Transcript Validation of the Riker Sedation

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.

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◦ 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.
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(Sigma theta Tau International,
2004, p.69)
Examples of QI

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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?
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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

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Generates new scientific knowledge
Formal proposal
Human subjects
IRB review
 Benefits and risks
 Protect human subjects
Research process adheres to strict
scientific standards
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

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
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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
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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
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Organizational system limitations
Excessive workloads leaving little or no time to
investigate better practices
Research Models
Academic Model

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Publications
Presentations
Funding
Tenure
PhD required
Clinical Model
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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.

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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” question
by identifying the practice problem
Common process for this is PICO
Patient
Intervention
Comparison
Outcome
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
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?
2,000,000 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 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 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
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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
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PARIHS
IOWA
ACE
ARCC
Stetler
CURN
Others
Iowa Model
ACE Star Model
Stetler Model
Ottawa Model
The Multi-system Model of Knowledge Integration and Translation (MKIT)
MICROSYSTEM
Transformational
Leader
Knowledge
Seeker
Disseminate
Practice
Knowledge
Monitor
Implement
MACROSYSTEM
MESOSYSTEM
Do we really need a model???

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Yes, Yes
Guide to move from concept to action
 Theory – abstract
 Model – helps with making day to day implementation
of practice understandable
 Sustainability
References
Baily, M. et al. (2006). The Ethics of Using QI Methods to Improve
Health Care Quality and Safety. Hastings Center Report, JulyAugust
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), II46II54.
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.