Evidence-Based Practice Exam One

The ARCC Model*

*evidence based mentors is included*

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., rapid critical appraisal, 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

Search Competencies

1. Determine Search Terms 2. Determine Databases/Sources 3. Construct Search Strategy 4. Select Appropriate Evidence to Read 5. Organize Citations & Search Strategy 6. Obtain Appropriate Literature 7. Identifies & Searches Grey Literature See Table 3.1, page 58 for Databases & Sources of External Evidence Grey literature can be like government reports. Not though usual channels you expect research to come from

Questions That Need to Be Asked About Databases Used for Searching Evidence

1. Is the evidence current? 2. Which search strategies are supported (e.g., are keywords, title searches, and subject heading searches all supported)? 3. How frequently is the database updated?

PICOT Format: Etiology Template

Are ________________(P) who have _________(I) compared to those without _________________(C) at ______________ risk for/of ___________ (O) over ____________(T)?

Objectives for Week 3

At the end of this week, the student will be able to: Describe sources of evidence for clinical decision-making. Describe how practice-based evidence, research, and evidence-based practice are complementary and supportive processes. Discuss improvement and implementation research. Discuss the importance of measurement of intended outcomes for demonstration of sustainable impact of evidence.

Week Four objectives

At the end of this week, the student will be able to: Describe various types of evidence-based practice models that guide the implementation and sustainability of evidence-based practice. Discuss how evidence-based practice models can improve healthcare quality and population health outcomes.

Objectives for Week Two

At the end of this week, the student will be able to: Explain the components of a PICOT question: population, issue or intervention of interest, comparison of interest, outcome, and time for intervention to achieve the outcome. Discuss the purpose of the PICOT format. Describe the difference among clinical questions, quality improvement questions, and research questions. Describe the difference between background and foreground questions. Craft a clinical question using proper PICOT format. Describe the role of the PICOT question Describe sources of evidence. Discuss basic and advanced strategies with which to conduct a systematic search. Discuss what constitutes a search yield.

Step 3: Critically Appraise the Evidence

Critical appraisal of external evidence includes three areas of evaluation: 1. Are the results of the study valid? (Validity) Did the researchers conduct the study using the best research design and methods possible? 2. What are the results? (Reliability) In quantitative research: Did the intervention work, and if so, how large was the effect? Can the results be generalized? In qualitative research: Does the research approach fit the purpose of the study? 3.Will the results help me in caring for my patients? (Applicability) Are the subjects in the study similar to the patients for whom I care? Are the benefits greater than the risks of treatment? Is the treatment feasible to implement in my practice setting? Would my patients readily accept the treatment and do they have the resources needed? Should have within their study proving their validity. If its not in there that's a red flag Will my patient actually use it? Patient preference, cost, etc.

LEVELS OF EVIDENCE: LEVEL ONE •Systematic Review:

Detailed & comprehensive plan and search strategy; goal is to identify, appraise, & synthesize all relevant studies on a particular topic

Week One Objectives

Discuss how evidence-based practice (EBP) assists hospitals and healthcare systems achieve the quadruple aim. Describe the differences among EBP, research, and quality improvement. Identify the seven steps of EBP Discuss barriers to EBP and key elements of cultures that support the implementation of EBP

The EBP Difference: Weighing the Evidence

EBP acknowledges the relative weight and role of knowledge sources in making clinical decisions. Grading the strength of a body of evidence should incorporate three domains: ·Quality ·Quantity ·Consistency

Sources of Knowledge for Clinical Decisions

Each clinical decision made, or action taken is based on knowledge. Sources of knowledge include: ·Research ·Theory ·Experience ·Tradition ·Trial and error ·Authority ·Logical reasoning · In the past, practice was based largely on tradition, logic, and expertise; distinguish knowledge that is or is not reliable and decide what is biased and not biased

Question: Is the following statement true or false? Foreground questions can often be answered by consulting an up-to-date nursing or science textbook.

False Rationale: Foreground questions are clinical questions that can only be answered by specific scientific evidence that is usually found in original studies or systematic reviews of original studies (e.g., RCTs). This type of evidence is not available in textbooks, which are more appropriate for answering background questions.

Is the following statement true or false? A single randomized controlled trial (RCT) constitutes the highest level of evidence and is the most reliable guide to nursing practice.

False Rationale: Meta-analyses and systematic reviews that synthesize the results of multiple RCTs or experiments are considered to be the highest form of evidence. A single RCT is classified as Level II evidence.

Is the following statement true or false? Internal evidence is characterized by findings that are applicable and generalizable to multiple practice settings.

False Rationale: Unlike external evidence, the generation of internal evidence is intended to improve clinical practice and patient outcomes within the local setting in which it is conducted.

Decision tree matching research design to category of research question

Figure 3-1 slide 32

Promoting Action on Research Implementation in Health Services Framework (PARIHS) Framework

Framework is based on the formula: SI = f(E,C,F) Whereas SI represents successful implementation; f, function of; E, evidence; C, context; and F, facilitation •The three elements (i.e., evidence, context, and facilitation) are each conceptualized on a high-to-low continuum; the focus is to move the elements in the formula toward "high" in order to optimize the chances of success

Differentiating question types: Clinical (PICOT) Question

Guides the systematic search for evidence Best available evidence

PICOT Format: Meaning Template

How do ________________(P) with _________(I) perceive _________________(O) during ____________(T)?

PICOT Format: Prognosis Template

In ________________(P) how does___________(I) compared to _____(C) influence/predict _______(O) over (T)____________?

PICOT Format: Intervention Template

In ________________(P) how does___________(I) compared to __________(C) affect ___________(O) within (T)____________?

PICOT Format: Diagnosis Template

In ________________(P) is ___________(I) compared to _____(C) more accurate in diagnosing (O) ____________?

Step 0: Cultivate a Spirit of Inquiry Within the Environment

Key elements of an EBP culture and environment include: ● A spirit of inquiry ● A philosophy, mission, clinical promotion system, and evaluation process that incorporate EBP ● Knowledgeable EBP mentors ● An infrastructure that provides support in using EBP ● Administration and leadership that supports, values, and models EBP ● Consistent recognition of individuals and groups who implement EBP

Determining if Evidence Should Be Used to Make a Practice Change

Once an environment conducive to EBP is established, it needs to be remembered that the confidence to make an evidence-based change comes from a combination of: level of evidence (positions of evidence in hierarchy) and quality of evidence (validity + reliability + applicability) Level of evidence (rct, systematic rcts, qualitative, etc.)

PubMed®: A Unique Resource

PubMed®: Database produced and maintained by the National Center for Biotechnology Information (NCBI) at the National Library of Medicine •Contains >19 million citations from >5,600 journals of biomedical sciences, nursing, dentistry, and pharmacy •Free and committed to providing access to all evidence •Provides free online access to the MEDLINE® database •Includes automatic term mapping that uses the keywords entered to map them to appropriate MeSH® terms Search results appear in the order in which they were added to the database. To find the most recently published article, use the "Sort by Pub Date" option.

Internal Evidence: Monitoring Quality

Several well-known systems can be used to track quality indicators of care over time. The value of doing so includes: ·The impact of continually improving innovations over time can be traced ·Overall performance can be monitored at regular intervals and trends identified ·Areas for improvement can be identified and targeted for intervention National quality indicator monitoring systems

LEVELS OF EVIDENCE: LEVEL ONE •Meta-analysis:

Statistical techniques to synthesize the data from several studies into a single quantitative estimate or summary

Level of evidence + quality of evidence=

Strength of evidence (confidence)

·Quality:

The extent to which a study's design, conduct, and analysis have minimized selection, measurement, and confounding biases (internal validity)

Why Evidence-Based Practice (EBP)?

The focus of healthcare reform in the United States encompasses what is known as the Institute of Healthcare Improvement's "Triple Aim," which includes: ·Enhancing the experience of care for those served ·Improving the health of populations throughout the nation ·Reducing per capita costs of national health care (http://www.ihi.org/engage/initiatives/TripleAim/Pages/default.aspx) EBP has been shown to be useful in reaching these aims

·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; small sample size not usually very valid.

Differentiating question types: Research Question

To generate new knowledge/external evidence External evidence

Differentiating question types: QI Question

To identify & fix the processes leading to a problem (internal) Internal evidence See examples Table 2.3, page 42 & 43

Is the following statement true or false? A well-formulated PICOT question should specify the measurable patient outcomes that need to be addressed.

True Rationale: A PICOT question should always specify the outcome that is expected from the clinical question. It is important that the outcome be measurable in some way so that the effectiveness of the change can be evaluated.

Is the following statement 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.

True Rationale: Controlled vocabulary systems exist to increase the relevance of search results while limiting the number of less relevant hits.

Is the following statement true or false? Finding a quasi-experimental study in a peer-reviewed nursing journal article that tests a protocol for the frequency of turning for immobile patients is an example of external evidence.

True Rationale: External evidence includes peer-reviewed publications that present the findings of research and are intended to be generalized to other clinical settings.

Question Is the following statement true or false? Both the Model for Evidence-Based Practice Change and the Iowa model include the use of a small-scale pilot study during the process of introducing an evidence-based change in practice.

True Rationale: Pilot studies are explicit components of both the Model for Evidence-Based Practice Change and the Iowa model.

·Consistency:

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

Exam Hints

Your exam on Tuesday has 29 questions and it is worth 75 points. Twenty-seven (27) of the 29 questions are multiple-choice. There will be one matching question on the test about the models. Listen very carefully to the lecture on chapter 14 and you will get hints that will help you answer that question. The other matching question has to do with the evidence-based process steps. The two matching questions are worth a total of 21 points.

In which stage of the PDSA cycle is external evidence most likely to be used? a.Plan b.Do c.Study d.Act

a. Plan Rationale: Although newly developing external evidence might be used in the Act stage if the outcomes from the change were not as expected, the Plan stage uses external evidence as a main foundation on which to plan a clinical change.

A group of nurses have successfully implemented a new evidence-based protocol related to postoperative patient assessment. What is the next step for this project? a.Tell others about the results of their project b.Elicit feedback from patients and other stakeholders c.Evaluate the costs of the change in practice d.Search the literature for research that relates to the practice change

a. Tell others about the results of their project Rationale: The EBP process culminates with the dissemination of results. Searching the literature, consulting with patients, and evaluating costs are actions that should already have been performed earlier in the EBP process.

Which of the following sources of evidence would be the best evidence to use to suggest a clinical practice change? a.A well-designed randomized controlled trial (RCT) b.A systematic review that encompasses multiple studies c.Expert opinion of experienced and educated nurses d.A case study that addresses a similar clinical situation

b. A systematic review that encompasses multiple studies Rationale: Systematic reviews are pre-appraised evidence, which are considered to be higher on the hierarchy of evidence than expert opinion, individual RCTs, or case studies.

Question The use of EBP mentors is a major component of which model for evidence-based practice change? a.The Model for Evidence-Based Practice Change b.The ARCC© model c.The Stetler model d.The Iowa model

b. The ARCC© model Rationale: The ARCC model is the only model of those listed that considers the lack of EBP mentors to be a major barrier to the implementation of EBP and uses training of a cadre of EBP mentors as a step in implementing the model.

An obstetrical nurse wants to implement a body of evidence related to fetal monitoring practices on the unit. What is the first step that this nurse should take? a.Review the literature about fetal monitoring practices b.Consult with the expert nurses on the unit c.Begin to foster an attitude of curiosity in the OB staff d.Evaluate the outcomes of current practices

c. Begin to foster an attitude of curiosity in the OB staff Rationale: Cultivating an attitude of inquisitiveness, curiosity, and inquiry is foundational to the EBP process and is considered to be "step 0." Although reviewing the literature and evaluating the current outcomes is important, if nurses are not open to questioning their practice, change will probably not occur. Consulting with the unit experts is a wise move but only if it is in an attempt to gain support for a practice change.

In performing a rapid critical appraisal of a research study as evidence, which three factors are the most important to be evaluated? a. Study validity, study veracity, study strength b. Study validity, study reliability, study confidence c. Study validity, study reliability, study applicability d. Study validity, study strength, study reproducibility

c. Study validity, study reliability, study applicability Rationale: Terms in the incorrect distractors include study strength, which is actually derived from the study validity and reliability; study confidence, which results from the appraisal of the strength of the study; and study reproducibility, which is a component of study reliability.

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

d. An evidence-based clinical practice guideline for preventing skin breakdown Rationale: Although EBP encompasses patient preferences and the clinical expertise of individual practitioners, the primary source of knowledge is research evidence. Evidence-based clinical practice guidelines synthesize this evidence in order to guide practice.

Which of the following components of a PICOT question is absent from the following clinical question? "Among patients with dementia, how does the use of reorientation therapy compared with regular, supervised mobility affect patient agitation?" a.P (Population) b.I (Intervention) c.O (Outcome) d.T (Time)

d. T (Time) Rationale: This question specifies the patient population (patients with dementia), the intervention (reorientation therapy), the comparison (regular, supervised mobility), and the relevant outcome (patient agitation), but does not provide the time frame for an expected outcome.

Which of the following online evidence sources is most likely to provide pre-appraised evidence? a.CINAHL b.MEDLINE c.PubMed d.The Cochrane Library

d. The Cochrane Library Rationale: The Cochrane Databases include the Cochrane Database of Systematic Reviews (CDSR), which is a collection of systematic reviews that synthesize RCTs from multiple peer-reviewed sources. CINAHL, MEDLINE, and PubMed may contain evidence at a synthesis level, but most of the sources are individual research articles that must be appraised by the user.

Question Feedback loops are a central component of which of the following models for evidence-based practice change? a.The Model for Evidence-Based Practice Change b.The Clinical Scholar model c.The ARCC model d.The Iowa model

d. The Iowa model Rationale: The Iowa model includes multiple feedback loops that refer the user back to earlier points in the process. This is not a central feature of the Model for Evidence-Based Practice Change, the Clinical Scholar model, or the ARCC model.

AHRQ National Healthcare Quality Report

https://www.ahrq.gov/ https://www.ahrq.gov/cahps/surveys-guidance/hospital/index.html - •The AHRQ tracks the state of national healthcare quality on an annual basis •Measures trends in effectiveness of care, patient safety, timeliness of care, patient centeredness and efficiency, care coordination, timeliness, infrastructure, and access to health care •Data are most useful when combined with external evidence that supports specific actions to improve outcomes

National Database of Nursing Quality Indicators® (NDNQI®)

https://www.pressganey.com/resources/program-summary/ndnqi-solution-summary - •Established by the ANA to facilitate continued nursing indicator development and further understanding of factors influencing the quality of nursing care •Provides quarterly and annual reports to members on structure, process, and outcome indicators on a unit level

National Quality Forum (NQF)

https://www.qualityforum.org/Publications.aspx - • •Endorses 15 consensus-based nursing standards (NQF-15) for inpatient care representing measures that examine nursing contributions to hospital care •NQF-15 includes measures of patient-centered outcomes (e.g., prevalence of pressure ulcers and inpatient falls), delivery of nursing-centered interventions (e.g., smoking cessation counseling), and system-centered measures (e.g., voluntary turnover and nursing care hours per patient day)

Stakeholders=

invested interest in whatever you are trying to do ex. nurses, patients, etc.

Hierarchy of Information Resources

patient-specific decisions based on unique patient variables= decision support in medical record; Decision support in medical record (it will prompt you based on specific patient and guidelines from within chart)

Control Theory as a Conceptual Guide for the ARCC Model

potential barriers is main takeaway

Chapter 14 Models to Guide Implementation and Sustainability of Evidence-Based Practice

powerpoint

Chapter 2: Asking Compelling Clinical Questions

powerpoint

Chapter 3: Finding Relevant Evidence to Answer Clinical Questions

powerpoint

Chapter 4: Critically Appraising Knowledge for Clinical Decision-Making

powerpoint

Chapter One: Making the Case for Evidence-Based Practice and Cultivating a Spirit of Inquiry

powerpoint

Is evidenced based practice the current standard of care?

still often not the standard of care implementation is not the norm Why? Clinicians often lack competency in EBP and practice is often steeped in tradition (always done it this way) mentality; Takes a lot of time for implementation. Corticosteroid shots for infant lungs in premature took 17 years to implement.

The Components of EBP and Types of Evidence Used

this should factor into clinical decisions

Three Commonly Used Search Strategies: ·Subject headings searching

uses a standardized set of preselected terms for the search ·Also referred to as controlled vocabulary, subject terms, thesaurus, descriptors, or taxonomies ·Major strengths: Searches can be broadened without considering every synonym for the chosen keyword; studies selected only if at least 25% relevant to the topic, thus decreasing the number of irrelevant hits ·Major weaknesses: Newly developed technologies, phrases, and acronyms may not yet be linked in the database and thus be missed

Three Commonly Used Search Strategies: ·Title searching

uses keywords generated from the "P," "I," and "O" components of the PICOT question to search article titles with the same keywords ·As with the use of keyword searches, all appropriate common terms, synonyms, acronyms, phrases, coined phrases, and brand names need to be used ·Major strengths: Increases the chance of the article found being relevant to the PICOT question and is highly effective in finding relevant articles ·Major weaknesses: Misses studies that do not contain the keywords in the title

PICOT Searches Using PubMed

video slide 15

PICOT Searches in CINAHL Database

video slide 8; look at word document, cinahl and other database instructions

PICOT Searches in Medline (Ovid) Database

video slide 9

AIM OF INFORMED EBP CLINICAL DECISIONS

§Improve patient's experience §Improve population health §Reduce healthcare costs §To meet these goals, clinicals must become proficient at obtaining information they need when they need it!

The haystack

§Scientific information is expanding faster than anyone could have imagined §Databases are massive §To remain truly "current", the clinician would need to read 17-19 journal articles a day; 365 days a year §Issues searching the haystack often include: §Lack of access to information §Low comfort level with library & search techniques §Poor access to electronic resources Lack of time to conduct searches

Four central goals of the model include that the Clinical Scholar Model should be able to:

·Challenge current direct care practices ·Speak and understand research language, making day-to-day dialog about new research findings a common occurrence ·Critique and synthesize current research as the core of evidence ·Serve as mentors to other staff and to teams who question their clinical practices and seek to improve clinical outcomes

Databases Useful for Finding Pre-Appraised Evidence

·Cochrane Database of Systematic Reviews ·BMJ Clinical Evidence ·Database of Reviews of Effects (DARE) ·National Guideline Clearinghouse (NGC) ·Physician's Information and Education Resources (PIER) ·American College of Physicians Journal Club (ACP) Cochrane is gold standard of all research

The Clinical Scholar (CS) Model

·Developed to promote the spirit of inquiry, educate direct care providers, and guide a mentorship program for EBP and the conduct of research at the point of care ·Clinical scholars are described as individuals with a high degree of curiosity that possess advanced critical thinking skills and continuously seek new knowledge through learning opportunities ·Clinical scholar mentors play a central role in the model ·The Clinical Scholar Program was developed to actualize the Clinical Scholar Model

The ACE Star Model

·Development of the ACE Star Model was prompted through the work of the Academic Center for Evidence-Based Practice (ACE) at the University of Texas Health Science Center San Antonio during the early phases of the EBP movement in the United States ·The ACE Star Model explains how to overcome the challenges of the volume of research evidence; the misfit between form and use of knowledge; and integration of expertise and patient preference into best practice ·The ACE Star Model is a model of knowledge transformation, to which quality improvement of healthcare processes and outcomes is the goal

Strategies to Eliminate Barriers to Using Evidence-Based Practice

·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 Question why things are done the way they are

Types of Evidence Used in EBP External evidence

·Evidence generated through rigorous research (e.g., RCTs and cohort studies) that is intended to be generalized to and used in other settings

Types of Evidence Used in EBP Internal evidence

·Evidence typically generated through practice initiatives such as outcomes management or quality improvement projects that are not intended to be generalized to other clinical settings

The three PARIHS elements and their subelements:*

·Evidence: Propositional and nonpropositional knowledge from the subelements of research, clinical experience, patient experience, and local data/information ·Context: The environment in which the proposed change is to be implemented. Subelements include culture, leadership, and evaluation. ·Facilitation: The process of enabling or making easier the implementation of evidence into practice. Subelements include role, skills, and attributes.; *on test: consists of three elements- evidence, context, and facilitation*

External Versus Internal Evidence

·External evidence is generated from rigorous research design and execution and is typically conducted to be generalized to other clinical settings ·Internal evidence is generated by outcomes management, quality improvement, or EBP implementation projects. The goal of collecting internal evidence is to evaluate outcomes solely at the site where improvement efforts were conducted.; internal evidence like determining how to reduce bed sores in ICU. internal evidence is not generalized like external evidence.

The Johns Hopkins Nursing Evidence- Based Practice (JHNEBP) Model

·Facilitates bedside nurses in translating evidence to clinical, administrative, and educational nursing practice ·Sets a goal of building a culture of nursing practice based on evidence ·Aims to demystify the EBP process for bedside nurses and embed EBP into the fabric of nursing practice ·Desired outcomes include enhancing nurse autonomy, leadership, and engagement with interdisciplinary colleagues

Step 6: Disseminate the Outcomes of the Evidence-Based Decision or Change

·For change to be sustainable, outcomes need to be shared with project stakeholders ·Internal communication strategies can include e-mail messages, reports at unit/department meetings, dashboards, and scorecards ·External communication strategies include podium or poster presentations at conferences and professional publications

The Iowa Model of EBP*

·Identifying problem- and knowledge-focused triggers ·Determining whether the issue is an organizational priority ·Forming a team ·Selecting, reviewing, critiquing, and synthesizing available research evidence ·Piloting the practice change ·Evaluating the pilot and dissemination of results ·Depending on pilot results, rollout and integration of the practice are facilitated with periodic evaluation; *on test: uses pilot study and feedback loops and the first step is identifying problems or identifying a problem*

Examples of Initiatives to Advance EBP

·Institute of Medicine's Roundtable on Evidence-Based Medicine: The IOM set a goal that by 2020, 90% of clinical decisions will be supported by external evidence (IOM has changed name to National Academy of Medicine https://nam.edu/ ) ·Preventive Services Task Force (USPSTF): Independent panel of experts who develop recommendations from best available external evidence for clinical preventive services, including screening, counseling, and preventive medications (http://www.uspreventiveservicestaskforce.org) •The Patient-Centered Outcomes Research Institute (PCORI): Authorized by Congress to produce and promote high-integrity, research-based information to help patients and their healthcare providers make more informed decisions (http://www.pcori.org) ·Magnet Recognition Program by the American Nurses Credentialing Center (ANCC): The program fosters EBP, as conducting research and using EBP are critical for attaining Magnet status (https://www.nursingworld.org/organizational-programs/magnet/ )(all nurses must be bsn prepared with magnet nurses) IOM set goal for instance by getting bsn prepared nurses to 80%. USPSTF determine when to get pap smear, colonoscopy, mammogram, etc.

Three Commonly Used Search Strategies: Keyword Searching

·Keyword searching uses words generated from each component of the PICOT question ·All appropriate keywords, including common terms, synonyms, acronyms, phrases, coined phrases, and brand names, need to be used ·Major strengths: Provides a quick snapshot of how helpful a database will be in finding relevant evidence ·Major weaknesses: May miss studies that do not exactly match the authors' keyword choices; may find many studies irrelevant to the PICOT question

Common Barriers to Using Evidence-Based Practice

·Lack of administrative/management support and mentors ·Resistance to change ·Misperceptions or negative attitudes about EBP ·Lack of EBP knowledge and skills ·Lack of autonomy over practice and lack of incentives

Barriers to Finding the Right Information at the Right Time

·Lack of proficiency in using computers ·Lack of computer access at point of care ·Low comfort level/lack of skill using search techniques ·Lack of access to appropriate electronic databases ·Lack of time to search for the best evidence

Step 2: Search for and Collect the Most Relevant Best Evidence—Hierarchy of Evidence

·Level I: Systematic reviews or meta-analyses of RCTs ·Level II: Single RCTs ·Level III: Controlled trials without randomization ·Level IV: Case-control and cohort studies ·Level V: Systematic reviews of descriptive and qualitative studies ·Level VI: Single descriptive or qualitative studies ·Level VII: Opinion of authorities and/or reports of expert committees/panels Always try and go with highest level possible. But all can be utilized based on what you are researching.

Licensed Databases Versus Web-Based Search Engines

·Licensed databases such as PubMed® list the journals indexed, which allows users to know which journals they are searching ·Internet search engines such as Google and Google Scholar search the Internet, but there is no transparency as to what information is included in the search ·Internet search engines include the grey literature, which include unpublished drug trials, reports, or conference proceedings. Because there is no peer review of this evidence, it should be appraised to ensure that the information is reliable. ·Combining a licensed database with an Internet search engine may yield the best search results

Databases Useful for Finding Individual Research Reports

·MEDLINE® ·CINAHL ·PsycINFO® ·PubMed · SEMO Kent Library Access Link: https://library.semo.edu/

Using Reference Management Software Systems (RMS) in Searches

·Often referred to as citation managers ·Used to save, search, sort, share, and continuously add, delete, and organize promising citations ·Web-based proprietary examples include RefWorks and Endnote® ·Open-source options include Mendeley (http://www.mendeley.com) and Zotero (http://www.zotero.org); Used to save searches in library

Step 5: Evaluate Outcomes of the Practice Decision or Change Based on Evidence

·Outcomes measurement determines whether the evidence-based change resulted in the expected outcome in the clinical practice setting

Asking Foreground Questions Using the PICOT Format

·P: Population of interest ·I: Intervention or issue of interest ·C: Comparison of interest ·O: Outcome expected ·T: Time needed for the intervention to achieve the outcome or the time in the course of the disease/symptom that the intervention is applied ·**Use the following templates to ensure PICOT question is appropriately formatted**

Step 1: Ask the Burning Clinical Question in PICOT Format

·Patient population ·Intervention or issue of interest ·Comparison intervention ·Outcome ·Time frame Example: "In teenagers (patient population), how does cognitive-behavioral skills building (intervention) compared with yoga (comparison) affect anxiety (outcome) after 6 weeks of treatment (time frame)?" May not always have time frame. Depends on question. Not always comparison especially if issue of interest instead of intervention.

Combining Searches

·Placing several concepts from the PICOT question in one search allows a simultaneous search, but it cannot be determined which concept has the most available evidence ·Running multiple single-word searches allows the number of "hits" to be seen for each. Then decisions can be made to possibly use Boolean operators. ·Using the Boolean operator "AND" is 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. ·Using "OR" will expand a search to include either one or both terms in the results

The JHNEBP Process for EBP:The PET Process

·Practice question: Identify an EBP question and define its scope; leadership responsibility assigned and interdisciplinary stakeholders recruited for team; team meetings scheduled ·Evidence: Internal and external evidence search conducted; evidence critiqued, summarized, and rated; recommendations developed depending on the evidence strength and need for change ·Translation: Determine appropriateness of recommendation in specific settings; develop action and evaluation plan; implement plan; evaluate and report outcomes; secure support for widespread change; identify next steps

Fives Phases of the Stetler Model of EBP*

·Preparation: Identifying the purpose, context, and sources of evidence ·Validation: Assessing the credibility of the evidence and its statistical and clinical significance ·Comparative evaluation/decision making: Synthesizing evidence and making decisions/recommendations for use ·Translation/application: Developing plan for implementation and measurement of processes/outcomes ·Evaluation: Evaluation of processes and outcomes; p 385; *this model is main focus is on critical thinking, geared toward pratitioners used for cns, nurse practitioner and five phases: preparation, valitation, comparitative, translation, evaluation. on test*

The ACE Star Model: Star Points*

·Star Point 1: Discovery—represents conduction of primary research studies ·Star Point 2: Evidence summary—represents the synthesis of all available knowledge compiled into a single harmonious statement/document, such as a systematic review ·Star Point 3: Translation into action—combining the existing evidential base with expertise to extend recommendations into evidence-based clinical practice guidelines ·Star Point 4: Integration into practice—practice is aligned to reflect the best evidence ·Star Point 5: Evaluation—an inclusive view of the impact that the evidence-based practice has on patient health outcomes, satisfaction, efficacy and efficiency of care, and health policy; *on test: stevens star model recognizes or acknowledges the challenges that you see with getting research moved into evidence based practice and it has five steps with first step being discovery.*

Knowledge Sources Used in EBP

·Systematic inquiry in the form of research (external evidence) is the primary basis for clinical decision making ·Practitioners' expertise fills gaps and combines external evidence with practice-based evidence (internal evidence) to make decisions within individual patient contexts ·Patients' choices and concerns are evidence on which to determine the acceptability of the clinical decision ·All three are necessary evidence to integrate into decision making—each alone is not sufficient for evidence-based practice; what research shows external evidence and what the practitioner knows internal evidence.

Commonly Used Models That Facilitate Integration of Evidence Into Practice (cont.)

·The Promoting Action on Research Implementation in Health Services (PARIHS) framework ·The Clinical Scholar model ·The Johns Hopkins Nursing Evidence-Based Practice model ·The ACE Star Model of Knowledge Transformation

Commonly Used Models That Facilitate Integration of Evidence Into Practice

·The Stetler Model of Evidence-Based Practice ·The Iowa Model of Evidence-Based Practice to promote quality care ·The Model for Evidence-Based Practice Change ·The Advancing Research and Clinical practice through close Collaboration (ARCC) model for implementation and sustainability of EBP

Step 4: Integrate the Best Evidence With Clinical Expertise and Patient Preferences

·This step is the synthesis of the external and internal evidence, the practitioner expertise, and the patient/family preferences that produces the implementation of a practice change ·Patients' histories and circumstances have a significant bearing on the choice of practice changes ·Availability of resources must also be considered

Using Limits in Searches

·Using the "limit" function pares down a large results list ·Options for limiting the results vary by database ·Limiting to RCTs or meta-analysis first can help determine the highest level of evidence that is available ·Limiting the search may result in missing relevant evidence (e.g., limiting the search to "full-text only" eliminates all publications that the database does not subscribe to in full text)

National quality indicator monitoring systems include:

•AHRQ National Healthcare Quality Report •National Quality Forum (NQF) •National Database of Nursing Quality Indicators® (NDNQI®)

LEVELS OF EVIDENCE: LEVEL TWO •Randomized Controlled Trials (RCT):

•An experimental design in which subjects are randomized into a treatment/intervention group and a control group •The intent is that the only expected difference between the two groups is the treatment/intervention •Therefore, different outcomes are attributed to the study treatment/intervention

LEVELS OF EVIDENCE: LEVEL FOUR •Cohort Study: (aka longitudinal studies)

•An observation of a group(s) cohort(s) to determine the development of an outcome (such as a disease) •Can be prospective (looking forward, exposure identified at the beginning) or retrospective (looking backward by viewing past medical records) •Ex: follow a group of smokers over time compared to a group of nonsmokers over time, then compare the outcomes •

Types of Questions to Develop Prior to Beginning a Literature Search: Background questions

•Asks for general information about a clinical issue •Usually has two components: o1. The starting place of the question (e.g., what, where, when, why, and how) o2. The outcome of interest •Broader in scope than a foreground (PICOT) question Example: "How does the drug acetaminophen work to affect fever?"

Types of Questions to Develop Prior to Beginning a Literature Search: Foreground questions (PICOT format)

•Asks for specific scientific evidence about diagnosing, treating, or educating patients •The focus is on specific knowledge •Use of PICOT format is recommended for a focused literature search Example: "In children aged 3 to 8 years, how does acetaminophen compare with ibuprofen in lowering a fever?" missing time in this example but it can be added by tacking on within 30 minutes, one hour etc.

Steps in the Model for Evidence-Based Practice Change (Larrabee, 2009; Rosswurm & Larrabee, 1999)*

•Assess the need for change in practice: Stakeholders collect internal data and compare with external evidence/benchmarks to identify problems and link them with interventions and outcomes •Locate the best evidence: Determine the types and sources of evidence; plan and conduct the search •Critically analyze the evidence: Appraise, weigh, and synthesize evidence; assess feasibility, benefits, and risks •Design practice change: Define proposed change and resources needed; design pilot implementation and its evaluation •Implement and evaluate change in practice: Implement pilot; evaluate processes, costs, and outcomes; develop conclusions and recommendations •Integrate and maintain change in practice: Communicate pilot results to stakeholders and make recommendations; integrate change into practice; routinely monitor process and outcomes; disseminate monitoring results and celebrate successes; *on test: this model also utilizes pilot studies and it has a six step process with the first step being assess the need for change*

LEVELS OF EVIDENCE: LEVEL SEVEN •Expert Opinion or Consensus:

•Authoritative opinion of experts or committees

Final Tips to an Efficient Search

•Begin with PICOT question to generate keywords •Use subject headings when available •If search results are sparse, expand it using the explode option (if not automatic) •Use available search engine mechanisms to focus the search so that the topic of interest is the main point of the article •Establish inclusion/exclusion criteria before searching so that the studies that answer the question are easily identifiable. Apply these criteria after search strategy is complete.; Ex. for searching: Preventative AND inflammatory bowel disease or IBD or ulcerative colitis or crohns disease Ex. routine care AND inflammatory bowel disease or IBD or ulcerative colitis or crohns disease Use key terms with similar meanings to ensure comprehensive search

Five Basic Types of Qualitative Study Designs

•Case Study: studies in-depth a single case example of a phenomenon •Grounded Theory: understand the social/psychological processes that characterize an event •Phenomenology: describes the structure of the lived experience of a phenomenon •Ethnography: field observations of sociocultural phenomena •Historical: looks at past occurrences to explain current events; p. 112 (under EBP. explains differences. p. 114 figure uses umbrella as graphic to demonstrate that research is at bottom, etc.)

Right information: the needle in the haystack

•Clinicians must stay informed & up to date on latest best practices •The DESIRE to gather right info at right time is not sufficient •Must be able to negotiate information-rich environment; "weed through the haystack" to find the proverbial needle •Need a sense of the needle's specific characteristic •The right question helps to define the needle and focus on the right area of the haystack

LEVELS OF EVIDENCE: LEVEL FOUR •Case Control:

•Comparison of those with a condition (case) with those who don't have the condition (case); to determine characteristics that might predict the condition •Ex: patients with cancer are compared with patients who don't have cancer; take the history from both groups & compare: draw conclusion; Is there an associational relationship b/w the condition and a certain risk factor?

The Origins of Evidence-Based Practice

•Concept began when Dr. Archie Cochrane published a report in 1972 for the Nuffield Provincial Hospitals Trust that demonstrated how slow the medical profession was in using published evidence to change practice •Cochrane died in 1988, and the Cochrane Center Collaboration was established in 1992 in his name to assist healthcare professionals in making clinical decisions based on the best external evidence •One of the best known sources of systematic reviews website: http://www.cochrane.org Florence nightgale was ahead of her time and displayed evidence practice before it was a thing. Cochrane caught the rcts for corticosteroids with premature infants and realized no one was acting on them.

Four Basic Types of Quantitative Study Designs

•Descriptive: observes & measures without manipulation of variables; describes the numerical characteristics •Correlational: measures a "relationship" ****correlation DOES NOT equal causation*** •Quasi-experimental: it is experimental but there is no random assignment •Experimental: random assignment to treatment/intervention

Quadruple Aim

•Evidence-based practice (EBP): •Enhances healthcare quality •Improves patient outcomes •Reduces costs •Empowers clinicians this is the purpose of evidence based practice

Answerable questions: Foreground questions

•Focus on specific knowledge •Answered from scientific evidence •Can only be answered by a group of studies (body of evidence)

Answerable questions: Background questions

•Foundational questions •Answered before asking foreground question •Ask for general info about issue •Usually only have 2 components; starting point & outcome •Broader in scope •Answers can be found in textbooks

Commonalities Found in Models Used for Implementation of EBP

•Identifying a problem that needs addressing •Identifying stakeholders or change agents who will help make the change happen in practice •Identifying a practice change shown to be effective through high-quality research that is designed to address the problem •Identifying and, if possible, addressing the potential barriers to the practice change; need conceptual framework for research

Types of Questions to Develop Prior to Beginning a Literature Search—(cont.): Types of foreground/ (PICOT) questions

•Intervention questions (What intervention most effectively leads to an outcome?) •Prognosis/prediction questions (What indicators are most predictive of an outcome?) •Diagnosis questions (What test most accurately diagnoses an outcome?) •Etiology questions (To what extent is a factor associated with an outcome?) •Meaning questions (How does an experience influence an outcome?)

Critical Appraisal of the Evidence: Part I LEVELS OF EVIDENCE

•LEVEL ONE: Systematic Review or Meta-analysis •LEVEL TWO: Randomized controlled trials •LEVEL THREE: Controlled trial without randomization •LEVEL FOUR: Case control or cohort studies •LEVEL FIVE: Systematic review of qualitative or descriptive studies •LEVEL SIX: Qualitative or descriptive study •LEVEL SEVEN: Expert opinions or consensus

Translational Research

•Often confused with EBP •Translational research: rigorous research that studies how evidence-based interventions are translated into real-world clinical settings How the research is being put into real practice and then studying how that works in practice.

Components That Need to Be Considered in the Clinical Decision-Making Model of EBP

•Patient preferences and behaviors (dominant element in decision making process) •Clinical state, setting, and circumstances (location such as remote areas)(certain interventions aren't applicable to certain age groups, etc.) • Availability of healthcare resources (home visits by primary care providers have proven to be more beneficial but it is not realistic due to cost and other elements) • High-quality research evidence; p. 379; nurse leaders and managers huge barrier to evidence based practice. p. 380 figure

The Advancing Research and Clinical Practice Through Close Collaboration Model (ARCC© Model)

•Provides healthcare institutions and clinical settings with an organized conceptual framework that can guide system-wide implementation and sustainability of EBP to achieve quality outcomes •Model is a product of nurse input about barriers and facilitators of EBP, control theory (Carver & Scheier, 1982, 1998), and cognitive behavioral theory (Beck, Rush, Shaw, & Emery, 1979) •Use of mentors is a central mechanism for implementing and sustaining EBP

LEVELS OF EVIDENCE: LEVEL SIX •Single Qualitative or Descriptive Studies:

•Qualitative studies: generates non-numerical data; summaries of experiences, feelings, opinions, values, etc. •Descriptive studies: observes & measures without manipulation of variables; describes the numerical characteristics; how many? What percent?; often deals with means, medians, mode, & standard deviations (gives static data about a population or variable)

Research (External Evidence)

•Research is highly valued as the basis for making clinical decisions •Research must be usable beyond the researchers who generated the research (generalizability) •Careful adherence to the systematic process allows for better evaluation & increased confidence in study findings

Answering Clinical Questions

•Searching for evidence that has already been appraised for validity and reliability decreases the amount of time needed to determine whether the information is reliable •Pre-appraised literature can include: oSystematic reviews and meta-analyses oMeta-syntheses oIntegrative reviews oSynopses/critiques of single studies

I have my PICOT Question....What's next?

•Select most effective action based on the best knowledge possible •Critical appraisal is one of the most valuable skills that you can possess in today's healthcare environment •Distinguish between best evidence vs unreliable evidence •Distinguish between biased evidence vs unbiased evidence

PubMed®: A Unique Resource—(cont.): Automatic term mapping uses a three-step process to search keywords entered in the search box and to map them to appropriate MeSH® terms:

•Step 1—MeSH® term: Looks for a match between keywords entered and a list of MeSH® terms. If a match is found, MeSH® term plus the keyword is used to run the search. •Step 2—Journal title: If no MeSH® term match, keywords are compared with a list of journal titles. If a match is found, the journal title is used to run the search. •Step 3—Author name: If no match is found in steps 1 and 2, words in the search box are then compared with a list of author names. If there is a match, author's name is used to run the search. If no match is found after step 3, search engine will drop the keyword farthest to the right in the search string and will repeat the three-step process If a match is found, then automatic term mapping will use the match (MeSH® term, journal title, or author name) plus the keyword as part of the search and return to process the term that was previously dropped to begin a separate search

LEVELS OF EVIDENCE: LEVEL THREE •Controlled trials without randomization:

•Still has a treatment/intervention group and a control group •However, the participants/subjects are NOT randomly assigned •They may either choose which group or may be arbitrarily assigned a group (group of men vs group of women) •Sometimes people are grouped in certain way; the reason for that grouping may impact the outcome of the study

LEVELS OF EVIDENCE: LEVEL FIVE •Systematic review of qualitative or descriptive studies:

•Synthesis of evidence from qualitative or descriptive studies •Qualitative studies: generates non-numerical data; summaries of experiences, feelings, opinions, values, etc. •Descriptive studies: observes & measures without manipulation of variables; describes the numerical characteristics; how many? What percent?; often deals with means, medians, mode, & standard deviations (gives static data about a population or variable)

Research vs quality improvement: Quality Improvement

•Systematic internal process •Often uses plan, do, study, act (PDSA) Model •Often used by healthcare systems to improve their processes or outcomes for a specific population Quality improvement is not true research. Quality improvement typically in one hospital to improve processes. Quality improvement is specific to specific population.

Sub-components of EBP

•Systematic reviews of RCT (randomized controlled trials), regarded as strongest level of evidence (level I) •Best level of evidence on which to base practice decisions •However, descriptive and qualitative studies are also valuable & should be factored into decisions Multiple rcts together is systematic reviews. Descriptive and qualitative studies example for family coped better when involved with patient end of life. Mental health areas would be a big use for descriptive and qualitative studies

Gaining Mastery of Systematic Searches

•Systematic reviews, primary studies, & guidelines often contain the answers to our questions; the challenge is how to efficiently & effectively find them •Systematic reviews are the type of preappraised synthesis of studies that form the heart of EBP •However, sometimes there may only be a handful of primary studies that exist; it is important to search several databases for this reason Cinahl, PubMed, etc.

The PDSA Cycle

•The PDSA cycle is considered a scientific method used in action-oriented learning & QI projects •Puts a planned change into effect on a temporary "small-trial" basis, then evaluates impact 1.Plan: Plan the change and measurement of outcomes (research stage) 2.Do: Try out the change on a small scale (pilot) 3.Study: Analyze the data and determine what was learned 4.Act: Refine the change based on what was learned and emerging external evidence, and repeat the outcomes measurement

The Three Components of EBP

•The conscientious use of current best evidence in making decisions about patient care: •A lifelong problem-solving approach to clinical practice that integrates •Critical appraisal and synthesis of the most relevant and best research (external evidence) •One's own clinical expertise, which includes internal evidence generated from outcomes management or quality improvement projects, patient assessment, and evaluation •Patient preferences and values Internal evidenence comes from ourselves. Things weve seenwork.

Remember... The Goal!

•The goal of EBP is to use the highest quality of knowledge in providing care •This entails using information from a combination of sources, to include: •Valid research (external) •Quantitative & qualitative •Clinical expertise & judgement •Internal evidence (QI & PBE, when available) •Patient choices & values

Implementing Practice-Based Evidence through Quality Improvement (Internal)

•The process for generating "Practice-Based Evidence" has become increasingly rigorous •External evidence is generated from rigorous scientific research, & is intended to be used across practice settings; internal evidence is generated by Quality Improvement (QI) and Practice Based Evidence (PBE) •At the core of QI & PBE is the planned effort to "test out" a given change to determine its impact on the desired outcome; can maybe utilize on other areas of hospital.

Clinical inquiry & uncertainty

•The role of uncertainty is that is spawns *clinical inquiry* •Clinical inquiry must be cultivated in the work environment •*Uncertainty is imperative to good practice and is a means to inquiry & clinical reasoning •Healthcare is an uncertain world; what works for one patient may not work for another •Asking the right question, in PICOT format assists clinicians to find the right evidence to answer those questions

Research vs quality improvement: Research

•Uses a scientific process to generate NEW knowledge/external evidence and research utilization •Research utilization-operationalized as the use of knowledge typically based on a single study

Commonalities Found in Models Used for Implementation of EBP—(cont.)

•Using effective strategies to disseminate information about the practice change to those implementing it •Implementing the practice change •Evaluating the impact of the practice change on structure, process, and outcome measures •Identifying activities that will help sustain the change in practice