use of data to monitor the outcomes of care processes •Use of improvement methods to design and test changes in practice
Critical appraisal
evaluating strengths and weaknesses of an article for scientific merit and application
Level VI
evidence from a single descriptive or qualitative study Evidence from a single qualitative study
Level V
evidence from systematic reviews of descriptive and qualitative studies (meta-synthesis) Evidence from qualitative studies
Level VII
evidence from the opinion of authorities and or reports of expert committees clinical guidelines
Critical thinking
examining ideas, assumptions, principles, arguments, conclusions, beliefs and actions
order of research
idea brainstorming literature review identify variables formulate question
The Level of Evidence and the quality of the body of evidence will determine
if a practice change should occur
Empirical testing is
implied can you measure it
EBP
improves healthcare quality and safety, patient outcomes and healthcare costs as well as empowers clinicians is a problem-solving approach to the delivery of healthcare that integrates the best evidence from research with the clinicians expertise and patient/family values and preferences
Standard QI relies primarily on
internal evidence and does not involve the systematic process and critical appraisal
Without EBP
it often takes years (and sometimes decades) to translate research findings into "real-world" clinical settings
Our studies we use need to be a
level IV or higher (not qualitative cause it doesn't relate to the whole population as well)
evidence obtained from at least one well-designed RCT
level ii
evidence obtained from well-designed controlled trials without randomization
level iii
evidence from well-designed case-control, cohort or cross-sectional studies
level iv
evidence from systematic reviews of descriptive and qualitative studies (meta-synthesis)
level v
evidence from a single descriptive or qualitative study
level vi
evidence from the opinion of authorities and/or reports of expert committees
level vii
is all quality improvement is evidence based
no, but it should be all QI should be evidence based
The variables are more commonly related in
noncausal ways They are systematically related but in an associative way
Research Questions are Influenced by
practical experience critical appraisal of the literature identifying gaps in the literature interest in a theory
research that seeks to understand
qualitative
subjective research
qualitative
Specific population, unit, or facility
quality improvement
data driven
quality improvement look at something and say that needs to change cause a lot of patients are getting hurt or they are having bad outcomes
length of quality improvement and research
quality improvement - rapid research - slow and long
objective research
quantitative
research that tests relationships
quantitative
2 main types of research
quantitative and qualitative
Research nurses study
questions relevant to nursing practice
follow the steps of the scientific process
research
I
so what we are going to do (treatment, therapy, think independent variable)
P
so who are you going to focus on (age, disease, setting)
Population is
specified setting may also be specified
Correlation coefficient
strength of the relationship (the higher the stronger the relationship can be positive or negative
levels don't always tell us
the quality of the study
T
time stamp (not asked to do for our project but it's a good thing to think about
testable hypothesis
variables can be observed or measured
Research Articles: Format and Style
•Abstract •Introduction •Definition of purpose •Literature review and theoretical framework •Hypothesis/research question •Research design •Sampling •Reliability and validity •Procedures and data-collection measures •Data analysis results •Discussion •Recommendations and implications •References •Dissemination/Communicating results
Research hypothesis
•Also known as scientific hypothesis •Predicts the expected outcome •May be directional or nondirectional
Research Question is fully developed when...
•Clearly identifies the relationship between the independent and dependent variables •Population is clear •Clarity of the empirical testing
Quality Improvement process
•Conducting an assessment •Setting specific goals for improvement •Identifying ideas for changing current practice •Deciding how improvements in care will be measured •Rapidly testing practice changes •Measuring improvements in care •Adopting the practice change as a new standard of care
Clinical Guidelines
•Consensus (expert developed) and evidence-based guidelines •Developed by expert panels using research findings (Don't use as primary research cause they've already done all the work - can use in significance section) •Assist in bridging practice and research •Provide clinicians with an algorithm for clinical management, or decision making, for specific diseases (e.g., colon cancer) or treatments (e.g., pain management)
Research Questions
•Define a specific topic area •Reflect the literature review •Identify the significance to nursing •Reflect the feasibility of studying this topic
Research questions focus on
•Describing variables •Specifying the population being studied •Examining testable relationships among variables
Research Hypothesis
•Flows from the research question, literature review, and theoretical framework •Predicts the expected outcome •Formulated before the study is started because it determines how data are collected, analyzed, and interpreted Flows from question, lit review and theory - often predicts the outcome
PICO(T)
•Population •Intervention •Comparison •Outcome •Time
Integrative Review
•Review and synthesis •Without Statistical techniques
Quantitative
•Seeks to test relationships or answer a question (is it true or false) •Explains cause-and-effect relationships (breast fed vs formula fed babies) •Uses specific statistical methods (looking at data and numbers) •Objectivity is important •Theory testing
Qualitative
•Seeks to understand the meaning of human experience •Usually conducted in natural settings •Describe EXPERIENCES and interpret meaning •Subjective approach •Theory generating
Meta-Analysis
•Synthesis •Statistical techniques Take all subjects from different studies and put together
Meta-Synthesis
•Synthesis of Qualitative Research •Using methodology No numbers
Study Purpose, Aims, or Objectives
•What the investigator hopes to achieve •Suggests the level of evidence to be obtained •Use verbs like discover, explore, or describe OR test or compare •While this can be changed throughout the planning of a study it is the defining feature of the study itself
purpose
•What the investigator hopes to achieve •Suggests the level of evidence to be obtained •What are the verbs used? •While this can be changed throughout the planning of a study it is the defining feature of the study itself