Chapter 11: Employ Evidence-Based Practice
Clinical guidelines
A guideline that provides a purposeful and clear evaluation of the effectiveness of therapeutic modalities; an evidence based guideline is one of the strongest sources for EBP; considers both the efficacy of an intervention and its acceptance by those to whom it is offered
Effectiveness
A measure of the benefit resulting from an intervention for a given health problem under average conditions of use
Outcomes research
A newer approach focused on determining the effectiveness of healthcare services and patient outcomes
Research
A systematic investigation that includes research development, testing and evaluation; designed to develop or contribute to generalizable knowledge
Nursing education research
Explores more effective an efficient educational processes and new teaching-learning practices to incorporate technology in the learning process, intergenerational learning differences and their impact on education, and the development of methods to improve lifelong learning and commitment to leadership
The NINR is located
At the NIH campus in Rockville, Maryland
2 major types of research
Basic and applied
CTSA
Clinical & Translational Science Award wise goal is to decrease the time taken to move research inno practice
2 initiatives were developed to address the need for evidence to support strategies employed to improve care:
Clinical and translational science awards and patient centered outcomes research institute
Major research focus area
Clinical research, health systems and outcomes research and nursing education
International council of nurses
Committed to supporting nursing research as a powerful tool for generating new knowledge and evidence to underpin nursing practice
Research question
Concise and developed before the research is conducted and stated in the research proposal
extramural study
Conducted at the researchers home institution or in collaboration with several institutions, grants are awarded
EBP is included in all 5 healthcare professions'
Core competencies
Funding
Critical part of any research because it provides resources to conduct the research such as researcher salary, staff pay, space, supplies, animal costs, etc.
Research purpose
Describes the potential uses of the results
Research analysis
Description of results and conclusions after the study has been conducted
Applied research
Designed to find a solution to a practical problem; often referred to as clinical research and carried out in a non-lab setting
Basic research
Designs to broaden the base of knowledge rather than solve an immediate problem and is typically done in a lab setting
Cochrane Database of Systematic Reviews
Develops, maintains and updates systematic reviews of healthcare interventions to allow practitioners to make informed decisions. Located in London
Sigma Theta Tau International (STTI) is an active supporter and developer of
EBP through its online nursing journal publication
Best practice clinical decisions require
EBP, healthcare provider expertise, patient assessment and inclusion of patient's perspective (preferences and values)
National Institutes of Nursing Research (NINR)
Established 1985 part of the national institute of health; important because it shows nursing has a presence in the most prestigious national research system; conducts research that has an impact ol for the nursing profession and allocates funding for nursing studies conducted in other institutions; encourage interprofessional research
After evidence is found, nurses must
Examine the validity of the evidence, it's relevance, and it's appicability to the EBP question. Then evidence may be applied in practice
Second ethical and legal concern in research
How best to balance benefits and risks/harms in studies
Institutional research board
IRB; committee that reviews research before it is conducted to ensure that the study is conducted ethically
Barriers to facilitators of research
Lack of funding Lack of sufficient time Lack of research competencies Lack of participants for the sample Inability to find the right setting Lack of statistics expertise
The nursing and allied health professionals are not as far along in implementing EBP as
Medicine
NCGs
National clinical guidelines. A EBP source that is the US government based through the AHRQ although the guidelines come from many different sources
Quality Improvement (QI)
Now focuses more on continuous quality improvement (CQI), the process that aims to ensure patients receive the best care when they need it and outcomes are met on an ongoing basis
Nurses may be involved in developing systematic reviews by
Revising studies based on specific criteria (though uncommon because reviewing studies takes a special expertise and in depth knowledge of statistics)
Policies and procedures
Written guides developed by organizations to inform staff about expectations related to care and management
Translational research
The application of discoveries generated in the lab and preclinical studies to the development of trials and studies in humans; research aimed at enhancing the adoption of best practices in the community
Systematic review
The consolidation of research evidence that incorporates a critical assessment and evaluation of the research and addresses a focused clinical question using methods designed to reduce the likelihood of bias; critique of multiple studies related to same research question
The largest source of grant monies
The federal government
Randomized control trials (RCTs)
The gold standard in research design; involve a true experiment; control and other variables, randomization of the sample, use of a control group and experimental group, and manipulation of an intervention ( aka independent variable)
Intervention in experimental studies represents
The independent variable
Florence Nightingale had some interest in clinical research however in early nursing history,
The nursing community did not pay much attention to research
Magnet Recognition Program
The only national designation built on and evolving through nursing research that is designed to recognize nursing excellence of healthcare organizations through a self-nominating, appraisal process; includes EBP as one of its recognition elements
Theory
Used in qualitative studies, the researcher may identify a theory or conceptual model to organize findings; described and related to research question
1920s-1930s nursing research
Very few studies focusing on nursing care
Agency for Healthcare Research and Quality (AHRQ)
a federal agency established to improve the quality, safety, efficiency, and effectiveness of health care for Americans; source of EBP literature and collection of evidence based on national clinical guidelines (NCGs)
Determining the comparative effectiveness of prevention and treatment strategies is part of
Translational science
Funding sources
Universities, private donations, foundations and organizations, local and state governments, and the federal government
EBP is the major initiative used to increase the
Use of best practice or evidence in making clinical decisions
EBP
evidence based practice; to integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible; tailored to individual patient needs and based on evidence from more than one study
EBM
evidence-based management; Systematic application of the best available evidence to the evaluation and managerial strategies for improving the performance of health services organizations
Nursing research develops knowledge for the following purposes:
- build scientific foundation for clinical practice - prevent disease and disability - manage and eliminate symptoms caused by illness - enhance end of life and palliative care
Key elements of EBP
- core competency - evidence based management - nursing research - EBP and quality improvement - tools for EBP success like clinical guidelines, policies and procedures - EBP and the students - EBP process models
NINR's goals to invest in research focusing on:
- enhance health promotion and disease prevention - improve quality of life by managing symptoms of acute and chronic illness - improve palliative and end of life care - enhance innovation in science and practice - develop the next generation of nurse scientists
The EBM Process:
- formulate the question - acquire research evidence - assess the quality of evidence - presenting the evidence - applying the evidence to the decision
All systemic reviews must:
- include clear criteria for conducting review process - review not only research reports but also review data from large databases and include published articles that are opinion or essay
In order for EBP to be used more effectively, healthcare professionals should have these abilities:
- know where & how to find the best possible sources of evidence - formulate clear clinical questions - search for relevant answers to questions from the best possible sources of evidence - determine when & how to integrate these new findings into practice
Barriers to EBP implementation
- lack of knowledge about EBP & it's value - limited time in practice settings - nursing shortage - greater need to emphasize both knowledge and practical approaches - concern that EBP represents a cookbook approach to care - lack of knowledge about EBP resources - lack of resources to find info - limited recognition by employers regarding the value of EBP
Experimental studies must have
- manipulation of intervention - control - randomization
Vulnerable research participant populations
- neonates - children - pregnant women - persons with mental illness - pertains with cognitive impairment - terminally ill person - persons confined to institutions
EBP data used most often by students:
- patient values and preferences - patient history - assessment data
ANA Research focuses on:
- the value of nursing contributions to safety, reliability, quality and efficiency - factors that increase the impact of nurses on quality and efficiency - use of national database of nursing qualitative indicators to enhance patient safety, quality care and efficiency - nurse workforce issues - population health issues
2 important EBP databases
1. Cochrane database of systematic reviews 2. Joanna Briggs institute EBP database
2 tools to ensure a higher use of EBP:
1. Healthcare organization policies & procedures 2. Clinical guidelines
PICOT used in 5 steps:
1. Identify burning clinical issue/question 2. Collect the best evidence relevant to the question 3. Critically appraise that evidence before it is used 4. Integrate evidence with other parts of EBP (patient preferences, clinical expertise, assessment info and patient history) 5. Evaluate practice decision or change
3 approaches to obtain funding:
1. Identify problem and develop proposal that is sent to funding sources that might have an interest in the particular problem 2. Develop research proposal that specifically addresses problem area that a funding source has identified as a critical need area 3. Funding sources require the researcher to conduct a pilot study or have data that indicates great need for research about a particular problem
Health systems and outcomes research
Focuses on identifying ways that the organization and delivery of care influence quality, cost and the experience of patients and their families
Hypothesis
Formal statement or the expected relationship or relationships between two or more variables in a specified population, which is a sample; stated before the research is conducted and included in the proposal
Research problem statement
Formulated to be an assessment to identify and describe the problem; researcher does this assessment using the researchers individual expertise; reviewing literature and possibly interviewing other experts
Intramural/internal study
Funded research conducted at the NINR campus
EBP is an organized approach to
Get research into practice
1950s nursing research
Greater interest in research; more nurses conducted studies and obtained grwduate degrees
IRB is mandated to review all research that
Includes human subjects in institutions that receive federal funds
Clinical research
Includes interventions for secure and chronic care experiences across the life span, health promotion and preventive care to end of life care and care for individuals, families and communities in diverse settings
Third ethical and legal concern in research
Informed consent
Fourth ethical and legal concern in research
Institutional review to ensure participant rights are protected and study is planned in an effective manner that meets sponsorinf orgs standards
Research and evidence based practice are
Interconnected
American Association of Colleges of Nursing (AACN) statement on research
Nursing researchers bring a holistic perspective to studying individuals, families and communities; their research takes a bio behavioral, interdisciplinary, and translational approach to science
1960s-1970s nursing research
Nursing theorists were very active in research, adding to scholarly work and increasing the amount of PhDs
Joanna Briggs Institute EBP Database
Organization that represents an international collaboration among nursing and allied health centers. Located in Australia main purpose is to train professionals to conduct systematic reviews
Nursing research serves as a framework for
Organizing facts and evidence into a cogent and usable format
Research report
Published article, poster or presentation after the study is completed for the researcher to describe what was done
PICOT
Patient, Intervention, Comparison, Outcome, Time; EBP question part of every search for evidence to improve practice; must be specific
Incorporating EBP evidence into standards of care help reduce
Practice variation and provide greater consistency based on evidence to improve quality and safety
Using EBP affects comparison of alternatives and interventions such as
Prevention, diagnostic tests, therapy or no intervention at all
Priorities of nursing research
Promotion of health and healthy lifestyles, advancement of quality and excellence in health care and the critical importance of basing professional nursing practice on research
National Guideline Clearinghouse
Provides a collection of evidence-based clinical practice guidelines, sponsored by the AHRQ
Research network
Provides a vehicle for continual exchange of knowledge and experience; greater global sharing of research info and expertise
EBP helps to provide
Quality care
Qualitative studies
Research question focuses on feelings or experiences; data collection is less structured
Quantitative studies
Research question focuses on how many or how much; data collection is highly structured and used statistics
Research Proposal
Researcher describes what will be done; plans the research and may be used to apply for funding; critical document used to obtain approval for a study and institutional review board; written in future tense
First step to applying EBP
Staff preparation
Research process
Step by step problem solving method
Research
Systematic investigation of a problem, question, issue or topic that uses a specific scientific process to gain new knowledge
The key component of EBP literature is
Systematic review
The staff nurse's most important role is
That of a consumer- applying knowledge from systematic reviews
First ethical and legal concern in research
To protect the rights of human participants
Nursing research framework must represent
The phenomenon of interest and guide the research question and the measurement of variables
Research design and methods
The specific plan for conducting the study; complex; include the details related to type of study, sample and means by which sample is selected, setting for study, measurement and data collection instruments, data collection process, data analysis and description of potential limitations; clear and detailed plan
Results of an RCT provide
The strongest support for a cause and effect relationship
Nursing research provides opportunities for linkages between
Those involved in the research process, practicing nurses, other health professionals, policy makers and the public
The purpose of EBP
To guide the use of limited resources, control costs and improve quality nursing care
CQI
continuous quality improvement; a structured organizational process for involving personnel in planning and executing a continuous flow of improvements to provide quality healthcare that meets or exceeds expectations