Evidence-Based Practice and Quality Improvement Processes

Level IV

Evidence from well-designed case-control and cohort studies the 3 cs

C

so what are you going to compare it to (was it before something was implemented, maybe use one floor that gets the bundle and one that does not)

O

so what do you want to achieve (decrease in falls)

Statistical hypothesis

•Also known as null hypothesis •States there is NO relationship between X (independent) and Y (dependent) variables

Evidence-Based Practice

•collection, interpretation, and integration of valid research evidence (Collection of facts that we believe to be true) •combined with clinical expertise •understanding of patient and family values and preferences to inform clinical decision making.

what we should be as nurses

"Knowledgeable consumers" of research •Appraise research evidence •Use existing standards to determine the merit and readiness of research for use in clinical practice

Good Hypothesis

A declarative statement that identifies a predicted relationship between X and Y

What is the clinical problem

Clearly states the population, problem, and setting 2-3 sentences Often 'introduces' and/or summarizes what will be your background and significance

brainstorming

Colleagues, research team, start developing research question

Research Critique

Critical appraisal Objectively and critically evaluates a research report's content for scientific merit and application to practice. Reader will need: •General knowledge of the subject matter •Knowledge of how to critically read •Use critiquing criteria

Level I

Evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs), or evidence-based clinical practice guidelines based on systematic reviews of RCTs or more RCTs of good quality that have similar results Takes randomized control trials cause it is the golden standard - it is the best research you can do - systematic review takes multiple of those trials and puts them together and synthesizes their findings and puts out new findings - uses best studies

Level II

Evidence obtained from at least one well-designed RCT Randomized control study

Level III

Evidence obtained from well-designed controlled trials without randomization Still high level study but the groups aren't randomized

summary vs synthesis

Have to summarize before you can synthesize - summary just describes the literature but synthesis makes it descriptive and combines them

Identify Variables

Independent, dependent

evidence from a systematic review or meta-analysis of all relevant RCTs (randomized controlled trial) or evidence based clinical practive guidelines based on systematic reviews RCTs or three or more RCTs of good quality that have similar results

Level i

Clinical questions have four components

PICO(T)

Critical Reading

Preliminary - •Familiarize yourself with the content (skim the article) Comprehensive - •Understand the author's purpose or intent Analysis - •Understand the parts of the study Synthesis - •Understand the whole article and each step of the research process

Formulate Question

Specific Question

Systematic Review

Summation and assessment of multiple research studies set out to test a research question

research

Systematic, rigorous, critical investigation to generate NEW knowledge Aims to answer questions about nursing phenomena

Consistency

The degree to which other studies, investigating the same research question report similar findings If you have 15 studies all saying the same thing but one study says something else then you'll probably go with the 15 studies that say same thing

independent variable

The experimental factor that is manipulated; the variable whose effect is being studied.

Quality

The extent to which a study's design, implementation, and analysis minimizes bias How well was the study conducted

Quantity

The number of studies that have evaluated the research question How many studies have been down to prove this

dependent variable

The outcome factor; the variable that may change in response to manipulations of the independent variable.

what levels are qualitative

V, VI, VII

literature review

What has been done, where are the gaps

Associative relationship

X and Y are systematically related

Causal relationship

X causes a change in Y

Critical reading

actively, intellectually engaging where you as a reader participates in an inner dialogue Actively engage in what you are doing with the research article or study

Evidence-Based Practice Process Steps

ask > gather > assess appraise . act > evaluate

Evidence-based QI is focused on

both internal and external evidence in decision making about a practice change to be implemented to improve an important clinical outcome

idea

clinical practice, theory

Theory base hypothesis

consistent with existing theory and research findings

goal of quality improvement

continuously improve the quality and safety of health care systems

Quality Improvement

done in the clinical setting •Systematic use of data to monitor the outcomes of care processes •Use of improvement methods to design and test changes in practice

Critical appraisal

evaluating strengths and weaknesses of an article for scientific merit and application

Level VI

evidence from a single descriptive or qualitative study Evidence from a single qualitative study

Level V

evidence from systematic reviews of descriptive and qualitative studies (meta-synthesis) Evidence from qualitative studies

Level VII

evidence from the opinion of authorities and or reports of expert committees clinical guidelines

Critical thinking

examining ideas, assumptions, principles, arguments, conclusions, beliefs and actions

order of research

idea brainstorming literature review identify variables formulate question

The Level of Evidence and the quality of the body of evidence will determine

if a practice change should occur

Empirical testing is

implied can you measure it

EBP

improves healthcare quality and safety, patient outcomes and healthcare costs as well as empowers clinicians is a problem-solving approach to the delivery of healthcare that integrates the best evidence from research with the clinicians expertise and patient/family values and preferences

Standard QI relies primarily on

internal evidence and does not involve the systematic process and critical appraisal

Without EBP

it often takes years (and sometimes decades) to translate research findings into "real-world" clinical settings

Our studies we use need to be a

level IV or higher (not qualitative cause it doesn't relate to the whole population as well)

evidence obtained from at least one well-designed RCT

level ii

evidence obtained from well-designed controlled trials without randomization

level iii

evidence from well-designed case-control, cohort or cross-sectional studies

level iv

evidence from systematic reviews of descriptive and qualitative studies (meta-synthesis)

level v

evidence from a single descriptive or qualitative study

level vi

evidence from the opinion of authorities and/or reports of expert committees

level vii

is all quality improvement is evidence based

no, but it should be all QI should be evidence based

The variables are more commonly related in

noncausal ways They are systematically related but in an associative way

Research Questions are Influenced by

practical experience critical appraisal of the literature identifying gaps in the literature interest in a theory

research that seeks to understand

qualitative

subjective research

qualitative

Specific population, unit, or facility

quality improvement

data driven

quality improvement look at something and say that needs to change cause a lot of patients are getting hurt or they are having bad outcomes

length of quality improvement and research

quality improvement - rapid research - slow and long

objective research

quantitative

research that tests relationships

quantitative

2 main types of research

quantitative and qualitative

Research nurses study

questions relevant to nursing practice

follow the steps of the scientific process

research

I

so what we are going to do (treatment, therapy, think independent variable)

P

so who are you going to focus on (age, disease, setting)

Population is

specified setting may also be specified

Correlation coefficient

strength of the relationship (the higher the stronger the relationship can be positive or negative

levels don't always tell us

the quality of the study

T

time stamp (not asked to do for our project but it's a good thing to think about

testable hypothesis

variables can be observed or measured

Research Articles: Format and Style

•Abstract •Introduction •Definition of purpose •Literature review and theoretical framework •Hypothesis/research question •Research design •Sampling •Reliability and validity •Procedures and data-collection measures •Data analysis results •Discussion •Recommendations and implications •References •Dissemination/Communicating results

Research hypothesis

•Also known as scientific hypothesis •Predicts the expected outcome •May be directional or nondirectional

Research Question is fully developed when...

•Clearly identifies the relationship between the independent and dependent variables •Population is clear •Clarity of the empirical testing

Quality Improvement process

•Conducting an assessment •Setting specific goals for improvement •Identifying ideas for changing current practice •Deciding how improvements in care will be measured •Rapidly testing practice changes •Measuring improvements in care •Adopting the practice change as a new standard of care

Clinical Guidelines

•Consensus (expert developed) and evidence-based guidelines •Developed by expert panels using research findings (Don't use as primary research cause they've already done all the work - can use in significance section) •Assist in bridging practice and research •Provide clinicians with an algorithm for clinical management, or decision making, for specific diseases (e.g., colon cancer) or treatments (e.g., pain management)

Research Questions

•Define a specific topic area •Reflect the literature review •Identify the significance to nursing •Reflect the feasibility of studying this topic

Research questions focus on

•Describing variables •Specifying the population being studied •Examining testable relationships among variables

Research Hypothesis

•Flows from the research question, literature review, and theoretical framework •Predicts the expected outcome •Formulated before the study is started because it determines how data are collected, analyzed, and interpreted Flows from question, lit review and theory - often predicts the outcome

PICO(T)

•Population •Intervention •Comparison •Outcome •Time

Integrative Review

•Review and synthesis •Without Statistical techniques

Quantitative

•Seeks to test relationships or answer a question (is it true or false) •Explains cause-and-effect relationships (breast fed vs formula fed babies) •Uses specific statistical methods (looking at data and numbers) •Objectivity is important •Theory testing

Qualitative

•Seeks to understand the meaning of human experience •Usually conducted in natural settings •Describe EXPERIENCES and interpret meaning •Subjective approach •Theory generating

Meta-Analysis

•Synthesis •Statistical techniques Take all subjects from different studies and put together

Meta-Synthesis

•Synthesis of Qualitative Research •Using methodology No numbers

Study Purpose, Aims, or Objectives

•What the investigator hopes to achieve •Suggests the level of evidence to be obtained •Use verbs like discover, explore, or describe OR test or compare •While this can be changed throughout the planning of a study it is the defining feature of the study itself

purpose

•What the investigator hopes to achieve •Suggests the level of evidence to be obtained •What are the verbs used? •While this can be changed throughout the planning of a study it is the defining feature of the study itself