Research 2 and 4

-Problem-solving approach that considers the clinical experience (the ability of the nurse to use clinical skills and experience to identify pt unique health, dx, and risk). -Combines research evidence, knowledge, and theory -Allows patient values to be heard (unique pt concerns, expectations is integrated into chemical decisions.)

3 components of EBP

A rigorous process of collecting and reviewing the literature to answer a specific clinical question

A systematic review

· Systematic investigation, including research development, testing, and evaluation designed to contribute to generalizable knowledge. Generation of new knowledge. Uses sequence of steps in logical manner. Attributes includes generalizing knowledge.

Analytical methods Research

• Production of results that can be shared with and or evaluated by peers. The scholarship application involves the translation of research into practice and the dissemination and integration of new knowledge. It aids professions and society in addressing problems. • Pragmatic (sensible and realistic) what is practical? • Holding a pragmatic purpose. • Examples of advancing the scholarship of Application: • Practicing as an advanced practice nurse or clinical specialist in partnerships to advance research and clinical improvement • Translating research and utilizing evidence to improve health and generate practice-based knowledge • Establishing and evaluating quality improvement project • Disseminate clinical programs or quality improvement initiatives in regional, national, or international arenas.

Application scholarship

-PICOT approach •Patient population or patient condition •Intervention or issue of interest •Comparison of interest (may not be relevant to every clinical question) •Desired outcomes •Time frame (may not be relevant to every clinical question)

Ask a clinical question

Questions are asked because of the need for basic, fundamental, or general knowledge about a condition or disorder

Background questions

focus on the scholarship of practice or translating evidence to practice, often working with unit-based quality improvement (QI) and evidence-based practice (EBP) projects to improve and transforming health care

DNP

• Informs science, enhances clinical practice, and impacts best practices. • The American Association of Colleges of Nursing (AACN) defines nursing scholarship as the generation, synthesis, translation, application, and dissemination of knowledge that aims to improve health and transform health care

Definition of nursing scholarship

-Inclusion and exclusion criteria -Search for key terms or phrases associated with patient population and intervention -Use a concept map to expand keywords to understand associations b/n similar words and phrases. -Subject headings and title search -Boolean operators -Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) assist researchers in reporting results associated with systematic reviews and meta-analyses

Develop search strategy

4 types of nursing scholarship by Boyer

Discovery Integration teaching application

•Expanding existing knowledge that is translatable into practice. Or transferring social problems into usable knowledge. • The epistemological question is What is True? • Holding an empirical purpose • Examples: • Publishing research papers and reports in peer review • Presenting research findings at regionals, nationals, or international conference • Securing competitive extramural grant • Mentoring junior colleagues in research and scholarship • Lead successful research initiatives

Discovery Scholarship

. Examines health services and the evaluation of quality healthcare. Types of data used to assess quality in healthcare are QI, EBP, and Research

Donabedian's framework in evaluating quality care

•Originally defined as a conscientious, explicit, and judicious use of best evidence in making decisions about pt care.

EBM

Practice focused on several steps including 1. selecting and formulating clinical questions 2. forming a team 3. tracking down the best evidence 4. appraising the evidence critically. EBP integrates research utilization with clinical expertise. Clinical expertise is obtained from clinical experience.

EBP

Purpose: Improve practices by using the latest, most appropriate evidence; best practices Structure: Individual/Group Process:EBP methods Outcome: Practice change or standards (local practice)

EBP

1. Provide the best care to improve individual experience 2. To improve the health of the whole population 3. Provide care at the lowest cost

EBP aims to provide

Ask gather assess and appraise act evaluate

EBP steps and significance.

Variety of forms nurses engage in scholarship

Entry level DNP PHD

identify potential nursing problems and begin to learn critical appraisal skills

Entry level BSN

•Present research findings with patients and families as part of decision-making process - information presented should Note whether great deal of evidence or limited evidence supports guideline -Feel free to express your informed views regarding meaning of findings

Ethical Concerns Around EBP

• Integrates the best evidence from well-designed studies with patients' preferences, values along with clinician's expertise Steps involved with EBP • Best evidence relies on several sources to support changes in practice • Grading the level of evidence • Rigorous search strategies used • Critical appraisal of evidence • Limitation • Lag-time between generating research findings and applying EBP. • Barriers include inadequate knowledge of EBP and skills • Organizational structures that do not support EBP • What EBP accomplish: • A systematic search, appraisal, & synthesis of the literature to assemble the best evidence to improve practice. Examples EBP metrix: • National Patient Safety Goals • Standards of Care • Core Measures • DVT prevention: SCD and Lovenox • Glucose control: <150 • Antibiotic stewardship

Evidence based practice

•Derived from the principle that health-care professionals should not center practice on tradition or experience, but scientific research findings. Expand to apply across all health-care.

Evidence based practice

•Daily changing of IV dressings •Perineal shaves & enemas for childbirth •Sugar paste for pressure ulcers

Example of practices routed in tradition outdated

Questions are asked for specific knowledge to inform clinical decision or actions.

Foreground questions.

-Members should be: •familiar with the problem •stakeholders in the delivery of care (those paying for the research or those participating) •from different healthcare professions -May also include administrators who will help implement EBP

Form a team

•Safe •Effective: providing services based on scientific evidence to all who could benefit, and refraining from providing services to those not likely to benefit •Patient-centered: respectful and responsive to individual preferences, needs, and values •Timely •Efficient •Equitable (meet people where they are)

Healthcare should be

Scientific inquiry has been considered the first and most important form of scholarship

Historical scholarship

Refers to synthesis of information across disciplines, making connections to shape a more coherent and integrated use of knowledge. Integration knowledge from different disciplines promotes innovative thinking and creates new and different perspectives on variety of issues. • Ontological question is what is good. • Holding interdependent purpose • Examples of advancing the scholarship • Work in integrated and collaborative partnerships to submit interdisciplinary grants. • Publish with colleagues on interdisciplinary programs or service projects • Collaborate with colleagues on submitting policy analyses, case studies, or integrative reviews. • Present findings with interpersonal colleagues

Integration scholarship

Uses three steps (PET) 1. Practice question 2. Evidence 3. Translation

JHM

Ideas generated when staff read, listen to presentations of topics such as skin breakdown, NG tube placement, and patency of arterial line. The available knowledge is used to improve patient outcomes.

Knowledge focused trigger

Systematic review or meta-analysis of randomized controlled trials (RCT) . Considered the strongest evidence level

Level 1

A well designed RCT

Level 2

controlled trial without randomization

Level 3

Single nonexperimental study (case-control, correlational, cohort studies)

Level 4

Sytematic reviews of descriptive and qualitative studies.

Level 5

Opinion of authorities and/or reports of expert committees

Level 7

•Shortage of coherent, consistent scientific evidence •Difficulties in applying any evidence to care for individual patients •Barriers to any practice of high-quality medicine •The need to develop skills in researching and appraising research •Limited time in practice to master skills •Resources scarce

Limitations of EBP

A statical technique that combines the results of many research studies in a specific area and synthesizes their findings to draw conclusions regarding the state of the science and area of focus.

Meta-Analysis

• scholarship that involves more than empirical research.

New Paradigm of scholarship

Measured indices of processes within the structure. Or effects of healthcare on the health status of patients and population. • Changes to health status • Changes in behavior • Changes in knowledge • Quality of life • Patient satisfaction

Outcome

focus on the scholarship of discovery, often working as nurse researchers/scientists generating new knowledge

PHD

Provides structure when framing a clinical question so that an appropriate literature review can be performed

PICOT

related to DNP-prepared nurses who focus on the scholarship of practice or translate evidence to practice, often working with unit-based QI and EBP projects to improve and transform healthcare delivery and patient outcome.

Practice focused

This trigger is based on the context of clinical practice e.g: incidence of DVT and pulmonary embolism. Begins by asking? What is the best possible evidence available to solve a clinical problem?

Problem focus trigger.

Refers to the steps involved in the provision of services and transactions between patients and providers throughout the delivery of healthcare • Diagnosis • Tx • Preventative care • Patient education • Pts family and their families

Process

a set of specific care actions for a patient population that has been endorsed by the hospital, agency, primary care clinic, or healthcare facility

Protocol:

Purpose: Review, revise and change the process to achieve an improved outcome Structure: Group/Team Process:. E.g: PDSA Outcome: Improved procedures or process (local practices)

QI

Types of nursing scholarship

QI EBP Analytical research

• Systematic and continuous actions that lead to mesasurable improvement n healthcare services and the health status of targeted patient groups. Scope of interest is local problem: specific to unit, patient population in an organization. Extraneous variables are not always measured. Patient, staff, and providers benefit. • Goal : • Analyze data and continuously improve systems related to processes and outcomes • Use the Plan-Do-Study-Act (PDSA) improvement cycle • Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines providing a framework for reporting results of QI initiatives • Steps involved are • Assessment • Data analysis • Use multiple tools • Develop plan • What QI accomplishes: • Impact practice by improving pt care processes and outcomes in specific health care settings. Examples of QI matrix • CAUTI-A catheter-associated urinary tract infection • CLAUBSI-central line acquired bloodstream infection • Falls-Humpty Dumpty Scale

Quality improvement

•Practicing nurses may delay using research findings if they: -do not know about current research findings -are unclear about the risks involved -do not develop opportunities for acceptance of innovation - Nurses do not associate with those producing knowledge •Nurse researchers may contribute to research-practice gap if they: -use a different language than nurse clinicians in reports -do not report findings in clinically meaningful way

Reasons for research practice gap

o IOM 2001 Crossing the Quality Chasm o IOM 2003 Health Professionals Education: A Bridge to Quality o RWJ 2002 Health Care's Human Crisis

Reports indicated healthcare needed a better and different educated workforce

• IOM 2000 report- To Err is Human: Building a Safer Health System • Standard of Care • National Patient Safety Goals • Core Measures • AHA 2002 In Our Hands • JACHO 2002 Healthcare at the Crossroads-Sentinel Events-25% Nurse Related

Reports on the state of Medicine

Purpose: Generate new knowledge Structure: Individual/group/team Process: Research method Outcome: New knowledge to be tested and to contribute to the developing evidence on the topic

Research

related to PHD prepared nurses who work as researchers conducting health-related knowledge generation through research

Research Focused

Period/point from when knowledge was produced to the point at which it is practiced.

Research practice Gap

•Research-generated knowledge is incorporated into practice •Often thought of as a subset of EBP . Process involves critical analysis, implementation, and evaluation. Purpose is to apply available knowledge to improve outcome. Emphasis translating empirically derived knowledge into real world application.

Research utilization

-Knowledge-focused trigger • -Problem-focused trigger •"Why do we do it this way?" or "Is there a better way to do this?"

Select a topic

1. Select topic 2. Ask a clinical question 3.For a team 4. Systematic review of literature 5.track down the best evidence 6. Identify electronic databases and other resources to use based on topic 7.Develop search strategy 8. Appraise evidence critically 9. Hierarchy of evidence.

Steps to EBP

• involves environment in which health-care services are provided. • People • Equipment • Physical space • Time • money

Structure

Refers to the systematic study of teaching and learning process. The scholarship of teaching involves stimulating active learning, engaging critical thinking, and encouraging a commitment to life long learning. Within nursing, the teaching focuses on the understanding, describing, and teaching of learning endeavors as well as controlling, predicting, and disseminating outcomes of teaching-learning processes. • Axiological (Goodness or value)? What is valuable • Educational purpose • Examples of advancing the scholarship: • Developing new teaching methos and strategies • Evaluating the impact and efficiency of teaching strategies in attainment of student learning • Applying technology to teaching an learning • Presenting findings related to teaching and learning at conference

Teaching scholarship

Textbooks not helpful in this review because information is outdated and not peer reviewed.

Why is textbook not helpful in review

Single descriptive or qualitative study

level 6

1purpose of translating research into quality improvement and evidence-based practice (EBP).

• to improve processes or patient experience; make organization better • to improve practices by using the latest, most appropriate evidence, best practices in patient care.

-Extract pertinent data from each original research study and assemble systematically -Arrange in matrix table using result or evaluation matrix. -Collaborate with more experienced researchers

•Appraise evidence critically

-Systematic reviews and randomized clinical trials (RCTs) are ranked as strongest evidence (level I) -Expert opinion of authorities and/or reports from expert committees ranked as weakest evidence (level VII)

•Hierarchy of evidence

-Basic/background information eg. Medline/review -Short critiques or recent studies/reviews E.g: MEDLINE/abstract and InfoPOEMS -Common well-studies topics E.g: MEDLINE/Reviews and Cochrane -Practice guidelines/algorithms E.g: Cochrane and MEDLINE/ National guideline clearinghouse -Uncommon/specific/current topics MEDLINE

•Identify electronic databases and other resources to use based on research topic

-Knowledge is more than just one finding (use multiple research findings from several studies to build a base clinical knowledge.) -Use scientific approach to summarize, appraise, and communicate results of several studies

•Systematic review of literature

-Start searching broadly -Identify indexes, journals, databases, and other sources worth pursuing -Textbooks not helpful in this review -Work with librarian to develop search strategy -Collaborate with other nurse colleagues _ can use text book reference as a guide

•Track down the best evidence