1. Translating research into practiceWendy McDonald RN MPH&TM

2. Meaning of Evidence ?Evidence in best practice includes: Research evidence Clinical knowledge - experience of the individualpractitioner Patient and practitioner preference Basic principles from theory and logic 3. Process Defined question Identify pertinent evidence Exhaustive search strategy Critically appraise & synthesize Reported in standard format Implement evidence into practice considering patient preferences & values 4. Where do you find the evidence? 5. Finding the information Electronic databases Journal Articles (electronic and paper) Internet Patient information Healthcare records Practice based data Textbooks 6. Examples of Where to FindEvidence Electronic Search Engines Web sources for EBP guidelines Professional Organizations LiteratureDetermine what the search will be from what the question focuses on. 7. Different types of Research Methods Randomised Controlled Systematic Meta-AnalysisTrialReview Cohort StudyQuantitative Case Control Study Descriptive StudiesQualitative 8. Quantitative Research In quantitative studies, researchers use objective,quantifiable data (such as blood pressure or pulserate) or use a survey instrument to measure knowledge, attitude. Quantitative research involves analysis of numerical data. 9. Types of Quantitative Research Randomized Controlled Trials Cohort study Descriptive study Case control study 10. Randomized Controlled Trials RCTs The randomized controlled trial is one of the simplest yetpowerful tools of research. RCTs are quantitative, comparative, controlledexperiments in which investigators study two or moreinterventions in a series of individuals who receive themin random order. 11. Randomized Controlled Trials cont. RCT - A study in which people are allocated at random (bychance alone) to receive one of several clinicalinterventions. One of these interventions is the standard of comparisonor control. The control may be a standard practice, a placebo, or nointervention at all. RCT seek to measure and compare the outcomes afterthe participants receive the interventions. 12. Cohort Study A cohort study is a research program investigating a particular group with acertain trait, and observes over a period of time. Observed for the occurrence of certain health effects over some period oftime, commonly years rather than weeks or months. The occurrence rates of the disease of interest are measured and relatedto estimated exposure levels. Cohort studies can either be performed prospectively or retrospectivelyfrom historical records. 13. Case-control Study Investigates why certain people develop a specific illness, have an adverse reaction to a particular treatment or behave in a particular way. 14. Case-Control Study Research that retrospectively compares individuals whohave a specific condition or disease ("cases") with a groupof individuals without the condition or disease("controls"). An application of medical history-taking that aims toidentify the cause of disease among a group of people, orthe cause-effect relationships of a condition of interest. 15. Design of a Case-Control Study NotNot ExposedExposedExposed Exposed Disease No DiseaseCASES CONTROLS 16. Case control study Often conducted to identify variables that might predict a condition or disease. Case-control studies have proved particularly useful in studying very rare conditions. 17. Descriptive StudyExamine differences in disease rates amongpopulations in relation to : age gender race and differences in temporal or environmental conditions. 18. Descriptive Study Continued These studies are often very useful for generating hypothesesfor further research. Useful in health service evaluation Can yield valuable information about a populations healthstatus, and they can be used to measure risks. Used periodically to determine whether a particular service isimproving, if serial description studies all show evidence ofreduced sickness or disability rates over a period of years. 19. Descriptive Study Continued can only identify patterns or trends in disease occurrence overtime or in different geographical locations. cannot ascertain the causal agent or degree of exposure. Examples include the U.S. National Health Care Survey, andperiodic reports from cancer registries. Descriptive studies include case reports or case series,surveillance systems, correlational ( ecological studies) cross-sectional studies and cluster investigations. 20. Levels of Evidence 21. Systematic ReviewsUses a detailed search strategy to find relevant evidence to answer a clinical question. 22. Need for Systematic Reviews Complexity of the studies Volume of research literature on a given topic Bias existing in single studies Contradictory results from similar studies Sample size variation 23. Has the systematic reviewer done a goodjob? 24. Systematic Review A summary of evidence, conducted by an expert orexpert panel on a specific topic. Uses rigorous process for Identifying Appraising Synthesizing studies To answer a specific clinical question & draw conclusions & implications of all research available on a clinical question based on the data collected. 25. Value of Systematic Reviews Brings together and assesses all available researchevidence into a single report about efficacy andeffectiveness of specific practices Efficiently integrates valid information Provides a basis for rational decision making Resolves inconsistencies Establishes generalizability Assembles evidence Increases power and validity of the cause-and-effect relationship between intervention and outcome Limits bias and reduces chance effects 26. What do all of the numbers mean? 27. Meta-analysis combines the results of several studies that address a setof related research hypotheses. the statistical synthesis of the data from a set ofcomparable studies of a problem. yields a quantitative summary of the pooled results. 28. Meta-analysis continued aggregates the data and results of many studies, thatused the same or similar methods and procedures. reanalyzing the data from all these combined studies. generates larger numbers, more stable rates &proportions for statistical analysis & significancetesting than can be achieved by any single study. 29. Qualitative Research Qualitative researchers use methods such as interviews ornarrative analyses to help understand a particularphenomenon Qualitative research involves analysis of data in nonnumeric forms such as words (e.g., from personalinterviews), pictures (e.g., video), or objects (e.g., anartifact). 30. Both Triangulated approaches use both quantitative and qualitative methods Regardless of the method they use, researchers must adhere to certain approaches to ensure both the quality and the accuracy of the data and related analyses. The intent of each approach is to answer questions and develop knowledge using the scientific method. 31. TRIP Turning Research Into Practice (TRIP) Data Base Plus. A Data base doing research searches. 32. Implementing Research Findings inPractice (EBP Cycle)Need for adecisionImplement findings Information need Appraise for Formulate validity and answerableusefulnessFind evidencequestionfrom research 33. Examples of Nursing Research Randomized clinical trial examining best practice fororthopedic-pin site care Reliability of methods used to determine NG tubeplacement The effects of relaxation and guided imagery onpreoperative anxiety Quality of life in patients with chronic pain The relationship of a preoperative teaching programfor joint replacement surgery and patient outcomes 34. Importance of EBP Evidence-based practice helps nurses provide high-quality patient care based on research andknowledge. Rather than because this is the way we have alwaysdone it, or based on myths, hunches, traditions, oroutdated textbooks. 35. Managing variance through EBPFor safe reliable healthcare 36. Study Design Good Design = Control Researchers need to control several variables that might affect the outcome of the study: Environment Subject selection Treatment Measurement 37. EBP - critically appraise theevidence for validity Validity Reliability Applicability - transferabilityThen synthesize that evidence. 38. Establishing Validity Are the result of the study valid? What were the results? Will the results help me in caring for my patients? 39. Validity Validity- were the results of the studyobtained via sound scientific researchmethods ? Bias or other confounding variables maycompromise the validity of the findings. 40. Bias Anything that distorts study findings in asystematic way often arises from studymethodology. Any tendency to influence the results of atrial (or their interpretation) other thanthe experimental intervention. 41. Bias Bias is any deviation of results or inferences from thetruth because of the way(s) in which the study isconducted.Blinding: A technique used in research to eliminate biasby hiding the intervention from the patient, clinician,and/or other researchers who are interpretingresults. 42. Study DesignSpecial types of control: Blind: Unaware of assigned treatment. Double blind: Provider also unaware of assigned treatment. Placebo: A look-alike treatment with no efficacy. 43. Confounding Confounding variable: A variable which is not the one you are interested in but which may affect the results of trial. 44. Reliability do the numbers add up? Do the results of the study have have sufficientinfluence on practice clinically andstatistically? Can the results be counted on to make adifference when practitioners apply them totheir practice? How large the reported intervention effect was& how precisely that effect was estimated. Together these determine reliability. 45. Reliability do the numbers add up? Do the results of the study have have sufficientinfluence on practice clinically andstatistically? Can the results be counted on to make adifference when practitioners apply them totheir practice? How large the reported intervention effect was& how precisely that effect was estimated. Together these determine reliability. 46. Another case ofeconomy class syndrome.Shouldnt everyonetake an aspirin andwear stockings?What do you think about flight socks? 47. Applicability Whether or not the results of the study are appropriate for a particular a patient situation 48. Applying it to the Patient What do the resultsmean on average? What do they mean forthis patient? 49. Consider Patient Values, Circumstances Unique preferences Concerns Expectations Financial resources Social supports 50. Are the studies consistent? Are variations in results between studies consistentwith chance?(Test of homogeneity: has low power) If NO, then WHY? Variation in study methods (biases) Variation in intervention Variation in outcome measure (e.g. timing) Variation in population 51. Critical Appraisal Terminology Null Hypothesis P-value Confidence intervals Relative vs Absolute Risk Reduction 52. Null Hypothesis States that there is no Tylenol is better thanrelationship between the Advil for headachesvariables being studied. Exercising 30 minutes a Opposite of what you are day is good for yourtrying to find out.health Lefthanders are prone to accidents 53. P-value Probability that the Small p-value dismissoutcomes are due to chancechance Large p-value means Accepted referencethat anything is possiblepoint is .05(chance, actual effect, orconfounding factors) Less than .05 isstatistically significant 54. Statistical Significance How strong are the statistical findings? What is the strength of the associations/ differences between 2 or more groups? What is the proportion of the variance that is accounted for? Statistical significance p-value 0.05 is accepted innursing. 55. Confidence interval Confidence interval (CI): The range around a studys result within which we would expect the true value to lie. CIs account for the sampling error between the study population and the wider population the study is supposed to represent. 56. Confidence Intervals Quantifies the uncertainty in measurement. A 95% confidence interval (CI) means that one can be95% confident that the population value falls within acertain range Example: A study states that 40% of a sample of 1000people are smokers with a CI of 95% +/- 3% meansthe frequency of smoking is between 37% and 43%. 57. Risk Relative Risk or risk ratio (RR) is the risk for achievingan outcome in the treatment group relative to that inthe control group Relative Risk Reduction (RRR) is the increase inoutcome with the treatment compared to the control(often expressed as a percentage) Absolute Risk Reduction (ARR) is the difference inoutcome rates for two groups, usually treatment andcontrol 58. Relative Risk or Risk ratio Indicates the likelihood (i.e. Risk) that the outcome would occur in one group compared to the other. 59. Relative Risk Reduction Not a good way to compare outcomes Amplifies small differences and makes insignificantfindings appear significant Does not reflect the baseline risk of the outcomeevent Can make weak results look good Making weak results look good makes them popular,thus they are reported in many journal articles RRR can mislead 60. Absolute Risk Reduction A better statistic to evaluate outcome Does not amplify small differences, but shows the true difference between the experimental and control interventions 61. Is the review any good?FAST appraisal Question What is the PICO? Finding Did they find most studies? Appraisal Did they select good ones? Synthesis What do they all mean? Transferability of resultsApplicability will the results help me care for my patients? 62. Critical Appraisal of Quantitative Studies Why was the study done? What is the sample size? Are the measurements of major variables valid andreliable? How were the data analyzed? Where there any untoward events during the conduct ofthe study? How do the results fit with previous research in thearea? What does this mean for clinical practice?Melnyk /Fineout-overholt 2011 63. Critical Appraisal of Qualitative Evidence Are the results valid/trustworthy and credible? Are the implications of the research stated? What is the effect on the reader? What were the result s of the study? How does the research identify the study approach? Is the significance/importance of the study explicit? Is the sampling study clear and guided by the study needs? Are data collection procedures clear? Are data analysis procedures described? Melnyk/ Fineout-overholt 2011 64. Assessing the Studies Our job as critical readers is to determine whetherthe weakness is serious enough to warrantreinterpretation of the studys finding. We need to question whether the study measures what it intended to measure and whether the researchers have accounted for bias and confounding variables. 65. References Greiner, A., & Knebel, E., (Eds.). (2003). Healthprofessions education: A bridge to quality.Washington, DC: The National Academies Press. Bio medical library University of Minnesota, EvidencePractice (power point)http://hsl.lib.umn.edu/learn/ebp/modo1/pico.html Malloch, K., Poter-OGrady, T., (2006)Introduction toEvidence -Based Practice in Nursing and Healthcare .Sudbury, MA, .Jones and Bartlet 66. Ireland M. C.(2010) Evidence -Based Practice What does itmean? Innovations and Perspectives Virginia Departmentof Education. 1,2 Glasziou P. Introduction to EBM 2010(power point)www.cebm.net/index.aspx?0=1382 Moseley, M., Evidence - Based Practice - an opportunityfor nursing (2006) (power point) Rocky MountainUniversity Provo, Utah. ww.rmuohp.edu/index. 67. Melnyk, Fine-Overholt Evidence based practice(2011). Evidence-based Practice in Nursing &Healthcare. 2nd edition. Philadelphia PA : LippincotWilliams & Wilkins Oakes, J. Evidence Based Practice for Beginners(power point) www.evidencebasedpractice.org.uk Dontje K. J.(2007)Evidence-Based Practice: Understanding the Process .Topics in Advanced practice Nursing Journal ,7,4. 68. Academy of Medical Surgical Nurse, Evidence-basedpractice module 1,2 (power point)www.amsn.org/cgi-bin/WebObjects/AMSNMain Glover ,J. Izzo, D.,Odato, K.,Wang, L. (2006) EBM Pyramid . Yale University School of Medicine. http://www.ebmpyramid.org/samples/complicated.h tml