Evidence-Based Practice, Research & Performance Improvement – Comprehensive Study Notes chap 5

Age of Accountability & Rationale for Evidence-Based Practice (EBP)

  • Modern nursing operates in an “age of accountability”: quality, safety, cost, transparency.

  • Public awareness of medical errors + payer penalties (e.g. CMS Hospital-Acquired Condition penalties) → pressure to use current science, not tradition.

  • ANA Scope & Standards of Practice, Standard 14: RNs must integrate “scholarship, evidence, and research” into practice.

  • Research priorities (Sun & Prufeta, 2019): nursing workflow, communication, collaboration, patient/family satisfaction, infection prevention, outcomes, safety.

Benefits & Foundations of EBP

  • Combines:

    • Best current evidence (research, guidelines, expert opinion)

    • Clinician expertise

    • Patient preferences/values

    • Available resources

  • Outcomes documented: ↑ patient satisfaction, ↓ costs, ↑ clinician empowerment, ↑ quality/consistency (Melnyk & Fineout-Overholt, 2019).

  • Aligned with QSEN competency; 12 EBP competencies validated for RNs, 11 more for APRNs.

Relationship to Clinical Judgment

  • Evidence informs interpretation of assessment data, identification of problems, selection of interventions.

  • Must still individualize: consider culture, beliefs, expectations.

7-Step EBP Process (Melnyk & Fineout-Overholt)

  1. Cultivate spirit of inquiry & supportive culture.

  2. Ask clinical question in PICOT format.

  3. Search for best evidence.

  4. Critically appraise evidence.

  5. Integrate evidence with expertise, patient values, resources.

  6. Evaluate outcomes.

  7. Communicate outcomes.

Step 0 – Cultivating Inquiry

  • Characteristics of supportive organizations: mentors, evidence-based P&Ps, infrastructure/tools, leaders who model EBP, inclusion in evaluations, recognition programs.

Step 1 – PICOT Questions

  • P = Patient/Population (age, gender, condition)

  • I = Intervention / area of Interest

  • C = Comparison (standard care)

  • O = Outcome (nondirectional statement)

  • T = Time frame (optional)

  • Types of triggers:

    • Problem-focused (e.g., ↑ CLABSI trend)

    • Knowledge-focused (new guideline, new drug)

  • Background vs foreground questions → foreground framed in PICOT.

  • Examples developed by Cathy & Tom:

    1. "Does 2% chlorhexidine (I) vs alcohol (C) for skin prep in hospitalized patients (P) affect CLABSI incidence (O) within 6 months (T)?"

    2. "Do sterile barrier techniques (I) vs sterile gloves only (C) during insertion affect CLABSI (O) in post-surgical patients (P) during hospitalization (T)?"

Step 2 – Searching for Evidence

  • Sources: P&P manuals, QI data, practice guidelines, journals.

  • Partner with medical librarian; manipulate keywords.

  • Major databases (Table 5.1): CINAHL, MEDLINE, PubMed, EMBASE, PsycINFO, Cochrane, AHRQ, World Views on EBN.

  • Hierarchy of evidence (Fig. 5.2):

    1. Systematic review / meta-analysis of RCTs; evidence-based guidelines.

    2. Single RCT

    3. Controlled trial without randomization

    4. Case-control / cohort / correlational (non-experimental)

    5. Systematic review of descriptive & qualitative

    6. Single descriptive / qualitative study

    7. Expert opinion & committees

Step 3 – Critical Appraisal

  • Determine value, feasibility, utility.

  • Use critical appraisal guides (purpose, sample, method, validity, results, limitations).

  • Elements of a research article:

    • Abstract, Introduction, Literature Review/Background, Manuscript Narrative (Purpose, Methods, Analysis, Results/Conclusions, Clinical Implications).

  • Statistical significance: p < 0.05 → < 5 % probability result due to chance.

  • Cathy & Tom: Level I systematic review found no dressing difference; CDC guidelines strongly recommend chlorhexidine & sterile barriers; Level IV cohort supported bundled interventions.

Step 4 – Integrating Evidence

  • Direct application to single patient OR larger-scale change (new protocol).

  • Gain stakeholder buy-in: administrators (cost/outcome), staff (workflow impact), providers (care implications).

  • Use mentors, education (seminars, newsletters), pilot testing (≈ 3 months) before system-wide roll-out.

  • Update P&Ps whenever new evidence emerges (not just annually).

Step 5 – Evaluation

  • Compare pre- & post-intervention data over 3−63{-}6 months.

  • Determine effectiveness, need for modification, or discontinuation.

  • Example: UPC audits CLABSI rates & staff adherence; unexpected ↑ infections would trigger reevaluation.

Step 6 – Communication & Sustainability

  • Share via huddles, Gemba boards, newsletters, councils, posters, conferences, publications.

  • Strategies to sustain (Box 5.2): leadership vision, EBP workgroups/journal clubs, certification, academic partnerships, visual management tools, fellowship programs.

Scientific Method (Research Foundation)

  1. Observation of problem.

  2. Literature review & data gathering.

  3. Form research question/hypothesis.

  4. Conduct rigorous study (quantitative or qualitative) → collect empirical data.

  5. Analyze & draw conclusions (validity, reliability, generalizability).

Comparison: Nursing Process vs Scientific Method (Table 5.2)

  • Assessment ↔ Observe & review literature

  • Diagnosis ↔ Formulate research question/hypothesis

  • Planning ↔ Design study (methodology, sampling, variables, analytics)

  • Implementation ↔ Conduct study & collect data

  • Evaluation ↔ Analyze data, draw conclusions, disseminate findings

Types & Methods of Research

  • Exploratory, Descriptive, Correlational, Historical, Evaluation, Experimental.

Quantitative Research

  • Objective, numeric, statistical.

  • Experimental (RCTs): random assignment; highest causal evidence.

  • Quasi-experimental (non-randomized controlled): potential bias.

  • Non-experimental/Descriptive: explain/predict phenomena (e.g., case-control, cohort).

  • Surveys: measure frequency, distribution; must minimize sampling error.

Qualitative Research

  • Subjective, narrative; explores meaning/experience.

  • Uses inductive reasoning.

  • Designs: Phenomenology, Ethnography, Grounded Theory.

  • Data = interview transcripts, field notes; analysis → themes.

Translation Research (Implementation Science)

  • Tests strategies to implement & sustain EBP in real-world settings.

  • Goal: determine what works, for whom, in which context.

  • 5-phase continuum: Basic → Phase 1 safety → Phase 2&3 efficacy → Phase 4 practice → Phase 5 community/population outcomes.

  • Example: testing adoption strategies for Naylor’s Transitional Care Model.

  • Differs from EBP (which applies known evidence); translation research creates evidence about implementation strategies.

Outcomes Research

  • Examines benefits, risks, costs, holistic effects of treatments.

  • Care delivery outcomes = measurable effects on recipients (not providers).

  • Nurse-sensitive indicators: falls, pressure injuries, CLABSI, etc.

  • Outcome components: indicator, measurement method, parameters (scale/range). Example: patient satisfaction scored 1−51{-}5.

Performance Improvement (PI)

  • Local, systematic analysis of existing processes; aims at efficiency & safety; results usually not generalizable.

  • Continuous effort to meet “triple aim”: better care, better health, lower cost.

  • Common models (Table 5.3):

    • PDSA (Plan → Do → Study → Act)

    • Root Cause Analysis (RCA) for sentinel events (identifies active vs latent errors)

    • Six Sigma

    • Balanced Scorecard

  • Just Culture: focuses on process, encourages error reporting.

Comparing EBP, Research, & PI (Table 5.4)

  • Purpose: implement best evidence vs generate new knowledge vs improve local processes.

  • Data sources: multiple studies/expert opinion vs defined sample vs unit/hospital records.

  • IRB: required for research, sometimes for EBP/PI when patient data or novel interventions involved.

  • Funding: internal for EBP/PI, often external grants for research.

Databases & Resources (exam ready)

  • AHRQ, CINAHL, MEDLINE/PubMed, EMBASE, PsycINFO, Cochrane Library.

  • Free sources: PubMed, Cochrane abstracts; institutional access often via OVID/EBSCO.

Ethical & Practical Implications

  • Informed consent elements: complete info, comprehension, voluntariness, confidentiality.

  • pp-value threshold (p≤0.05p\le0.05) denotes statistical significance; guides decision to adopt change.

  • Must balance patient preferences with strongest evidence; cultural sensitivity (e.g., therapeutic touch example).

  • Nurses obligated to question status quo, avoid tradition-only care.

Numerical / Statistical Reminders

  • CMS HAC penalties: lowest-performing 25%25\% hospitals lose reimbursement.

  • p-value: p<0.05 → <5 % chance result due to randomness.

  • Pilot implementation suggested duration ≈ 3 months3\text{ months}.

  • PICOT time element often 6 months6\text{ months} in CLABSI example.