Chapter 11: Employ Evidence-Based Practice

Clinical guidelines

A guideline that provides a purposeful and clear evaluation of the effectiveness of therapeutic modalities; an evidence based guideline is one of the strongest sources for EBP; considers both the efficacy of an intervention and its acceptance by those to whom it is offered

Effectiveness

A measure of the benefit resulting from an intervention for a given health problem under average conditions of use

Outcomes research

A newer approach focused on determining the effectiveness of healthcare services and patient outcomes

Research

A systematic investigation that includes research development, testing and evaluation; designed to develop or contribute to generalizable knowledge

Nursing education research

Explores more effective an efficient educational processes and new teaching-learning practices to incorporate technology in the learning process, intergenerational learning differences and their impact on education, and the development of methods to improve lifelong learning and commitment to leadership

The NINR is located

At the NIH campus in Rockville, Maryland

2 major types of research

Basic and applied

CTSA

Clinical & Translational Science Award wise goal is to decrease the time taken to move research inno practice

2 initiatives were developed to address the need for evidence to support strategies employed to improve care:

Clinical and translational science awards and patient centered outcomes research institute

Major research focus area

Clinical research, health systems and outcomes research and nursing education

International council of nurses

Committed to supporting nursing research as a powerful tool for generating new knowledge and evidence to underpin nursing practice

Research question

Concise and developed before the research is conducted and stated in the research proposal

extramural study

Conducted at the researchers home institution or in collaboration with several institutions, grants are awarded

EBP is included in all 5 healthcare professions'

Core competencies

Funding

Critical part of any research because it provides resources to conduct the research such as researcher salary, staff pay, space, supplies, animal costs, etc.

Research purpose

Describes the potential uses of the results

Research analysis

Description of results and conclusions after the study has been conducted

Applied research

Designed to find a solution to a practical problem; often referred to as clinical research and carried out in a non-lab setting

Basic research

Designs to broaden the base of knowledge rather than solve an immediate problem and is typically done in a lab setting

Cochrane Database of Systematic Reviews

Develops, maintains and updates systematic reviews of healthcare interventions to allow practitioners to make informed decisions. Located in London

Sigma Theta Tau International (STTI) is an active supporter and developer of

EBP through its online nursing journal publication

Best practice clinical decisions require

EBP, healthcare provider expertise, patient assessment and inclusion of patient's perspective (preferences and values)

National Institutes of Nursing Research (NINR)

Established 1985 part of the national institute of health; important because it shows nursing has a presence in the most prestigious national research system; conducts research that has an impact ol for the nursing profession and allocates funding for nursing studies conducted in other institutions; encourage interprofessional research

After evidence is found, nurses must

Examine the validity of the evidence, it's relevance, and it's appicability to the EBP question. Then evidence may be applied in practice

Second ethical and legal concern in research

How best to balance benefits and risks/harms in studies

Institutional research board

IRB; committee that reviews research before it is conducted to ensure that the study is conducted ethically

Barriers to facilitators of research

Lack of funding Lack of sufficient time Lack of research competencies Lack of participants for the sample Inability to find the right setting Lack of statistics expertise

The nursing and allied health professionals are not as far along in implementing EBP as

Medicine

NCGs

National clinical guidelines. A EBP source that is the US government based through the AHRQ although the guidelines come from many different sources

Quality Improvement (QI)

Now focuses more on continuous quality improvement (CQI), the process that aims to ensure patients receive the best care when they need it and outcomes are met on an ongoing basis

Nurses may be involved in developing systematic reviews by

Revising studies based on specific criteria (though uncommon because reviewing studies takes a special expertise and in depth knowledge of statistics)

Policies and procedures

Written guides developed by organizations to inform staff about expectations related to care and management

Translational research

The application of discoveries generated in the lab and preclinical studies to the development of trials and studies in humans; research aimed at enhancing the adoption of best practices in the community

Systematic review

The consolidation of research evidence that incorporates a critical assessment and evaluation of the research and addresses a focused clinical question using methods designed to reduce the likelihood of bias; critique of multiple studies related to same research question

The largest source of grant monies

The federal government

Randomized control trials (RCTs)

The gold standard in research design; involve a true experiment; control and other variables, randomization of the sample, use of a control group and experimental group, and manipulation of an intervention ( aka independent variable)

Intervention in experimental studies represents

The independent variable

Florence Nightingale had some interest in clinical research however in early nursing history,

The nursing community did not pay much attention to research

Magnet Recognition Program

The only national designation built on and evolving through nursing research that is designed to recognize nursing excellence of healthcare organizations through a self-nominating, appraisal process; includes EBP as one of its recognition elements

Theory

Used in qualitative studies, the researcher may identify a theory or conceptual model to organize findings; described and related to research question

1920s-1930s nursing research

Very few studies focusing on nursing care

Agency for Healthcare Research and Quality (AHRQ)

a federal agency established to improve the quality, safety, efficiency, and effectiveness of health care for Americans; source of EBP literature and collection of evidence based on national clinical guidelines (NCGs)

Determining the comparative effectiveness of prevention and treatment strategies is part of

Translational science

Funding sources

Universities, private donations, foundations and organizations, local and state governments, and the federal government

EBP is the major initiative used to increase the

Use of best practice or evidence in making clinical decisions

EBP

evidence based practice; to integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible; tailored to individual patient needs and based on evidence from more than one study

EBM

evidence-based management; Systematic application of the best available evidence to the evaluation and managerial strategies for improving the performance of health services organizations

Nursing research develops knowledge for the following purposes:

- build scientific foundation for clinical practice - prevent disease and disability - manage and eliminate symptoms caused by illness - enhance end of life and palliative care

Key elements of EBP

- core competency - evidence based management - nursing research - EBP and quality improvement - tools for EBP success like clinical guidelines, policies and procedures - EBP and the students - EBP process models

NINR's goals to invest in research focusing on:

- enhance health promotion and disease prevention - improve quality of life by managing symptoms of acute and chronic illness - improve palliative and end of life care - enhance innovation in science and practice - develop the next generation of nurse scientists

The EBM Process:

- formulate the question - acquire research evidence - assess the quality of evidence - presenting the evidence - applying the evidence to the decision

All systemic reviews must:

- include clear criteria for conducting review process - review not only research reports but also review data from large databases and include published articles that are opinion or essay

In order for EBP to be used more effectively, healthcare professionals should have these abilities:

- know where & how to find the best possible sources of evidence - formulate clear clinical questions - search for relevant answers to questions from the best possible sources of evidence - determine when & how to integrate these new findings into practice

Barriers to EBP implementation

- lack of knowledge about EBP & it's value - limited time in practice settings - nursing shortage - greater need to emphasize both knowledge and practical approaches - concern that EBP represents a cookbook approach to care - lack of knowledge about EBP resources - lack of resources to find info - limited recognition by employers regarding the value of EBP

Experimental studies must have

- manipulation of intervention - control - randomization

Vulnerable research participant populations

- neonates - children - pregnant women - persons with mental illness - pertains with cognitive impairment - terminally ill person - persons confined to institutions

EBP data used most often by students:

- patient values and preferences - patient history - assessment data

ANA Research focuses on:

- the value of nursing contributions to safety, reliability, quality and efficiency - factors that increase the impact of nurses on quality and efficiency - use of national database of nursing qualitative indicators to enhance patient safety, quality care and efficiency - nurse workforce issues - population health issues

2 important EBP databases

1. Cochrane database of systematic reviews 2. Joanna Briggs institute EBP database

2 tools to ensure a higher use of EBP:

1. Healthcare organization policies & procedures 2. Clinical guidelines

PICOT used in 5 steps:

1. Identify burning clinical issue/question 2. Collect the best evidence relevant to the question 3. Critically appraise that evidence before it is used 4. Integrate evidence with other parts of EBP (patient preferences, clinical expertise, assessment info and patient history) 5. Evaluate practice decision or change

3 approaches to obtain funding:

1. Identify problem and develop proposal that is sent to funding sources that might have an interest in the particular problem 2. Develop research proposal that specifically addresses problem area that a funding source has identified as a critical need area 3. Funding sources require the researcher to conduct a pilot study or have data that indicates great need for research about a particular problem

Health systems and outcomes research

Focuses on identifying ways that the organization and delivery of care influence quality, cost and the experience of patients and their families

Hypothesis

Formal statement or the expected relationship or relationships between two or more variables in a specified population, which is a sample; stated before the research is conducted and included in the proposal

Research problem statement

Formulated to be an assessment to identify and describe the problem; researcher does this assessment using the researchers individual expertise; reviewing literature and possibly interviewing other experts

Intramural/internal study

Funded research conducted at the NINR campus

EBP is an organized approach to

Get research into practice

1950s nursing research

Greater interest in research; more nurses conducted studies and obtained grwduate degrees

IRB is mandated to review all research that

Includes human subjects in institutions that receive federal funds

Clinical research

Includes interventions for secure and chronic care experiences across the life span, health promotion and preventive care to end of life care and care for individuals, families and communities in diverse settings

Third ethical and legal concern in research

Informed consent

Fourth ethical and legal concern in research

Institutional review to ensure participant rights are protected and study is planned in an effective manner that meets sponsorinf orgs standards

Research and evidence based practice are

Interconnected

American Association of Colleges of Nursing (AACN) statement on research

Nursing researchers bring a holistic perspective to studying individuals, families and communities; their research takes a bio behavioral, interdisciplinary, and translational approach to science

1960s-1970s nursing research

Nursing theorists were very active in research, adding to scholarly work and increasing the amount of PhDs

Joanna Briggs Institute EBP Database

Organization that represents an international collaboration among nursing and allied health centers. Located in Australia main purpose is to train professionals to conduct systematic reviews

Nursing research serves as a framework for

Organizing facts and evidence into a cogent and usable format

Research report

Published article, poster or presentation after the study is completed for the researcher to describe what was done

PICOT

Patient, Intervention, Comparison, Outcome, Time; EBP question part of every search for evidence to improve practice; must be specific

Incorporating EBP evidence into standards of care help reduce

Practice variation and provide greater consistency based on evidence to improve quality and safety

Using EBP affects comparison of alternatives and interventions such as

Prevention, diagnostic tests, therapy or no intervention at all

Priorities of nursing research

Promotion of health and healthy lifestyles, advancement of quality and excellence in health care and the critical importance of basing professional nursing practice on research

National Guideline Clearinghouse

Provides a collection of evidence-based clinical practice guidelines, sponsored by the AHRQ

Research network

Provides a vehicle for continual exchange of knowledge and experience; greater global sharing of research info and expertise

EBP helps to provide

Quality care

Qualitative studies

Research question focuses on feelings or experiences; data collection is less structured

Quantitative studies

Research question focuses on how many or how much; data collection is highly structured and used statistics

Research Proposal

Researcher describes what will be done; plans the research and may be used to apply for funding; critical document used to obtain approval for a study and institutional review board; written in future tense

First step to applying EBP

Staff preparation

Research process

Step by step problem solving method

Research

Systematic investigation of a problem, question, issue or topic that uses a specific scientific process to gain new knowledge

The key component of EBP literature is

Systematic review

The staff nurse's most important role is

That of a consumer- applying knowledge from systematic reviews

First ethical and legal concern in research

To protect the rights of human participants

Nursing research framework must represent

The phenomenon of interest and guide the research question and the measurement of variables

Research design and methods

The specific plan for conducting the study; complex; include the details related to type of study, sample and means by which sample is selected, setting for study, measurement and data collection instruments, data collection process, data analysis and description of potential limitations; clear and detailed plan

Results of an RCT provide

The strongest support for a cause and effect relationship

Nursing research provides opportunities for linkages between

Those involved in the research process, practicing nurses, other health professionals, policy makers and the public

The purpose of EBP

To guide the use of limited resources, control costs and improve quality nursing care

CQI

continuous quality improvement; a structured organizational process for involving personnel in planning and executing a continuous flow of improvements to provide quality healthcare that meets or exceeds expectations