EBP Exam 1

Enhance healthcare quality, Improve patient outcomes, Reduce costs, Empower clinicians

quadriple AIM?

1) 1970s

2) 1990s

3) Dr. Archie Cochrane

1) what years: criticized the medical field for not using research evidence to help guide best practice

2) what years: collaboration was founded

3) who?

0

what step to EBP?

Spirit of inquiry

• Reflecting on your own clinical practice

• "What if...?"

• "It would be nice if...."

• "I wonder why......"

1

what step to EBP?

• Formulate a PICOT question

patient population, intervention or issue of interest, comparison group, outcome, time for intervention to achieve the outcome

what does each letter in PICOT stand for?

2

what step to EBP?

• Search for the evidence

• Where do I search?

• What do I search for?

• Why is this important?

• What are levels of evidence and why do they matter?

3

what step to EBP?

Critically appraise the evidence

3 main components:

1. validity (are the results valid?)

2. reliability (what are the results?)

3. applicability (can I apply these results to my own patients?)

4

what step to EBP?

• Integrate the evidence with clinical experience and patient/family preferences

• Concepts:

• Clinical wisdom and judgment

• Patient-centeredness

5

what step to EBP:

• Evaluate the outcomes of practice change

• What is an outcome?

• What are outcome measures and why are they important?

6

what step to EBP?

• Disseminate outcomes of the EBP change

anyone on the healthcare team

who should use EBP?

Lack of knowledge, Time, Resources

3 Barriers to EBP?

Incorporating EBP in curriculum, Create positive beliefs about EBP, Mentorship, Commitment to EBP among nurse leaders

4 Facilitators of EBP implementation?

bsn

Continuum of Nurses’ Roles in Research/which education level?:

Read and critically appraise studies. Use best evidence with guidance. Assist with problem identification and data collection.

msn

Continuum of Nurses’ Roles in Research/which education level?:

Critically appraise and synthesize studies to develop protocols, clinical algorithms, and policies. Collaborate in research projects and provide clinical expertise for research.

dnp

Continuum of Nurses’ Roles in Research/which education level?:

Participate in EBP guideline development. Develop, implement, evaluate, and revise protocols, policies, and EBP guidelines. Conduct clinical trials in conjunction with nurse researchers.

phd

Continuum of Nurses’ Roles in Research/which education level?:

Assume major scientific role in conducting research to generate empirical knowledge. Obtain research funding and lead research teams.

1) Descriptive, Correlational, Quasi-experimental, Experimental

2) Phenomenological, Grounded theory research, Ethnographic, Exploratory-descriptive

Types of Research:

Quantitative

1) what 4 types?

Qualitative

2) what 4 types?

Mixed Methods

quantitative

Basics of ____ Research:

• Describes concepts (e.g., CVD) and corresponding variables (e.g., BP, medication type, duration of symptoms), examines relationships between variables, and may determine impact of an intervention on relevant outcomes

• Yields data that can be quantified • Descriptions

• “In the past month, there have been 1,500 COVID cases in X town.”

• Comparisons

• “The harm-reduction center in Newark sees an average of 100 people per week vs. 50 people seen weekly in the Paterson harm reduction center.”

Descriptive

what type of research?

• accurate account of characteristics of individuals, groups, epidemics, or contexts.

• useful in early investigations of a phenomenon (e.g., long-COVID).

Correlational

what type of research?

• systematic investigation of relationships between variables:

• positive (e.g., higher depression scores are associated with heavier alcohol use) or

• negative (e.g., more frequent exercise is associated with lower risk for falls)

• Pearson’s r statistic: relationship strength ( r = 0.20 vs. r = 0.65)

• does not determine cause and effect

Quasi-experimental

what type of research?

• examines causal relationships and why certain changes happen; no randomization

Experimental

what type of research?

• systematic controlled investigation performed to predict and control the phenomena via randomization to groups

Experimental, quasi-experimental, correlational, descriptive

list the level of control for quantitative research methods (highest to lowest)?

quantitative

tools of ____ research:

• Interviewer-administered structured interviews (“How often do you drink alcohol” never; a few times per year; a few times per month; a few times per week; daily)

• Self-reported surveys (scales measuring one’s depression symptoms or level of social support)

• Daily diaries (“I used X medication 4 out of 5 days this week.”)

• Physiological measurements (cholesterol levels; blood pressure)

Population

the entirety of a group of people, people in a defined setting (e.g., all nursing students)?

Sample

subset of people in the defined setting (e.g., female nursing students)?

Validity

extent to which a tool (scale, interview, diary) measures the actual condition it is meant to measure?

Reliability

consistency of measures over time?

Inference

reasoned judgment that the characteristics of the sample resemble patient population?

independent variable

purported cause or predictor variable (e.g., level of carbon monoxide exposure)?

dependent variable

outcome variable (e.g., toxicity)?

bias

i.e., systematic error “The systematic introduction of error into a study that can distort the results in a non-random way.”

• Introduced at any point in study?

Null hypothesis

assume no relationship

• Diet does not influence blood pressure.

p-values

likelihood of results due to chance?

Confidence intervals

contains range of true value; measure of precision?

variables

Attributes of patients and clinical events that vary and can be measured?

Covariates

other variables associated with the outcome?

confounding variables

variable that influences both the independent and dependent variables in a study, creating a false association between them?

measurement

The assignment of numbers or categories to represent the amount, frequency or degree of an attribute or phenomenon/occurrence. Used to operationalize or measure variables in a study.?

nominal

type of measurement?

You can categorize your data by labeling them in mutually exclusive groups, but there is no order between the categories.

•City of birth

•Ethnicity

•Car brands

•Marital status at a given time

ordinal

type of measurement?

You can categorize and rank your data in an order, but you cannot say anything about the intervals between the rankings.

• can rank the top 5 Olympic medalists; unknown how close or far apart they are in number of wins.

•Top 5 Olympic medalists

•Language ability (e.g., beginner, intermediate, fluent)

•Likert-type (e.g., very dissatisfied to very satisfied)

interval

type of measurement?

You can categorize, rank, and infer equal intervals between neighboring data points, but there is no true zero point.

• difference between any two adjacent temperatures is always one degree; zero degrees is defined differently depending on the scale and doesn’t mean absolute absence of temperature.

• no absolute lack of a personality trait. •Scores (e.g., IQ)

•Personality inventories

•Temperature in Fahrenheit or Celsius

ratio

type of measurement?

You can categorize, rank, and infer equal intervals between neighboring data points, and there is a true zero point.

• a true zero is the absence of the variable of interest

• in the Kelvin scale, there are no negative degrees of temperature – zero means an absolute lack of thermal energy.

•Age

•Weight

•Temperature in Kelvin

categorical, Dichotomous, Trichotomous

Nominal and ordinal data are considered ______ data

- ______ (low/high; 18-29 vs. 30 and above; no suicide risk vs. suicide risk)

- _______ (no depression/mild depression/severe depression)

continuous

Interval and ratio data are considered ______ data

- Discrete numbers: 15, 56.8, -10

Face validity

Does the instrument appear to measure phenomenon of interest/the extent to which a measurement instrument appears to measure what it's intended to measure, based on a superficial assessment?

• Ask experts if your tool/scale seems appropriate

Content validity

Does the instrument include dimensions of the phenomenon under study?

• i.e., scale for measuring pain should include questions about severity and sensation of pain (e.g. dull, throbbing), but not about itching

• Often assessed using the Content Validity Index i.e., CVI, in which a panel of experts rate the representativeness and comprehensives of instrument questions

face, content

____ validity is a superficial assessment of whether a test appears to measure the intended construct, while ____ validity is a more rigorous evaluation of whether the test's content comprehensively covers all aspects of the construct

1) Construct Validity

2) Convergent Validity

3) Discriminant Validity

1) Does the instrument perform as expected in relation to similar and dissimilar constructs?

2) Like-constructs have similar scores (e.g., expect to see similarities between pain and distress scores)

3) Unlike-constructs do not have similar scores (e.g., pain scores would differ from intelligence scores)

Validity

Instrument ____ (Accuracy)?

Instrument Reliability

The consistency with which an instrument measures the target attribute

• stronger values likely less measurement error

Internal consistency

The extent to which all the items/questions on an instrument are measuring the same attribute

• Evaluated by administering instrument on one occasion

• Appropriate for most multi-item instruments • Assessed by computing coefficient alpha (Cronbach’s alpha)

• Alphas ≥ .80 are highly desirable.

Stability

The extent to which scores uphold across time

• Scores are similar on two separate administrations of an instrument

• Measured with test-retest reliability – a correlation (Pearson’s r) is calculated between scores and expected to be high for a stable instrument

selection bias

flawed sample selection procedures; preexisting differences exist between groups being compared; study sample not representative of larger population?

measurement bias

biases arise when measures are not valid or reliable, or are performed inconsistently between study groups?

social desirability bias

biases that stem from desire to report favorable information

• Explicit vs. implicit bias

Directional hypothesis

Predicts the direction of a relationship

• Frequent studying will yield higher exam scores

non-directional hypothesis

Predicts the existence of a relationship, not its characteristics

• There will be a difference in white blood cell count between patients receiving medication X vs. patients receiving medication Y

null hypothesis

• Postulates the absence of a relationship

• Statistical testing performed to provide probabilistic information to support or reject

hypothesis

• Stated expectations, a predicted answer to the research question

null hypothesis

In an experimental study, researchers test their hypothesis of whether a new treatment (A) is more effective than standard of practice (B)

_______- assumes NO difference between A and B.

• Statistical tests used to reject or accept the null hypothesis

type 1 error, false positive

null hypothesis is true, reject null hypothesis?

correct outcome, true negative

null hypothesis is true, fail to reject null hypothesis?

correct outcome, true positive

null hypothesis is false, reject null hypothesis?

type 2 error, false negative

null hypothesis is false, fail to reject null hypothesis?

1

“What is the effect of Tylenol versus Advil on temperature in patients with fever?” The null hypothesis is: There is no difference in temperature reduction in the experimental group (those getting Tylenol) and the control group (those getting the Advil)

Type __ error: Researchers assert that Tylenol is more effective in reducing fever than Advil, when in fact it is not more effective.

2

“What is the effect of Tylenol versus Advil on temperature in patients with fever?” The null hypothesis is: There is no difference in temperature reduction in the experimental group (those getting Tylenol) and the control group (those getting the Advil)

Type ___ error: Researchers assert that there is no difference in fever reduction between Tylenol and Advil when there is a difference.

1) 1

2) 0.05, 5

P-values and probability:

1) Closer to ___ = more likely result is due to chance, not considered a significant finding

2) Standard cut-off point __ (_%)

confidence interval

a range of values, calculated from sample data, that is likely to contain the true value of an unknown population parameter?

appraisal, internal validity, reliability, applicability

determines the usefulness of a study to patient care? 3 steps?

title

section: Title Authors Author Affiliations Author Credentials?

Abstract

section: Brief study overview?

Background

section: Significance *Purpose statement - answers “why” the study was conducted?

Methods

section: Details on how the study was conducted – procedures (e.g., study design, study setting, participants, instruments, analyses, etc.)?

Results

section: Reports study findings?

Discussion

section: Places study findings in context with existing literature, explains results, describes study limitations?

purpose statement

succinctly provides the objective of the study?

participant flowchart

Progression through Intervention and Assessments across Time?

cross-sectional study, level 2

• an observational study that examines data (outcomes and predictors/exposures) from a sample at one point in time

• observe variables without influencing them?

• where does it fall under the EBM scale?

cross-sectional study

what type of study is best:

• Examining prevalence of a disease (how frequently it occurs)

• Learning about characteristics of a population (e.g., their knowledge, practices)

• Monitoring trends over time but not link individuals across time

longitudinal study

• an observational study that examines data (outcomes and predictors/exposures) from a sample at several points in time

• observe variables without influencing them?

Descriptive

type of cross-sectional study:

- characterize prevalence of one or several health outcomes within a certain population

• Example- prevalence of hypertension in adults living in Morningside Heights

Analytical

type of cross-sectional study:

data are collected for predictors/exposures and outcomes at one set point in time and differences between those experiencing a phenomenon and those not experiencing it are examined

• - prevalence of asthma among children from Newark and Princeton

• phenomenon/exposure- geographical setting

• outcome- asthma

Serial

type of cross-sectional study:

- data are collected on same population (different samples) at different points of time

• Example- children with seizures admitted to a hospital over a ten-year span

prevalance

is the proportion of a population who have a specific characteristic in a given time period. • Reported as a percentage (5%, or 5 people out of 100), or as the number of cases per 10,000 or 100,000 people.

Point prevalence

is the proportion of a population that has the characteristic at a specific point in time?

Period prevalence

is the proportion of a population that has the characteristic at any point during a given time period of interest (e.g., past 12 months)?

Lifetime prevalence

is the proportion of a population who, at some point in life, has ever had the characteristic?

greater, positive

If OR > 1, then odds of disease are ____ among exposed compared to non-exposed (_____ association between exposure and disease)

lower, negative

If OR < 1, then odds of disease are ___ among exposed compared to non-exposed (____ association between exposure and disease)

the same

If OR = 1, then the odds of disease in exposed and non-exposed groups are ____

short, one, multiple, hypothesis

Strengths of Cross-Sectional Studies:

• Can be conducted in a ____ amount of time

• Data collection can be done at ___point in time (except for serial cross-sectional studies)

• _____ outcomes and exposures can be studied

• Can lead to creation of _____

prevalence, incidence, causality, occurrence, historical, contextual

Weaknesses of Cross-Sectional Studies:

• Examines the _____ (total estimated cases), not the _____ (new cases) of a disease

• Cannot make inferences related to _____

• Cannot examine the temporal ____ of outcomes and exposures (e.g., risk factors)

• Data are influenced by ____ or ____ factors (e.g., collecting data before or after 9/11, COVID, Ukraine invasion, marriage equality, elections, etc)

observational study

Used to answer PROGNOSIS / PREDICTION and ETIOLOGY questions

• Researchers do not intervene by controlling the independent variable so observational (observing what happens naturally)

• Not all independent variables (“causes”) of interest to researchers can be manipulated experimentally

• Gender, age at menarche cannot be manipulated

• Smoking cannot ethically be manipulated

cohort

cohort or case-control?

present: exposed & not exposed

future: outcome & no outcome

case-control

cohort or case-control?

past: exposed & not exposed

present: outcome & no outcome

cohort study

A prospective correlational design where a potential cause in the present (e.g., exposure to cigarette smoke vs non - exposure) is linked to a hypothesized later outcome (e.g. lung cancer).

Data for these studies may also be collected retrospectively.

etiology, incidence, prognosis, temporal sequence

Cohort Study Advantages:

• Useful for estimating ___ and ___ of disease conditions

• Useful for answering questions on ____

• Can show a ____ ____ between exposure and outcome

large, long, loss, rare diseases

Cohort Study Disadvantages:

• Require ___ sample sizes

• Need ____ time duration for follow up (so can be expensive)

• ____ to follow up

• Not suitable for ___ ____