section epub:type=”chapter” id=”c0045″ role=”doc-chapter”> Perianesthesia nurses are commonly faced with a host of common and uncommon patient scenarios demanding thoughtful, efficient decision making and intervention. Decisions associated with all aspects of patient care should be evidence-based, a process of considerable complexity that involves identifying a clear question/problem, locating sources of information, evaluating the quality and relevance of information, recognizing the contextual elements that may alter the application of that information in a particular setting, and evaluating the effect of an evidence-based intervention on various clinical outcomes. The purpose of this chapter is to explore the basic concepts of evidence-based practice (EBP) and their relationship to research and quality/performance improvement, as well as to explore the application of EBP in the perianesthesia setting. evidence-based practice; research; quality improvement; performance improvement Definitions Clinical Practice Guideline Systematically developed statements/guides designed to provide a key link between evidence-based knowledge and health care practice and offer a mechanism to advance the quality and equity of patient care through the translation of evidence to practice.1–3 Evidence-Based Practice The conscientious and judicious use of current best available evidence in conjunction with clinical expertise and patient values/preference to guide the care given to patients.1,4,5 Experimental Design A study whose purpose is to test cause-and-effect relationships, specifically to examine the effects of an intervention or treatment on selected outcomes. An experimental design always includes an intervention and control group with random assignment to groups.1,2,5 Generalizable Knowledge Knowledge or findings that can be generalized from the sample to the larger population.5 Meta-Analysis A technique for quantitatively integrating the results of multiple similar studies addressing the same research question to produce a single estimate of the effect of the intervention of interest.2,5 Nonexperimental Design Also called an observatory or exploratory study, a nonexperimental design is a study in which data is collected regarding a phenomenon without the introduction of an intervention by the researcher.1,2,5 Prospective Study Follows patients forward in time with the use of carefully defined protocols to determine an outcome that is unknown beforehand. This powerful type of research allows one to determine cause-and-effect relationships.2,5 Qualitative Research The investigation of phenomena using an in-depth and holistic approach, often involving personal interviews and observations.1,2,5 Quantitative Research The investigation of phenomena involving the use of precise measurement and manipulation of numeric data via statistical analysis.1,2,5 Quasi-Experimental Design A type of design that examines the effect of an intervention on an outcome, but lacks one or more characteristics of a true experimental design.1,2,5 Randomized Controlled Clinical Trial Patients are randomly assigned to a control (receiving the standard treatment or placebo) or intervention group (receiving the new or experimental treatment), and the outcome is measured and compared. Such trials are considered the most reliable and impartial method of determination of treatment effectiveness.1,2,5 Retrospective Study Looks backward in time, usually with use of medical records or existing databases. This type of study is weaker than a prospective study and only permits one to determine the nature of association between a treatment and outcome.1,2,5 Scoping Review A preliminary review of research findings for the purpose of clarifying the range and nature of evidence surrounding a topic. Often a preliminary step to refining the question or protocol for a systematic review.5 Systematic Review (also known as Integrative Review or Metasynthesis) A rigorous systematic review of the literature on a similar topic involving a clearly defined method for identifying, appraising, and synthesizing the literature and drawing conclusions regarding the question of interest.1,2,5 Perianesthesia nurses are commonly faced with a host of common and uncommon patient scenarios demanding thoughtful, efficient decision making and intervention. The choice of what course of action to take is, in many cases, as important as the action itself. Decisions associated with all aspects of patient care should be evidence-based, a process of considerable complexity that involves identifying a clear question/problem, locating sources of evidence, evaluating the quality and relevance of evidence, recognizing the contextual elements that may alter the application of that information in a particular setting, and assessing its effect on the patient. The purpose of this chapter is to explore the basic concepts of evidence-based practice (EBP) and their relationship to research, as well as to explore the application of EBP in the perianesthesia setting. Research, EBP, and quality improvement have many similarities and are thus often easily confused. In the practice setting, all three processes generally start with a clinical question and involve measurable outcomes and some form of data collection and analysis. Quality improvement is a process used to internally evaluate structure and process with the intent of improving outcomes. Internal data is used to continuously monitor and improve processes in an effort to contribute to improved outcomes.2,6 EBP in the clinical setting involves the application or translation of best available evidence to practice.1,2,6 Quality improvement and EBP projects are local in nature and not defined as “research” in that they do not produce generalizable findings.5,7 While these projects may undergo some type of internal review/approval process, they typically do not require Institutional Review Board (IRB)/Ethics Committee approval and if reviewed, are typically deemed “not human subjects research.” Research, on the other hand, involves the systematic generation of new knowledge or evidence. Research follows the scientific method and as such, results in generalizable findings that can be applied across similar settings.2,5,6 Research studies require IRB approval, and if they involve nursing, are often reviewed by the institution’s Nursing Research Council. Definitions and examples are provided in Table 9.1. EBP, Evidence-based practice; IRB, Institutional Review Board; PICO, patient/population, intervention, comparison, and outcome; PONV, postoperative nausea and vomiting. From Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing & healthcare: a guide to best practice. 4th ed. Lippincott, Williams, & Wilkins; 2018; LoBiondo-Wood G, Haber J. Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice. 10th ed. Elsevier; 2021; Newhouse RP. Diffusing confusion among evidence-based practice, quality improvement, and research. J Nurs Adm. 2007;37:432–435. EBP involves the conscientious and judicious use of the most current and best available evidence along with the clinician’s expertise and consideration of the patient’s values and preferences to provide patient care.1,2,4–6 Evidence-based care has been recognized by the Institute of Medicine (IOM) as a critical component of safe, quality patient care.8 Despite the ongoing emphasis on evidence-based care and the millions of dollars spent in the development and conduct of research designed to improve patient care, translation of evidence to practice continues to be delayed, with experts continuing to postulate that it may take as long as 17 years for newly discovered knowledge to be translated to clinical practice.9–12 Nursing has a long history of applying evidence to practice; however, little recognized progress was made in the formal EBP movement until the development of the Cochrane Collaboration, established by Archie Cochrane in the early 1970s in the United Kingdom. As this collaboration was evolving, a similar movement was evolving at the McMaster Medical School in Canada. Originally designated as evidence-based medicine, the concept has shifted over time to be referred to as EBP and is inclusive of all health care disciplines.1,5,13 There are many models to guide the EBP process. Some of the best known models include the Iowa Model of EBP,14–16 the Hopkins Model of EBP,6,17 the Melnyk/Fineout-Overholt model,1 the Rosswurm and Larrabee model,18,19 and the Joanna Briggs Institute (JBI) model.20,21Common steps in the EBP process can be guided by a translational model22 adapted from Dobbins et al.,9 Larrabee,18 Rogers23, and Graham and Tetroe24 (Fig. 9.1). Basic steps include: Chart shows innovation to implementation model. Knowledge leads to persuasion, decision, implementation, and confirmation. • Knowledge: New Innovation or Practice Change or Regulation. • Persuasion: Vetting Groups • United Shared Governance • Practice Council • Other related councils or groups. • Decision: Adoption Decision using Evidence-based Decision making Process • Practice Change Decision Council • C N O group. • Implementation: Dissemination or Implementation of Innovation. • Confirmation: Process and Outcome Evaluation to Judge initial Uptake and Long Term Sustainability. • Cyclic diagram shows innovation characteristics (relative advantage, compatibility) leading to organizational characteristics (size, skill mix), environmental characteristics (administrative support, available resources), and individual characteristics (age, education). The cycle continues. • Another cyclic diagram shows adapt innovation to target environment, leads to assess barriers to implementation, select and tailor education roll-out strategies, launch, monitor adoption or implementation process, adjust implementation as indicated, evaluate and sustain. • Education roll-out strategies are L M S • Reminders • S B A R • Interactive education • Huddles • Audit and feedback • Informal opinion leaders • Local consensus process • Patient mediated interventions. • An arrow from assess need for practice change leads to selection of highest quality evidence from most to least synthesized resource available. • Second arrow from locate best evidence points toward environmental characteristics. • Critically analyze evidence is interrelated to type of decision, followed by design practice change. • Implement and evaluate is interrelated to monitor adoption or implementation process. • Integrate and maintain is interrelated to outcome measures.
9: Evidence-Based Practice and Research
Abstract
Keywords
Research, EBP, AND quality improvement
Definition
Example
IRB Approval Required
Quality improvement
A process in which systematic data is used to monitor care process outcomes for the purposes of continually monitoring and improving outcomes on a local basis.
Monthly monitoring and reporting of adverse events associated with the administration of moderate and deep sedation.
No
EBP
The conscientious and judicious use of current best available evidence in conjunction with clinical expertise and patient values/preferences to guide the care given to patients.
Based on national guidelines regarding the prevention and/or management of PONV, an ambulatory care unit decides to add acupressure bands as a routine nursing intervention for the prevention of PONV. Their PICO question is as follows: In adult PACU patients, what is the effect of acupressure bands compared with standard treatment on the incidence of PONV?
No
Research
The systematic, rigorous, empirical investigation of the relationship among particular phenomena. Involves research development, testing, and evaluation. Designed to develop or contribute to generalizable knowledge.
The effect of preoperative warming (none, 30 minutes, 60 minutes) on the development of unplanned perioperative hypothermia is investigated by a perianesthesia research team.
Yes
Overview of EBP
The process of EBP
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