EBP Exam #3

ethical violations of Michigan ICU study

-Independent review -Informed consent The study was submitted to Johns Hopkins University IRB, which deemed it exempt from review because they believed that the project was an EBP implementation and QI initiative, not clinical research. -OHRP disagreed and held that it was research. Informed consent was not obtained because it was considered exempt from IRB review. -OHRP held that informed consent should not have been waived for this reason because it viewed the project as clinical research.

roundtable presentations

-Informal way to disseminate information to small groups -Typically 6-12 people (little smaller) -More informal, conversational atmosphere -Allow for group discussion about practical application of content -Need suitable room; often AV equipment not available (PowerPoint with such a small group feels cold/distant) -Use *printed handouts* if necessary

questions to ask in selecting right journal for publication

-Is the journal peer-reviewed? -What is the journal's impact factor? -What is the profile of the journal's readership? -What is the turnaround cycle for review? -What is the "in-press" period (time between acceptance and publication)? -What are the technical specifications? -Is the journal an open or closed access journal? -Are there specific reporting guidelines for selected manuscripts?

before the panel presentation

-Prepare an overview of the panel's purpose, brief biographical introductions of panelists, and their evidence-based topic --Bio information: can introduce them -Speak with panelists individually to obtain information about their presentation and expertise -Serve as a liaison for exchanging logistic information -Assure that panelists' remarks meet the *session's objectives* → keeps everyone on task

great slide presentation

-Present a minimal amount of material on each slide -Use bullet points -Timing: one slide for every 30-60 seconds -Font: size 24-32; type should be consistent throughout -Photographs or graphics enhance presentations -Test use of multimedia within the presentation on site; *have a plan B in case it doesn't work!*

moderator responsibilities

-Provide a brief introduction of each panelist, emphasizing his or her expertise or experience with the evidence-based topic. -Select audience members who have questions to ask of panelists. *-Repeat questions (or have panelists do it) for the audience's benefit.* -Remind the audience members or panelists of time constraints if too much time is used. -Redirect the panelists' comments as needed to ensure that one or two panelists do not dominate the session.

poster presentations

-allows *more and best interaction* between presenter and participants -allows dissemination of preliminary research data or evidence reviews These are: -Usually displayed for longer periods of time -Less intimidating for presenters -Better for visual learners Plan for: -Poster creation -Printing -Transportation

research

-focused on discovering an answer when none is known *(generating data/new knowledge)* -carries risk for patient safety (review board, risk/benefit ratio) -Researchers not often part of patient-care team. -Most funding is from *external sources* -Generalizable -Expected outcome: publication

EBQI

-focused on implementing the best evidence with the best processes -carries low to no risk for patients (working on the best evidence -Most often part of patient-care team -If funding available, more often generated *internally* -Not generalizable; may be transferrable (consider whether patients on one unit match patients on the unit it was done on) -Expected outcome: dissemination, which may include publication

four factors for EBP dissemination

1) Advanced practice nurses → can serve as the leaders/mentors 2) Infrastructure (technology, computers, etc.) → need to have rapid exchange of information via computers/technology 3) Librarians → good literature sources 4) Managers/leaders expressing a shared vision → helps to get people below to follow up and support that vision

content of an evidence-based poster presentation

1) Background/significance 2) Clinical question 3) Search for evidence/accepted practice 4) Presentation and critical appraisal of the evidence 5) Clinical practice implications

steps in disseminating evidence through publication

1) Find a mentor or collaborate on a joint writing project with experienced author(s). 2) Generate the general concept/idea. 3) Decide what type of publication the idea would best fit. 4) Plan and organize the manuscript outline. 5) Adopting a positive attitude. --Be persistent! A rejection doesn't mean that it's a bad idea → can retool the article using the comments provided. 6) Select a journal. 7) Develop the content *following publisher's guidelines*! 8) Develop a timeline for completion of manuscript sections, including literature review. 9) Proofread the manuscript before submitting it.

15 ethical principles of universal declaration on bioethics and human rights

1. Human dignity and human rights 2. Benefit and harm 3. Autonomy and individual responsibility 4. Consent 5. Persons without the capacity to consent 6. Respect for human vulnerability and personal integrity 7. Privacy and confidentiality 8. Equality, justice, and equity 9. Nondiscriminization and nonstigmatization 10. Respect for cultural diversity and pluralism. 11. Solidarity and cooperation 12. Social responsibility and health 13. Sharing of benefits 14. Protecting future generations 15. Protection of the environment, the biosphere, and biodiversity

7 ethical requirements (upon which clinical research should be based)

1. Social or scientific value 2. Scientific validity 3. Fair subject selection (randomization; equal representation) 4. Favorable risk-benefit ratio (risks do not outweigh benefits; should get a good result with very little negative impact) 5. Independent review (get other people's opinions - valid? Reliable? Does it work?) 6. Respect for potential and enrolled subjects 7. Informed consent

informed consent

Informed consent, whether for research participation or for treatment, is a foundational component of clinical and research ethics.

a. Evidence-based treatments may be a benefit to some clients' healing but exacerbate others. (Helps some, but hurts others → violates the principle of nonmaleficence)

A leadership team is planning an EBQI initiative that will address the policies and protocols around wound care. Which development in the implementation may be construed as unethical? a. Evidence-based treatments may be a benefit to some clients' healing but exacerbate others. b. The clinical practice guidelines that form the basis of the practice change may have been developed at a different site. c. Clinicians may find that existing routines around wound care are difficult to change.

essential information - podium/oral presentation

Analyze your audience: -Who are they? What's their background? How many? -Gives you an understanding of the language level you can include, teaching style, etc. -How many → tells you what you can do with the presentation (group participation, etc.), can provide enough handouts for entire group Assess technology capabilities/resources: -AV equipment available? Recording the presentation? Access to internet? Microphone? Tech support on hand? -Why? → Need to know what is available to you, need to know if you have a microphone or need to project your voice, latest tech vs. older tech Plan the content: -Length and format of presentation? Content to be addressed? Expectations? Handouts? -Length: need to know so you can adjust your content and fit what you need to in the time frame -Tailor content -Stage? Ground level?

EBQI initiatives - conflict with ethical principles

Attempts to improve quality for some patients that may cause harm for others -Ex: Some people are just high-risk falls and need sitters. If you assign a sitter from CNAs that have been assigned to do patient care on a unit, you have decreased the amount of people able to help patients on the unit by 1 → not equitable anymore. Strategies intended to improve quality that may turn out to be ineffective and waste scarce resources -Ex: To offset downtime, a hospital decides to cross-train professionals (ex: housekeeper trained as a phlebotomist). Sometimes, phlebotomy needs were so high that rooms that were empty didn't get cleaned, and the ER couldn't transfer patients up to the unit. -Ex: It used to be the job of night nurses to take individuals who died to the morgue. This would waste the resource of a nurse for patients. Activities declared to be EBP or EBQI that may be more accurately clinical research -Ex: If you implement practice changes that are not based in valid and reliable evidence, you are changing practice without a good reason. There should have been more research instead of simply making a practice change.

working with the media

Basics: *-Always engage your PR or marketing department before engaging with the media!* --What you can say/do and what you can't say/do; helps you find an angle -Have a clear and newsworthy message that is easy to understand -Know the audience you intend to reach -Formulate a plan -Develop a "pitch"; make your case quickly why a reporter should cover your story! --News/media wants to pitch things that are of human interest and that make a difference

responsibilities of journal club leader

Before: -Decide how article is going to be chosen -Disseminate article and information about location/time to participants -Secure the site During: -Clearly communicate purpose and expectations -Use open-ended questions to facilitate discussion (hand out questions!) -Actively listen -Avoid appearance of preferences or bias -Monitor flow of discussion to stay on topic *Get articles out ahead of time; no time during the club to read the article, so it should be read beforehand*

disseminating evidence to small groups

Brief consultations: -Informal -"Hallway consultations" -On-the-ground approach to facilitate discussion Digitizing evidence communications: utilizing technology can be very effective in disseminating information to a targeted audience -Podcasts -Videocasts -Webinars -Social media (ex: Twitter)

pretest

Can often assess knowledge that the audience already has on the subject; will bridge that back into the presentation

d. Independent review

Controversy about ethical principles as applied to EBQI versus clinical research is seen *most* clearly in which of the following domains of ethics? a. Scientific validity b. Social or scientific value c. Fair subject selection d. Independent review

clinical practice implications

Describe clinical practice implications, based on the process of collecting and evaluating the evidence.

post test

Did they remember anything that you talked about?

publication

Dissemination is *incomplete* until you convert your presentation into this! -Need to get the info out -Nurses are one of the worst professional groups at this process → how the profession grew up (Many people think you have to do it on your own, but many other disciplines do this as a group.) Plan time for multiple drafts/revisions! -Have to be *persistent*! -Do not take rejections personally Goal: submit manuscript for publication within 90 days of oral presentation

panelist's dos and dont's

Do: -Be sensitive to time limitations for both prepared and spontaneous remarks! -Make notations of other speakers' comments for response and essential points for an organized, well-thought-out reply. Don't: -"Jump" on the remarks of other speakers (i.e., enable them to speak without interruption). -Look at another panelist when responding to his or her comments; rather, speak directly to the audience. -Express political or partisan opinions.

dont's when working with media

Don't: -Use scientific jargon -Wait for hours to return calls; call back immediately -Expect a story to name every contributor -Assume the reporter is familiar with your project or discipline -Dictate the "proper" angle to take -Talk about only the positive aspects; discuss the challenges or limitations as well -Don't ask to see a copy of story before it is published (may be okay to prevent misquoting)

connecting EBP and ethics

EBP involves using evidence to improve practice. Once improvements are implemented, the outcomes must be evaluated. -Measure the outcomes -When you measure the outcomes of a project, that tells you whether you've been successful or not. -Typically measured over time -If a consistent issue is present → try to change something in the process Ethical principles influence both the importance of evaluating the impact of evidence on patients and the way those evaluations are conducted. -Important to evaluate outcome of whatever is being done and the process that is going on

social or scientific value

For research, EBP, or EBQI to be ethical, it should be worth the time, resources, and risks; in other words, adds either social or scientific value.

disseminating evidence to influence health policy

Health policy briefs allow opportunity to provide evidence to inform policy creation. Should be: -Succinct (brief and to the point; 1 page, hit key points) -Written in language that legislators can understand Examples of topics: -Health care financing -Quality and safety of patient outcomes -Risk/benefit analysis of cost reduction alternatives -Human resource needs

search for evidence/accepted practice

Identify briefly the methods and sources used to collect evidence (ex: search strategy for review of literature, focus groups, and surveys of institutional practices).

bridge

If you know your audience, you can start at some common base. You can tailor the information to them.

informed consent

In order for research to be done, you have to inform participants of what they're enrolling in → participation is voluntary; if they choose not to participate, nothing bad is going to happen to them (will still receive same quality of care)

disseminating evidence - hospital/organizational and professional committee meetings

In preparing, consider: -What is the composition of the audience? -What do they know about the topic? -How much time do I have? Remember: -Time is tight! -Stick to the key points. -Anticipate latecomers; anticipate questions the group might have.

fair subject selection

Inclusion and exclusion criteria for recruiting study participants should be based on scientific rationale, not convenience or vulnerability; patients involved in an EBP or EBQI project should be determined by the population of patients served by the organization rather than the ability to generalize outcome findings.

independent review

Independent review of research is ethically required because of the potential conflicts of interest and resultant human rights violations.

participatory learning

Is there any interactive learning that can be done? Hard to do with a large group...

b. Building expertise and confidence in reading and appraising research studies

Journal clubs are an effective mechanism for enhancing which of the following aspects? a. Clinician's ability to conduct research studies b. Building expertise and confidence in reading and appraising research studies c. Identifying patient preferences d. Helping participants better understand how to write PICO(T) questions

DIY opportunities to disseminate

Op-Ed or commentary: -Follow publication guidelines -Show thought leadership and expertise -Short (typically 500-800 words) Disseminate using social media!

disseminating - panel presentations

Panel: usually made up of a moderator and panelists; provides a mechanism to share different perspectives on the topic -Effective way to disseminate information/experiences/perspectives from various professions, clinical sites, etc. -Both formal and informal formats can be utilized

dissemination

Primary goal: to *facilitate transfer and adoption of research findings into clinical practice* or disseminate results from EBP and EBQI projects Will help: -Build cache of evidence available for discovery -Increase chance of translation of evidence into practice -Increase quality of care through informing evidence-based decision-making Really supplies the background and significance for what you want to do on your clinical unit! -Need to supply quality and cost data to build a case for change -3 "Be": be interesting, be brief, be gone

privacy and confidentiality

Privacy ex: closing curtain/door, not having a care conference in the middle of a hallway Confidentiality: HIPAA, FERPA → can't disclose information

presentation and critical appraisal of the evidence

Provide a succinct summary of the conclusions drawn from evaluating the scope of evidence available.

background/significance

Provide background as to the nature or status of the clinical problem (ex: prevalence data or other statistics demonstrating the growing importance of the problem, professional association's power statements).

scientific validity

Research projects must be methodologically sound enough to ensure valid and generalizable findings; poorly designed or implemented EBP or EBQI projects waste resources and the time of those involved.

favorable risk-benefit ratio

Research, EBP, and EBQI should be committed to minimizing the risks and maximizing the gains of all studies and projects.

b. Whether the article will have an accompanying commentary

Which of the following areas is the *least* important to address when choosing a journal for a manuscript submission? a. The readership profile of the journal b. Whether the article will have an accompanying commentary c. The lag time between manuscript acceptance and its publication d. The average length of time it takes for peer review

clinical question

Specifically identify what clinical problem/question was investigated.

d. The leadership and management of the unit

The nurses on a nephrology unit wish to implement an evidence-based change in the assessment and management of patients' arteriovenous fistulas. Which of the following should perform the first (and possibly only) review for the ethical considerations of this change? a. The hospital's ethics review board b. The state board of nursing's ethics committee c. Expert nurses on the unit d. The leadership and management of the unit

d. By ensuring resources will not be wasted and clients will not be placed at risk (Triage involves deciding where someone should go and what resources need to be allocated. Doing this would provide rigor and ensure fairness.)

The nursing leaders at a county hospital are aware of the need for rigor during the implementation of an EBQI project that will address ED triage. How should the leaders *best* apply rigor to this project? a. By ensuring that instruments for measuring effectiveness have face and content validity b. By justifying their choice of methodology in terms of the clinical question and the characteristics of the site c. By seeking ethical approval and client consent prior to beginning the project d. By ensuring resources will not be wasted and clients will not be placed at risk

b. Preparing a well-thought out study

Which of the following is NOT an ethical principle? a. Human dignity and human rights b. Preparing a well-thought out study c. Autonomy and individual responsibility d. Privacy and confidentiality

d. Change slides not less than every 30 seconds

Which of these strategies is the best advice to podium speakers who are using slide presentations? a. Use several different fonts and font sizes throughout the presentation b. Present as much written material as possible on each slide c. Vary the slide background from slide to slide d. Change slides not less than every 30 seconds

respect for potential and enrolled subjects

The well-being of the individual research subject takes precedence over all other interests; refusal of EBP treatment is always the patient's right.

c. Publication in a peer-reviewed journal

There are many opportunities to disseminate your work through various media. Which of the following is likely to reach the largest audience? a. Podium presentation at a large conference b. Poster presentation at a large conference c. Publication in a peer-reviewed journal d. News story

informed consent and EBQI

There is a great debate as to whether this is needed in EBQI. Debate includes: -Whether patients should expect EBP and EBQI as part of standard healthcare -Whether informed consent is needed if patients are actively participating in decision-making; one of the cornerstones of EBP and EBQI. Initiatives like PCORI allow patients, their caregivers, and the broader healthcare community to drive research agendas and help ensure ethical principles are upheld. *As EBQI became more formalized and more intricate (looks more like research), the question became whether it needs to go before a review board. Some believe that it should, but that the only thing that needs to be looked at is the safety of human subjects.*

False

True or false: There is a lack of agreement regarding the question of whether ethical principles need to be applied to EBQI initiatives.

summary

What did you cover? Synopsis?

objectives

What will you cover?

evidence-based practice (EBP)

a lifelong problem-solving approach to clinical decision-making that involves the conscientious use of the best evidence with clinical expertise (including internal evidence) and patient preferences and values to improve outcomes for individuals, groups, communities, and systems; broader than research/research utilization

autonomy

acknowledges that patients have the right to make decisions about their health, lives, and bodies -Absolutely the most important; usually the most difficult for us to respect --We all have beliefs/opinions based on our expertise and knowledge from textbooks, classes, etc. → If a patient goes against that, it is going to cause internal conflict → still must respect patient's wishes, but talk and debrief with other nurses, physicians, etc.

clinical research

activities involving direct interaction by investigators with human subjects or material of human origin; *generates knowledge* on which practice should be based -typically generalizable as long as it's valid and reliable

fidelity

added to capture the importance of trust and honesty -says that you keep your promises -At its simplest form: If you're very busy and someone needs you, say, "You're okay for now. I'll get someone to get some water for you. I or someone will be back." --Must circle back → increase trust in you

nonmaleficence

addresses the importance of not harming patients -Normally involves *advocating* for patient → don't want anyone else to do harm to them -Also have to do your own check → you don't want to do harm! -Harm can be intentional or unintentional → recognize that you don't have the expertise to decide what is right here, but your gut says that something is not right; talk to experts

BOPPPS

an interdisciplinary model for developing presentations -based on audience analysis and conference purpose *B*ridge *O*bjectives *P*retest *P*articipatory learning *P*ost test *S*ummary

beneficence

captures the importance of doing good for patients -doing the right thing

EBQI

combining the EBP process with the QI process to impact process outcomes. Interventions/strategies to be implemented are arrived at using the EBP process, then QI processes are engaged to guide the implementation and evaluation phase. -Research out there says that there's a better way to do something. -Could involve QI data (internal data) -Implemented on a unit; typically not generalizable or randomized -Typically not publishable

justice

core ethical principle involved with the IOM quality dimension of equity

beneficence

core principle involved with the IOM quality dimension of effectiveness (quality)

autonomy

core principle involved with the IOM quality dimension of patient-centeredness (care the patient wants) Examples of patient-centeredness: -Menu at bedside -Change-of-shift report at bedside -Visiting hours shifted to more of what the patient wants

nonmaleficence

core principle involved with the IOM quality dimension of safety

beneficence and nonmaleficence

core principles involved with the IOM quality dimensions of timeliness and efficiency

justice

declares that resources should be distributed fairly among people and without prejudice -Also pertains to you personally as a nurse → if you have 5 patients to take care of, every patient has the right to equal and fair treatment! --Should see you more than once during shift, should all get physical assessments, etc. --Can't just brush off one patient

evidence-based grand rounds

designed for clinicians to speak directly to their colleagues; can serve as a major forum for evidence-based presentations -in-person or internet-based -large; everyone can come and attend the session (ex: anyone in the hospital) -usually consist of formal oral presentations accompanied by AV slides or video presentation, followed by a Q&A period

disseminating evidence - journal clubs

evolved over the years; held in a variety of settings -provides opportunity for clinicians to share and learn -can be on-site or online Typically led by an *advanced-level clinician who understands research* design, methods, statistics, but may be led by faculty mentor or trainee Purpose: learn how to appraise articles and do research

institutional review boards (IRBs)

expert panels assembled to review research studies and be sure human subjects are protected and ethical principles are not violated Why did these come into being? -Nuremberg Trials, Tuskegee study, twin studies, Stanford prison experiment, etc. -Impact on those family members Debate exists over whether EBP and EBQI initiatives should undergo review by these or whether review by clinical management and supervisors is sufficient.

peer-reviewed

means that other people have read it and agree with it -signifies quality research journals → people like you with scientific background have reviewed article

impact factor

measures the journal's importance (0+ to 10+) -does this by counting the number of times that articles a journal has published have been cited in other published works

Michigan ICU study

occurred in 2004; clinicians from Johns Hopkins University coordinated a prospective cohort study to examine the impact of introducing evidence-based strategies to reduce infection rates in all ICUs in Michigan. -Over 100 ICUs participated in the 18-month study. -Large and sustained reduction in rates of catheter-related infections occurred. -Involved a large number of educational interventions targeted at ICU personnel -Checklist: hand-washing, using full-barrier precautions during insertion of central venous catheters, cleansing skin with chlorhexidine prior to insertion, avoiding, when possible, the femoral site for catheter insertion, and removing unnecessary catheters

quality improvement (QI) initiatives

systematic, data-guided activities designed to immediately improve healthcare delivery in specific settings -use *internal data* → unit-based; will use internal data that has been collected from that unit (ex: use of data from patient satisfaction surveys)

evidence-based clinical rounds

smaller in scope than grand rounds; unit-based -walking patient to patient (ex: group of med students walking with a professor from room to room); often interdisciplinary -used to present findings from unit or department level EBP projects back to the other members of the unit/department Clinicians usually do the following to prepare for these rounds: 1. Identify a clinical question. 2. Conduct a systematic search for evidence to answer the clinical question. 3. Critically appraise the evidence found. 4. Recommend guidelines for practice changes based on the evidence.

in-press period

time between acceptance and publication

turnaround cycle for review

want to disseminate information rapidly; if cycle is 3-5 years, the info you have may no longer be current. -Call publisher to find this out!