EBP

Bias: Define the following and how bias is prevented: Gatekeepers

- Occurs when a well-intentioned person acts as a gatekeeper in studies involving vulnerable populations resulting in a sample not representative of the population - Can occur in convenience sampling when patients may be chosen because they are more likely to volunteer, resulting in a sample not representative of the target population - Convenience Sampling: Quantitative study to see if only prelaw freshman students prefer to live on campus or off campus in an urban campus -->Not getting a good representation of all the freshman, but it was an easy way to get all the information

Research evidence and evidence- based theories (best evidence) ~what is the definition of evidence based theories?

- systematic reviews of RCTs has been regarded as the strongest level of evidence on which to base practice decisions about treatments to achieve a desire outcome, but evidence from descriptive and qualitative studies as well as from opinion leaders should be factored into clinical decisions - evidence based theories: theories that are empirically supported through well-designed studies

Clinical expertise (evidence from patient assessment, internal evidence, and the use of healthcare resources) -clinical judgement and clinical reasoning

-Clinical Judgement: the ability to think about, understand, and use research evidence; the ability to assess a patient's condition through subjective history taking, thorough physical examination findings, and laboratory reports -internal evidence generated from quality improvement or outcome management projects -Clinical Reasoning: the ability to apply the above information to a clinical issue -Evaluation and use of available healthcare resources needed to implement the chosen treatment(s) and achieve the expected outcome

Describe Guba and Lincoln criteria of trustworthiness

-Credibility, Transferability, Dependability, Confirmability 1. Credibility -->Demonstrated by accuracy and validity that is assured by thorough documentation -->Approximates to internal validity in quantitative appraisal -->Internal Validity: Did the independent variable effect the dependent variable? 2. Transferability -->Demonstrated by information that is sufficient for a research consumer to determine whether findings are meaningful to other people in similar situations --> Approximates to external validity --> External Validity: What you find in your sample size, is it generalizable to the whole population? 3. Dependability -->Demonstrated by a research process that is carefully documented to provide evidence of how conclusions were reached and whether, under similar conditions, a researcher might expect to obtain similar findings -->Approximates reliability 4. Confirmability --> Demonstrated by providing substantiation that findings and interpretations are grounded in data --> Approximates objectivity

What are the 7 steps of EBP? (0-6)

0. Cultivate a spirit of inquiry within the environment -->make you think about something you saw in the clinical setting, thinking that didnt look right or there may be a better way to do it --> Consistently questioning attitude toward practice 1. Asking the clinical question in PICOT format --> why are we doing it this way? 2. Search for and collect the most relevant and best evidence --> literature research --> think about the hierarchy of evidence 3. critically appraise the evidence --> Rapid critical appraisal, evaluation, and synthesis --> Critical appraisal of external evidence includes three areas of evaluation: validity, reliability, applicability 4. Integrates the best evidence with one's clinical expertise and patient preference and values in making a practice decision or change --> use the literature (external), clinical experience (internal), and patient's preference and values 5. Evaluate outcomes of the change --> how would you evaluate that change? --> outcome measurement determines whether the evidence-based change resulted in the expected outcome --> Determines whether the practice change based on evidence had the expected outcome in a "real world" practice setting 6. Disseminate the outcomes of the evidence based change --> internal communication strategies can include email, messages, reports at un/department meetings, dashboards, and score cards --> external communication strategies include podium or poster presentations at conferences and professional publications

What is clinical inquiry?

1. A process in which clinicians gather data together using narrowly defined clinical parameters; it allows for an appraisal of the available choices of treatment for the purpose of finding the most appropriate choice of action 2. Clinical inquiry in action includes problem identification and clinical judgement across time about the particular transitions of particular patient/family clinical situations 3. Four aspects of clinical inquiry in action include making qualitative distinctions, engaging in detective work, recognizing changing relevance, and developing clinical knowledge about specific patient populations. 4. To foster clinical inquiry, one must have a level of comfort with uncertainty --> The inability to predict what an experience will mean or what outcome will occur when encountering ambiguity It may be uncomfortable but it is imperative to good practice and to developing focused foreground questions

List 3 government agencies which ensure quality practice for care

1. Agency for Healthcare Research and Quality (AHRQ) National Healthcare Quality Report 2. National Quality Forum (NQF) 3. National Database of Nursing Quality Indicators (NDNQI)

Describe the strength and weakness of: Keyword search

1. All appropriate keywords, including common terms, synonyms, acronyms, phrases, coined phrases, and brand names, need to be used 2. Strengths: Provides a quick snapshot of resource's relevance to PICOT question 3. Weaknesses: May miss studies that do not exactly match the authors' keyword choices; may find many studies irrelevant to the PICOT question

List the Sources of External Evidence, in which subject heading searches would be effective

1. CINHAL 2. Cochrane Databases 3. EMBASE 4. Joanna Briggs Institute EBP Database 5. MEDLINE 6. PsycINFO 7. Scottish Intercollegiate Guideline Network

What is a Foreground question?

1. Can be answered from scientific evidence 2. Focus on specific knowledge 3. Asks for specific, scientific evidence about diagnosing, treating, or educating patients 4. PICOT questions, recommended for a focused literature search i. Helps you come back to focus ii. In children ages 3-8 years old, how does acetaminophen compare to ibuprofen in lowering a fever?

List the Sources of External Evidence, which are free to users (p. 41-42):

1. Cochrane Databases: Free website access with restricted content 2. MEDLINE: Free via PubMed --> Therefore, PubMed is free too 3. National Guideline Clearing House 4. National Institute for Health and Care Excellence 5. Registered Nurses Association of Ontario 6. Scottish Intercollegiate Guideline Network 7. Trip

Define Confidence Interval

1. Describes the range in which the true effect lies with a given degree of certainty 2. The CI provides clinicians a range of values in which they can be reasonably confident (95%) that they will find a result when implementing the study findings 3. In general, researchers present a 95% CI which means that clinicians can have 95% confidence that the value they can achieve falls within this range of values

What is external evidence?

1. Generated through rigorous research and is intended to be generalized to and used in other settings to answer a burning clinical question 2. A systematic search for as well as critical appraisal and synthesis of the most relevant and best research (from research, evidence based theories, opinion leaders, and expert panels) 3. Literature, from other medical research/ disciplines 4. Best evidence from research

Describe the strength and weakness of: Subject holding search

1. More advanced searching using standardized set of preselected terms for the search 2. AKA: Controlled vocabulary, subject terms, thesaurus, descriptors, MeSH, or taxonomies 3. 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 4. 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 5. Weaknesses: Newly developed technologies, phrases, and acronyms may not yet be linked in the database and thus be missed

Bias: Define the following and how bias is prevented: knowing who receives treatment

1. Occurs if subjects or those measuring outcomes know subject group assignment (know who is getting the intervention and who is getting the placebo) 2. Reduced by blinding, in which subjects and those measuring outcomes do not know the group assignments 3. Blinding: Giving unlabeled intervention/placebo to group A and B 4. Primary investigator is the only one that knows, but they are not collecting data

What are the seven critical steps to implementation of EBPG into practice?

1. Processes and structures that facilitate the use of EBP including ongoing administrative support 2. A positive milieu (social with structures and processes that foster EBPG use 3. Interactive education with skills building practice and attention to patient education 4. Use of reminders 5. Electronic systems offering easy access to guidelines and real-time outcome feedback 6. Organizational structures and processes that alert staff to EBPG initiation and revision 7. EBP champions and mentors at all levels of the organization

Three essential characteristics of experimental designs

1. Randomization 2. Comparison 3. Intervention

How does bias relate to the validity of a study? what is study bias?

1. Refers to whether the results of the study were obtained using sound scientific methods 2. Bias or confounding variables may compromise the validity of the results/findings -By the way they obtained samples -The way they analyzed the data -Not addressing missing data 3. The less influence these factors have on the study, the more likely the results will be valid Study Bias: Anything that distorts study findings in a systematic way and arises from the study of methodology

List the Three Components of EBP and define each**

1. Research evidence and evidence- based theories (best evidence) 2. Clinical expertise (evidence from patient assessment, internal evidence, and the use of healthcare resources) 3. Patient preferences, Values, and concerns

What are the 6 AGREE areas of appraisal?

1. Scope and purpose 2. Stakeholder involvement --->Who are you trying to convince that his is the best evidence possible? 3. Rigor of development 4. Clarity and presentation 5. Application 6. Editorial independence

What does Magnitude of the Effect mean and how does it relate to the reliability of a study?

1. The degree of the difference in effect (or its lack) between study groups -->Effect is the rate of occurrence in each group for the outcome of interest 2. Statistical tests are usually conducted to determine whether the effects differ significantly between/among groups 3. Do you have enough sample size to make your results reliable? i. 3 subjects would not get you very reliable results ii. The more people that you have, the more likely it will be a reliable indication of the generalized population

What is a Background question?

1. The foundational question --> constantly questioning, asks general information about a clinical issue 2. Broader in scope 3. leads to the foreground question 4. two components: starting place (what, where, when, why, how) and the outcome of interest (how does acetaminophen work to affect a fever?

Define each of the steps for developing EBPGs

1. Use a formal and explicit process -The process should be detailed enough that it could be replicated 2. Identify the guideline panel -Members should be able to address relevant interventions, meaningful outcomes, benefits, and harms. Experts who bring the different perspectives of research, clinical practice, administration, education, policy, and feasibility should be included. 3. Develop an analytic framework or causal pathway -Diagrams should provide a precise description of the target population, setting of care, interventions, and any intermediate as well as final health outcomes 4. Perform a formal search and review of the literature -Pre-appraisal work 5. Develop recommendations based on the strength of the evidence -Each question identified in the analytic framework should be addressed. If evidence is lacking for a specific recommendation and expert opinion used, this should be stated. 6. Perform peer review -This step will help to identify any omissions or misinterpretations of the guideline

Describe the strength and weakness of: Title search

1. Uses the keywords generated by the P, O, and T, to search article titles 2. As with the use of keyword searches, all appropriate common terms, synonyms, acronyms, phrases, coined phrases, and brand names need to be used 3. Most narrow type of search 4. Strengths: Increases the chances of the article found being relevant to the PICOT question and is highly effective in finding relevant articles 5. Weaknesses: Misses studies that do not contain the keywords in the title

What makes a study applicable? What is applicability?

1. Will the results help me in caring for my patients? 2. Is it applicable to our population in our clinical setting? 3. If I repeated the test, would I get the same results in my population? 4. Includes asking whether (a) the subjects in the study are similar to the patients for whom care is being delivered, (b) the benefits are greater than the risk of treatment (i.e., potential for harm), (c) the treatment is feasible to implement in the practice setting (d) the patient desires the treatment

Qualitative research techniques

1. observation and fieldnotes 2. interviews and focus groups 3. Narrative and content analysis 4. Sampling strategies 5. Data Management and analysis 6. Mixing methods

qualitative research traditions: Fieldwork*

All research activities carried out in the field/study setting (informants' natural settings) -->Activities include the many social and personal skills required when gaining entry to the field, maintaining field relationships, collecting and analyzing data, resolving political and ethical issues, and leaving the field

Confidence interval

An interval estimate that might contain the true value of an unknown population parameter (typically .95 but also can be set at .99

qualitative research traditions: Hermeneutics*

Method of interpretation of lived experience through the interpreter's dialogical engagement 1. Interpreting the lived experience 2. Historically and originally associated with interpretation of Biblical texts 3. Example of a study of the meaning of comfort care for hospice nurses -Comfort, relief, peace/ease, spirituality and meaning 4. Also, associated with phenomenology as in hermeneutic phenomenology to denote summarizations as interpretative rather than descriptive

Multivariate analysis of variance (MANOVA):

Multivariate analysis of variance (MANOVA): analyzes mean score of 2+ groups or 2+ variables at the same time -Done to describe the relationship between 3 or more variables -Also used to find differences between groups on the measures of central tendency -Examples: Multiple Regressions Analysis, One Way Analysis of Variance, Two Way Analysis of Variance

Narrative and Content analysis

Narrative Analysis: A specific way to generating, interpreting, and understanding stories about life experiences from textual data Content Analysis: Most commonly used in qualitative reports. Procedure involving breaking down data through coding, comparing, contrasting, and categorization, then reconstitution them in some new form, such as description, interpretation, or theory

observation and fieldnotes

Observation: takes on different dimensions 1. Complete observer 2. Observer as participant 3. Participant as observer 4. Complete participation Fieldnotes: : Self-designed, highly detailed records of observational protocols for recording notes about field observations 1. Analytic notes are written by researchers about idea for analysis, issues to pursue, people to contact, questions, personal emotions, and point-of-view understandings.

Bias: Define the following and how bias is prevented: Measurement bias

Occurs if instruments are incorrectly calibrated (thus consistently producing higher or lower measurements) or if data collectors deviate from established data collection protocols (especially if observation is being used or psychological variables are being measure)

Bias: Define the following and how bias is prevented: Contamination

Occurs if intervention and control groups have interaction and information is shared, especially if the intervention is educational in nature

What is internal evidence?

One's own clinical experience - which includes internal evidence generated from outcomes management or quality improvement projects, a thorough patient assessment and evaluation, and use of available resources

Define the components of the PICOT format?**

P: Population of interest (population/disease) -->Age, gender, ethnicity, with certain disorder (hepatitis) I: Intervention or issue of interest --> Therapy, exposure to disease, prognostic factor A, risk behavior (smoking) C: Comparison of interest --> What you want to compare the intervention or issue against -->Alternative therapy, placebo, or no intervention/therapy, no disease, prognostic factor B, absence of risk factor (non-smoking) O: Outcome Expected --> Outcome expected from therapy, risk of disease, accuracy of diagnosis, rate of occurrence of adverse outcomes (death T: Time --> The time it takes for the intervention to achieve the outcome, the time over which populations are observed for the outcome to occur, given a certain condition

Mixing methods (paradigm, method, techniques)

Paradigm: A world view or set of beliefs, assumptions, and values that guide all types of research by identifying where the researcher stands on issues related to the nature of reality (ontology), relationship of the researcher to the researched (epistemology), roles of value (axiology), use of language (rhetoric), and process (methodology) Method: The theory of how certain type of research should be carried out (i.e., strategy approach, process/overall design, and logic of design). Researchers often subsume description of techniques under a discussion of method Techniques: Tools or procedures used to generate or analyze data (e.g., interviewing, observation, standardized tests and measures, constant comparison, document analysis, content analysis, statistical analysis). Techniques are method-neutral and may be used, as appropriate, in any research design - either qualitative or quantitative

Data Management and Analysis (qualitative data management, computer-assisted qualitative data analysis, qualitative data analysis)

Qualitative Data Management: The act of designing systems to organize, catalog, code, store, and retrieve data (system design influences, in turn, how the researcher approaches the task of analysis) Computer-Assisted Qualitative Data Analysis: An area of technological innovation that in qualitative research has resulted in uses of word processing and software packages to support data management Qualitative Data Analysis: A variety of techniques that are used to move back and forth between data and ideas throughout the course of research

Sampling Strategies (purposeful, nominated/snowball, volunteer/ convenience, theoretical)

Sampling decisions involve choices about study sites or settings and people who will be able to provide information and insights about the study topic 1. Purposeful/purposive Sampling: Intentional selection of people or events in accordance with the needs of the study 2. Nominated/snowball Sampling: Recruitment of participants with the help of informants already enrolled in the study 3. Volunteer/convenience Sampling: A sample obtained by solicitation or advertising for participants who meet study criteria 4. Theoretical Sampling: In grounded theory, purposeful sampling used in specific ways to build theory

Describe MeSH (Medical Subject Headings):

Set of terms used by the National Library of Medicine (NLM) to describe contents of articles indexed in MEDLINE i. Search: Acquired immunodeficiency syndrome ii. Finds: All articles under the subject HIV, HIV-positive, STI, STD, as well as, acquired immunodeficiency syndrome

qualitative research traditions: ethnography*

Study of a social group's culture through combining participant observation, in-depth interviews, and the collection of artifacts -->Addresses questions about experiences within a culture provides a better understanding of answers to specific research questions regarding: -Health/illness, -caregiver concerns, -response to certain types of settings

What are clinical practice guidelines?

Systematically developed statements to assist clinicians and patients in making decisions about care; ideally, the guidelines consist of a systematic review of the literature, in conjunction with consensus of a group of expert decision makers, including: administrators, policy makers, clinicians, and consumers who consider the evidence and make recommendations

What are clinical practice guidelines?

Systematically developed statements to assist clinicians and patients in making decisions about care; ideally, the guidelines consist of a systematic review of the literature, in conjunction with consensus of a group of expert decision makers, including administrators, policy makers, clinicians, and consumers who consider the evidence and make recommendations

qualitative research traditions: Grounded Theory*

Used to generate theory, which is grounded in empirical data -Addresses questions about how people deal with life situations by describing processes by which they move through experiences over time -May describe the process in terms such as phases of stages (i.e. stages of grief)

qualitative research traditions: Phenomenology*

Used to study the essences intuited or grasped through descriptions of lived experience -Lived Experience: Understandings about life's meanings, which lie outside of a person's conscious awareness -Addresses questions about how people perceive their experiences in a specified situation to achieve better understanding of the phenomenon -Offers perspectives shaped through ongoing intellectual dialogue rather than explicit procedures -Researching, looking at, and describing lived experience

interviews and Focus groups

Ways in which the informants express their own thoughts, remembrances, reflections, and ideas 1. Unstructured, open-ended - Informal conversational occurring in the natural course of participant observation 2. Semistructured interview - More formal using interview guides which outlines in advanced the topics and questions to be covered; use a flexible questioning which allows informants to answer in their own ways 3. Structured, open-ended - Use a question format with little flexibility in the way the questions are asked, but allows informants to respond on their own terms 4. Focus groups are group interviews that generate data on designated topics through discussion and interaction

How do you know if the results of a study is valid? What is validity?

a. Are the results of the study valid? b. Are the results as close to the truth as possible? c. Did the researched conduct the study using the best research methods possible? d. Measured truly what it is meant to measure e. For example, in intervention trials, it would be important to determine whether the subjects were randomly assigned to treatment or control groups and whether they were equal on key characteristics prior to treatment

Define each of the American College of Cardiology (ACC) and the American Hospital Association (AHA) classification of recommendations from Practice Guidelines (p. 190):

a. Class I: Evidence and/or general agreement that an intervention is useful and effective b. Class II: Conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of an intervention c. Class IIa: Weight of evidence/opinion is in favor of intervention d. Class IIb: Usefulness/efficacy is not well established e. Class III: Evidence or general agreement that the intervention is not useful/effective and may be harmful

List four evidenced-based practice guidelines (EBPG)/clinical practice guidelines web sites:

a. National Guideline Clearinghouse b. Canadian Medical Association c. Registered Nurses' Association of Ontario d. United States Preventive Services Task Force

What is a Boolean operator?

a. Placing several concepts from the PICOT question in one search allows a simultaneous search b. 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 c. 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 d. Using "or" will expand a search to include either one or both terms in the results --> You will get more options using "or"

Define qualitative research:

a. Primarily exploratory research b. Used to gain understanding of underlying -Reasons -Opinions -Motivations c. Placed near the bottom of hierarches of evidence with RCTs near the top d. However, arguably provides strongest evidence in addressing human responses and meaning, which is important for patient centered care e. Beneficial in answering questions related to EBP components of patient preferences and values

**List the three domains to grading the strength of a body of evidence: - quality, quantity, consistency?

a. Quality: The extent to which a study's design, conduct, and analysis have minimized selection, measurement, and confounding biases b. 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 ration c. Consistency: Whether investigations with both similar and different study designs report similar findings (requires numerous studies)

What are examples of quantitative study designs? (5)

a. Randomized Control Trials (RCTs): The most appropriate research design to establish cause and effect through the use of controlled methodology b. Systematic Reviews: Produced by a rigorous search strategy, including determination of study inclusion and exclusion criteria, resulting in answering a clinical question c. Case Studies -->Disadvantages: Ranked lower in the hierarchy of quantitative evidence, based on one or few clinical cases, therefore, not reliable as a sole source of evidence, unable to make generalizations to general population -->Advantages: May alert clinicians to new issues and rare and/or adverse events in practice, assists in hypothesis generation d. Case-Control: Sample is categorized into condition (case/intervention) or not (control). Retrospective investigation is performed to ascertain the presence presumed causes -->A case-control study selects individuals with a particular disease and looks back to identify factors that may underlie that disease e. Cohort Studies: A sample exposed to a treatment or condition is followed over time for a presumed outcome. There may or may not be a comparison group -->Taking ADD program and only going to pick a cohort of ADD

What is the AGREE instrument?

a. The U.K. National Health Services Management Executive began the development of an appraisal instrument for the National Health Services in 1922; its completion was subsequently funded by the European Union b. Final development and evaluation was done by an international group of guideline developers and researchers c. Meant for use by a panel of reviewers rather than for individual's use **

What makes the results of a study reliable? What is Reliability?

a. What are the results? b. Consistency c. A study can be reliable but not valid d. Can be it be repeated over and over and the same results would happen? e. For example, in an intervention trial, this includes (a) whether the intervention worked, (b) how large a treatment effect was obtained, (c) whether clinicians could expect similar results if they implemented the intervention in their own clinical setting f. In qualitative studies, this includes evaluating whether the research approach fits the purpose of the study, along with evaluating other aspects of the study

Analysis of Variance (ANOVA)

analyzes mean score differences between 3+ groups

Meta Analysis

combining data from multiple studies

Chi-Square

compares actual number w/ expected number. It is used when data are in categories (high pain vs. low pain) -->Used for testing relationships between categorical variables -->Null Hypothesis is that no relationship exists between the variables -->Example of a bivariate analyses that describes the relationship b/w 2 variables through statistical tests

Bias: Define the following and how bias is prevented: Loss to follow up

i. Attrition could occur due to unforeseen side effects of the intervention or burdensome data collection procedures, leading to non-comparable groups 1. Attrition: Subjects start to leave, don't want to put up with this, lose interest 2. Need to have enough subjects to cover those who leave

Bias: Define the following and how bias is prevented: Selection bias

i. Occurs if participants are selectively assigned to groups ii. Reduced when researchers randomly assign participants to groups -->Researchers are manipulating how they are selecting their participants to make their study look better

Bias: Define the following and how bias is prevented: information Bias (what is a longitudinal study?)

i. Occurs in longitudinal cohort studies if participants know the subject of the study and "act differently" if they know that they are in the group that has been "exposed" to the condition being studied -Longitudinal Study: Over a long period of time, monitoring and watching the subject for a long time (sometimes a lifetime)

Bias: Define the following and how bias is prevented: Recall Bias

i. Occurs when subjects are asked to recall past actions or events ii. Subjects may give answers that are "socially acceptable" or that they "think" is what happened -Occurs among the subjects, they want to answer in the way they know the researcher wants to hear it

Correlation

relationship between 2 variables. if 2 variables are correlated it means that they are associated with each other but NOT that one caused another - can be positive or negative - closer the value is to 1, the more the variables are related

Effect Size

strength of a relationship between 2 variables or an estimate of the impact of an intervention (0.3 is small, 0.8 is large)