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Utilizing an Evidence-based Practice Model at the Bedside Debra Palmer RN, MS Co-owner, Zebra Utilizing an Evidence-based Practice Model at the Bedside Debra Palmer RN, MS Co-owner, Zebra Consulting, LLC www. zebraconsult. com

Objectives n n Identify the distinct differences between QI, Research and Evidence-based Practice Identify Objectives n n Identify the distinct differences between QI, Research and Evidence-based Practice Identify the steps in the EBP process

Definitions n Quality Improvement: “Systematic data guided activities designed to bring about immediate positive Definitions n Quality Improvement: “Systematic data guided activities designed to bring about immediate positive changes in the delivery of health care in a particular setting. ” n Hastings Center Report, 2006 Goal: to find interventions that work well, implement them more broadly, and thereby improve clinical practice.

Definitions n Research: “A systematic investigation, including research development, testing, and evaluation, designed to Definitions n Research: “A systematic investigation, including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge” n (Office of Human Research Protection).

Generalizability n Generalizable: Results or findings from a study that can be applied to Generalizability n Generalizable: Results or findings from a study that can be applied to populations or situations beyond those being immediately studied. n n ◦ High attention to internal validity To ensure generalizability, the sample procedure and the data need to meet certain methodological standards.

Definitions n n THE BIG UMBRELLA EBP is the integration of the best evidence Definitions n n 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. n (Sigma theta Tau International, 2004, p. 69)

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

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

Examples of EBP n n Use of evidence-based standards from professional organizations Use of Examples of EBP n n Use of evidence-based standards from professional organizations Use of research to guide protocols Institute for Healthcare Improvement (IHI) bundles Specifics: n Prevention of VAP n Falls prevention n Pressure ulcer prevention n Restraint free environments

What is Not Evidence Based Practice? n n n Rituals, Customs Traditions Ungrounded Opinions What is Not Evidence Based Practice? n n n Rituals, Customs Traditions Ungrounded Opinions Trial and Error Isolated Clinical Experience

Quality Improvement –Ingredients n Works to: n Make the system better n More cost-effective Quality Improvement –Ingredients n Works to: n Make the system better n More cost-effective n Increase productivity n Create continual gains (improvement) in a identified process –ex. Falls, pressure ulcers n Knowledge specific to that organization n Limited audience n Results intended for individuals internal to the organization (reason why do not usually need to go through IRB )

Research – Ingredients n n n Generates new scientific knowledge Formal proposal Human subjects Research – Ingredients n n n Generates new scientific knowledge Formal proposal Human subjects IRB review n Benefits and risks n Protect human subjects Research process adheres to strict scientific standards

A Comparison of Research to QI Topic Research Quality Improvement Purpose To generate new, A Comparison of Research to QI Topic Research Quality Improvement Purpose To generate new, scientific knowledge To improve internal processes, practices, Decrease costs or increase productivity Goal To test a hypothesis or describe a phenomenon To implement EBP and/or measure an existing 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 Intervention General benefit to organization and society Benefits individuals *Risks Most likely some risk No risk beyond usual care Sample size Most of the time done by a formal power analysis Convenience sample, usually small is size Voluntary participation Always Rarely Data analysis Inferential statistics Descriptive statistics or graphs that show trends Project timeline Takes a considerable amount of time to complete May be done quickly through rapid cycles Funding and other resources needed Usually Not usually Dissemination Publish or present Usually communicated within hospital or department only Change in practice Practice changes occur slowly after multiple studies validate the results Practice changes may be made immediately Resources Often rely on external resources to conduct Internal resources only

n Department of Health and Human Services (DHHS), Office of Human Research Protection (OHRP) n 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… n n It is often very foggy when deciding if If You have Questions… n n 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 n Researcher n IRB If still unsure, always err on the side of research

Why is EBP Important? n n Studies in the US and Netherlands suggest that Why is EBP Important? n n 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! n Grol, R. (2001).

Challenges n n New nurses more concerned with clinical and organizational skills than applying Challenges n n 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 n n 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) n Strong pull of traditional culture, habits and practices that may block Challenges (cont) n Strong pull of traditional culture, habits and practices that may block creative thinking n Lack of knowledge about the research synthesis process n Negative viewpoints about research n The explosion of knowledge in the literature n n Organizational system limitations Excessive workloads leaving little or no time to investigate better practices

Research Models Academic Model n n n Publications Presentations Funding Tenure Ph. D required Research Models Academic Model n n n Publications Presentations Funding Tenure Ph. D required Clinical Model n n n Improves patient care Decreases costs Increases interdisciplinary collaboration Advances the nursing profession Decreases variations in practice Ph. D not required

ANA Position Statement on Nursing Research n n Associate Degree - Identify problems at ANA Position Statement on Nursing Research n n 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 Importance of Research Pt. Benefits Clinician Benefits Organization Benefits Profession Benefits

EBP Step #1 Start with Reflective Practice n In your day to day practice, EBP Step #1 Start with Reflective Practice n In your day to day practice, have you ever n wondered why you are doing a procedure a certain way? n n 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? n n Reflection is a process of paying attention to What is Reflective Practice? n n 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” question EBP Step #2 What is the Question? Form a clinically relevant and “searchable” question by identifying the practice problem Common process for this is PICO Patient Intervention Comparison Outcome

Elements of the clinical question n n Patient: Describe as accurately as possible the Elements of the clinical question n n 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 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, Pub. Med, Ovid, ERIC and others

EBP Step #4 Critical Appraisal of the Evidence What is critical appraisal? Critical appraisal 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 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 Retrospective chart data Quality improvement data Risk management Patient satisfaction Types of Evidence Internal Retrospective chart data Quality improvement data Risk management Patient satisfaction Nurse satisfaction External Review of the literature Current research National clinical guidelines Integration of findings Identify level of evidence

Why examine the evidence? 2, 000 health related manuscripts published yearly 20, 000 health Why examine the evidence? 2, 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 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 staff §Implement on EBP Step #4 Implement §Conduct research: Send to IRB, yes/no? §Educate staff §Implement on pilot unit §Monitor outcomes §Evaluate §Implement housewide change to new practice, discard old practice §Integrate the evidence with expert opinions and patient preferences

EBP Step # 6 Disseminate Research is of little value unless the findings are 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 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 n n n n n It’s not my job Myths and Fears of Research n n n n n 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 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 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 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 n n n n PARIHS IOWA ACE ARCC Stetler Evidence – Based Practice Models n n n n PARIHS IOWA ACE ARCC Stetler CURN Others

Iowa Model Iowa Model

ACE Star Model ACE Star Model

Stetler Model Stetler Model

Ottawa Model Ottawa Model

The Multi-system Model of Knowledge Integration and Translation (MKIT) O F MICROSYSTEM Transformational Leader The Multi-system Model of Knowledge Integration and Translation (MKIT) O F MICROSYSTEM Transformational Leader Knowledge Seeker Disseminate Practice Knowledge Monitor Implement MACROSYSTEM MESOSYSTEM

Do we really need a model? ? ? n n Yes, Yes Guide to Do we really need a model? ? ? n n Yes, Yes Guide to move from concept to action n Theory – abstract n Model – helps with making day to day implementation of practice understandable n Sustainability

References Baily, M. et al. (2006). The Ethics of Using QI Methods to Improve References Baily, 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), II 46 -II 54. 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.