Improving Care Through Research, Evidenced
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Transcript Improving Care Through Research, Evidenced
EVIDENCE-BASED PRACTICE:
WHAT’S IN IT FOR YOU?
Sharon Bond, PhD, CNM
Associate Professor
Special Thanks to:
Barbara J. Edlund RN, PhD, ANP, BC
Professor
College of Nursing, MUSC
SO MANY QUESTIONS . . .
Evidence-Based Practice (EBP): What is the best approach
for managing neuropathic pain in the terminally ill
patient?
What research has been done that could provide clinical
practice guidelines?
Quality Improvement (QI): Are we doing the right things to
appropriately manage patients’ neuropathic pain?
How do we know? How are we measuring patient
outcomes?
Research (R): What is it like to live with neuropathic
pain?Does drug “A” work better than drug “B?”
What’s been studied? Where are the gaps?
COMMONALITIES – PROVIDE STRUCTURE!
Evidence-based practice (EBP) – utilizes the best clinical
evidence in making patient care decisions typically from
research. EBP translates knowledge into practice
Quality improvement (QI) - utilizes a system to monitor
and evaluate the quality and appropriateness of care
(outcomes) based on EBP and research
Research (R) - applies a methodology whether
quantitative or qualitative to develop, uncover, create,
find, add new nursing knowledge
COMMONALITIES – IMPROVE CARE
DELIVERY!
Involve teamwork – not done in isolation
Call for critical thinking and creativity
Commitment to improve care
One informs the other
Nurses base their practice on emerging evidence from research
(EBP)
Research starts in practice and ends in practice
Quality improvement evaluates and monitors care, and identifies
opportunities to improve care as the processes and outcomes of
care are measured, continuously evaluated and improved
WHAT IS EVIDENCE-BASED
PRACTICE?
Conscientious use of current best evidence to make
decisions about patient care
A problem-solving approach to clinical practice
Based on:
1. systematic search for and appraisal of most
relevant evidence to answer questions
2. one’s clinical experience and expertise
3. patient preference and values
LEVELS OF EVIDENCE
I
II
III
IV
V
VI
VII
Evidence - Systematic reviews, meta-analysis
RCTs, EB clinical practice guidelines based on RCTs
Evidence - One well designed RCT
Evidence - CTs without randomization
Evidence - Well-designed case control or cohort
studies
Evidence - Systematic reviews of descriptive or
qualitative studies
Evidence - Single descriptive or qualitative study
Evidence – Opinions of authorities, reports of
experts
EVIDENCE-BASED PRACTICE
The process of doing the “right thing”
Standards of care
Baseline description of quality- may be
discipline focused AANP standards of NP practice
Clinical guidelines
Broad-based recommendations
Critical pathways
Identify key/critical activities that must occur in
predictable fashion
Protocols
Detailed procedures on how to proceed with
evaluation and treatment
NONPF
FIVE STEPS OF EVIDENCE-BASED PRACTICE
Ask the burning clinical question (Picot format)
Search for and collect the most relevant and best evidence
Critically appraise the evidence
Integrate all evidence with one’s clinical expertise, patient
preferences and values in making a practice decision or
change
Evaluate the practice decision or change
(Disseminate)
Unlike research utilization (info from a single study), EBP - takes into account
expertise of the practitioner and patient preferences / values
Melnyk & Fineout-Overholt 2005
STAR MODEL – FIVE STAGES: EBP
Depicts 5 major stages of knowledge in a relative sequence as
research evidence is moved through several cycles, combined
with other knowledge and integrated into practice
Converting knowledge into practice
Provides a framework for systematically putting evidencebased practice processes into operation
Stevens 2004 (www.acestar.uthscsa.edu)
Reference: Haynes (1998). Barriers and bridges to evidence-based
clinical practice. BMJ, 317:273-276.
QUALITY IMPROVEMENT
Process
that utilizes a system to monitor
and evaluate the quality and
appropriateness of care based on
evidence-based practice and research
ASPECTS OF QUALITY IMPROVEMENT
On-going process to improve quality of care
Whole team collaborates across departments and
systems…team with clear aims, clear outcome measures
of results to be achieved…process for implementing
change and institutional or organizational support
Information systems…show me the data
System focused (not individual)
Practice process changes to meet guidelines (EBP) and
to see if changes are working
NONPF
QUALITY IMPROVEMENT: FOCUS
Questions (3)
1. What are we trying to accomplish?
2. How will we know a change is an
improvement?
3. What changes can we make that will
result in improvement?
Rapid Improvement or PDSA cycles
PDSA: THE DEMING MODEL
Plan
- Test objectives
- Who will do what
- Predict outcomes
Do
- What happened
- Did it work
Study
- Analyze outcomes in context of predicted
- Summarize lessons learned
Act
- What modification needs to be made
- Statement of new plan ….. PDSA cycle repeats
NATIONAL GUIDELINES OR
BENCHMARKS
Need quantifiable measures
Need to know the difference between your practice and
national benchmarks
National Guidelines Clearing House
Guidelines.gov
National benchmarks or quality goals…AHRQ
NONPF
BARRIERS TO EVIDENCE-BASED
PRACTICE
Overwhelming patient workloads
Misperceptions about EBP and research
Lack of time and resources to search for and appraise
evidence
Organizational constraints – lack of support
Peer pressure to continue with practices that are
steeped in tradition – “we’ve always done it this way
and we are not changing now”
Melnyk & Fineout-Overholt 2005
BARRIERS TO EVIDENCE-BASED PRACTICE
Knowledge… lack of knowledge/awareness .… unfamiliar
with guidelines and guideline accessibility
Attitudes …. lack of confidence in the guideline
developer, lack of motivation to perform the guideline
recommendations
Behaviors …. inability to incorporate patient preferences
into the clinical decision making process
Melnyk & Fineout-Overholt 2005
WHAT ARE YOUR EXPERIENCES WITH
CHANGE?
Have you ever tried to change a
practice at your work site?
What worked?
What didn’t?
What was the final outcome?
What would you do differently?
Do facts (evidence) change behavior?
RESEARCH:
WHEN EVIDENCE IS NOT THERE/NOT SUFFICIENT
Conduct a research study to determine the “what is it
we want to know”
Nature of the question will determine the level of the
research study
1 - What is the nature of the phenomenon?
2 - Who, what, how many, how much?
3 - What are the relationships among the
variables?
4 - Does one variable cause the other?
RESEARCH QUESTIONS…..
First three questions - reflect levels of research seeking
descriptive knowledge of the variables under
study…non-experimental design
Fourth question reflects a level of research that
examines cause and effect…experimental design
Before one conducts an experimental research study,
one must have data from the three previous levels to
support such a study…the preliminary work!
Value of research…adds new knowledge…to guide and
improve nursing practice
QI VS. RESEARCH
Intervention may be
multifactorial represents
best practices
Rapid improvement
cycles
No risk to patients
Audience is organization
Data source: organization
Design - no controls
Not generalizable
NONPF
Untried intervention
being tested
Risk may be present
Complex protocol
Audience is scientific
community
Data source –randomized
population, multiple sites
Design – focus on
controls
Generalizable
HOW DOES FOCUS OF DNP DIFFER
FROM PHD?
DNP: Experts in EBP
PhD: Experts in Research
Eating during labor
Identify the problem
Find the evidence
Appraise the evidence
Integrate evidence with
clinical expertise, patient
values
Evaluate outcomes
Disseminate
Eating during labor
Explore, compare cultural
differences
Compare differences in
practice by geographic
region, type of hospital,
birth center
Physiologic effects of
restriction
QUALITY IMPROVEMENT (QI) VS. PERFORMANCE
IMPROVEMENT (PI)
Often
used interchangeably
Useful to think of PI as a “drill down process” to look
at a specific problem that occurs with the
implementation of EBP
OTHER THOUGHTS….
Research, quality improvement and evidence based
practice are integral to the delivery of quality patient
care
Each informs the other and improves upon the other
Each requires commitment, team work, vision, critical
thinking, creativity, leadership, energy and endurance
“Doing the right thing” in each of these areas
contributes to an environment of excellence, quality
patient care and clinician satisfaction…and sets you
apart as an organization!
YOUR DNP PRACTICE INQUIRY
PROJECTS
What
are your burning issues in health care, in
your advanced nursing practice (why are you
here)?
Implement innovations
Apply evidence-based interventions
Propose changes to care delivery models
Implement quality improvement projects
Develop and implement health policy
You are a Change Agent !
REFERENCES
Burns & Grove (2005). The Practice of Nursing Research (5th ed).St. Louis: Elsevier
Saunders
Polit & Beck (2008). Nursing Research: Generating and Assessing Evidence for Nursing
Practice. Philadelphia : Lippincott Williams & Wilkins
Melnyk & Fine-Overholt (2005). Evidence-Based Practice in Nursing & Health Care.
Philadelphia: Lippincott Williams & Wilkins
Roberts & Bourke (1989). Nursing Research: A Quantitative and Qualitative Approach.
Boston: Jones & Bartlett
NONPF
ACE Star Model: http://www.acestar.uthscsa.edu/Learn_model.htm
Deming Model:
http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/