Chapter 25Using Theory in Evidence-Based

Advanced Nursing Practice

Introduction

• In advanced practice nursing, theory and evidence are equivalent.

• Translational research helps transform research findings into practical actions.

• These concepts are especially relevant to Essential I, Essential III, and Essential VIII of the DNP essentials.

Theory and Evidence

• A theory-practice gap exists because theories are typically thought of as formulations that are not relevant to practice.

• In actuality, theory- and evidence-based practice are one and the same.

• Evidence-based nursing is actually the deliberate and critical use of theories.

• Not all practical actions are based on theory, however.

Translational Research

• Translational research is the process used to determine which conditions, costs, and resources are required to progress theory into evidence-based practice.

• Ultimate goal is decreasing time required for theories to be translated into tools and protocols that improve quality of life.

• Interest in translating theory to action has increased recently.

• Five types of theories as fundamental patterns of knowing:– Empirical theories– Aesthetic theories– Ethical theories– Personal knowing theories– Sociopolitical theory

• They are integrated.

Translational Research

Types of Theories, Research, and Practice Tools

• Descriptive theories can be translated into patient assessment tools.

• Explanatory theories tested can be translated into comprehensive assessment tools.

• Most researchers recognize that predictive theories can be translated into intervention protocols, but often fail to see the practical value of descriptive and explanatory theories.

Translating Theories into Practical Actions

• Translating theories into evidence-based tools and protocols follows a seven-step sequence:– Identifying a practice problem– Asking questions about the problem– Searching for literature about the problem– Critically evaluating the literature– Integrating the literature with elements of evidence-

based tools– Evaluating the action of the theory in practice– Disseminating evaluation results

First Step

• Identifying a practice problem requires awareness of the problem and the possibility of a new way of assessing it or intervening to help people overcome it.

• Awareness may be catalyzed by a number of things—patient experiences, journal articles, workshop presentations, or position statements.

Second Step

• Asking questions is best done through the PICOT format, which considers five things:– Patient population– Intervention or area of interest– Group comparisons– Desired outcome– Time

Third Step• Searching published literature is done through

scoping review in order to determine the amount of literature available on the subject.

• Review focuses on the theory component of the C-T-E structure.

• Search terms can be drawn from the conceptual model, PICOT format, type of article being searched, practice guidelines, review summaries, and best practices.

Fourth Step• Critically evaluating the literature requires a realist review

that synthesizes research with an explanatory focus.• Realist review unpacks how certain tools work in particular

contexts, and involves appraisal and integration of theory-generating and theory-testing research.

• A worksheet may be used to record the research retrieved and its quality.

• FAME (Feasibility, Appropriateness, Meaningfulness, Effectiveness, and Economic) is used to rate the overall level of evidence of an integrated review

Fifth Step (1 of 3)

• Integrating the literature with patient needs, situational contexts, clinical judgments, and patient preferences requires practical action guided by the criterion of pragmatic adequacy.

• Pragmatic adequacy is the extent to which a theory serves as evidence for practical actions.

Fifth Step (2 of 3)

• Pragmatically adequate theories address four things:– Social meaningfulness: The extent to which

translation of the theory into a tool yields desired outcomes consistent with patient needs

– Compatibility: The extent to which the context of the research situation in which the tool was developed is compatible with a particular practice specialty, health condition, or patient group

Fifth Step (3 of 3)

– Feasibility: The complexity of implementing the new tool into practice

– Consistency: The extent to which the new tool is consistent with patient preferences for and expectations of treatment

Sixth Step

• Evaluating the theory after implementation is often done through research projects or quality assurance programs.

• Both methods are useful for determining whether application of the theory yields the innovative results expected.

Seventh Step

• Disseminating results of evaluations requires public presentation of findings about the innovative action of an applied theory.

• Also includes publication of findings in appropriate journals.

• These are the final components needed to translate a theory into practical actions of evidence-based practice.

Conclusion

• All nurses should be skilled in reviewing and evaluating current findings to determine in they are applicable to their practice setting.

• Evaluation is important for determining whether or not a theory is pragmatically adequate.

• Advanced practice nurses should be leaders in evaluating, translating, and helping others utilize theories.