Once the EBP product has been developed, the next step is to pilot testit (give it a trial run) in a clinical setting and to evaluate the outcome. Building on the Iowa Model, this phase of the project likely would involve the following activities:
1.Developing an evaluation plan (e.g., identifying outcomes to be achieved, deter- mining how many clients to include, deciding when and how often to measure outcomes)
2.Measuring client outcomes before implementing the innovation, to establish a comparison against which the outcomes of the innovation can be assessed
3.Training relevant staff in the use of the new guideline and, if necessary, “market- ing” the innovation to users so that it is given a fair test
4.Trying the guideline out on one or more units or with a group of clients
5.Evaluating the pilot project, in terms of both process (e.g., How was the innova- tion received? To what extent were the guidelines followed? What problems were encountered?) and outcomes (e.g., How were client outcomes affected? What were the costs?)
A variety of research strategies and designs can be used to evaluate the innova- tion, as described in our discussion of evaluation research in Chapter 11. A fairly informal evaluation usually will be adequate, for example, comparing outcome information before and after the innovation, and gathering information about patient and staff satisfaction. Qualitative information can also contribute consider- ably because a qualitative perspective can uncover subtleties about the implemen- tation process and help to explain research findings.
TIP
Every nurse can play a role in using research evidence. Here are some strategies:
*Read widely and critically. Professionally accountable nurses keep up to date on important developments and read journals relating to their specialty, including research reports in them.
*Attend professional conferences. Many nursing conferences include presentations of studies that have clinical relevance. Conference attendees get opportunities to meet researchers and to explore practice implications.
*Insist on evidence that a procedure is effective. Every time nurses or nursing students are told about a standard nursing procedure, they have a right to ask the question: Why? Nurses need to develop expectations that the decisions they make in their clinical practice are based on sound evidence-based rationales.
*Become involved in a journal club. Many organizations that employ nurses sponsor journal clubs that discuss research articles that have potential relevance to practice. The traditional approach for a journal club (nurses coming together as a group to discuss and critique an arti- cle), in some settings, has been replaced with electronic online journal clubs that acknowledge time constraints and the inability of nurses from all shifts to come together at one time.
*Pursue and participate in RU/EBP projects. Several studies have found that nurses who are involved in research-related activities (e.g., a utilization project or data collection activities) develop more positive attitudes toward research and better research skills.
EXAMPLE 1 ■ Research Translation Project
Hundreds of projects to translate research evidence into nursing practice are underway worldwide, and many that have been described in the nursing literature offer good
information about planning and implementing such an endeavor. In this section, we summa- rize such a project. The article appears in its entirely in the accompanying Study Guide.
Study
Translating best practices in nondrug postoperative pain management (Tracy et al., 2006).
Background
A team of researchers and clinicians observed that nondrug methods of relieving pain, many of which have been empirically validated as being beneficial, are underused as standard post- operative pain management practices in most hospitals. They cited evidence that nursing knowledge about pain and pain relief is typically inadequate.
Purpose
The purpose of the project was to use an RU model—the Collaborative Research Utilization (CRU) Model—to translate research into practice in a hospital in Rhode Island, using nondrug pain management protocols for postoperative pain of older adults as the example.
R E S E A R C H E X A M P L E S A N D C R I T I C A L T H I N K I N G A C T I V I T I E S
Model
The CRU Model is a six-step model adapted from the CURN project, underpinned by Rogers’
(1995) Diffusion of Innovation Theory. The model involves student and staff nurses in each step. The use of nursing students to evaluate the strength of research evidence and assist in generating best-practice protocols is unique to this model.
Method
The first step in the model was to identify a clinical problem and assess the evidence base.
Using both qualitative and quantitative approaches, the team ascertained the desirability of addressing the underuse of nondrug treatments for pain management in the study hos- pital. Interventions (massage, music, and self-guided imagery) were selected based on an AHRQ evidence summary, and undergraduate nursing students performed a literature search on these therapies. Step 2 involved evaluating the relevance of the research vis-à-vis the problem, agency values, and potential costs and benefits. Roundtable discussions, held on surgical and rehabilitative care units, resulted in the generation of 22 specific
recommendations. In Step 3, the recommendations were transformed into three best- practice protocols for a tailored teaching intervention by a team of clinicians and
researchers. A 12-member nursing Comfort Therapy Service was formed and trained in the use of the protocols. Step 4 involved the implementation and evaluation of the protocols for feasibility, usefulness, and effectiveness. This step included both a pilot study, which was the focus of the 2006 report, and a larger study that was still in progress when the paper was published. The pilot study examined, for 46 surgical patients, changes in knowl- edge of, attitudes toward, and use of the three interventions, from preadmission to the third postoperative day. In Step 5 of the model, the team presented pilot results to nursing staff and administration for decisional consideration. The final step is dissemination of the project results.
Findings
The team found that, in the pilot study, there were gains in patients’ knowledge, attitudes, and use of the three nondrug interventions for pain management. At the time the paper was writ- ten, more than 300 patients had used the comfort therapy services. Nurses reported that implementing the protocols did not interfere with their other responsibilities, and that the time required to implement them was about 15 minutes.
Conclusions
Although administrators had not yet made a decision about the ongoing use of the protocols, hospital volunteers at the study site agreed to help in ensuring that nurses and patients have the supplies needed to carry out the comfort protocols. The team concluded that preliminary results were encouraging, but noted the desirability of conducting further studies with the intervention in sites with a more heterogeneous group of patients.
CRITICAL THINKING SUGGESTIONS*:
*See the Student Resource CD-ROM for a discussion of these questions.
1. Of the EBP-focused purposes described in Chapter 1, which purpose did this project address?
2. How does the CRU Model used in this project compare with the Iowa Model (Figure 2.1)?
3. Would you say that this project had a knowledge-focused or problem-focused trigger?
CHAPTER REVIEW
Key new terms introduced in the chapter, together with a summary of major points, are presented in this section. Chapter 2 of the accompanying Study Guide for Essen- tials of Nursing Research,7th edition also offers exercises and study suggestions for reinforcing the concepts presented in this chapter. For additional review, see self- study questions on the CD-ROM provided with this book.
Key New Terms
EXAMPLE 2 ■ Quantitative Research in Appendix A
1. Read the abstract and the introduction from Howell and colleagues’ (2007) study
(“Anxiety, anger, and blood pressure in children”) in Appendix A of this book. Identify one or more clinical foreground question that, if posed, would be addressed by this study.
Which PICOT components does your question capture?
2. How, if at all, might evidence from this study be used in an EBP project (individual or organizational)?
EXAMPLE 3 ■ Qualitative Research in Appendix B
1. Read the abstract and the introduction from Beck’s (2006) study (“Anniversary of birth trauma”) in Appendix B of this book. Identify one or more clinical foreground questions that, if posed, would be addressed by this study. Which PICOT components does your question capture?
2. How, if at all, might evidence from this study be used in an EBP project (individual or organizational)?
Background question Clinical practice
guideline
Cochrane Collaboration Critically appraised topic
(CAT)
Diffusion of Innovations Theory
Evidence hierarchy Evidence-based practice Foreground question Implementation potential
Iowa Model Meta-analysis Metasynthesis Pilot test Stetler Model Systematic review
Summary Points
* Evidence-based practice (EBP) is the conscientious use of current best evidence in making clinical decisions about patient care; it is a clinical problem-solving strategy that de-emphasizes decision making based on custom and emphasizes the integration of research evidence with clinical expertise and patient preferences.
* Research utilization (RU) and EBP are overlapping concepts that concern efforts to use research as a basis for clinical decisions, but RU starts with a research-based innovation that gets evaluated for possible use in practice.
* Research utilization exists on a continuum, with direct utilization of some spe- cific innovation at one end and, at the other end, more diffuse use in which peo- ple are influenced in their thinking about an issue based on research findings.
* Nurse researchers have undertaken several major utilization projects (e.g., the Con- duct and Utilization of Research in Nursing or CURN project), which demon- strated that RU can be increased but also shed light on barriers to utilization.
* Two underpinnings of the EBP movement are the Cochrane Collaboration (which is based on the work of British epidemiologist Archie Cochrane), and the clinical learning strategy called evidence-based medicine developed at the McMaster Medical School.
* EBP typically involves weighing various types of evidence in an effort to determine best evidence; often an evidence hierarchyis used to rank study findings and other information according to the strength of evidence provided. Hierarchies for evalu- ating evidence about health care interventions typically put systematic reviews of randomized clinical trials(RCTs) at the pinnacle and expert opinion at the base.
* Researchers have found that EBP/RU efforts often face a variety of barriers, includ- ing the quality of the evidence, nurses’ characteristics (limited training in research and EBP) and organizational factors (e.g., lack of organizational support).
* Resources to support EBP are growing at a phenomenal pace. Among the resources are systematic reviews (and electronic databases that make them easy to locate); evidence-based clinical practice guidelines and other decision sup- port tools; a wealth of other preappraised evidencethat makes it possible to prac- tice EBP efficiently; and models of RU and EBP that provide a framework for undertaking EBP efforts.
* Systematic reviews, a cornerstone of EBP, are rigorous integrations of research evidence from multiple studies on a topic. Systematic reviews can involve either qualitative, narrative approaches to integration (including metasynthesis of qualitative studies), or quantitative methods (meta-analysis) that integrate findings statistically.
* Many models of RU and EBP have been developed, including models that pro- vide a framework for individual clinicians (e.g., the Stetler Model) and others for organizations or teams of clinicians (e.g., the Iowa Model of Evidence- Based Practice to Promote Quality Care). Another widely used model in RU/EBP efforts is Rogers’ Diffusion of Innovations Theory.
* Individual nurses have regular opportunity to put research into practice. The five basic steps for individual EBP are (1) framing an answerable clinical question;
(2) searching for relevant research-based evidence; (3) appraising and synthesizing the evidence; (4) integrating evidence with other factors; and (5) assessing effectiveness.
* One scheme for asking well-worded clinical questions involves five components, an acronym for which is PICOT: population (P), intervention or issue (I), com- parison of interest (C), outcome (O), and time (T).
* An appraisal of the evidence involves such considerations as the validity of study findings; their clinical importance; the precision of estimates of effects; associ- ated costs and risks; and utility in a particular clinical situation.
* EBP in an organizational context involves many of the same steps as an indi- vidual EBP effort, but tends to be more formalized and must take organizational and interpersonal factors into account. Triggers for an organizational project include both pressing clinical problems and existing knowledge.
* Team-based or organizational EBP projects typically involve the implementa- tion, development, or adaptation of clinical practice guidelines or clinical pro- tocols. Evidence-based clinical practice guidelines combine a synthesis and appraisal of research evidence with specific recommendations for clinical deci- sion making. Clinical practice guidelines should be carefully and systematically appraised, for example using the Appraisal of Guidelines Research and Evalua- tion (AGREE) instrument.
* Before an EBP-based guideline or protocol can be tested, there should be an assessment of the implementation potentialof the innovation, which includes the dimensions of transferability of findings, feasibility of using the findings in the new setting, and the cost-to-benefit ratio of a new practice.
* Once an evidence-based protocol or guideline has been developed and deemed worthy of implementation, the team can move forward with a pilot testof the innovation and an assessment of the outcomes before widespread adoption.