NURS 3201: EBP - Unit 1

quadruple aim

-Improved patient experience -Improved outcomes -Cost reduction -Organization-driven and often includes such things as joy in work (improved clinician experience vs. equity vs. organizational readiness) We used to focus on the triple aim, but we have now moved to this. EBP helps us get there!

key initiatives to advance EBP

-U.S. Preventive Services Task Force (USPSTF) -Community Services Task Force -Patient-Centered Outcomes Research Institute (PCORI) -American Nurse Credentialing Center's (ANCC) Magnet Designation and Pathways to Excellence -Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare

EBP (evidence-based practice)

-a decision-making process -based on a body of evidence that has been identified, critically appraised, and synthesized -generating new knowledge about practice through implementation of evidence-based recommendations -not generalizable, but rather transferrable -sometimes requiring submission to Institutional Review Board (IRB)

how to eliminate barriers to using EBP

-establishing a clear philosophy and organizational vision in which EBP is valued and expected -developing a strategic plan to create a culture and environment that fosters EBP -dispelling misperceptions about EBP -teaching the basics of EBP -encouraging questions about currently used clinical practices -developing EBP mentors

external evidence

-evidence generated through rigorous research -systematic reviews -evidence-based theories -national benchmarks -opinion leaders and expert panels

barriers to EBP

-lack of administrative/management support -resistance to change -misperceptions or negative attitudes about EBP -lack of EBP knowledge and skills -lack of time and resources -lack of EBP mentors

internal evidence

-practice initiatives, such as: -outcomes management -evidence-based quality improvement projects -patient assessment and evaulation -use of available resources within your organization

facilitators of EBP

-support and encouragement from administration/management -EBP mentors w/excellent EBP skills, knowledge, and proficiency in individual and organizational change strategies -evidence-based policies and procedures -EBP education -proper integration of EBP into health professions curricula -proper tools to assist with and support EBP -EBP councils

research

-tests a hypothesis -generates new knowledge to fill a knowledge gap -results are generalizable -requires review by an Institutional Review Board (IRB)

sources of external evidence

-textbooks (address background questions) -individual journals (address foreground questions) -bibliographic databases (PubMed, CINAHL) -pre-appraised source (ex: Cochrane Database of SRs) -guidelines/standards -Google Scholar (CAUTION: pulls up gray literature)

quality improvement (QI)

-uses a systematic process (quality improvement model such as PDSA/PDCA) to identify and address issues within the organization -looks at structures and processes to identify issues that are impeding quality and safety -uses internal evidence to identify and track trends -results are *not* generalizable -typically does not require review by an Institutional Review Board (IRB)

Steps of the EBP process

0: Cultivate a spirit of inquiry within the 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., RCA, evaluation, and synthesis). 4: Integrate the best evidence with one's clinical expertise and patient preferences and values in making a practice decision or change. 5. Evaluate outcomes of the change. 6. Disseminate the outcomes of the evidence-based change.

10 key visions for guideline development

1) Make evidence available on a worldwide basis. 2) Focus on questions important to patients and clinicians and include relevant stakeholders. 3) Undertake collaborative evidence reviews relevant to health care questions and recommendations. 4) Use a common metric to assess quality of evidence and strength of recommendations. 5) Consider comorbidities in guideline development. 6) Identify ways that help guideline consumers understand and implement guidelines using the best available tools. 7) Deal with conflicts of interest and guideline sponsoring transparently. 8) Support development of decision aids to assist implementation of value-and-preference-sensitive guideline recommendations. 9) Maintain a collaboration of international organizations. 10) Examine collaborative models for funding guideline development and implementation.

information bias

A prejudice in the data that results when either the respondent or the interviewer has an agenda and is not presenting impartial questions or responding with truly honest responses, respectively

USPSTF grading system

A: The USPSTF recommends this service. There is high certainty that the service improves health outcomes - net benefit is substantial. B: The USPSTF recommends this service. There is high certainty that the service improves health outcomes - net benefit is fair or fair certainty that the net benefit is moderate - substantial. C: The USPSTF recommends against routinely providing this service. There is moderate or high certainty that health outcomes are not improved - net benefit is small. However there may be occasions that warrant provision of this service in a patient. D: The USPSTF recommends against providing this service. There is moderate or high certainty that the service does not have any net benefits or harms outweigh benefits. I: There is insufficient evidence to recommend for or against the service.

Boolean operators

AND, OR, and NOT used in search strings to refine the scope of the search

study bias

Anything that distorts study findings in a systematic way arising from the methodology of the study

licensed database, Internet search engine

Combining a _______________ ________________ with an _____________ _____________ ___________ may yield the best results.

internet search engines

Ex: Google and Google Scholar; search the internet, but there is no transparency as to what information is included in the search

licenesed databases

Ex: PubMed; list the journals indexed, which allows users to know which journals they are searching

recommendation

Goal: "next steps" for practice, based on the evidence, are clearly articulated

evaluation

Goal: extract data from individual studies to establish agreement across studies

rapid critical appraisal (RCA)

Goal: identify "keeper studies"

synthesis

Goal: pull data together from studies within the body of evidence to paint the picture of what the body of evidence tells us

meaning question

How does something influence an outcome? -type of foreground question

PDSA model

PLAN the change and observe 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 testing.

Loss to follow-up bias

People with outcome often leave study and affect incidence rates

d. The timing and stipulations for attendance of the unit-based journal clubs (Proper support and structure must be put into place to allow nurses to attend journal clubs. The timing and stipulations - no staffing support or release time - is a barrier to EBP.

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 a 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

AGREE instrument

Six areas of appraisal: -scope and purpose -stakeholder involvement -rigor of development -clarity and presentation -application -editorial independence

hierarchy of evidence

System used to rank the strength of research according to its possibility of bias

recall bias

Systematic error due to differences in accuracy or completeness of recall to memory of past events or experiences.

90%

The IOM's Roundtable on Evidence-Based Medicine put forth that, by 2020, _________ of clinical decisions would be supported by evidence. We have not reached this goal, but we are striving to continue to increase the amount of clinical decisions that are backed by research and supported by evidence.

strategy, project

The PICOT question is a search _______________; it is NOT the ______________.

Absolute Risk Reduction (ARR)

The difference in risk (not the proportion) attributable to the intervention as compared to a control

Number needed to harm (NNH)

The number of individuals that need to be treated before one additional harmful effect occurs.

Number needed to treat (NNT)

The number of patients who must receive a particular drug or treatment in order for one to benefit.

Odds Ratio (OR)

The odds that an individual with a prognostic (risk) factor had an outcome of interest as compared to the odds for an individual without the prognostic (risk) factor

a. How big is the magnitude of the effect? (B and D are related to validity, and C is related to instrument reliability. Magnitude of effect allows for determination of certitude of results in similar patient populations - generalizability.)

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. How big is the magnitude of the effect? (This determines reliability of a study, not validity.)

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 bias that influenced study results? d. Were there any confounding factors that influenced study results?

Relative Risk Reduction (RRR)

The reduction in risk associated with an intervention relative to the risk without the intervention (control); the absolute difference between the experimental event rate and the control event rate divided by the control event rate.

c. GAO is a working form that allows clinicians the opportunity to document their thinking about a study

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.

True (PICOTs should always specify the outcome that is expected from the clinical question, and the outcome must be measurable in some way so that effectiveness of change can be evaluated.)

True or false: A well-formulated PICOT question should specify the measurable patient outcomes that need to be addressed.

False (Initially, there were 6 steps, but a 7th step (step 0) was later added after research supported the importance of organizational culture to EBP implementation and sustainability. The steps must be implemented in sequence!)

True or false: According to Melnyk & Fineout-Overholt, there are six steps to the EBP process.

False (Sometimes, there isn't sufficient evidence available to support making a recommendation.)

True or false: All recommendations within an EBPG or CPG are based on evidence and therefore are safe to implement.

False (An EBP culture and environment must be created within an organization if EBP is to be implemented and sustained.)

True or false: Although organizational culture and context are important, they are not necessary for EBP to be implemented and sustained in the organization.

True (Critical appraisal is about determining the quality of a study, which includes determining the validity, reliability, and applicability of a study to practice.)

True or false: Determining the validity, reliability, and applicability to practice are central to critical appraisal of a study.

False (EBP begins with inquiry, requires a searchable question in PICOT format, and entails critically appraising evidence and synthesis of best internal evidence. EBP does *not* entail defining a conceptual framework or defining the purpose of the project. It does not entail critiquing either; these are all constructs of research.)

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

True (External evidence includes research articles published in peer-reviewed journals.)

True or false: 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.

False (Foreground questions are clinical questions that can only be answered by specific scientific evidence usually found in studies or SRs. The evidence is not available in textbooks.)

True or false: Foreground questions can often be answered by consulting an up-to-date nursing or science textbook.

True (Controlled vocabulary systems exist to increase relevance of results while limiting number of less relevant hits.)

True or false: 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.

False (Evaluation tables serve to organize a body of evidence and identify patterns. Synthesis tables put together results of several studies to tell a story of a body of evidence. They contain aspects that are common or unique across studies.)

True or false: 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.

False (CPGs are based on the best available evidence, but it is the clinician's responsibility to integrate patient preferences and clinical expertise.)

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

False (PICOT is NOT the project, but is instead a search strategy that provides the key words you'll use to search the databases. The PICOT question and the project do not necessarily need to match one another - may discover an approach to addressing the inquiry that you never thought of before!)

True or false: Your PICOT question defines your project.

P - patient/population/problem I - intervention C - comparison O - outcome T - time

What does PICOT stand for?

etiology question

What factors are associated with the outcome? -type of foreground question

predictive/prognostic question

What is better, A or B, at predicting the outcome? -type of foreground question

intervention question

What is the effect of the chosen intervention on the outcome? -type of foreground question

diagnostic question

What test will most accurately diagnose "X"? -type of foreground question

d. The commitment of the healthcare team members who will put the guideline into practice (Successful implementation is dependent on the commitment of practitioners to the process.)

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

a. evidence-based practice (EBP is bringing together the best evidence with the clinical expertise and patient preferences and values to make the best practice decisions.)

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. Do the developers focus on outcomes that are meaningful to providers? (EBPGs and CPGs should focus on outcomes that are meaningful to patients, not providers.)

Which of the following is not a primary consideration when considerhing how well and 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?

b. CINAHL (Cumulative Index for Nursing and Allied Health Literature)

Which of the following sources of external evidence is an example of a bibliographic database? a. Cochrane Database of SRs b. CINAHL (Cumulative Index for Nursing and Allied Health Literature) c. BMJ Clinical Evidence d. Google Scholar

d. An evidence-based clinical practice guideline for preventing skin breakdown (Although EBP encompasses patient preferences and clinical expertise of individual practitioners, the primary source of knowledge is research evidence.)

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

measurement bias

a form of inaccurate measurement in which the data consistently overestimate or underestimate the true value of an event

selection bias

a polling error in which the sample is not representative of the population being studied, so that some opinions are over- or underrepresented

general appraisal overview (GAO)

a working form that allows clinicians the opportunity to document their thinking about a study; an overview to get appraisers to start thinking about a study -Not an RCA; a preliminary step to an RCA Contains: -Study overview (purpose, design, ethics review) -General description of study (research question, sampling) -Major variables studied (dependent and independent, how data was analyzed, what this means for clinical practice)

critique

an in-depth analysis and critical evaluation of a study that identifies its strengths and limitations -essential to research

limits

can help to pare down a large results list; options for this vary by database

external evidence (research), internal evidence (clinical expertise, patient assessments, etc.), and patient preferences and values

components of EBP

clinical significance

defined as study findings that will directly influence clinical practice, whether they are statistically significant or not -not influenced by sample size

internal evidence

i.e., practice-based evidence through quality improvement, outcomes management, or EBP implementation projects -generated within the organization; not generalizable, but rather specific to the organization where it was generated

external evidence

i.e., research, clinical practice guidelines, articles about evidence-based practice projects or quality improvement projects, national benchmarks -generalizable to other practice settings

bibliographic databases

indexed, electronic databases of journal articles and other publications that can provide citations and abstracts as well as articles in full text or links to full text (when available) Ex: MEDLINE, PubMed, CINAHL, PsycINFO, ERIC, Embase, Cochrane Database of SRs, BMJ Clinical Evidence, ACP Journal Club

contamination bias

occurs when members of the 'control' group inadvertently receive the treatment or are exposed to the intervention, thus potentially minimizing the difference in outcomes between the two groups

reference management software systems (RMS)

often referred to as citation managers; used to save, search, sort, share, and continuously add, delete, and organize promising citations Ex: RefWords, Endnote, Mendeley, Zotero

critical appraisal

process of evaluating a study for its worth (i.e., validity, reliability, and applicability to clinical practice) -essential to EBP Helps us distinguish: -Best evidence from unreliable evidence -Unbiased evidence from biased -Level of evidence + quality of study = strength of study

background questions

questions focusing on basic or general knowledge; can often be answered using a textbook

foreground questions

questions that focus on specific knowledge that can be used to make clinical decisions; often need to use verified sources (peer-reviewed research, SRs) to answer these

effect

rate of occurrence in each of the groups for the outcome of interest

study reliability

refers to the "repeatability" of the study—that is, if the study were repeated under the same circumstances, would the results be the same?

instrument reliability

refers to the consistency of the instruments—will they yield the same results under the same conditions?

reliability

refers to the interpretation of the numerical results methods and whether the study could be repeated and produce the same results; whether or not the effects of the study have sufficient influence on practice, clinically and statistically Key questions: -Do the numbers add up? -What is the magnitude of the effect? -How precise was the effect estimated? -What is the strength of the association?

applicability

refers to whether or not the results from a study are appropriate for a particular patient population

validity

refers to whether the results of the study were obtained using sound scientific methods Key questions with study validity: -Can the results of the study be "believed"? (internal validity) -Can the results of the study be generalized to other settings/patient populations? (external validity)

translational research

studies how evidence-based interventions are translated into real-world settings

evidence-based practice guidelines (EBPGs)

systematically developed statements based on the best available evidence, including synthesis, make recommendations in order to assist practitioners with decisions regarding the most effective interventions for specific clinical conditions across a broad array of clinical diagnoses and situations.

clinical practice guidelines (CPGs)

systematically developed statements to assist clinicians and patients in making decisions about care Consist of a SR of the literature; consensus of a group of expert decision makers -Administrators -Policy makers -Clinicians -Comsumers A group of experts considers the evidence and makes recommendations.

quality

the extent to which a study's design, conduct, and analysis have minimized selection, measurement, and confounding biases

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

statistical significance

the result of statistical analysis of data are unlikely to have been caused by chance, at a predetermined level of probability -represented by p value -when p < .05

gatekeeping bias

the tendency for the media or a particular media outlet not to report stories of a particular nature

confounding variables

those factors that interfere with the relationship between the independent and dependent variables -Most often encountered in studies about lifestyle and health.

gray literature

unpublished drug trials, reports, conference proceedings, articles, etc.; because there is no peer review of this evidence, it should be appraised to determine its reliability.

research utilization

use of results from a *single study* to inform practice decisions

AND

useful when narrowing a search to combine two search results; BOTH terms need to be present or an article will not be included in the results

subject headings searching (controlled vocabulary, subject terms, thesaurus, descriptors, taxonomies, etc.)

uses a standardized set of preselected terms for the search Strengths: Searches can be broadened without considering every synonym for the chosen keywords; helps decrease number of irrelevant hits (selects studies only if at least 25% relevant to topic) Weaknesses: Newly developed technologies, phrases, and acronyms may not yet be linked to the database -- would be missed.

title searching

uses keywords generated from the "P", "I", and "O" components of the PICOT question to search article titles with the same keywords Strengths: increases chance of article found being relevant to PICOT question Weaknesses: misses studies that do not contain keywords in the title

keyword searching

uses words generated from each component of the PICOT question Strengths: provides a quick snapshot of how helpful a database will be in finding relevant evidence Weaknesses: may miss studies that do not exactly match word choices; may find studies that are irrelevant to the PICOT question

consistency

whether investigations with both similar and different study designs report similar findings, which requires numerous studies

instrument validity

whether the instruments are measuring what they are supposed to be measuring

OR

will expand a search to include either one or both terms in the results (MORE)