CHAPTER 4. Evidence-Based Practice and Nursing Research
Susan Jane Fetzer
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. Define evidence-based practice, nursing research, and research utilization.
2. Rank the strength of their contribution and list the major sources of evidence used to develop clinical practice guidelines.
3. Describe the link between research and the development of evidence-based practice.
4. Describe the nurse’s role in protection of patients from unethical or harmful research.
5. Identify the components of a research proposal.
6. Differentiate the research process from the quality assurance process.
7. Identify three areas of perianesthesia nursing practice that are in need of research.
8. Identify three methods of applying ambulatory perianesthesia research in practice.
I. DEFINITION OF EVIDENCE-BASED PRACTICE (EBP)
A. Problem-solving approach to clinical decision-making
B. Research utilization
1. Is one part of EBP
2. Assessment of single research report
3. Research study results will suggest change or support existing practice.
C. Requires search for best and latest evidence
1. Scientific evidence
2. Experiential evidence of patient and provider
D. Four components
1. Analysis of best research
2. Integrating clinical expertise
3. Integrating patient values and cultural needs
4. Integrating preferences of patient, family, and community
E. Approach is systematic and rigorous.
F. Requires synthesis of quality of evidence
G. Conscientious integration of evidence in practice
II. GOAL OF EBP
A. Implement effective nursing interventions
B. Provide quality cost-effective care
C. Reduce variations in practice
D. Improve patient outcomes
III. STIMULI FOR EBP INITIATIVES
A. Unusual or low-frequency clinical practice
B. Indicated when outcome of care differs between similar patient situations
C. Reference for developing nursing policies and procedures
IV. STEPS OF EBP
A. Assess need for practice change; formulate a clinical question.
1. Develop a problem-focused clinical question.
a. Derived from recurrent clinical problem
b. Encouraged by a quality improvement (QI) recommendation
c. Stimulated by a benchmarking report
2. Develop a knowledge-focused clinical question.
a. New practice is identified.
(1) Recently published research
(2) Scientific paper at conference
(3) Published clinical practice guideline
b. Unit is interested in maintaining competency.
3. Clinical question developed using PICO question format
a. P—population of interest
b. I—intervention of interest
c. C—comparison intervention
d. O—outcome
e. Example: in patients undergoing bowel resection [P], does prewarming to 38° C [I], compared with no prewarming [C], result in less postoperative hypothermia [O]?
B. Collect evidence.
1. Sources of evidence
a. Meta-analysis
(1) Collection of multiple quantitative studies on the research question
(2) Sample for analysis composed of the research studies identified
(3) Application of statistical techniques to combine results into one data set
(4) Determines strength of relationship between variables
(5) Highest level of evidence to determine practice effectiveness
(6) Example: a meta-analysis of studies of nurses’ job satisfaction
b. Systematic reviews
(1) Collection of evidence related to specific clinical issue
(2) Quantitative studies with similar methodology
(3) Rigorous search designed to ensure complete database
(4) Summary of findings provided
(5) Highest level of evidence to determine practice effectiveness
(6) Examples:
(a) Cochrane Database of Systematic Reviews
(b) Joanna Briggs Institute
c. Integrative literature reviews
(1) Similar to systematic review
(2) Includes qualitative and quantitative studies
(3) Draws narrative conclusions from summary of findings
(4) Provides understanding of state of the science
(5) Example: the relationship between nurse educational level and patient safety
d. Metasummary
(1) Synthesis of multiple qualitative studies
(2) Provides narrative understanding of selected phenomenon
e. Metasynthesis
(1) Similar to metasummary
(2) Develops a new theory or framework for topic
f. EBP guidelines
(1) General outline for specific course of action
(2) Systematically developed
(3) Recommendations supported by evidence
(4) Developed by experts who have evaluated evidence
(5) Goal is to translate evidence from research evaluations into practice
(6) Formats of guidelines
(a) Decision trees
(b) Algorithms
(c) Protocols
(d) Clinical pathways
(7) Sources of guidelines
(a) National Guideline Clearinghouse
(b) Agency for Healthcare Research and Quality
(c) PeriAnesthesia guidelines
(i) Normothermia
(ii) Postoperative nausea and vomiting
(iii) Pain and comfort
g. Original clinical studies
(1) Located through databases or indexes
(a) Cumulative Index to Nursing and Allied Health Literature
(b) PubMed
(2) Types of clinical studies
(a) Randomized controlled clinical trial (RCT)
(b) Quantitative studies
(i) Quasi-experimental
(ii) Correlational
(iii) Descriptive
(c) Qualitative studies
C. Evidence appraisal
1. Evidence appraised (critiqued) based on criteria
a. Merit
b. Feasibility
c. Utility
2. Evidence rated based on strength and quality
3. Strength of evidence
a. Level I—meta-analysis of multiple controlled studies; systematic review, evidence-based clinical guideline
b. Level II—single, well-designed RCT
c. Level III—quasi-experimental study, not randomized, single group
d. Level IV—well-designed, nonexperimental study: correlation, descriptive, qualitative
e. Level V—case report, program evaluation data
f. Level VI—expert opinion, nationally known authorities
4. Quality of evidence
a. A—well-designed study
b. B—observational study or controlled trials with less consistent results
c. C—dramatic results but lacks controlled trial, evidence not consistent
d. D—study has major flaw, findings suspect
5. Evidence summarized
a. Narrative summary
b. Table of evidence
D. Integrate evidence into practice recommendations.
1. Practice guidelines
a. General outline for specific course of action
2. Practice protocols
a. Specific actions for direct application of an intervention
E. Implement practice change.
1. Pilot study or demonstration project
2. Evaluate need for change.
a. Adopt a practice change based on evidence.
b. Adapt a practice change based on evidence and setting characteristics.
c. Reject a practice change for nonapplicability to the situation.
3. Rogers’ Theory of Diffusion of Innovation
a. Guide for implementing changes in practice based on research
b. Five-stage process
(1) Knowledge—first awareness of innovation
(2) Persuasion—attitude formation toward innovation
(3) Decision—determination to adopt or reject innovation
(4) Implementation—using innovation in practice
(5) Confirmation—reconsider adoption or rejection of innovation
F. Evaluate and monitor practice change.
1. QI monitoring
2. Conduct an original research study.
V. DEVELOPING AN EVIDENCE-BASED CULTURE
A. Creation of environment that allows questions of current practices and actions
B. Policies and procedures supported by literature citations
C. Research committee is active.
1. Inservice staff
a. Promote positive attitude toward EBP.
b. Methods of critical appraisal
c. Accessing databases
d. Steps of the research process
e. Grading evidence
2. Facilitate journal clubs.
3. Change agents for EBP
a. Champion a positive attitude toward research.
b. Identify clinical practice questions.
D. Resources needed to support EBP culture
1. Time to reflect on practice
2. Time to access and review evidence
3. Consultants with research expertise
4. Access to databases
5. Authority to implement change
VI. DEFINITION OF NURSING RESEARCH
A. Research: process of applying the scientific method designed to develop or contribute to generalizable knowledge
B. Scientific method: controlled, systematic process for conducting studies in which data are collected under constant conditions to decrease error so that all data are collected in the same manner
C. Nursing research: process of applying the scientific method to answer questions about nursing education, nursing practice, and nursing administration
VII. GOALS OF PERIANESTHESIA NURSING RESEARCH
A. Maximize perianesthesia patient outcomes from nursing interventions.
B. Validate a unique body of perianesthesia knowledge that impacts perianesthesia nursing.
C. Maximize the effectiveness and efficiency of perianesthesia nursing care delivery.
VIII. OBJECTIVES OF PERIANESTHESIA NURSING RESEARCH
A. Validate interventions used by perianesthesia nurses.
B. Uncover perianesthesia phenomena not previously realized.
C. Develop and test theories able to explain, predict, and control perianesthesia nursing practice and patient outcomes.
D. Substantiate the unique contribution of perianesthesia nurses as health care providers.
IX. DEVELOPING AND PLANNING A RESEARCH STUDY
A. Phases of a research study
1. Proposal development
2. Institutional review board (IRB) approval
3. Data collection
4. Analysis
5. Communication of findings
B. Proposal development
1. A proposal is the plan the researcher intends to implement to solve the research problem by answering the research question or supporting the research hypothesis.
2. Proposal precedes the implementation of a research study
a. Assists the researcher to think through all steps in a study so nothing is missed
b. Allows the researcher to make changes before investing time and money in procedures that may not be appropriate
c. Encourages researcher to plan study with such clarity that it can be replicated (e.g., reproduced with another group)
d. Provides an opportunity for peer review that allows constructive criticism from others who are knowledgeable about topic and research process for purpose of improving the study
e. Proposal reviewed by the human subjects committee or IRB before data collection
X. COMPONENTS OF A RESEARCH PROPOSAL
A. Introduction and problem statement (Box 4-1)
1. Introduction: defines problem and provides background information so reader can understand why study needs to be conducted
2. One to two paragraphs at the beginning of a research proposal that introduces the topic to the reader
3. Problem statement: description of a dilemma or situation
a. Dilemma or situation requires resolution by scientific inquiry and the development of new knowledge.
b. Situation has not been satisfactorily resolved by past research studies.
c. Dilemma exists because of a knowledge gap in the nursing literature.
d. Example of perianesthesia nursing introduction and problem statement:
4. Perianesthesia topics that can be developed into research problems
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a. Preoperative examples:
(1) Effectiveness of take-home preoperative video on patient compliance with preoperative regimen
(2) Completeness of data provided by patient for preoperative database
(3) Appropriate scheduling of preadmission visits
b. Phase I examples:
(1) Role of registered nurse during conscious sedation
(2) Speed of patient rewarming on pain management
(3) Role of PACU visitation on patient, family, and staff
c. Phase II examples:
(1) Validity of discharge criteria for regional anesthesia patients
(2) Effectiveness of postoperative telephone calls in measuring patient outcomes
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