quiz 1
quality indicators
"nursing sensitive indicators" reflect elements of pt care that're directly affected by nursing practice how nursing departments are evaluated three types: structural indicators: supply of staff/skill level/education process indicators: methods of pt assessmt y nursing interv/job satisf outcome indicators: pt outcomes that depend on nursing quality or quantity of care (falls)
phenomenological
-Examines human experience •Methods seek to understand how the context of the persons' lives affect the meaning they assign to their experiences •Methods rely on inductively building understanding of the experience across several, a few, or a small number of persons •"LIVED EXPERIENCE" what was it like to live that? oEx: experience of being father of a baby in ICU oHolding changes everything. Felt like they were gonna hurt the baby. Once hold baby they fall in love
5 steps of EBP
1. ask burning clinical QUESTION (PICOT) 2. SEARCH for y collect most relevant y best evidence 3. critically APPRAISE evidence (assess value) 4. integrate all evidence w one's clinical expertise, pt preferences y values in making practice decision or change (3 PRINCIPLES) 5. EVALUATE practice decision or change 6. disseminate- some authors include this
7 steps in research process
1. define research problem 2. review of literature 3. formulate hypothesis/research questions 4. select research design 5. data colelction 6. test hypotheses thru data analysis 7. interpretation; compare results to prev estab theory or findings 8. disseminate findings: write report/manuscript, conference presentation
variable
A characteristic or quality that takes on different values, i.e., that varies from one person to the next Examples: • Blood type • Weight • Length of stay in hospital The term "variable" is used almost exclusively in quantitative research
grounded theory
BASIC SOCIAL PROCESSES •Tradition of inquiry conducted to capture social processes that play out in situations of interest •Goal = incrementally generate a theory that accounts for behavior or decisions •Basic social processes •"Theory generation" •Used in sociology
PDSA cycle is called what in 6 sigma?
DMAIC Define Measure ANalyze Improve Control
EBP vs quality improvement vs research
EBP: uses best clinical evidence in making pt care decisions typically from research//translates knowledge into practice QI: utilizes a system to monitor and evaluate the quality and appropriateness of care/outcomes based on EBP y research research: applies a methodology whether qualitative or quanitative to develop, uncover, create, find, add new nursing knowledge
why reduce variation, correct work flow processes and or improve efficiency?
For quality improvement in pt care y in nursing practice variation leads to: variable quality of care higher cost of care potential for errors that may cause harm
six common quality improvement strategies used in health care agencies
PDSA: plan do study act the deming cycle total quality management lean product system six sigma failure models
foreground questions
PICOT format ask for specific scientific evidence about dianosing, treating, educating pts focus: specific knowledge
5 components of an answerable clinical question
Population Intervention Comparison Outcome expected Time
define EBP
Process by which hcp know how to find, critically appraise, and apply research provides the direction for the way to think about clinical practice and lead practice change
why all the fuss about implementing EBP?
To provide the highest quality pt care by making evidence based clinical decisions Reduces variation- do things by standard best practices approach
differentiate standards of care, protocols, critical pathways and guidelines
a. Standards of care: compare what a prudent nurse would do in court//baseline description of quality b. Guidelines: more fluid, this is best practice but can use your judgment to know it isn't best for your pt//broad based recommendations c. Critical pathways: not used as much anymore, tells you on day 1 w pt w this infection this is what we do, this is what we do day 2//identify key/critical activities that must occur in predictable fashion d. Protocols: this is the way we do- more procedural, not as much decision making//detailed procedures on how to proceed w evaluation y tx
step 8 disseminate findings
aka disperse write report/manuscript conference presentation
step 6 test hypothesis thru data analysis
analysis of data requires a number of closely related operations such as establishment of categories gotta clean the data- make sure its all filled in, randomly check 5th or so if assistant helped
good or bad? are mass media interventions effective in preventing smoking in young people?
answerable closer but still not PICOT what interventions exactly?
good or bad? in women w HIV, do peer based interventions reduce health inequalities?
answerable very specific
good or bad? in men who have sex w men does condom use reduce the risk of HIV transmission?
answerable but not perfect no time
background questions
asks for general info about clinical issue usually 2 components: 1. starting place of question (what, where, why, when how) 2. outcome of interest broader in scope than foreground ex: how does the drug acetaminophen work to affect fever?
good or bad ? which interventions reduce health inequities among people w HIV?
bad too broad- need a specific intervention
good or bad ? are condoms effective in preventing HIV?
bad what pop? used correctly?
list the 3 foundational principals of EBP
best available research evidence clinical expertise patient preference
step 7 interpretation
compare results to prev established theory or findings researcher has to prepare the report of completed work if what learned is not shared thru dissemination, it is not fully completed research
benchmarking
continous process by which an org compares its own processes w those of orgs that're leaders in a particular area a part of total quality management identifies quantitative measures of success
dependent variable
depends on independent variable ex: how memory changes w age- memory changes depend on age often referred to as OUTCOME
categories of research design
description correlational quasi-experimental- sorta eperimental generally missing randomization experimental- random participants, ctrl group, intervention group, intervention systematic review- high level of research meta-analysis- taking everything you can find and bring it together very sophisticated
core measures
evidence based criteria that indicate timeliness and effectiveness of care for specific conditions used to analyze hospitals- readmission is a core measure set of common measures required of accredited hospitals
experimental research vs nonexperimental
experimental: researchers actively introduce an intervention or tx nonexperimental: researchers collect data w/out intervening or introducing tx
importance of formulating an answerable clinical question
focus on key issues identify what evidence is needed to answer your question perform an EFFICIENT search for evidence
meaning questions
how does an experience influence an outcome?
PICOT format
how to develop EBP questions P opulation of interest I ntervention of interest C omparison of interest/ctrl O utcome expected T ime needed for intervention to achieve outcome or time in course of disease/symptom that the intervention is applied • Are __________(Population) who have _________(Intervention) compared to those without _________(Control) at risk for _________(Outcome) over _____(Time)?
operational definition
how you measure a concept ex: depression inventory is a measure of depression
types of foreground questions
intervention prognosis/prediction diagnosis etiology meaning prevention
TQM total quality management
management strategy aimed at embedding awareness of quality in all organizational processes primarily focuses on: review the quality of all factors involved in production striving to prevent mistakes or defects
six sigma
measure how many defects/errors in a process figure out how to systematically eliminate defects/errors finally determine how to get as close as possible to perfection as possible phases: Six Sigma is a set of techniques and tools for process improvement: -statistical process control -design of experiments -failure mode and effects analysis (FMEA) in an overall framework. Improves the quality of process outputs by identifying and removing the causes of defects (errors) and minimizing variability. Structure: Creates an infrastructure of quality people within the organization (black belt)
fade QI model
o FOCUS: Define and verify the process to be improved o ANALYZE: Collect and analyze data to establish baselines, identify root causes and point toward possible solutions o DEVELOP: Based on the data, develop action plans for improvement, including implementation, communication, and measuring/monitoring o EXECUTE: Implement the action plans, on a pilot basis as indicated, and o EVALUATE: Install an ongoing measuring or monitoring (process control) system to ensure success.
prevention questions
o Form: ♣ For ________ (P) does the use of ______ (I) reduce the future risk of ________ (O) compared with _________ (C)? o Example: ♣ In OR nurses doing a five minute scrub (P) what are the differences in the presence and types of microbes (O) found on natural polished nails and nail beds (I) and artificial nails (C) at the time of surgery (T)?
barriers to EBP
o Lack of time to locate and synthesize knowledge o Negative attitudes towards research and EBP--Patients, most important-nurses, doctors o Lack of skill to search the literature and to interpret evidence o Access to the internet and computerized resources--Ask if people have access to the EBP resources o The perception of lack of authority to change practice o Organizational constraints - lack of support o Peer pressure to continue with practices that are steeped in tradition - "we've always done it this way and we are not changing now" o Knowledge... lack of knowledge/awareness .... unfamiliar with guidelines and guideline accessibility o Attitudes .... lack of confidence in the guideline developer, lack of motivation to perform the guideline recommendations o Behaviors .... inability to incorporate patient preferences into the clinical decision making process
lean product system
o Maximize customer value while minimizing waste. The ultimate goal is to provide perfect value to the customer through a perfect value creation process that has zero waste. o Eliminating waste along entire value streams creates processes that need less human effort, less space, less capital, and less time o Provide services at far less costs and with much fewer defects, compared with traditional business systems
ANA 10 critical nursing sensitive indicators for acute care settings
o Patient satisfaction with pain management o Patient satisfaction with nursing care o Patient satisfaction with overall care o Patient satisfaction with medical information provided o Pressure ulcers o Patient falls o Nurse job satisfaction o Rates of nosocomial infections o Total hours of nursing care per patient, per day-->How many pts are on unit, how many nurses are there each shift, also depends on level of acuity of pt o Staffing mix (ratios of RNs, LPNs, and unlicensed staff)
failure models
o Select a high-risk process and assemble a team. o Diagram the process. o Brainstorm potential failure modes o Failure Model Steps ♣Calculate the risk priority number ♣Prioritize failure modes ♣Identify contributing factors of failure modes ♣Redesign process ♣Analyze and test the new process ♣Implement and monitor the redesigned
quantitative
o The process of gathering information for the purpose of initiating, modifying or terminating a particular investment or group of investments.
levels of research relationships
observational: relationship btwn variables ex: person in classroom listen to convos before class to study anxiety correlation/association: functionall relationship ex: black boy bbs more likely to die in ICU causal: cause and effect ex: cigarette causes lung cancer A causes B
step 2: review of literature
once problem is defined, a brief summary of it should be reviewed and synthesized--take the data and make it short
if you decide to measure depression using the BDI (beck's depression inventory), then the scale is a
operational definition
primary data can be collected through:
order is most prone to error to least prone observation interview focus groups random dialing telephone interview mailing of questionnaires biological or physiological data
purpose statement
part of step #1 define a problem o An interrogative sentence which summarizes the specific topic and goals of a document. o Summarizes the specific topic and goals of a research report. o Usually in the introduction - at the end "the purpose of this study is to..." o Gives the reader an accurate, concrete understanding what the report will cover. o Ex: The purpose of this study is to test Kern's theory (2004) by relating leadership style to autonomy for hourly employees at a major retail center in central Florida.
research question
part of step #1 define research problem oAn answerable inquiry into a specific concern or issue. oResearch questions are the core of the research project. ♣Everything else depends on it oAn interrogative statement oSamples ♣Is taking estrogen associated with a lower risk of osteoporosis in women 60+? • Independent: estrogen//dependent: osteoporosis ♣ Does a plant-based diet reduce serum cholesterol levels in patients with cardiovascular disease? • Indep: plant based diet//dep: cholesterol levels//population: pts w cardiovascular disease ♣ Can a structured intensive diabetes education program help patients with type 2 diabetes control their blood glucose levels? • Intervention based: education program
PDSA
plan do study act deming cycle is a model of a logical sequence of four repetitive steps for continuous quality improvement and learning PLAN: plan ahead for change. analyze y predict resuls DO: execute the plan, take small steps in controlled circumstances STUDY: check, study the results ACT: take action to stdize or improve process
problem statement vs research question vs hypothesis
problem statement: expression of a dilemma or disturbing situation that needs investigating purpose statement: interrogative sentence summarizes specific topics y goals of document research question: answerable inquiry into specific concern or issue hypothesis: guide researcher by delimiting area of research and keep on right track. best guess of what outcome will be based on lit
step 3: formulate hypotheses/research questions
proposed explanation made on basis of evidence available at starting point of study role: guide the researcher by delimiting the area of research and keep him on right track
identify at least 2 data sources that lead us to change or improve practice
quality indicators benchmarks: compare your hospital to another one core measures patient safety indicators- falls, med errors, surgical complications
systems of data to monitor outcomes and care quality
quality indicators patient safety indicators benchmarks core indicators
what is different between qualitative and quantitative research methods?
quantitative: measure quantities and does analysis based on data anything you can measure qualitative: searches for meaning rigorous style- get the meaning of things from people data collection is prolonged until saturation one person at a time- when you hear same data over and over again you know its saturated and you've gathered enough
step 4: select the research design
question drives what design you do it is the recipe to conduct the study function: provide for relevant evidence w minimal expenditure of effort, time, money
overall goal of EBP
reduce variability in practice to improve quality variability is the problem
patient safety indicators
set of measures that screen for adverse events that pts experience as result of exposure to health care system likely amenable to prevention by changes at the system or provider level
qualitative research terms
study participant informant phenomena sonstructs, concepts data (narratives) patterns of associations
quantitative research terms
subject participant respondent concepts, constructs variables data (numeric values) relationships
population
the entire X that you're studying ex: adolescents- all adolescents
why conduct a root cause analysis?
to figure the cause out!
etiology questions
to what extent is a factor ASSOCIATED w an outcome? o Form: ♣ Are __________(P) who have _________(I) compared to those without _________(C) at risk for _________(O) over _____(T)? o Example: ♣ Are kids (P) who have obese adoptive parents (I) at Increased risk for obesity (O) compared with kids (P) without obese adoptive parents (C) during the ages of five and 18 (T)? ♣ Is obesity genetic or envioronment/learned
step 5 data collection
use population y sample operational definition: how you measure concept
variation in nursing practice leads to
variable quality of care higher cost of care potential for errors that may cause harm
prognosis/prediction questions
what indicators are most PREDICTIVE of an outcome? o Form: ♣ In __________(P), how does _________(I) compared to _________(C) influence/predict _________(O) over _____(T)? o Example: ♣ Does telemonitoring blood pressure (I) in urban African Americans with hypertension (P) improve blood pressure control (O) within the six months of initiation of the medication (T)?
intervention questions
what intervention most effectively LEADS to an outcome? ♣ In __________(P), how does _________(I) compared to _________(C) affect _________(O) within _____(T)? o Example: ♣ In adult patients with total hip replacements (Patient population) how effective is PCA pain medication (Intervention of interest) compared to prn IM pain medication (Comparison intervention) in controlling post operative pain (Outcome) during the perioperative and recovery time?
diagnosis questions
what test most accurately diagnoses an outcome? o Form: ♣ In __________(P), is_________(I) compared to _________(C) more accurate in diagnosing _________(O)? o Example: ♣ Is a PKU test (I) done on two week old infants (P) more accurate in diagnosis inborn errors in metabolism (O) compared with PKU tests done at 24 hours of age (C)? Time is implied in two weeks and 24 hours old. ♣ PKU: blood test newborns get
sample
what you select from population to measure the population want it to measure entire pop
independent variable
you control this ex: how memory changes w age- independent is age
ethnography
• Examines CULTURES Y SUBCULTURES to understand how they work and the meaning of members' behaviors • "Insider perspective" people have to accept you • Ex: white woman lived in another culture for 2 years in southern black culture
qualitative description
• Goal = produce a STRAIGHT FORWARD DESCRIPTION OF PARTICIPANT'S EXPERIENCES in words similar to what the participants said (as possible) • Sampling for diversity, interviews/focus groups, content analysis, theme/pattern identification • Ex: ebola nurses describing their experience caring for those patients
systematic review vs literature review
• Systematic review reviews several studies. It is a research process/method. Step by step exhausted review. Like past 10 years everything you can find. Very rigorous • Literature review just me writing a review of something, my opinion and what I get from reading the literature
systematic review
• Systematic review: a research process. Step by step process you have to follow so you can find the data and exclude things rationally. Good way to see- what is the evidence? They usually say systematic review. They say step by step what they included and excluded. A Review- me interpreting the literature me doing my own thing. o ex: lots of studies show yoga helps with blood pressure • Systematic review reviews several studires. It is a research process/method. Step by step exhausted review. Like past 10 years everything you can find. Very rigorous
value of qualitative research in EBP
•6 main ways oGeneration of hypotheses oDevelopment and validation of instruments oHave to be strong reliable questions oProvision of context for evaluation oDevelopment of nursing interventions oDevelopment of new research questions oApplication of Qualitative Outcome Analysis
what can qualitative accomplish that quantitative cannot?
•Different kind of info- how the patient feels, what they think. Not as much about the numbers and stone hard facts •There's a theme •Different depth
historical analysis
•Examines past events and trends •Utilizes records, documents, articles, and personal diaries •"Historical context" •Ex: historical analysis of school of nursing in the 70's interviewed those students
making sense of qualitative data
•Make notes: noteworthy events, feelings, emotion, recurring experiences, reasoning oConcrete CODES, not abstract words I hate that nurse. •Look for groups of codes that represent slightly more abstract interpretations, o - Angry responses to limits •Develop themes -overarching o - Angry responses to limits, lashes out when re-directed, turns to cigs or food
rigor in qualitative
•Openness o Better off not lookig at research..go do the research then come back and look at it. This helps you be unbiased. Do you really listen to what they're saying and probing further. Hear what they're saying •Depth •Consider all the data •Probe areas of vagueness or incompleteness •Findings are rooted in the data •Findings are vivid and useful o Ex: study in another culture in florida she was able to figure out it was there •Provide a fresh or new perspective •Provide a decision trail o In write up, explain why you included and excluded some data, what changed your mind
discourse analysis
•Used to analyze the dynamics and structure of CONVERSATIONS •Example: patient-provider dialogue •What cues were missed between the two...once dr walks out..."what did they say" •"Communication"
problem statement
•an expression of a dilemma or disturbing situation that needs investigating. part of step #1: define a research problem o It should be a clear, precise, and concise statement stating the variables, population, and research setting under study. o Getting into the topic and seeing what the problem is o Bring down the data to one question: this is what my problem is o Ex: patients in a surgical unit having post operative back pain from being on the table for so long- does length of the operation relate to reported back pain? o Ex: Given the importance of understanding the pain levels associated with pressure ulcers, the purpose of this study was to examine the relationship between pressure ulcer stage and bodily pain intensity in nursing home residents after adjusting for other variables that may be associated with bodily pain intensity, using the national MDS 3.0 assessment data.
conceptual definition
♣the abstract or theoretical meaning of a concept being studied •Ex: define what depression is, we think we understand it the same way, but a researcher has to provide a definition of it
