EBP Midterm
Ø Chapter 1:
o Differentiate the key differences between Research and EBP.
§ It means that understandings each definition and being able to identify the differences.
Research: a planes and systemic activity that generates new knowledge and/or discovery of solutions to problems or questions that are important to the nursing profession
- Systematic problem-solving approach that is inquiry driven
- Develop research aims
- The most rigorous: provides for highest level of evidence
Evidence Based Practice: the integration of best research evidence with clinical expertise and patient values
- Translates new knowledge into clinical, administrative, and educational practice
- Systematic problem-solving approach that is evidence driven
- Develop PICOT questions
- Somewhat rigorous
Quality Improvement: incorporates existing knowledge into process improvement activities
- Systematic problem-solving approach that is data driven
- Use PDSA cycle (plan, do, study, act)
- Least rigorous: provides for lowest level of evidence
o Understand 3 general elements of EBP (research evidence, nurse expertise, and patient preference) and its application
Three General Elements of EBP:
1. Research Evidence: external evidence
2. Clinical Expertise: internal evidence
3. Patient Preferences
o Understand type of research specifically Differentiate between Quantitative vs Qualitative Research
Quantitative Research: one reality that can be objectively viewed by the researcher
- Primarily deductive
- Controlled and structured
- Control and manipulation of situations
- Analysis of numbers with statistical tests
- Larger number of subjects
- Designs could be descriptive survey, correlational, experimental or quasi-experimental
Qualitative Research: multiple realities that are subjective, occurring within the context of the situation
- Primarily inductive
- Participative and ongoing
- Naturalistic; allows situations to unfold without interference
- Analysis of words to identify themes
- Smaller number of participants
- Designs could be phenomenological, ethnographic, grounded theory, historical
o Know Barriers to EBP e.g., traditional practice, trial & errors, intuition. What does it mean by each barrier?
- Individual factors
- Organizational factors
o Understand the evidence hierarchy (aka the pyramid of evidence)
§ Purpose of ranking the evidence as to why do we use the evidence hierarch. What does it tell us?)
Evidence Hierarchy: helps understand which evidence is stronger, more reliable, and preferred for EBP
o The overall steps of the EBP process start from the first step.
Steps of Evidence Based Practice (IOWA Model)
1. Ask the clinical question
2. Search literature
3. Critically appraise evidence
4. Implement practice change
5. Evaluate the outcome
o Sections of Research Articles
§ Understand sections of research articles. What key information is in the Introduction section, the Methods section, the Results, and Discussion section.
Research Article Sections
- Abstract: first section
- Introduction: contains main idea of study, problem statement, and purpose statement
- Review of Literature
- Theoretical Framework
- Methods: full description of each step in research; design, samples, tools, data collection, data analysis
- Results: relevant study findings
- Discussion: interpretation of study findings, limitations, implications of the results
- List of Preferences
Ø Chapter 2:
o Know 5 levels of EBP collaborations.
§ Strategies used in each of the 5 Levels of Collaboration
§ Focus on staff nurse & organization level, and the overall purpose of the 5 Levels of Collaboration.
Five Levels of EBP Collaborations
Level 1: Individual Nurse
- Staff nurses, nurse managers, advanced practice nurse, nurse executives
- Questions current practice
- Implements changes in practice based on evidence
- Participates as member of an EBP team
- Reads evidence related to practice
- Participates in quality improvement (QI) initiative
- Suggests resolutions for clinical issues based on evidence
Level 2: Organizational
- Health care system actions
- Recognize nurses’ increased interests to practice from a research base
- Set vision of excellence
- Establish infrastructure to accommodate EBP
- Embrace culture of EBP
Level 3: Regional (universities)
Level 4: National (national Institutes)
Level 5: International (global organizations)
o Describe the major ethical principles for protection of human subjects including (a) beneficence, (b) respect for person, (c) and justice
Belmont Report: U.S. ethical guidelines for protection of human subjects of biomedical and behavioral research, has 3 major principles.
a. Respect for Persons
- Individuals have autonomy and ability to make decisions
- Individuals are voluntary
- Persons with diminished autonomy are entitled to protection
b. Beneficence
- The principle of doing good for patients
- Researchers endorse nonmaleficence (do not harm) to maximize possible benefits and minimize possible harm
- Research participation should not make someone worse off than they were previously
c. Justice
- The equity and fairness in distribution of burdens and benefits
- Individuals have the right to fair treatment and the right to privacy (confidentiality and anonymity)
- Researchers must recruit subjects equitably
o Understand the Meaning and its application of (a) Informed Consent and (b) Confidentiality.
Informed Consent: implemented to ensure ethic principles are maintains
- Participants have adequate information about the research
- Can comprehend information
- Have free choice in deciding whether to participate in or withdraw from the study
- Researchers obligated to provide information to potential subjects in a manner comprehensible to them
- Document that subject agrees to participate in study
- Researchers must uphold right to self-determination and right to full disclosure
Confidentiality: protecting subject identity
- Identifying information cannot be revealed to maintain confidentiality
o Identify who are vulnerable groups/populations in research
Vulnerable Populations: lack ability to fully consent to participate in a study
- Individuals with diminished authority less able to defend themselves
- Limited mental capacity or ability to understand and process information
- Ex: children, pregnant women, unborn fetuses, prisoners, language, education, and gender identity
o Understand IRB Review and be able to identify Types of each Review i.e., expedited, full board, exempt) and what they are for
Institutional Review Board: group of people who review research involving human subjects
- Have the authority to approve research, require progress reports, place restrictions on, suspend, or terminate the approval of research
- It ensures research follows federal regulations and ethical standards
Types of Review: 3 different types
Full Review
- Necessary when commonly vulnerable populations are involved, and risks are not minimal
- Requires all members of board to participate in review
Expedited Review
- Used when there is minimal risk to human subjects
- Not all IRB members required to review the protocol
- Researchers must obtain consent from participants
- Ex: collection of body secretions without pain, surveys, noninvasive monitoring, some blood draws, research on vitamin drugs, or not new drugs, collection of data from voice, video, digital or image recordings made for research
Exempt Review
- Study has no apparent risk when participating
- Researcher must submit at least one copy of the protocol to IRB chairperson, so that authorized person affirms that research is exempt
- Ex: research in an educational setting, use of de-identified data and specimens already collected previously, public behavior observations, how public service programs are delivered
Ø Chapter 3:
o Know sources / issues that can be used to identify research problems.
Sources of Research Problems
- Clinical Problem/Experience
- Personal interest and expertise
- Previous research literature review
- Current practice thesis
- National initiatives
o Understand Key terms: Research statement, Problem statement, Purpose statement.
§ Be able to differentiate and determine which statements are Research statement, Problem statement, or Purpose statement according to the scenario.
Research Statement: guides the type of data to collect in a study, has 3 parts; the questioning part, word that indicates what researcher wants to know, and the population or variables
Problem Statement: formally identifies what problem is being addressed in the study
Purpose Statement: indicates the aim of the study, research purpose (aim)
o Review each type of variables
§ Know the definition and be able to Identify independent, dependent, confounding/extraneous variable from research contexts.
Independent: commonly labeled X, influences the dependent variable or outcome, it’s the intervention or treatment that the researcher applies to the experimental group
Dependent: commonly labeled Y, variable or outcome of the study’s focus, the entity that the researcher wants to modify/ predict, it is not manipulated
Confounding/Extraneous: commonly labeled C, factor or variable other than the one being studied that is interfered with the dependent variable and the independent variable
Mediators: an intervening variable necessary to complete a cause-and-effect link between independent and dependent variables, could have more than one, (the how and why variables are associated)
Moderators: an interaction variable that affect the direction and or strength of the relationship between the independent and the outcome variable (changes the strength or direction between variables)
o General concept of hypotheses, when and how it will be developed
Hypotheses: formal statements about the expected or predicted relationship between two or more variables in a specific population
- Derive from problem statement or research question
- Include at least two variables of interest
o Understand and Differentiate various types of Hypothesis
§ According to the example that will be given, determine the type of hypotheses presented
· Directional vs Non-directional, Simple vs Complex, Null hypothesis vs Research hypothesis
Types of Hypotheses
Associative: proposes a relationship or association between variables (a and b are associated or there is a relationship between a and b)
Casual: declares one variable is caused by another (a causes b)
Simple: involves two variables
Complex: involves more than 2 variables
Directional: specifies the direction of change that the researcher expects to occur (a will increase b, if a increases then b will decrease)
Nondirectional: does not specify the direction between variables (increasing a will change b)
Null: there is no relationship between two variables (there is no difference between a and b)
Research: proposes what the researcher will discover (a will be better that reducing effects than b)
o Clinical Questions (PICO question): Know the components of PICO question and be able to identify each component in the situation.
PICOT: population of interest, intervention, comparison of interest, outcome expected, time needed for intervention to achieve outcome
o Review Types of PICO and Format of Intervention, Diagnosis, Meaning, etc.
Five Types of PICOT
Intervention or therapy: to determine which treatment leads to the best outcome
Etiology: to determine greatest risk factors or causes of a condition
Diagnosis/ Diagnostic Test: to determine which test is more accurate and precise in diagnosing a condition
Prognosis/ Prediction: to determine the clinical course over time
Meaning: to understand an experience for a particular individual, group, or community
Ø Chapter 4:
o Identify health science databases that are used to search for answers to clinical nursing questions e.g., CINAHL, PubMed, Cochrane Library database, Web of Science. See 419 library course guide to understand health science databases
o General search strategies, including keywords used, truncation, Boolean, and consultation with the librarian, inclusion/exclusion criteria, etc.)
§ What would you do if your search produced too many initial search results?
§ What would you do if your search produced too little, limited search results?
o Differentiate Primary vs Secondary sources.
Ø Chapter 5:
o Understand the definition and components of Theory
Theory: a set of concepts linked through propositions to provide an explanation of a phenomenon
Concepts: words or phrases that convey a unique idea that is relevant to a theory
Propositions: a statement about the relationship between two or more concepts
Construct: an abstract concept that is specifically created to explain a given phenomenon
o Generally, how are these three concepts (Theory, Research, Practice) related?
o How Theory guides Nursing Practice
- Grand nursing theories (ex. Florence nightingale)
- Middle Range Nursing Theories (ex. Self-management)
- Situation Specific Theories (ex. Situation specific care transitions)
o Three ways that Theory can be used in research
Deductive Approach: research is undertaken to test a theory (quantitative research, theory testing)
Framework: theory is used as research framework, as the context for a study (qualitative or quantitative designs)
Inductive Approach: theory is generated as the outcome of a research study (qualitative research, theory generation research)
o What does Operational definition mean?
Operational: how the variable will be measured or counted
o Review Metaparadigm of nursing i.e., Nursing, Health, Environment, and Person
Metaparadigm of Nursing: the most global perspective of a discipline including four broad core concepts, explains how the discipline deals with phenomena in a unique matter
- Person
- Health
- Environment
- Nursing
Ø Chapter 6:
o Understand key terms of quantitative research and be able to determine these terms in research contexts.
§ e.g., With-in subjects vs Between subjects, prospective vs retrospective, history, operational definition, selection bias, control, causality, generalization, sampling methods, blinding, etc.
Causality: the independent variable must precede the dependent variable in terms of time sequence, there must be a strong relationship between the variables, the relationship between variables cannot be explained as being due to influence of other variables (cause and effect)
Between Groups Designs: studies designed to 2 or more treatment conditions (different groups test different options)
Within Groups Designs: compare the same groups but at different points in time
Prospective: individuals (same participants) are followed over time and data is collected as circumstances change
Retrospective: designed after some participants have already experienced events that are of relevance
Longitudinal: employ continuous or repeated measures to follow particular individuals over prolonged periods of time (years or decades)
Cross Sectional: examine data at one point in time (from one group or multiple groups)
o Review Quantitative research designs:
§ Review general definitions of the Experimental, Quasi-Experimental, and Non-Experimental designs (know what elements must be included for each of these designs)
§ Be able to differentiate between Experimental, Quasi-Experimental, and Non-experimental designs in research contexts
§ Strength of Experimental design
Experimental Design:
- Manipulation
- Randomization
- Control
Quasi-Experimental Design
- Manipulation
- Other components lacking (either lack of both randomization and control OR no randomization but have control)
Non-Experimental Design
- No manipulation
- No randomization
- No control groups
o Review threats to internal validity (e.g., testing, instrumentation, selection bias, history, Maturation, Mortality/Attrition rate) and be able to determine which one is the potential threat to the research studies.
Internal Validity: extent to which an independent variable causes a change in dependent variable and results are not attributable to other factors or other explanations
Threats to Internal Validity: history, testing, maturation, mortality, selection, instrumentation, statistical conclusion validity
o Review threats to external validity e.g., a threat of construct validity, reactions of subjects and experimenters including techniques to control it e.g., Hawthorn effect, Blinding, Random Assignment, etc.
External Validity: the degree to which the results of a study can be generalized to population
Threats to External Validity: construct validity, effect of selection, interaction of treatment and selection of subjects, interaction of treatment and setting, interaction of treatment and history
Ø Chapter 7:
o Know the differences between and be able to Identify major experimental design types from the abstract and/or research situations:
§ Experimental [e.g., Randomized control trial (Experimental design), Factorial, Crossover, two groups pre and posttest randomization (classic), etc.]
Experimental Designs: provide best evidence to claim cause and effect relationship, often include pretests and posttests to indicate point in time of data collection, look for differences between treated and untreated groups, external validity often reduced
6 Main Types of Experimental Designs
1. Two Group Pretest- Posttest: the classic experimental design, allows researchers to measure between group and within group differences, disadvantage is testing and mortality/ attrition
2. Two Groups Posttest Only: threats to testing and attrition are minimized, but we can never assume the groups are equivalent at baseline
3. Solomon Four Group: four groups and one intervention, it’s a variation of classic pre-posttest design, it reduces threat of testing, disadvantage is its not used a lot in practice, high cost, requires larger sample sizes
4. Multiple Experimental Group: multiple experimental groups and one control group, advantage is compares effect of multiple interventions on a DV at the same time, disadvantage is it requires larger sample sizes
5. Factorial: multiple experimental groups and more than one intervention, but only one control group, allows researcher to manipulate more than one intervention during the same experiment
6. Crossover: only one group is used and at least 2 interventions, experiment group receives different treatments at different points in time while in study, smaller sample size needed, disadvantage is carry over effects
§ Quasi-experimental [e.g., Time series, Nonequivalent control group posttest only (Quasi-experimental design) nonequivalent control group pretest-posttest, one group post-test only, etc.]
4 Quasi Experimental Designs
1. One Group Pretest- posttest: one group is measured before and after an intervention, no randomization, no control group
2. Nonequivalent Control Group Pretest-posttest: two groups are measured before and after an intervention, has experimental and comparison groups but no randomization
3. Time Series Design: one group is measured prior to an intervention and then measured multiple times over a prolonged period
4. Pre-Experimental Designs: posttest only
§ Non-experimental [e.g., descriptive, correlational, predictive].
Non-Experimental: important when there is little information known about a phenomenon and unethical to manipulate independent variable
2 Non-Experimental Designs
1. Descriptive: purpose is to describe a phenomenon of interest in detail (exploratory research, comparative research, survey research)
2. Correlational: used in quantifying the strength and direction of the relationship between two or more variables
Ø Chapter 8:
o Review key terms/concepts and be able to determine the key terms according to scenarios:
§ What are key Epidemiological Measures?
· e.g., Prevalence vs Incidence, Odds ratio, etc.
Epidemiology: study of distribution and determinants of health-related states or events in specified populations
Distribution: is concerned with the frequency and pattern (by time, place, person) of health events in a population
Determinants: are the causes and other factors that influence the occurrence of disease and other health related events
Common Epidemiologic Measures
Count Data: raw number (how many cases)
Ratio: a comparison of any two values; formula a/b (can be related or unrelated)
Proportion: the comparison of a part to the whole; formula a/a+b
Rate: measure of the frequency with which an event occurs in a defined population over a specified period of time
Incidence: number of new cases of disease in a defined population during a specified period of time
- measures disease occurrence
- used to investigate causes of disease, risk in populations
Prevalence: number of existing cases in a defined population
- indicates extent
- often used for chronic diseases (long term)
- point prevalence: cases at a given point in time
- lifetime prevalence: cases at any time in the past (cumulative)
- period prevalence: cases during a given period
§ Differences between Epidemic vs Pandemic: What does it mean?
o Review and differentiate types of Descriptive and Analytic epidemiologic studies.
§ Differentiate between Descriptive and Analytic epidemiology
· The purpose difference between these two
· What are the Examples of measures in Descriptive epidemiology?
· What are the Examples of measures in Analytic epidemiology?
Descriptive Epidemiology
- Can identify patterns among cases and in populations by time, place, and person
- Aim to identify population subgroups that may have higher risk for specific disease or outcome
- Focuses on what, where, who and when
Analytic Epidemiology
- Used to test hypotheses or association between exposure and disease outcome
- Have comparison groups
- Focuses on why/how
§ Understand analytic epidemiologic studies, including:
· Case reports, ecological studies, Case control, Cohort study, etc.
· What are the key characteristics of each measure? For example, if it is a case control what does it look like? If it is a cohort study, what made it a cohort study?
Case Reports/ Case Series:
Ecological Studies: compare summary measure disease frequency across summary measures of exposure
- Use aggregate data (data from individuals are reported as group information)
- Use a population as unit of analysis
Cross Sectional Studies: measure exposure and disease as each exists in a defined population simultaneously at one point in time
- Calculate the prevalence of disease
Case Control Studies: determine cases (individuals with disease) and controls (individuals at risk)
- Calculate odds ratio
Cohort Studies: compares probability of disease in exposed individuals vs not exposed individuals
- Calculate relative risk
Intervention Studies:
Screening: test people without known disease to determine if they have it
- Uses validity measures: sensitivity, specificity, positive predictive value
o Screening and interpretation
§ Differentiate between Sensitivity vs Specificity in the situation
Sensitivity: the ability of test to correctly identify people with the disease by positive test result
Specificity: the ability of the test to correctly identify people without the disease by negative test result
§ Positive Predictive Value: Definition of it
Positive Predictive Value: the probability that a person who screens positive actually has the disease
o Ecological Study (Epidemiology research design)
§ What are the key characteristics of ecological study? For example, if it is an ecological study what does it look like? What type of data will be used?
