Fundamentals Chapter 5: Evidence-Based Practice

Steps of Evidence Based Practice

0. Cultivate a spirit of inquiry. 1. Ask a clinical question in PICOT format. 2. Search for the most relevant evidence. 3. Critically appraise the evidence you gather. 4. Integrate all evidence with your clinical expertise and patient preferences and values. 5. Evaluate the outcomes of practice decisions or changes using evidence. 6. Share the outcomes with others.

11. Which of the following statements about evidence-based practice (EBP) made by a nursing student would require the nursing professor to correct the student's understanding? 1. "In evidence-based practice the patients are the subjects." 2. "It is important to talk with experts and patients when making an evidence-based decision." 3. "A nurse wanting to investigate the evidence to solve a problem starts by forming a PICOT question." 4. "It is important to ask a librarian for help when searching for literature to help you answer your PICOT question."

1. "In evidence-based practice the patients are the subjects."

12. A nurse is reading a research article. The nurse just finished reading a brief summary of the research study that included the purpose of the study and its implications for nursing practice. Which part of the article did the nurse just read? 1. Abstract 2. Analysis 3. Discussion 4. Literature review

1. Abstract

9. A nursing student is preparing to read the methods section of a research article. Which type of information will the student expect to find in this section? (Select all that apply.) 1. How the researcher conducted the study 2. A description about how to use the findings of the study 3. The number and type of subjects who participated in the study 4. Summaries of other research articles that support the need for this study 5. Implications for future research studies

1. How the researcher conducted the study 3. The number and type of subjects who participated in the study

13. A researcher is studying the effectiveness of an individualized evidence-based teaching plan on young women's intention to wear sunscreen to prevent skin cancer. In this study which of the following research terms best describes the individualized evidencebased teaching plan? 1. Sample 2. Intervention 3. Survey 4. Results

2. Intervention

10. A group of nurses on the research council of a local hospital are measuring nursing-sensitive outcomes. Which of the following is a nursing-sensitive outcome that the nurses need to consider measuring? (Select all that apply.) 1. Frequency of low blood sugar episodes in children at a local school 2. Number of patients who develop a urinary tract infection from a Foley catheter 3. Number of patients who fall and experience subsequent injury on the evening shift 4. Number of sexually active adolescent girls who attend the community-based clinic for birth control 5. Patient-reported quality of life following coronary artery bypass graft surgery and cardiac rehabilitation

2. Number of patients who develop a urinary tract infection from a Foley catheter 3. Number of patients who fall and experience subsequent injury on the evening shift

14. A nurse researcher wants to conduct historical research. Which of the following ideas for a study could the nurses conduct? (Select all that apply.) 1. Determining the effect of unemployment on emergency room usage 2. Understanding how Clara Barton shaped nursing in America 3. Evaluating the effect of the Vietnam War on nursing leadership and practice 4. Analyzing the evolution of nursing and patient care during recent disasters 5. Investigating barriers to exercise in women who have become mothers in the past year

2. Understanding how Clara Barton shaped nursing in America 3. Evaluating the effect of the Vietnam War on nursing leadership and practice 4. Analyzing the evolution of nursing and patient care during recent disasters

5. Arrange the following steps of evidence-based practice (EBP) in the appropriate order. 1. Integrate the evidence. 2. Ask the burning clinical question. 3. Create a spirit of inquiry. 4. Evaluate the practice decision or change. 5. Share the results with others. 6. Critically evaluate the evidence you gather. 7. Collect the most relevant and best evidence.

3, 2, 7, 6, 1, 4, 5 3. Create a spirit of inquiry. 2. Ask the burning clinical question. 7. Collect the most relevant and best evidence. 6. Critically evaluate the evidence you gather. 1. Integrate the evidence. 4. Evaluate the practice decision or change. 5. Share the results with others.

15. A nurse researcher is collecting data following approval from the institutional review board (IRB). In which part of the research process is this nurse? 1. Analyzing the data 2. Designing the study 3. Conducting the study 4. Identifying the problem

3. Conducting the study

6. When recruiting subjects to participate in a study about the effects of an educational program to help patients at home take their medications as ordered, the researcher tells the subjects that their names will not be used and no one but the research team will have access to their information and responses. This is an example of: 1. Bias. 2. Anonymity. 3. Confidentiality. 4. Informed consent.

3. Confidentiality.

3. A nurse researcher wants to know which factors are associated with a person's decision to exercise. The nurse distributes a survey to people who recently joined an exercise wellness program and analyzes the data to determine which factors and characteristics are most significantly linked to the decision to start exercising. Which type of a research study is this? 1. Qualitative 2. Descriptive 3. Correlational 4. Randomized controlled trial

3. Correlational

7. Nurses in a community clinic have seen an increase in the numbers of obese children. The nurses who care for children are discussing ways to reduce childhood obesity. One nurse asks a colleague, "I wonder what the most effective ways are to help school-age children maintain a healthy weight?" This question is an example of a/an: 1. Hypothesis. 2. PICOT question. 3. Problem-focused trigger. 4. Knowledge-focused trigger.

3. Problem-focused trigger.

8. The nurses on a medical unit have seen an increase in the number of medication errors on their unit. They decide to evaluate the medication administration process on the basis of data gained from chart reviews and direct observation of nurses administering medications. Which process are the nurses using? 1. Evidence-based practice 2. Research 3. Quality improvement 4. Problem identification

3. Quality improvement

2. A nurse who works on a pediatric unit asks, "I wonder if children who interact with therapy dogs have reduced anxiety when they are in the hospital." In this example of a PICOT question, which of the following is the O? 1. Children 2. Therapy dogs 3. The pediatric unit 4. Anxiety

4. Anxiety

4. A group of nurses have identified that the elderly patients on their unit have a high incidence of pressure ulcers after they have a stroke. During a unit meeting they discuss different interventions that they think may reduce the development of pressure ulcers. What is the nurses' next step to investigate this clinical problem further? 1. Conduct a literature review 2. Share the findings with others 3. Conduct a statistical analysis 4. Create a well-defined PICOT question

4. Create a well-defined PICOT question

1. A nurse researcher studies the effectiveness of a new program designed to educate parents to promote the immunization of children. The nurse divides the parents randomly into two groups. One group receives the typical educational program and the other group receives the new program. This is an example of which type of study? 1. Historical 2. Qualitative 3. Correlational 4. Experimental

4. Experimental

Bias

A particular preference or point of view that is personal, rather than scientific.

Experimental study

A study in which the researcher manipulates one of the variables and tries to determine how the manipulation influences other variables.

Inductive reasoning

A type of logic in which generalizations are based on a large number of specific observations.

Nursing research

A way to identify new knowledge, improve professional education and practice, and use resources effectively

The nurse is preparing to conduct research that will allow precise measurement of a phenom-enon. Which of the following methods will provide the nurse with the right kind of data? (Se-lect all that apply.) a. Experimental research b. Surveys c. Evaluation research d. Phenomenology e. Grounded theory

A, B, C a. Experimental research b. Surveys c. Evaluation research

Before conducting any study with human subjects, the researcher must obtain approval from the agency's human subjects committee or institutional review board (IRB). The IRB ensures that the researcher (Select all that apply.) a. Obtains informed consent. b. Minimizes risk to subjects. c. Ensures confidentiality. d. Identifies risks and benefits of participation. e. Ensures that subjects complete the study.

A, B, C, D a. Obtains informed consent. b. Minimizes risk to subjects. c. Ensures confidentiality. d. Identifies risks and benefits of participation.

Reliability

Ability of a test to yield very similar scores for the same individual over repeated testings

Informed consent

An ethical principle requiring that research participants be told enough to enable them to choose whether they wish to participate.

The nurse is doing a literature review related to a potential problem that has been identified on the nursing unit. The nurse realizes that nursing research is important in that it is designed to (Select all that apply.) a. Enhance the nurse's chance at promotion. b. Identify new knowledge. c. Improve professional practice. d. Enhance effective use of resources. e. Lead to decreases in budget expenditures.

B, C, D b. Identify new knowledge. c. Improve professional practice. d. Enhance effective use of resources.

The nursing staff on Rick's surgical unit have been reviewing their patients' medical records and have seen a steady increase in the incidence of catheter-acquired urinary tract infections (CAUTIs) in patients over the last 3 months. The staff agrees to look into the current practice guidelines about the prevention of CAUTIs and determine if a change in practice is indicated. 2. The nurses on Rick's unit conduct a literature search and gather research articles about the PICOT question. Which step of the evidence-based practice (EBP) process do they need to implement next? Describe what the nurses will do during this step.

Critically appraise the evidence they gathered. In this step; the nurses will critically read and analyze the research articles to determine if the evidence has value and is useful in informing a practice change.

The nursing staff on Rick's surgical unit have been reviewing their patients' medical records and have seen a steady increase in the incidence of catheter-acquired urinary tract infections (CAUTIs) in patients over the last 3 months. The staff agrees to look into the current practice guidelines about the prevention of CAUTIs and determine if a change in practice is indicated. 1. What is an appropriate PICOT question for this group to ask? Identify each part of the PICOT question.

Does the implementation of current clinical practice guidelines (I) in patients who have surgery (P) reduce the incidence of CAUTIs (O) after surgery (T) when compared with patients who receive the current standard of care (C)?

Generalizability

Extent to which research results apply to a range of individuals not included in the study.

Empirical data

Information gathered from sensory observation and experimentation

PICOT question

P = Patient population of interest Identify patients by age, gender, ethnicity, and disease or health problem. I = Intervention of interest Which intervention is worthwhile to use in practice (e.g., a treatment, diagnostic test, prognostic factor)? C = Comparison of interest What is the usual standard of care or current intervention used now in practice? O = Outcome What result do you wish to achieve or observe as a result of an intervention (e.g., change in patient behavior, physical finding, or patient perception)? T = Time What amount of time is needed for an intervention to achieve an outcome

The nursing staff on Rick's surgical unit have been reviewing their patients' medical records and have seen a steady increase in the incidence of catheter-acquired urinary tract infections (CAUTIs) in patients over the last 3 months. The staff agrees to look into the current practice guidelines about the prevention of CAUTIs and determine if a change in practice is indicated. 3. The staff on the surgical unit implemented a new protocol 4 months ago for patients who have catheters after surgery. The staff need to determine if this practice change has been effective. Identify one outcome the nurses could measure to determine the effectiveness of this change. Describe one method they could use to measure this outcome.

The nurses could measure the current incidence of CAUTI on the unit. They could complete a chart audit to determine the number of patients diagnosed with CAUTI every month since the practice change and compare this with the number of patients diagnosed with CAUTI for 4 months before the practice change.

Evaluation research

a form of quantitative research that determines how well a program, practice, procedure, or policy is working

Scientific method

a method of procedure that has characterized natural science since the 17th century, consisting in systematic observation, measurement, and experiment, and the formulation, testing, and modification of hypotheses.

To provide patient care of the highest quality, nurses utilize an evidence-based practice approach because evidence-based practice is a. A guide for nurses in making clinical decisions. b. Based on the latest textbook information. c. Easily attained at the bedside. d. Always right for all situations.

a. A guide for nurses in making clinical decisions.

The hospital's quality improvement committee has identified a problem on one of the units. In using the PDSA method to help determine ways to deal with the issue, the committee decides to do a literature review. This is an example of quality improvement a. Combined with evidence-based practice. b. With inability to make the right decision. c. With delay in the action needed. d. With no designated method for dealing with issues.

a. Combined with evidence-based practice.

The hospital quality improvement committee has noted that the incidence of needlestick injuries on a particular unit has increased. When faced with issues, the committee applies the PDSA model, a formal model for exploring and resolving quality concerns. Because the committee is multidisciplinary in nature, and few members are nurses, it is imperative that the committee first a. Plan. b. Do. c. Study. d. Act.

a. Plan.

In reviewing literature for an evidence-based practice study, the nurse realizes that the most reliable level of evidence is the a. Systematic review and meta-analysis. b. Randomized control trial (RCT). c. Case control study. d. Control trial without randomization.

a. Systematic review and meta-analysis.

In collecting the best evidence, the gold standard for research is a. The randomized controlled trial (RCT). b. The peer-reviewed article. c. Qualitative research. d. The opinion of expert committees.

a. The randomized controlled trial (RCT).

Research process

an orderly series of steps that allow a researcher to move from asking the research question to finding the answer

The nurse is developing a PICO question related to whether her patient's blood pressure is more accurate while measuring with the patient's legs crossed versus with the patient's feet flat on the floor. With P being the population of interest, I the intervention of interest, C the comparison of interest, and O the outcome, the nurse determines that this is a. A true PICO question, because the outcome always comes before the interven-tion. b. A true PICO question regardless of placement of elements. c. Not a true PICO question, because the comparison comes after the intervention. d. Not a true PICO question, because the outcome comes after the population.

b. A true PICO question regardless of placement of elements.

The hospital policy states that when starting an intravenous (IV) catheter, the nurse must first prepare the potential IV site with alcohol and dress it using a gauze dressing. The nurse has done a literature review and believes that evidence-based practice dictates the use of a trans-parent dressing to prevent catheter dislodgment. What should the nurse do? a. Begin to use transparent dressing instead of gauze dressings. b. Bring findings to the policy and procedure committee. c. Use transparent dressings on half of her IV starts and gauze on the other. d. Continue following hospital policy without saying anything.

b. Bring findings to the policy and procedure committee.

In conducting a research study, the researcher must guarantee that any information the subject provides will not be reported in any manner that identifies the subject and will not be accessi-ble to people outside the research team. This concept is known as a. Anonymity. b. Confidentiality. c. Informed consent. d. The research process.

b. Confidentiality.

The nurse is writing a research article on a patient care topic. The nurse realizes that the section that will get the reader to read the article because of the value of the topic for the reader is the a. Abstract. b. Introduction. c. Literature review or background. d. Results.

b. Introduction.

When evaluating quality improvement (QI) programs in relation to evidence-based practice (EBP), it is easy to note that a. Both are designed to improve performance. b. When implementing EBP projects, it is important to review QI data. c. EBP is not at all related to QI. d. Evaluation of processes is the realm of performance improvement (PI), not QI.

b. When implementing EBP projects, it is important to review QI data.

In caring for patients, it is important for the nurse to realize that evidence-based practice is a. The only valid source of knowledge that should be used. b. Secondary to traditional or standard care knowledge. c. Dependent on patient values and expectations. d. Not shown to provide better patient outcomes.

c. Dependent on patient values and expectations.

The first step in evidence-based practice is to ask a clinical question. In doing so, the nurse needs to realize that in researching interventions, the question a. Is more important than its format. b. Will lead you to hundreds of articles that must be read. c. May be easier if in PICO format. d. May be more useful the more general it is.

c. May be easier if in PICO format.

The nurse is trying to identify common general themes relative to the effectiveness of cardiac rehabilitation for patients who have had heart attacks and have gone through cardiac rehabili-tation programs. The nurse conducts interviews and focus groups. What type of research is the nurse conducting? a. Evaluation research b. Experimental research c. Qualitative research d. Nonexperimental research

c. Qualitative research

Evidence-based practice (EBP)

clinical decision making that integrates the best available research with clinical expertise and patient characteristics and preferences

Variables

concepts, characteristics, or traits that vary within or among subjects

The nurse is caring for a patient with chronic low back pain. In providing care for this patient, the nurse wonders whether the guidelines utilized for this type of pain are adequate. The nurse wants to determine the best evidence-based practice regarding these guidelines. What is the best database for the nurse to access? a. MEDLINE b. EMBASE c. PsycINFO d. AHRQ

d. AHRQ

The researcher is preparing to publish his study findings. In doing so, the researcher is aware of many ways that the study could have been done better, but that he did not have the ability to do. The researcher discloses these limitations in the manuscript, but they are most likely detected during which phase of the research process? a. Problem identification b. Study design c. Formulation of recommendations d. Analysis of data

d. Analysis of data

The quality improvement committee has been alerted to an increased number of falls in the hospital. Most of these falls have occurred at night and have involved patients who were try-ing to crawl over bedrails. A literature review brought out that most falls occur because pa-tients are trying to go to the bathroom. The committee created a practice change that bedrails should be left in the down position, and hourly nursing rounds should be conducted. What is the committee's next step? a. Evaluate the changes in 1 month. b. Wait a month before implementing the changes. c. Implement the changes as a pilot study. d. Communicate to staff the results of this inquiry.

d. Communicate to staff the results of this inquiry.

The nurse has used her PICO question to develop an evidence-based change in protocol for a certain nursing procedure. However, to make these changes throughout the entire institution would require more support staff than is available at this time. What is the nurse's best option? a. Drop the idea of making the change at this time. b. Insist that management hire the needed staff to facilitate the change. c. Seek employment in another institution that may have the staff needed. d. Conduct a pilot study to develop evidence to support the change.

d. Conduct a pilot study to develop evidence to support the change.

The quality improvement committee is examining an increase in medication errors on a particular unit. In conducting its analysis, what should be the committee's primary focus? a. Nurses who administer the medications b. Pharmacy that prepares the medications c. Secretaries who enter the orders d. None of the above

d. None of the above

Qualitative nursing research is valuable in that it a. Excludes all bias. b. Uses randomization in structure. c. Determines associations between variables and conditions. d. Studies phenomena that are difficult to quantify.

d. Studies phenomena that are difficult to quantify.

Peer-reviewed

designation of an academic journal that indicates that its articles have been approved by experts in the field

Confidentiality

guarantees that any information a subject provides will not be reported in any manner that identifies the subject and will not be accessible to people outside the research team.

Hypotheses

predictions made about the relationship or difference among study variables.

Performance improvement (PI)

process of identifying and analyzing important organizational and individual performance gaps, planning for future performance improvement, designing and developing cost-effective and ethically justifiable interventions to close performance gaps, implementing the interventions, and evaluating the financial and non-financial results

Clinical guidelines

systematically developed statements about a plan of care for a specific set of clinical circumstances involving a specific patient population.

Validity

the extent to which a test measures or predicts what it is supposed to

Quantitative nursing research

the study of nursing phenomena that offers precise measurement and quantification

Qualitative nursing research

the study of phenomena that are difficult to quantify or categorize such as patients' perceptions of illness or quality of life

Key points to remember

• A challenge in EBP is to obtain the very best and most relevant, accurate, and current information at the right time, when you need it for patient care. • Using your clinical expertise and considering patients' values and preferences ensures that you will apply the evidence in practice both safely and appropriately. • The steps of EBP provide a systematic approach to rational clinical decision making. • A focused PICOT question allows you to search for evidence in the scientific literature. • The hierarchy of available evidence offers a guide to the types of literature or information that offer the best scientific evidence. • An RCT is the highest level of experimental research. • Expert clinicians are a rich source of evidence because they use it frequently to build their own practice and solve clinical problems. • The critique or evaluation of evidence includes determining the value, feasibility, and usefulness of evidence for making a practice change. • After critiquing all articles for a PICOT question, synthesize or combine the findings to consider the scientific rigor of the evidence and whether it has application in practice. • When you decide to apply evidence, consider the setting and whether there is support from staff and available resources. • Research is a systematic process that asks and answers questions that generate knowledge, which provides a scientific basis for nursing practice. • Outcomes research is designed to assess and document the effectiveness of health care services and interventions. • Nursing research involves two broad approaches for conducting studies: quantitative and qualitative methods. • Although EBP, research, and QI are closely related, they are separate processes. • When posed with a clinical problem, you need to use the appropriate approach.