Utilizing an Evidence-based Practice Model at the Bedside

Debra Palmer RN, MS

Co-owner, Zebra Consulting, LLC

www.zebraconsult.com

Objectives

Identify the distinct differences between QI, Research and Evidence-based Practice

Identify the steps in the EBP process

Definitions

Quality Improvement: “Systematic data guided activities designed to bring about immediate positive changes in the delivery of health care in a particular setting.”

Hastings Center Report, 2006

Goal: to find interventions that work well, implement them more broadly, and thereby improve clinical practice.

Definitions

Research: “A systematic investigation, including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge”

(Office of Human Research Protection).

Generalizability

Generalizable: Results or findings from a study that can be applied to populations or situations beyond those being immediately studied.

◦ High attention to internal validity

To ensure generalizability, the sample procedure and the data need to meet certain methodological standards.

Definitions

THE BIG UMBRELLA

EBP is the integration of the best evidence available, nursing expertise, and the values and preferences of the individuals, families and communities who are served.

(Sigma theta Tau International, 2004, p.69)

Examples of QI

Nursing Sensitive indicators (falls, pressure ulcers) Performance Measures (LOS, pt. satisfaction) Compliance checks (code cart checks)

Example of Nursing Research

Testing of an innovation that may impact nursing practice in general (comparing heparin flushes to normal saline flushes of IV locks).

Examples of EBP

Use of evidence-based standards from professional organizations

Use of research to guide protocols

Institute for Healthcare Improvement (IHI) bundles Specifics:

Prevention of VAP Falls prevention Pressure ulcer prevention Restraint free environments

What is Not Evidence Based Practice?

Rituals, Customs Traditions Ungrounded Opinions Trial and Error Isolated Clinical Experience

Quality Improvement –Ingredients Works to:

Make the system better More cost-effective Increase productivity Create continual gains

(improvement) in a identified process –ex. Falls, pressure ulcers

Knowledge specific to that organization

Limited audience

Results intended for individuals internal to the organization (reason why do not usually need to go through IRB )

Research – Ingredients

Generates new scientific knowledge Formal proposal Human subjects IRB review

Benefits and risks Protect human subjects

Research process adheres to strict scientific standards

Topic Research Quality Improvement

Purpose To generate new, scientific knowledgeTo improve internal processes, practices,Decrease costs or increase productivity

GoalTo test a hypothesis or describe aphenomenon

To implement EBP and/or measure anexisting practice

Patient Expectations Not expected to be a part of routine care Part of routine hospital practice

Consent Most of the time, occasionally waived Never needed

Beneficiary Most likely, future patients Participating and future patients

InterventionGeneral benefit to organization andsociety Benefits individuals

*Risks Most likely some risk No risk beyond usual care

Sample sizeMost of the time done by a formal poweranalysis Convenience sample, usually small is size

Voluntary participation Always Rarely

Data analysis Inferential statisticsDescriptive statistics or graphs that showtrends

Project timelineTakes a considerable amount of time tocomplete May be done quickly through rapid cycles

Funding and otherresources needed Usually Not usually

Dissemination Publish or presentUsually communicated within hospital ordepartment only

Change in practicePractice changes occur slowly aftermultiple studies validate the results

Practice changes may be madeimmediately

ResourcesOften rely on external resources toconduct Internal resources only

A Comparison of Research to QI

Department of Health and Human Services (DHHS), Office of Human Research Protection (OHRP) has issued guidance stating that researchers should not be allowed to decide on their own that their projects are exempt.

If You have Questions…

It is often very foggy when deciding if a project is QI or research.

It is imperative that the patients are protected

If you are not sure, check with an expert Researcher IRB

If still unsure, always err on the side of research

Why is EBP Important?

Studies in the US and Netherlands suggest that 30-40% of patients do not receive care complying with current research evidence

20-25% of the care in not needed and may be potentially harmful!

Grol, R. (2001).

Challenges

New nurses more concerned with clinical and organizational skills than applying EBP

Seasoned nurses did not learn this is their program Use of evidence in nursing is sporadic and inconsistent Challenges to implementing EBP include

Conflicting research results Research reports that are difficult to understand Isolation of colleagues knowledgeable about research Relevant studies not being compiled in one place

Challenges (cont)

Strong pull of traditional culture, habits and practices that may block creative thinking

Lack of knowledge about the research synthesis process

Negative viewpoints about research

The explosion of knowledge in the literature

Organizational system limitations

Excessive workloads leaving little or no time to investigate better practices

Research Models

Academic Model

Publications Presentations Funding Tenure PhD required

Clinical Model

Improves patient care Decreases costs Increases

interdisciplinary collaboration

Advances the nursing profession

Decreases variations in practice

PhD not required

ANA Position Statement on Nursing Research Associate Degree - Identify problems at the clinical level, participate in

data collection and put research findings to use in day-to-day practice.

Baccalaureate Degree - Look at research with a critical eye and use current standards to decide if the research findings are ready to put into clinical practice?. Identifies clinical issues and utilizes research findings in daily practice. Able to assist more experienced researchers with obtaining clinical site access and assessing appropriate methods of data collection.

Master’s Degree - Takes on the role of clinical expert from proposals to data collection through data analysis and the interpretation of the findings. they make sure the practice environment supports “scholarly inquiry, scientific integrity and scientific investigation of clinical nursing problems”, and lead the way in the integration of the research results in clinical practice.

Doctoral Level - Conduct research focused on theory generation/testing. “conceptual models” of nursing, and methodologies. Design independent studies, but they also collaborate with other disciplines. The doctoral nurse will make sure the research results are disseminated, through journals, books, reports, and presenting at scientific conferences.

Importance of Research

Pt. Benefits

Clinician Benefits

Organization Benefits

Profession Benefits

EBP Step #1 Start with Reflective Practice

In your day to day practice, have you ever wondered why you are doing a procedure

a certain way?

Wondered why some pts. recovery more quickly than others from the same procedure?

Thought maybe a particular practice was a waste of your time?

What is Reflective Practice?

Reflection is a process of paying attention to and learning through everyday experiences

Reflection draws on any combination of formally taught knowledge, reading, tacit knowledge, experience, critical incidents, and emotions to create new knowledge which enhances the capacity to visualize new realities and outcomes.

EBP Step #2 What is the Question?

Form a clinically relevant and “searchable” questionby identifying the practice problem

Common process for this is PICOPatientInterventionComparisonOutcome

Elements of the clinical question Patient: Describe as accurately as possible the patient or group of patients

of interest

Intervention (or cause, prognosis): What is the main intervention or therapy you wish to consider?Including an exposure to disease, a diagnostic test, a prognostic factor, a treatment, a patient perception, a risk factor, etc.

Comparison (optional): Is there an alternative treatment to compare?Including no disease, placebo, a different prognotic factor, absence of risk factor, etc.

Outcome: What is the clinical outcome, including a time horizon if relevant?

Example: Among family-members of patients undergoing diagnostic procedures, does standard care, listening to tranquil music, or audio-taped comedy routines make a difference in the reduction of reported anxiety.

EBP Step #3 Search for the Evidence

Systematic search for the most relevant scientific evidence

Cochrane Library (www.cochrane.org)

National Guideline Clearinghouse (www.guideline.gov)

Johanna Briggs Institute (johannabriggs.edu)

Agency for Healthcare Research and Quality (ahrq.gov)

CINAHL, PubMed, Ovid, ERIC and others

EBP Step #4 Critical Appraisal of the Evidence

What is critical appraisal?

Critical appraisal is a systematic method of appraising the strengths and limitations of a piece of research in order to determine its credibility and applicability to practice.

Critical Appraisal (continued)

Are the methods valid?

Are the results of the study likely to be true?

Are the results likely to be free of systematic bias?

Will the results help me in caring for my patients?

Critically reading an article is a way in which to evaluate the material to see if there is value in the research findings to your practice.

Types of Evidence

Internal External

Retrospective chart data

Quality improvement data

Risk management

Patient satisfaction

Nurse satisfaction

Review of the literature

Current research

National clinical guidelines

Integration of findings

Identify level of evidence

Why examine the evidence?

2,000,000 health related manuscripts published yearly

20,000 health care journals

Growing number of electronic databases

Publication bias

Poor quality studies

Sample size is often inadequate

New information can change the way we see a Problem

I had a problem with a bowl of jelly beans. After a few weeks, they’d begin to stick together, and the colors would fade. Before friends arrived, I would have to stir the bowl because nobody would eat them if they stuck together. I suspected that sunlight was the problem. I knew what heat would do to chocolate, and I just assumed that jelly beans would be subject to melting as well. One day when I was home alone, I hear the sound of someone stirring the jelly beans. I knew the sound because I had stirred them myself many times. A glance around the corner cause me to revise my interpretation of causation. My dog, Lindy, a 3 yr. old cockapoo, was licking the jelly beans in the bowl. I immediately decided that I needed a cover for the bowl and then smiled as I thought of all my friends who had been eating jelly beans. Interesting how only a little additional information can drastically change the interpretation!

EBP Step #4 Implement

Conduct research: Send to IRB, yes/no?Educate staffImplement on pilot unitMonitor outcomesEvaluateImplement housewide change to new practice, discard old practiceIntegrate the evidence with expert opinions and patient preferences

EBP Step # 6 Disseminate

Research is of little value unless the findings are used in practice to improve care

Disseminate successes and failures with our colleagues both in presentation and in print

Disseminate your work to other practitioners, researchers and the general public

A Word of Caution

Need to be careful of premature implementation of new practices before sufficient evidence of effectiveness has been seen

No single research study can provide sufficient valid research evidence

Myths and Fears of Research

It’s not my job (Oh yes it is!) I have to have an advanced degree (No you don’t) I have to do statistics (No you don’t) I don’t have the skills (You can learn them) I don’t have anyone to help me (Find someone) I don’t understand research lingo (Learn it) I’m not a good writer (Get help from someone who is) I don’t have time (Make it) I don’t have the money to do the study (Seek funding) I don’t have the support from my manager (Keep after them!)

Hints for successful research project

Start small

Keep it simple

Begin in an area which you are familiar with

Review what is currently in the literature

Involve other interested staff members, stakeholders

Replicate a current study for a great beginning

Have fun with it, your passion for research will grow

What interests you?

What is your practice setting?

What interests you within your practice setting? What are you passionate about?

What have you wondered about as a practice discrepancy in your practice setting?

Getting Started. . .

Think critically about practice problems that you encounter

Discuss your concerns with colleagues

Search the literature for the state of the science

Recruit a researcher to help you

In this way, you will use and build knowledge to improve the lives of your patients and enhance your profession.

Evidence – Based Practice Models

PARIHS IOWA ACE ARCC Stetler CURN Others

Iowa Model

ACE Star Model

Stetler Model

Ottawa Model

MICROSYSTEM

MESOSYSTEMMACROSYSTEM

The Multi-system Model of Knowledge Integration and Translation (MKIT)

Transformational Leader

KnowledgeSeeker

Knowledge

Implement

Monitor

Disseminate

Practice

OF

Do we really need a model???

Yes, Yes Guide to move from concept to action

Theory – abstract Model – helps with making day to day implementation

of practice understandable Sustainability

ReferencesBaily, M. et al. (2006). The Ethics of Using QI Methods to Improve

Health Care Quality and Safety. Hastings Center Report, July-August

Dawes et. al. (2005). Sicily statement of evidence-based practice.BMC Medical Education, 5 (1).

Grol, R. (2001). Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care, 39(8), II46-II54.

IOM (Institute of Medicine). (2003). Health Professions Education: A Bridge to Quality. National Academic Press: Washington D.C.

Clinical Scholarship Task force. (1999). Sigma Theta Tau International Clinical Scholarship White Paper. Retrieved from www.nursingsociety.org/new/CSwhite-paper.pdf.