Understanding Evidence-Based Practice in Nursing

Alright, so today's topic is evidence-based practice and this is something that often is intimidating even to experienced nurses, but there really is no reason to be intimidated by evidence-based practice because it really is just taking current best evidence from clinical research and making sure that you're using it in the management of your individual patients so this is essentially how we get high quality care it's supported by evidence if we just did things out of habit that would would be completely different. So doing things based on evidence is exactly what evidence-based practice is. I really like this little quote here that I found in a journal that I was reading recently. And it's a nurse who says, we need to understand that evidence-based practice should not be confused with research, but rather that research is fueled by evidence-based practice. And I think if more nurses slowed down and thought about that, then maybe they'd be a little bit less intimidated by evidence-based practice because we're not asking you to go out and do research. We're asking you to go out and do research. asking you to be aware of the research that's being done to critically evaluate that and to bring the best of that evidence into your patient care. So any of your evidence-based projects shouldn't require any statistical analysis and they shouldn't be intimidating. This is what we should be doing in our daily practice. So why is evidence-based practice so important? It's important because it allows nurses to structure how they make accurate, timely, and appropriate clinical decisions and that's what nursing... is all about, being able to think in action and make appropriate decisions. So with our evidence based practice, it is a problem solving approach to our clinical practice. So it integrates best evidence together with our clinicians expertise together with patients preferences and values. And that's what gets us our again, our quality patient care, and that is best practice. So without evidence based practice, nursing would be based solely on tradition. And that quite frankly would be a scary place to be. be and we'd be going backwards. Alright, so when we look at evidence-based practice, there's many different definitions for it, but they're all really very, very similar. So the one that's on your slide here comes from a couple of researchers from a few years ago, but it's still a very valid definition. And here we say that it is... A way that we are integrating best scientific evidence with our clinical expertise, knowledge of pathophysiology, psychosocial issues, and the decision-making preferences of patients, their families, and communities. The next slide is sort of another way of looking at the pathophysiology of patients. at the same thing, so more of a graph version, but really we're saying the same thing. When we're making evidence-based decisions, we're taking evidence from research, we're taking our assessment data, we're taking information from the patients about their preferences of value. and we're using our clinical expertise and all of this is how we are making an evidence-based clinical decision. So with this it really is important to remember that when we're looking at these problem-solving approaches we're integrating everything. We're looking at the patient's values, we're looking at our expertise, and we're using all of that to make the best possible clinical decision. And this quote here I wish I could remember who said this I'm happy I remembered the quote but I cannot remember who says it so I can't credit this, but I love the thought behind this and here we're saying each nurse has the responsibility to go beyond what is easy, habitual, or traditional to locate and implement evidence that enhances patient care safety and satisfaction. And it's very simple but I think it's important for us to realize that this is our responsibility. We can't just keep doing things the way that people did it before us and not question. And that's what a lot of evidence-based practice is about. It is about people going out and questioning. questioning what has been habitually and traditionally done and seeing is there a better way of doing something and that is really important to our practice. So there are of course steps to this. We'll go through this in a little bit as far as asking the clinical question because that is the most important part of this whole process. If you don't ask a good question, then you're not going to get good evidence and you're not going to be able to support that. But in looking at these steps, we're looking at first asking a clinical question, then doing your literature review to be able to gather your evidence then you're critiquing that evidence you're making some change based on it you're evaluating that and then if that change was successful then you're sharing the success of that with others so that they also can implement these changes All right, so when we're looking at a clinical practice question, it really is just looking at is there a better way to do something? What do experts recommend? How can we do something differently? So it's looking at your own practice and saying, why am I doing this? So the pictures that I have on this slide here comes from something a few years back in my own practice where the nurses in the ICU were questioning why we were flushing patients'G-tubes with sterile water when they go directly into the stomach and we don't drink sterile water. We drink tap water, we drink milk, we drink, you know, other things. So why do these tubes need to be flushed with sterile water was our question. And it was something where we asked that clinical question. And again, it wasn't a research question. It was just, you know, why are we doing this? So the first thing we did was go to the literature to see what does the literature say. And it was quite obvious as soon as we looked that up that there was a good reason for it in that these are critically ill patients and so their immune systems are compromised and there's usually a lot of different acute issues going on with them that got them to the state that they're at. So this isn't simply somebody who's at home getting feeding through their G-tube. This is somebody who's in an intensive care unit who has... has a lot of other issues going on and therefore we use sterile water to prevent any complications, any infections. And so that made sense to us. But it was nice that we were able to ask that question, look at that research and say, oh okay, we are doing the right thing. And if we had seen different evidence that said there was nothing that supports it, then perhaps we would have looked at doing a research study to see what are the outcomes of somebody who got tap water versus somebody who got sterile water. All right, and then this slide. here I was pretty impressed with myself when I found this because I thought it related to the topic really well so this is obviously Albert Einstein he says if I had a problem to solve if I had an hour to solve a problem and my life depended on it I would use the first 55 minutes determining the proper questions to ask. And I think this really relates to our evidence-based practice because in order to find good evidence, you have to be able to ask a good question. So that's what we're focusing on here. And your book does a really nice job of talking about this PICO or PCOT question and really helping to break that down. So I want to make sure that you guys are looking at that because it's obviously a little bit more complex than just what's on this slide here. It originally, the PICO question originally developed from basically again, like I said, just that spirit of inquiry with nurses examining practice under the lens of evidence from the literature. So essentially, we're just asking why are we doing things this way? And we're looking for a way to find answers to that. A lot of nursing questions only include the P, I, and O because we're not doing true research. If you're doing research, then you're doing comparisons, you're doing interventions. But if we're just looking at what's out there then a lot of times it's just the you know the patient the intervention and the outcome and then some Some meaning questions will have only the P and the I so if you had a meaning type question It would be how do I see you patients which would be the P? Experience delirium which would be the O if you had something that was a nursing Type question that's going to lead to some literature We can have a question that says, in ICU patients, which would be the P, how does sedation vacation, meaning taking the patient off of their sedation for a small period of time, would be the I, affect delirium, which would be the O? So kind of think about that, look through your book because it's a kind of a big topic, but hopefully that makes sense to you and if not we can discuss it a little bit further. All right, so when we are gathering evidence, we really are trying to get a really focused peak up question because that makes it so much easier to research the evidence. If you don't really know what you're looking for then it's very difficult to find it. Sometimes when we're doing that, you know, we're looking for evidence, we're looking for evidence that is relevant to the looking at what are all these different findings, what's the rigor of the evidence. We're critiquing all of that. So it really is, it's important to know what you're looking for. Then you can really look at the literature that you have and critique it fairly. The next slide here is a very famous model that outlines the steps of evidence-based practice. It's called the Iowa Model. And so it's funny because there's actually one portion of this that I would like to flip-flop. But it is the Iowa Model. It's not the Professor Ray Model. So I don't have to. have the right to do that so I will go through it here and I'll tell you what my slight beef with this one is so if you go through and you are asking a question basically that's your first step and then you need to know down in this there's sort of a diamond shape of the next level which says is this topic a priority for the organization if this is something that you are asking that is going to affect patient care in the organization you're working in then that's a Fair question, right? We need to know is this something the organization is going to support looking into. If it is, then this model says the next step is to form a team. And this is where I beg to differ a little bit because I really think the step below that, assembling relevant research and related literature and critiquing it and synthesizing that, makes more sense to do that before you develop a team. So the example that I gave you of the sterile water, if the couple of nurses where we were questioning that, If we had gone and formed an entire team, talked to our managers, said can we form a team to look into this? It would have been kind of a waste of everybody's time because as soon as we got off the literature and we looked at it it was very obvious that the practice that we were doing was the way that it was supposed to be for a reason and we didn't need to jump through any more hoops. So we would have pulled all these different people together, formed this great team and told them okay, you guys are gonna help us look at this and then we would have looked at those articles and said okay well, that's it. Keep, go back to work. So to me it seems to make more sense to look at that first but again this is the Iowa model and that's how they set it up. Again then if once you have that then you're looking is there sufficient research base if there is and it supports changing something then you're going to do a pilot project on changing that you're not going to change practice in the entire hospital maybe you're going to pick one unit where you're going to start this change and then you look to see is that change appropriate for adoption so did this change Was it a positive change? Well, if it was a positive change, then we can continue to do that. And then we would also want to share the change and the positive results with the rest of the hospital or the rest of a nursing community or whatever, ever population it affects so that others can follow our best practice that we now have seen makes a difference in patient care. Hopefully that makes sense to you guys. All right. So when we are looking at studies and this is where some people get intimidated. when you're looking at research articles sometimes it can be a little bit overwhelming when you're reading an article don't just put it down and walk away because the statistics and the technical language scare you break it down and really look at what are they talking about. Read the abstract first. That's a brief summary that quickly tells you if it's research or clinically based, what the purpose is. That one's usually pretty digestible. And then read the introduction. This is where you get a little bit more information about the purpose. If you have a good author, they're going to give you some detailed information of the science or the clinical information. Then you've got the whole middle section, which will describe their topic. their population, all of that, the method of design of it, the whole how did they go about all this. And then there's the results and conclusion portion which tells you what did they find. And then usually there's also a section that talks about further research that's needed, looking at what else can we do moving forward. So, again, there's a lot of technical terms and sometimes that can get a little bit intimidating. But really, as you're reading these, you know, don't just walk away and say, this isn't for me. I'm not smart enough because we've all been there. And, you know, some articles are written at a very high level. But there's help out there to understand these articles. You've got your, you know, your research professors. You've got every hospital now that is going, that's in the magnet. journey. They have researchers and again most of this research we're trying to do a good job of disseminating information so the authors are trying not to make it so very intimidating that no one other than researchers can read it because then we're not getting our information. to the people who can make a difference who are in clinical practice. So when we're rating our research we have to look at a couple different things. So we want to look at how is the study designed and I'll show you we have sort of a pyramid that that talks about strength of evidence. There's a hierarchy to that, so I'll show that to you in a couple of slides. But you also have to look at the internal validity, which would be things like how big is the population size? If you study two patients in North Dakota, that's not really enough of an internal validity to say that this is how patients across the United States are gonna be affected. So you need to have a pretty decent size patient population. then you have to look at you know if it's if the study was only on males can you relate it to females so really looking at that internal validity how well was it designed how well was it executed how large a size did they have and then you need to look at consistency and volume of evidence as in is it one study that says X while all the other studies say Y in which case are you going to base your practice on X or are you going to want to see some more studies that back that up. And then the magnitude of effect is really how much effect did this intervention have. Was it a large effect on the outcome or was it a teeny tiny change? And then you really need to look at is it applicable applicable to your practice. That's important as well. So there's a lot of different things to look at and there's a lot of different tools out there that can help you to rate research. This is just sort of an overview again to try and make it not such an overwhelming experience. So after you've critiqued the article and you've figured out what the Peacock question is, then that's when you're looking at what the findings are. You are considering the rigor as far as, you know, is this good evidence? And then you're looking at, again, does it apply to your practice? So essentially what I just said. Let me see here. All right, I think I said all of that. All right, so as you are reading research, you're looking first, you want to know, you want to know what their question was. So their research question, their hypothesis, that should be clear to you. When I read studies, I highlight that because to me, that's important to know. They also should be telling you that they did a literature review. You don't just go out and do research without having done a literature review first to see are there others that have researched the same thing. and what did they find. So they should be saying how they did their literature review, what keywords they used when they were doing their research, what the literature said, and then basically why are they doing their studies. So was there something that was not researched that they thought, okay, the literature talks a lot about this. in males, but they don't talk about at all about how this affects females, so we're going to do some research on females. There should be some kind of connection between the literature and then the study that they choose to do. Their study strategy should be clearly outlined, and it should be reproducible. So they should outline it clearly enough that somebody else could come along and do essentially the same thing following their steps. And then as far as their data analysis goes, are they clearly processed? Are they clearly explaining how they're doing this data analysis. And there's usually a whole section dedicated to that. And that section is usually a little overwhelming because there's a lot of technical terms in that. But if you then go to the conclusion, then that's where you find, you know, what did they really find? And in here, they should also talk about their study limitations. So was their group too small that they looked at? Were they only looking at patients in... colder climates, warmer climates, you know, there's usually some kind of limitations to a study and then somebody picks up the other piece of that and studies the other section that wasn't covered as well. The next slide is the hierarchy of evidence that I was telling you about and we will go through each of these. So this is more for you to refer back to because right now you don't know what a random control study is and you met us Meta-analysis and all of that so it doesn't really make so much sense right now But this is for you to look back at after we've kind of talked about all these different systems or all these different types of evidence Essentially the synopsis of this is that if you had a random control study Which I will talk about then that's considered the gold standard. That is really, really good evidence. If you had a meta-analysis of randomized control studies, meaning several of them all saying the same thing, then that is the peak of that triangle. You can't get any better than that. But it doesn't mean that the types of evidence that are below here are less valid. It just, they support in different ways. So some things can only be studied by doing qualitative research. in that case, then that's a valid type of evidence. And it does on here list as well the opinions of authorities and expert committees. That's important, but if you have other types of evidence, then they, of course, are ranking above that. So when we look at the meta-analysis and the systematic reviews, this is, like I said, multiple studies that are addressing the very same or similar topics, and they're looking at all these studies side by side, And they're looking at what did they find. So these are very nice if you have a topic where there's a lot of evidence out there. Somebody else is taking all those articles, pulling them together, comparing and contrasting, and then giving you their opinion on that. Similar with the systematic reviews, here they're really looking at all these multiple studies that have affected the same thing and saying, you know, what exact questions were they looking at? Are we seeing the same thing reproduced over and over? The Cochrane Collaboration does a lot of reviews based on evidence. I left you their their website ...a site down here, but you can also just Google Cochrane Collaboration and it'll take you right there. And that's another useful tool when you're doing lit reviews, getting ready to write papers, that type of thing. So the randomized control study, this is the one that I told you about. is the highest level of evidence unless you had a meta-analysis of randomized control trials. So, with this, you have to have an intervention, you have to have a control group, there has to be random assignment to both the intervention and the control group. and you have to be manipulating some independent variables. This, like I said, when we're talking about the peacock question, this is not so often used in nursing because it is very difficult to do that randomization and to have the control group and the intervention group with a nursing focus. This is more common, something that they will do in medicine, in pharmacy, pharmacology, that type of thing. All right, and then quasi-experimental, again, this is a rung below our randomized control trials. With this there is an intervention. It may or may not have a control group. There's not usually random assignment to the intervention in the control group and there's usually some manipulation of the variables. So this is something that we could see in where we would see a pre-test and a post-test. So you can see pre-test and then you give the education of whatever it is you're going to educate the group about and then you do a post-test to see how did this affect your outcomes. So this is an easier type of research, I don't know if that's the right word. But it applies more to our nursing type of research. And then there's non-experimental research as well. So this may or may not have an intervention. There's no randomized assignment to a group. There's no control group. There's no manipulation of independent variables. And these are your descriptive, predictive, explanatory case studies, that type of research. Then when you get to qualitative, there is no randomization, there's no manipulation of independent variables, there's very little control over the environment because usually this type of research is being done outside of a controlled settings. So you're going out and you're essentially talking to people. With these, you could have met a synthesis of multiple qualitative studies. And again, that would then be a higher source of evidence than just one study. And then there's some studies that are mixed methods, which have both a quantitative and a qualitative feature. All right, so again, when you have all of this evidence, you have to try and decide if this is something that you want to apply. So what is the setting? Is there going to be support from staff? Is there going to be support from management? And then you're looking at evaluating the change. Was it a positive change? and then again sharing that information. So kind of coming full circle and talking about how do we go through this process, like the steps that we talked about before. All right, so there's also some terminology as far as human research goes. So if you hear anybody talking about IRB, that's Institutional Review Board, this is a group that is essentially protecting those that the research is being conducted on. So the IRB at a hospital is protective of its patients. So if If I say I want to go do some research and I want to have a control group and I want to have all these things, the IRB is going to look at that and say, is this okay? Is this all right with our patients? Are our patients going to be safe? Are they going to be protected? How are you going to keep identities concealed? I did a small research study a few years back and it was very low level. It was on high school students who were coming into the hospital to do a week-long health professions academy. And really all I wanted to do was give them a pre-test, then have them there for the week academy where they were introduced to different health careers and had different speakers and got to go shadow on the floors, and then do a post-test at the end of that to see what did they walk away with. Did they walk away with more knowledge? Did they have a better understanding of what nursing is, what physical therapy is? That's really all I wanted to do. Even that had to go to the IRB for approval. And one of their things, one of their caveats that they said to me is that you have to be able to not only protect their identity, so it had to be in a locked room, in a locked drawer. I had to not be able to, they had to be numbered. I couldn't see names on them so that I wouldn't know who said what. And then their one concern for the student safety was that somebody might feel bad about themselves if they didn't score well on it. And so you can see they take this very seriously and really look at what could be the consequences. All right. So the other term that you will hear is informed consent and this is very important. So with this it really means that the participants have received full and complete information, that they can understand it, that they have free choice to participate. So that was the same thing even in my little low-level study I had to make it very clear to them that this is the study that I'm doing if you choose not to participate in it you can still participate in the week you can still have all those activities I won't know whether you participate or not because I have to walk out of the room when you do your pre-test and somebody else is in there monitoring and same thing for the post test and then that confidentiality that i mentioned so it was very important that everybody was numbered there could be no names on it and it had to be under lock and key at all times so i couldn't just stick it on my desk or put it in a drawer somewhere it had to be inside a locked drawer inside a locked room. So these are really very important and there are some studies that I don't know how familiar you are with them but there are some studies that were done. probably 50, 60, 70 years ago now that did not really look out for the participants and the participants were not fully understanding why the research was being done or what was happening to them and they didn't really have free choice to participate and that certainly is not okay and that's not a place we want to go back to. Alright so again our research process is very organized you're really looking at Just identifying your problem, deciding how you want to design your study, conducting your study, analyzing the data from your study, and then doing something with the findings that come out of that. So when you break it down in that level then I think it's a little bit easier. easier to understand what we're talking about. Alright, so within nursing research, we're looking at trying to identify new knowledge, improve our professional education and practice, and use our resources effectively. ICN is the International Council of Nursing and this group supports nursing priorities and guides research. They have an online, I think it's almost eight hours, course that you have to take before you're allowed to do any type of research. So they again, they're trying to make sure that the research that we're doing is valid, is high quality. quality is safe for our patients and is producing good results. So with this, our research becomes really a systematic process where we're asking and answering questions, we're generating knowledge, and we're providing a scientific base for nursing practice. And that's a big deal. When we look at Joint Commission, they mandate that healthcare institutions have a formal process For reviewing the latest research and ensuring that their policies and procedures are consistently revised to reflect this. So now it has become even mandated by joint commission, not just for our magnet hospitals and that type. So this is good. This is moving forward in our profession. All right. And there is definitely a link between our scientific method and research. So the scientific method essentially becomes the foundation for research. It minimizes the chance that there's going to be bond. bias or opinion by a researcher. Researchers can try and control those external factors that are not being studied and they can gather empirical data through the use of observations and assessments and then use this data to discover new knowledge. So we see these two processes go hand in hand. When we're looking at nursing research, again, this is really how we're studying things and how they affect us. Just to be clear on the quantitative, these are the control group, the randomization, all of that. And then our qualitative, these are really the questions that can't really be measured specifically. So these, they're more used for phenomena. So things that are difficult to quantify are studied qualitatively, where we are able to get written transcripts, do interviews, and really get a hold of what were the... perceptions, what were the experiences that somebody had versus real precise systematic objective, which is more your quantitative. All right. So then there's a couple other areas that we need to look at. So the other thing we're looking at is quality performance improvement, which is a big deal to all of our healthcare organizations. The Joint Commission defines quality improvement as an approach to to continue a study and improvement of the process of providing healthcare services to meet the needs of the population. the needs of patients and others. So some of the things we look at are things like fall prevention, medication delivery, decreases in hospital acquired infections, pressure ulcers. These are all quality improvement areas where we want to try and make an improvement. Our nursing sensitive indicators fall into that. So a lot of those that I just mentioned are nursing sensitive indicators. And so those are things that you're going to see on your big bulletin boards in your nursing units where those are the QI projects that we're working on. And this is how we work to look at what our data is saying and are there changes that we need to make based on that. So performance improvement, we're really looking at what are we currently doing, are those results good enough, and then maybe we're looking to evidence-based practice because these go hand in hand. And maybe there's something that we can change that will then serve to improve our performance and our quality. quality. So if there's an example of how you would do a QI change. So the first thing is that it's a PDSA is what we call this and a lot of the hospitals still use this so I want to make sure if you hear that term that you understand what we're talking about. So the P is for plan where you're really reviewing your available data and you're making sure you understand what is currently going on and you're looking is there need to change something. The D is the do, so here you're selecting an intervention based on the data that you have and you're implementing a change. Then the S is for study where you're really evaluating the results of this change. So what happened when you changed whatever it is that you changed. And the A is for act. So this is where you now are going to change if there was a positive outcome. So if what you did had a positive outcome then you need to act and incorporate this into the daily unit performance. So through this we're able to understand our work processes and see when we need to make changes in our practice. And the next slide is just really a look at again the three different components. So our research, which supports our evidence-based practice because it is the evidence, right? Research is another word for evidence. And then our quality improvement, which is what we're doing by implementing these things. We're trying to improve the outcomes for our patients. So as a BSN nurse, what is your role in research? Your role is to keep your eyes open, to make sure that you're not scared of it, to not be afraid to ask questions. to be able to find these studies, to be able to appraise them critically and see are they valid studies, to be able to incorporate this into policies and procedures, to be able to look at this research and have it guide your practice and to really look around for those questions. So see if you can find out what questions do you have. Some of the things that come to mind from my own background, we looked at ventilator associated pneumonia in one of the ICUs that I worked at. And it was sort of, it was something that just sort of happened. You know, you had very, very sick people, they're on ventilator for an extended period of time. And every once in a while, somebody would get pneumonia. And for a long time, it seemed as if that was just the way that it is. Sometimes people are just so sick, they don't have any immune defense, there's really not a lot you can do. But when we started to really focus on it as a nursing department and started to look at who developed pneumonia, who didn't develop pneumonia, we realized that we didn't all have the same nursing practice. And we came up with what we called a bundle of care. So this is where we decided all patients who are on a ventilator need to have their head of bed at 45 degrees. They need to have oral care every two to four hours. They need to be repositioned every two hours. Lots of different things that we put into place and lo and behold, we ended up with zero ventilator associated pneumonias for years and years and years. So these were changes that we made. that made a big difference in patient outcomes. So this was us looking at evidence and seeing what were other people doing. Other people were doing this and they were having more success than we were. So that's where we took that from. So again, evidence-based practice really begins with questions that arise in your everyday clinical practice. So you need to feel empowered as nurses to ask those clinical questions because you're looking for opportunities to improve nursing practice and patient outcomes. And that is what it's all about. it's all about, right? So in conclusion, our evidence-based practice interventions, we learn how to improve our patient outcomes, how to help to be part of providing that high quality care. We're reducing costs and we're eliminating practices that have become obsolete or are not effective. And that's really important. We really want to always be looking at the latest and greatest because that's how we're going to continue to grow our profession. And then this was another quote from the article that I recently read. One of the key points we learn in nursing school is to be a generation that provides high quality care that is supported by evidence. So I hope that's something that you are taking away and I hope that is second nature to you because again I went to nursing school a few years ago but this is not how I was taught. I was not taught to question things and I think that's being a good nurse you have to question things. So I do hope that you feel that you are being taught to question things and that high quality nursing care needs to be supported by evidence. All right, I think that's all I have for you. All right, well, there we go, a little technical issues. All right, so hopefully this all made sense to you. If not, then please let me know what questions you have. Sorry, I'm still goofing with my computer here. But hopefully all that made sense to you. Make sure you read the topic in your book as well because there's a lot more detail in there that will help bring some of the fuzzy, muddy parts of this to the surface for you. And then please don't hesitate to ask questions. If there's something that didn't make sense to you, then please ask some questions so it can be clarified. All right, thank you.

And I think if more nurses slowed down and thought about that, then maybe they'd be a little bit less intimidated by evidence-based practice because we're not asking you to go out and do research. We're asking you to go out and do research. asking you to be aware of the research that's being done to critically evaluate that and to bring the best of that evidence into your patient care.

So any of your evidence-based projects shouldn't require any statistical analysis and they shouldn't be intimidating. This is what we should be doing in our daily practice. So why is evidence-based practice so important?

It's important because it allows nurses to structure how they make accurate, timely, and appropriate clinical decisions and that's what nursing... is all about, being able to think in action and make appropriate decisions. So with our evidence based practice, it is a problem solving approach to our clinical practice. So it integrates best evidence together with our clinicians expertise together with patients preferences and values. And that's what gets us our again, our quality patient care, and that is best practice.

So without evidence based practice, nursing would be based solely on tradition. And that quite frankly would be a scary place to be. be and we'd be going backwards. Alright, so when we look at evidence-based practice, there's many different definitions for it, but they're all really very, very similar. So the one that's on your slide here comes from a couple of researchers from a few years ago, but it's still a very valid definition.

And here we say that it is... A way that we are integrating best scientific evidence with our clinical expertise, knowledge of pathophysiology, psychosocial issues, and the decision-making preferences of patients, their families, and communities. The next slide is sort of another way of looking at the pathophysiology of patients.

at the same thing, so more of a graph version, but really we're saying the same thing. When we're making evidence-based decisions, we're taking evidence from research, we're taking our assessment data, we're taking information from the patients about their preferences of value. and we're using our clinical expertise and all of this is how we are making an evidence-based clinical decision.

So with this it really is important to remember that when we're looking at these problem-solving approaches we're integrating everything. We're looking at the patient's values, we're looking at our expertise, and we're using all of that to make the best possible clinical decision. And this quote here I wish I could remember who said this I'm happy I remembered the quote but I cannot remember who says it so I can't credit this, but I love the thought behind this and here we're saying each nurse has the responsibility to go beyond what is easy, habitual, or traditional to locate and implement evidence that enhances patient care safety and satisfaction.

And it's very simple but I think it's important for us to realize that this is our responsibility. We can't just keep doing things the way that people did it before us and not question. And that's what a lot of evidence-based practice is about.

It is about people going out and questioning. questioning what has been habitually and traditionally done and seeing is there a better way of doing something and that is really important to our practice. So there are of course steps to this.

We'll go through this in a little bit as far as asking the clinical question because that is the most important part of this whole process. If you don't ask a good question, then you're not going to get good evidence and you're not going to be able to support that. But in looking at these steps, we're looking at first asking a clinical question, then doing your literature review to be able to gather your evidence then you're critiquing that evidence you're making some change based on it you're evaluating that and then if that change was successful then you're sharing the success of that with others so that they also can implement these changes All right, so when we're looking at a clinical practice question, it really is just looking at is there a better way to do something? What do experts recommend?

How can we do something differently? So it's looking at your own practice and saying, why am I doing this? So the pictures that I have on this slide here comes from something a few years back in my own practice where the nurses in the ICU were questioning why we were flushing patients'G-tubes with sterile water when they go directly into the stomach and we don't drink sterile water. We drink tap water, we drink milk, we drink, you know, other things. So why do these tubes need to be flushed with sterile water was our question.

And it was something where we asked that clinical question. And again, it wasn't a research question. It was just, you know, why are we doing this?

So the first thing we did was go to the literature to see what does the literature say. And it was quite obvious as soon as we looked that up that there was a good reason for it in that these are critically ill patients and so their immune systems are compromised and there's usually a lot of different acute issues going on with them that got them to the state that they're at. So this isn't simply somebody who's at home getting feeding through their G-tube.

This is somebody who's in an intensive care unit who has... has a lot of other issues going on and therefore we use sterile water to prevent any complications, any infections. And so that made sense to us.

But it was nice that we were able to ask that question, look at that research and say, oh okay, we are doing the right thing. And if we had seen different evidence that said there was nothing that supports it, then perhaps we would have looked at doing a research study to see what are the outcomes of somebody who got tap water versus somebody who got sterile water. All right, and then this slide. here I was pretty impressed with myself when I found this because I thought it related to the topic really well so this is obviously Albert Einstein he says if I had a problem to solve if I had an hour to solve a problem and my life depended on it I would use the first 55 minutes determining the proper questions to ask.

And I think this really relates to our evidence-based practice because in order to find good evidence, you have to be able to ask a good question. So that's what we're focusing on here. And your book does a really nice job of talking about this PICO or PCOT question and really helping to break that down.

So I want to make sure that you guys are looking at that because it's obviously a little bit more complex than just what's on this slide here. It originally, the PICO question originally developed from basically again, like I said, just that spirit of inquiry with nurses examining practice under the lens of evidence from the literature. So essentially, we're just asking why are we doing things this way? And we're looking for a way to find answers to that. A lot of nursing questions only include the P, I, and O because we're not doing true research.

If you're doing research, then you're doing comparisons, you're doing interventions. But if we're just looking at what's out there then a lot of times it's just the you know the patient the intervention and the outcome and then some Some meaning questions will have only the P and the I so if you had a meaning type question It would be how do I see you patients which would be the P? Experience delirium which would be the O if you had something that was a nursing Type question that's going to lead to some literature We can have a question that says, in ICU patients, which would be the P, how does sedation vacation, meaning taking the patient off of their sedation for a small period of time, would be the I, affect delirium, which would be the O?

So kind of think about that, look through your book because it's a kind of a big topic, but hopefully that makes sense to you and if not we can discuss it a little bit further. All right, so when we are gathering evidence, we really are trying to get a really focused peak up question because that makes it so much easier to research the evidence. If you don't really know what you're looking for then it's very difficult to find it. Sometimes when we're doing that, you know, we're looking for evidence, we're looking for evidence that is relevant to the looking at what are all these different findings, what's the rigor of the evidence.

We're critiquing all of that. So it really is, it's important to know what you're looking for. Then you can really look at the literature that you have and critique it fairly. The next slide here is a very famous model that outlines the steps of evidence-based practice.

It's called the Iowa Model. And so it's funny because there's actually one portion of this that I would like to flip-flop. But it is the Iowa Model. It's not the Professor Ray Model. So I don't have to.

have the right to do that so I will go through it here and I'll tell you what my slight beef with this one is so if you go through and you are asking a question basically that's your first step and then you need to know down in this there's sort of a diamond shape of the next level which says is this topic a priority for the organization if this is something that you are asking that is going to affect patient care in the organization you're working in then that's a Fair question, right? We need to know is this something the organization is going to support looking into. If it is, then this model says the next step is to form a team.

And this is where I beg to differ a little bit because I really think the step below that, assembling relevant research and related literature and critiquing it and synthesizing that, makes more sense to do that before you develop a team. So the example that I gave you of the sterile water, if the couple of nurses where we were questioning that, If we had gone and formed an entire team, talked to our managers, said can we form a team to look into this? It would have been kind of a waste of everybody's time because as soon as we got off the literature and we looked at it it was very obvious that the practice that we were doing was the way that it was supposed to be for a reason and we didn't need to jump through any more hoops.

So we would have pulled all these different people together, formed this great team and told them okay, you guys are gonna help us look at this and then we would have looked at those articles and said okay well, that's it. Keep, go back to work. So to me it seems to make more sense to look at that first but again this is the Iowa model and that's how they set it up. Again then if once you have that then you're looking is there sufficient research base if there is and it supports changing something then you're going to do a pilot project on changing that you're not going to change practice in the entire hospital maybe you're going to pick one unit where you're going to start this change and then you look to see is that change appropriate for adoption so did this change Was it a positive change? Well, if it was a positive change, then we can continue to do that.

And then we would also want to share the change and the positive results with the rest of the hospital or the rest of a nursing community or whatever, ever population it affects so that others can follow our best practice that we now have seen makes a difference in patient care. Hopefully that makes sense to you guys. All right.

So when we are looking at studies and this is where some people get intimidated. when you're looking at research articles sometimes it can be a little bit overwhelming when you're reading an article don't just put it down and walk away because the statistics and the technical language scare you break it down and really look at what are they talking about. Read the abstract first. That's a brief summary that quickly tells you if it's research or clinically based, what the purpose is. That one's usually pretty digestible.

And then read the introduction. This is where you get a little bit more information about the purpose. If you have a good author, they're going to give you some detailed information of the science or the clinical information. Then you've got the whole middle section, which will describe their topic. their population, all of that, the method of design of it, the whole how did they go about all this.

And then there's the results and conclusion portion which tells you what did they find. And then usually there's also a section that talks about further research that's needed, looking at what else can we do moving forward. So, again, there's a lot of technical terms and sometimes that can get a little bit intimidating. But really, as you're reading these, you know, don't just walk away and say, this isn't for me. I'm not smart enough because we've all been there.

And, you know, some articles are written at a very high level. But there's help out there to understand these articles. You've got your, you know, your research professors.

You've got every hospital now that is going, that's in the magnet. journey. They have researchers and again most of this research we're trying to do a good job of disseminating information so the authors are trying not to make it so very intimidating that no one other than researchers can read it because then we're not getting our information. to the people who can make a difference who are in clinical practice.

So when we're rating our research we have to look at a couple different things. So we want to look at how is the study designed and I'll show you we have sort of a pyramid that that talks about strength of evidence. There's a hierarchy to that, so I'll show that to you in a couple of slides.

But you also have to look at the internal validity, which would be things like how big is the population size? If you study two patients in North Dakota, that's not really enough of an internal validity to say that this is how patients across the United States are gonna be affected. So you need to have a pretty decent size patient population.

then you have to look at you know if it's if the study was only on males can you relate it to females so really looking at that internal validity how well was it designed how well was it executed how large a size did they have and then you need to look at consistency and volume of evidence as in is it one study that says X while all the other studies say Y in which case are you going to base your practice on X or are you going to want to see some more studies that back that up. And then the magnitude of effect is really how much effect did this intervention have. Was it a large effect on the outcome or was it a teeny tiny change? And then you really need to look at is it applicable applicable to your practice. That's important as well.

So there's a lot of different things to look at and there's a lot of different tools out there that can help you to rate research. This is just sort of an overview again to try and make it not such an overwhelming experience. So after you've critiqued the article and you've figured out what the Peacock question is, then that's when you're looking at what the findings are. You are considering the rigor as far as, you know, is this good evidence?

And then you're looking at, again, does it apply to your practice? So essentially what I just said. Let me see here.

All right, I think I said all of that. All right, so as you are reading research, you're looking first, you want to know, you want to know what their question was. So their research question, their hypothesis, that should be clear to you.

When I read studies, I highlight that because to me, that's important to know. They also should be telling you that they did a literature review. You don't just go out and do research without having done a literature review first to see are there others that have researched the same thing. and what did they find.

So they should be saying how they did their literature review, what keywords they used when they were doing their research, what the literature said, and then basically why are they doing their studies. So was there something that was not researched that they thought, okay, the literature talks a lot about this. in males, but they don't talk about at all about how this affects females, so we're going to do some research on females.

There should be some kind of connection between the literature and then the study that they choose to do. Their study strategy should be clearly outlined, and it should be reproducible. So they should outline it clearly enough that somebody else could come along and do essentially the same thing following their steps.

And then as far as their data analysis goes, are they clearly processed? Are they clearly explaining how they're doing this data analysis. And there's usually a whole section dedicated to that. And that section is usually a little overwhelming because there's a lot of technical terms in that.

But if you then go to the conclusion, then that's where you find, you know, what did they really find? And in here, they should also talk about their study limitations. So was their group too small that they looked at? Were they only looking at patients in...

colder climates, warmer climates, you know, there's usually some kind of limitations to a study and then somebody picks up the other piece of that and studies the other section that wasn't covered as well. The next slide is the hierarchy of evidence that I was telling you about and we will go through each of these. So this is more for you to refer back to because right now you don't know what a random control study is and you met us Meta-analysis and all of that so it doesn't really make so much sense right now But this is for you to look back at after we've kind of talked about all these different systems or all these different types of evidence Essentially the synopsis of this is that if you had a random control study Which I will talk about then that's considered the gold standard.

That is really, really good evidence. If you had a meta-analysis of randomized control studies, meaning several of them all saying the same thing, then that is the peak of that triangle. You can't get any better than that. But it doesn't mean that the types of evidence that are below here are less valid.

It just, they support in different ways. So some things can only be studied by doing qualitative research. in that case, then that's a valid type of evidence.

And it does on here list as well the opinions of authorities and expert committees. That's important, but if you have other types of evidence, then they, of course, are ranking above that. So when we look at the meta-analysis and the systematic reviews, this is, like I said, multiple studies that are addressing the very same or similar topics, and they're looking at all these studies side by side, And they're looking at what did they find. So these are very nice if you have a topic where there's a lot of evidence out there.

Somebody else is taking all those articles, pulling them together, comparing and contrasting, and then giving you their opinion on that. Similar with the systematic reviews, here they're really looking at all these multiple studies that have affected the same thing and saying, you know, what exact questions were they looking at? Are we seeing the same thing reproduced over and over?

The Cochrane Collaboration does a lot of reviews based on evidence. I left you their their website ...a site down here, but you can also just Google Cochrane Collaboration and it'll take you right there. And that's another useful tool when you're doing lit reviews, getting ready to write papers, that type of thing. So the randomized control study, this is the one that I told you about.

is the highest level of evidence unless you had a meta-analysis of randomized control trials. So, with this, you have to have an intervention, you have to have a control group, there has to be random assignment to both the intervention and the control group. and you have to be manipulating some independent variables. This, like I said, when we're talking about the peacock question, this is not so often used in nursing because it is very difficult to do that randomization and to have the control group and the intervention group with a nursing focus. This is more common, something that they will do in medicine, in pharmacy, pharmacology, that type of thing.

All right, and then quasi-experimental, again, this is a rung below our randomized control trials. With this there is an intervention. It may or may not have a control group.

There's not usually random assignment to the intervention in the control group and there's usually some manipulation of the variables. So this is something that we could see in where we would see a pre-test and a post-test. So you can see pre-test and then you give the education of whatever it is you're going to educate the group about and then you do a post-test to see how did this affect your outcomes.

So this is an easier type of research, I don't know if that's the right word. But it applies more to our nursing type of research. And then there's non-experimental research as well.

So this may or may not have an intervention. There's no randomized assignment to a group. There's no control group. There's no manipulation of independent variables. And these are your descriptive, predictive, explanatory case studies, that type of research.

Then when you get to qualitative, there is no randomization, there's no manipulation of independent variables, there's very little control over the environment because usually this type of research is being done outside of a controlled settings. So you're going out and you're essentially talking to people. With these, you could have met a synthesis of multiple qualitative studies.

And again, that would then be a higher source of evidence than just one study. And then there's some studies that are mixed methods, which have both a quantitative and a qualitative feature. All right, so again, when you have all of this evidence, you have to try and decide if this is something that you want to apply.

So what is the setting? Is there going to be support from staff? Is there going to be support from management? And then you're looking at evaluating the change.

Was it a positive change? and then again sharing that information. So kind of coming full circle and talking about how do we go through this process, like the steps that we talked about before.

All right, so there's also some terminology as far as human research goes. So if you hear anybody talking about IRB, that's Institutional Review Board, this is a group that is essentially protecting those that the research is being conducted on. So the IRB at a hospital is protective of its patients. So if If I say I want to go do some research and I want to have a control group and I want to have all these things, the IRB is going to look at that and say, is this okay?

Is this all right with our patients? Are our patients going to be safe? Are they going to be protected?

How are you going to keep identities concealed? I did a small research study a few years back and it was very low level. It was on high school students who were coming into the hospital to do a week-long health professions academy.

And really all I wanted to do was give them a pre-test, then have them there for the week academy where they were introduced to different health careers and had different speakers and got to go shadow on the floors, and then do a post-test at the end of that to see what did they walk away with. Did they walk away with more knowledge? Did they have a better understanding of what nursing is, what physical therapy is?

That's really all I wanted to do. Even that had to go to the IRB for approval. And one of their things, one of their caveats that they said to me is that you have to be able to not only protect their identity, so it had to be in a locked room, in a locked drawer. I had to not be able to, they had to be numbered.

I couldn't see names on them so that I wouldn't know who said what. And then their one concern for the student safety was that somebody might feel bad about themselves if they didn't score well on it. And so you can see they take this very seriously and really look at what could be the consequences.

All right. So the other term that you will hear is informed consent and this is very important. So with this it really means that the participants have received full and complete information, that they can understand it, that they have free choice to participate. So that was the same thing even in my little low-level study I had to make it very clear to them that this is the study that I'm doing if you choose not to participate in it you can still participate in the week you can still have all those activities I won't know whether you participate or not because I have to walk out of the room when you do your pre-test and somebody else is in there monitoring and same thing for the post test and then that confidentiality that i mentioned so it was very important that everybody was numbered there could be no names on it and it had to be under lock and key at all times so i couldn't just stick it on my desk or put it in a drawer somewhere it had to be inside a locked drawer inside a locked room. So these are really very important and there are some studies that I don't know how familiar you are with them but there are some studies that were done.

probably 50, 60, 70 years ago now that did not really look out for the participants and the participants were not fully understanding why the research was being done or what was happening to them and they didn't really have free choice to participate and that certainly is not okay and that's not a place we want to go back to. Alright so again our research process is very organized you're really looking at Just identifying your problem, deciding how you want to design your study, conducting your study, analyzing the data from your study, and then doing something with the findings that come out of that. So when you break it down in that level then I think it's a little bit easier.

easier to understand what we're talking about. Alright, so within nursing research, we're looking at trying to identify new knowledge, improve our professional education and practice, and use our resources effectively. ICN is the International Council of Nursing and this group supports nursing priorities and guides research.

They have an online, I think it's almost eight hours, course that you have to take before you're allowed to do any type of research. So they again, they're trying to make sure that the research that we're doing is valid, is high quality. quality is safe for our patients and is producing good results.

So with this, our research becomes really a systematic process where we're asking and answering questions, we're generating knowledge, and we're providing a scientific base for nursing practice. And that's a big deal. When we look at Joint Commission, they mandate that healthcare institutions have a formal process For reviewing the latest research and ensuring that their policies and procedures are consistently revised to reflect this.

So now it has become even mandated by joint commission, not just for our magnet hospitals and that type. So this is good. This is moving forward in our profession. All right. And there is definitely a link between our scientific method and research.

So the scientific method essentially becomes the foundation for research. It minimizes the chance that there's going to be bond. bias or opinion by a researcher. Researchers can try and control those external factors that are not being studied and they can gather empirical data through the use of observations and assessments and then use this data to discover new knowledge. So we see these two processes go hand in hand.

When we're looking at nursing research, again, this is really how we're studying things and how they affect us. Just to be clear on the quantitative, these are the control group, the randomization, all of that. And then our qualitative, these are really the questions that can't really be measured specifically.

So these, they're more used for phenomena. So things that are difficult to quantify are studied qualitatively, where we are able to get written transcripts, do interviews, and really get a hold of what were the... perceptions, what were the experiences that somebody had versus real precise systematic objective, which is more your quantitative. All right.

So then there's a couple other areas that we need to look at. So the other thing we're looking at is quality performance improvement, which is a big deal to all of our healthcare organizations. The Joint Commission defines quality improvement as an approach to to continue a study and improvement of the process of providing healthcare services to meet the needs of the population.

the needs of patients and others. So some of the things we look at are things like fall prevention, medication delivery, decreases in hospital acquired infections, pressure ulcers. These are all quality improvement areas where we want to try and make an improvement. Our nursing sensitive indicators fall into that.

So a lot of those that I just mentioned are nursing sensitive indicators. And so those are things that you're going to see on your big bulletin boards in your nursing units where those are the QI projects that we're working on. And this is how we work to look at what our data is saying and are there changes that we need to make based on that. So performance improvement, we're really looking at what are we currently doing, are those results good enough, and then maybe we're looking to evidence-based practice because these go hand in hand.

And maybe there's something that we can change that will then serve to improve our performance and our quality. quality. So if there's an example of how you would do a QI change. So the first thing is that it's a PDSA is what we call this and a lot of the hospitals still use this so I want to make sure if you hear that term that you understand what we're talking about. So the P is for plan where you're really reviewing your available data and you're making sure you understand what is currently going on and you're looking is there need to change something.

The D is the do, so here you're selecting an intervention based on the data that you have and you're implementing a change. Then the S is for study where you're really evaluating the results of this change. So what happened when you changed whatever it is that you changed. And the A is for act. So this is where you now are going to change if there was a positive outcome.

So if what you did had a positive outcome then you need to act and incorporate this into the daily unit performance. So through this we're able to understand our work processes and see when we need to make changes in our practice. And the next slide is just really a look at again the three different components.

So our research, which supports our evidence-based practice because it is the evidence, right? Research is another word for evidence. And then our quality improvement, which is what we're doing by implementing these things.

We're trying to improve the outcomes for our patients. So as a BSN nurse, what is your role in research? Your role is to keep your eyes open, to make sure that you're not scared of it, to not be afraid to ask questions.

to be able to find these studies, to be able to appraise them critically and see are they valid studies, to be able to incorporate this into policies and procedures, to be able to look at this research and have it guide your practice and to really look around for those questions. So see if you can find out what questions do you have. Some of the things that come to mind from my own background, we looked at ventilator associated pneumonia in one of the ICUs that I worked at.

And it was sort of, it was something that just sort of happened. You know, you had very, very sick people, they're on ventilator for an extended period of time. And every once in a while, somebody would get pneumonia.

And for a long time, it seemed as if that was just the way that it is. Sometimes people are just so sick, they don't have any immune defense, there's really not a lot you can do. But when we started to really focus on it as a nursing department and started to look at who developed pneumonia, who didn't develop pneumonia, we realized that we didn't all have the same nursing practice.

And we came up with what we called a bundle of care. So this is where we decided all patients who are on a ventilator need to have their head of bed at 45 degrees. They need to have oral care every two to four hours.

They need to be repositioned every two hours. Lots of different things that we put into place and lo and behold, we ended up with zero ventilator associated pneumonias for years and years and years. So these were changes that we made.

that made a big difference in patient outcomes. So this was us looking at evidence and seeing what were other people doing. Other people were doing this and they were having more success than we were.

So that's where we took that from. So again, evidence-based practice really begins with questions that arise in your everyday clinical practice. So you need to feel empowered as nurses to ask those clinical questions because you're looking for opportunities to improve nursing practice and patient outcomes.

And that is what it's all about. it's all about, right? So in conclusion, our evidence-based practice interventions, we learn how to improve our patient outcomes, how to help to be part of providing that high quality care. We're reducing costs and we're eliminating practices that have become obsolete or are not effective.

And that's really important. We really want to always be looking at the latest and greatest because that's how we're going to continue to grow our profession. And then this was another quote from the article that I recently read.

One of the key points we learn in nursing school is to be a generation that provides high quality care that is supported by evidence. So I hope that's something that you are taking away and I hope that is second nature to you because again I went to nursing school a few years ago but this is not how I was taught. I was not taught to question things and I think that's being a good nurse you have to question things.

So I do hope that you feel that you are being taught to question things and that high quality nursing care needs to be supported by evidence. All right, I think that's all I have for you. All right, well, there we go, a little technical issues. All right, so hopefully this all made sense to you. If not, then please let me know what questions you have.

Sorry, I'm still goofing with my computer here. But hopefully all that made sense to you. Make sure you read the topic in your book as well because there's a lot more detail in there that will help bring some of the fuzzy, muddy parts of this to the surface for you. And then please don't hesitate to ask questions.

If there's something that didn't make sense to you, then please ask some questions so it can be clarified. All right, thank you.

Transcript for:Understanding Evidence-Based Practice in Nursing

Transcript for:
Understanding Evidence-Based Practice in Nursing