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Translation of Evidence into Nursing Practice

Heather Carter-Templeton

INTRODUCTION

Clinical decisions are often made with uncertainty. It is widely recognized that evidence-based practice (EBP) can improve healthcare quality and improve patient care outcomes. An increased emphasis on EBP to facilitate this now requires nurses at all levels to engage in EBP. For a nurse practicing across inpatient, ambulatory, home and other settings as well as education, administration, and research, it can be challenging to keep up with both the latest technology as well as new scientific publications. Staying current is central to safe and high-quality care even though care based on evidence is not always the norm (Melnyk & Fineout-Overholt, 2015). Although nurses in different settings may consider different types of information to be “evidence,” the profession is rapidly learning together how human and electronic information resources, as well as print information resources, contribute to improved outcomes (Carter-Templeton, 2013). Informatics facilitates this journey by strengthening the merger of evidence with technology in convenient, yet transformative, ways. This chapter focuses on the translation of evidence into practice and how translation intersects with technology.

DEFINING EVIDENCE, IMPLEMENTATION, AND TRANSLATIONAL SCIENCES

Evidence-based practice adds action to the use of evidence. EBP provides processes for using evidence to generate knowledge. It is an extensively used term that is easier to define than to operationalize. Though challenging, it is widely recognized that EBP, which is defined as a process by which clinical decisions are shared between providers and the patient and families, is the best approach to improving patient quality and safety (Harrington, 2017). These decisions are guided by the best available research evidence in conjunction with the provider’s knowledge and patient preferences. Additionally, evidence-based pathways, protocols, and guidelines can be used to decrease undesirable differences in the way care is delivered (Macias, Loveless, Jackson, & Suresh, 2017).

Evidence-based practice has been discussed in great detail in nursing literature. It has many siblings, and the distinctions can be confusing when searching the literature. The barriers to EBP such as time restrictions, limited access to evidence-based sources, lack of information seeking and appraisal skills have been discussed for some time in nursing literature. Strategies to overcome these barriers have not received the same attention. Furthermore, the nursing discipline has acknowledged that evidence, albeit strong, does little if it cannot be implemented and sustained (Tucker, Olson, & Frusti, 2009).

Implementation Science

Implementation science is a growing field that is both multifaceted and complex and is an important area of study as we begin to learn more about the application of evidence in specific contexts. It is especially relevant to nurses and others who work directly with patients since it focuses on what is needed to improve outcomes.

While great strides in standardizing EBP have been made recently, the implementation phase remains the most challenging step in the process. Reasons for challenges surrounding this phase vary. Tucker & Gallagher-Ford (2019) have cited various explanations such as: “pulling staff away from patient care to lead the practice change, or the necessity of certain equipment and supplies for practice change” (p. 51). They also mention fast-paced and ever-evolving hospital environments, regulatory and payer demands, the struggles associated with change, and deficient time and effort to sustain the change (Tucker & Gallagher-Ford 2019). More information can be found in their series titled EBP 2.0: Implementing and Sustaining Change found in the American Journal of Nursing beginning in April 2019.

The complex nature of EBP contributes to the slow adoption of research into practice. One report estimated that it takes 17 years for research findings to be used in practice (Balas & Boren, 2000). Meanwhile, more and more research-based information is being added to databases and online clinical resources. In 2008, it was estimated that around 2,000 articles per day would be added to the Medline database (Phillips & Glasziou, 2008). Also, the implementation phase is often underrated and therefore challenges related to the sustaining practice change arise. We also lack information on nurses’ knowledge and skills related to the implementation of evidence in the clinical setting (Tucker, Gallagher-Ford, Melnyk, 2018).

Much of the research is empirically driven but often did not account for the context in which it was to be implemented. And, nurses spend a great deal of time interfacing with the patients they care for. As a result, nurse-led research is an essential mechanism for the translation of nursing evidence into the clinical setting which can result in the delivery of safe and effective care (Curtis, Fry, Shaban, & Considine, 2016). Implementation of EBP findings remains inconsistent in daily practice, and the gap between research and practice remains significant (Wallen et al., 2010). Therefore, implementation science developed in healthcare in response to researchers’ realizations that proven treatments were not being implemented and/or sustained in clinical settings. This area of study is dedicated to applying concepts in pursuit of supporting evidence-based findings to improve outcomes (Annie E. Casey Foundation, 2019). It is specifically defined as “the study of methods to promote the adoption and integration of evidence-based practices, interventions and policies into routine health care and public health settings” (National Institutes of Health Fogarty International Center, 2017).

Translational Science

Knowledge translation and implementation science are terms that have been given more attention by researchers in the last 20 years. In many cases, the terms associated with these processes such as knowledge translation, utilization, exchange, dissemination, implementation science, and utilization have been used interchangeably. These terms often vary by geographic region as well (Khalil, 2016). A recent study of multiple research funding agencies from nine different countries identified 29 different terms used to describe knowledge translation (Curtis et al., 2016). This can contribute to the confusion associated with understanding and engaging in these processes.

Since no one standard international terminology conclusively defines translation, sorting out the definitions can be overwhelming. Understanding the commonly used terms associated with evidence-driven care is potentially valuable since adhering only to one way of thinking about evidence misses what these terms have in common. The collective actions associated with terms such as evidence-based practice, implementation science, translational research, knowledge translation, and related terms share a goal to move science close to what makes a difference for patients and populations. But much is being learned, and technology offers momentum. Struggling with what it takes to apply evidence in ways that promote lasting, safe, cost-effective, and high-quality care is gradually leading to measurable outcome improvements.

TOOLS USED FOR SUPPORTING TRANSLATION OF DATA TO INFORMATION TO KNOWLEDGE TO WISDOM

Nursing is an information-based discipline (Graves & Corcoran, 1989). Nursing informatics unites nursing science, computer science, and information science in ways that transform what this means. The evolution of nursing as an information-based discipline changes how data, information, and knowledge are managed in nursing practice (Staggers & Thompson, 2002). Figure 25.1 is inspired by Englebardt & Nelson’s (2002). Relationship of Data, Information, Knowledge, and Wisdom and illustrates examples of tools facilitating translation at each informatics meta-structure level. The actions occurring as data are transformed into information, knowledge, and wisdom are dynamic and iterative. What is learned through research, evaluation, quality improvement, and safety activities contribute to wisdom? Once wisdom is achieved, feedback contributes to ongoing improvements and to generate new hypotheses.

• FIGURE 25.1. Example Tools Facilitating Translation at Each Informatics Meta-structure Level. (Adapted from Englebardt, S., & Nelson, R. (2002). Health care informatics: An interdisciplinary approach (Figure 1-4, p. 13). St. Louis, MO: Elsevier.)

In an evolving healthcare system, nurses’ information needs are fluid and evolve. The development of knowledge accompanies the use of evidence. But only recently the scientific knowledge base has become relevant to translational research and implementation science and is strong enough to support the use of specific evidencebased tools and strategies during translation as well as to address how local factors, such as attitudes toward EBP, influence translation (Upton, Upton, & Scurlock-Evans, 2014). Measurement of the impact of using a specific evidence-based tool aids in the ongoing understanding of the barriers and facilitators that influence sustained improvements. Peer-reviewed publications reporting the results of measuring impact add relevance to the scientific knowledge base. Nurses have been the early stages of identifying best practices as well as gaps in the body of knowledge related to health information technology (HIT) implementation (Abbott, Foster, Marin, & Dykes, 2014). As innovations spread, more will be known about how to tailor HIT tools to a local setting, including better understanding about how to adjust implementation strategies based on factors associated with the nursing interventions, patients, and resources.

EVALUATION OF RESEARCH EVIDENCE

Research results can be used to address critical clinical questions after being accepted as part of the evidence base for a clinical problem. Research results become part of the evidence base for a disease or condition only after going through rigorous and explicit processes designed to find, compare, and combine data. Reviews of research findings involve critical appraisal using precise and objective inclusion and exclusion criteria. Such criteria identify studies to be considered when trying to answer a clinical question, such as which nursing interventions for reducing pain are the most effective and scientifically grounded. An organized approach is used to identify valid and reliable peerreviewed publications to be considered further. Rigorous methods determine the efficacy of specific interventions and their effectiveness when used with real patients outside of tightly controlled conditions. Advanced statistical analysis, using Bayesian or other methods, help understand how best to combine findings. Through these techniques, systematic reviews pull together what is known about the benefits and harms of the interventions surrounding a clinical question. The credible methodology helps reveal the tradeoffs associated with essential treatment, diagnostic, or prevention interventions. The cumulative findings related to specific questions can then be reviewed and rated by unbiased experts. Typically, ratings are accomplished by a multidisciplinary expert team. A team’s systematic review often results in rated recommendations about what does and does not contribute to improved outcomes.

The UNITED STATE PREVENTIVE SERVICES TASK FORCE USPSTF assigns A, B, C, D, or I letter grade to signify the strength of each recommendation that comes from synthesizing research findings. USPSTF, 2020_ The highest rating of evidence is A for strongly recommended and I means insufficient evidence to make a recommendation.

CRITICAL APPRAISAL TOOLS AND REPORTING GUIDELINES

Nurses involved in EBP may use essential appraisal tools or reporting guidelines. Essential tools of appraisal assist in helping the reader through an evaluation process of the evidence. Having the knowledge and skills needed to select the appropriate critical appraisal tool or reporting guidelines is an essential EBP competency and a key to appropriately evaluating and ultimately translating evidence. A recent study explored the definitions and descriptions of critical appraisal tools and reporting guidelines along with rationales for their use. The tools and guidelines along with their full-text URLs are provided below in Tables 25.1 and 25.2. (Buccheri & Sharifi, 2017):

Further understanding and increased use of the above tools by nurses in the clinical setting can help support and facilitate EBP. Some US resources that can be used by healthcare providers and instructors are in Table 25.3.

MODELS AND THEORETICAL FRAMEWORKS CONNECTING CRITICAL THINKING TO PROCESSES THAT SUPPORT THE USE OF EVIDENCE IN NURSING PRACTICE

Models and frameworks help link critical thinking to stepwise processes that promote the use of evidence, including accounting for factors that lead to the safe and lasting outcome and organizational improvements. Because translation involves implementing evidence and evidencebased tools outside tightly controlled situations, such as randomized controlled trials (RCT), theories help nurses critically examine the contextual factors, assumptions, and influences surrounding implementation. Using models and frameworks helps nurses prepare a compelling plan for translation within complicated situations, such as the implementation of an EBP when change and disruption are anticipated.

Nursing leaders across countries have contributed to theories about translation and quality improvement. These theories include Donabedian’s (1980) structure, process, and outcomes framework, which focus on problem-solving. Other theories directly relevant to translation are found in Rogers’ Diffusion of Innovations Model, the Funk Model, the PRECEDE Model, the Chronic Care Model, the PARiHS Model, the Stetler Model, the Iowa Model, Translation Research Model, Rosswurm and Larrabee’s Model, the ARCC Model, Kitson’s Framework, Melnyk and Fineout-Overholt’s Model of EBP, the Lean Framework, the PICOT Model, the QUERI model, and the Institute for Healthcare Improvement’s breakthrough model. Some of these models are briefly described in this chapter.

Exploring how nurses conceptualize translation helps nurses learn from each other. Specific contributions include Rogers’ understanding of “attributes” (including complexity) and Alison Kitson’s emphasis on understanding the environment, including the importance of a clearly articulated collaborative knowledge translation (KT) approach that can be embedded into the research design (Kitson et al., 2013). The Promoting Action on Research Implementation in Health Services (PARiHS) framework helps define and measure key factors leading to successful implementation and has been widely used, including by Squires et al. (2012) who designed strategies to implement research-based policies and procedures. Dr. Marita Titler provided leadership for AHRQ’s TRIP initiatives and has also studied the context in which EBPs are translated. Important influences found include (1) the nature of the innovation (such as the strength of evidence) and (2) the manner it is communicated to nurses and physicians (Herr et al., 2012; Titler, 2010, 2011). Dr. Carole Estabrooks described the importance of considering the significant needs found in complex care environments, such as nursing homes (Estabrooks et al., 2013). Dr. Cheryl Stetler evolved her practitioner-oriented Stetler Model of Evidence-Based Practice in ways that have shaped the evolution of EBP (Stetler, 2001, 2010; Stetler & Caramanica, 2007; Stetler et al., 2006) and also synthesized literature on use of the PARiHS framework, including development of a companion guide to assist researchers using PARiHS (Stetler, Damschroder, Helfrich, & Hagedorn, 2011). The PARiHS framework is widely used internationally, including by Bergström, Peterson, Namusoko, Waiswa, and Wallin (2012) who used PARiHS as a framework for knowledge translation in Uganda.

As new technologies combine with novel approaches to measuring the complex factors affecting outcomes, theories and frameworks are being customized, including tailoring them to the workflow of nurses and the needs of developing nations (Dalheim, Harthug, Nilsen, & Nortvedt, 2012). Melnyk and Fineout-Overholt adopted EBP competencies for nurses and advanced practice nurses (APNs) working in real-world clinical situations (Melnyk, Gallagher-Ford, Long, & Fineout-Overholt, 2014). Rycroft-Malone et al. (2012) and McCormack et al. (2013) described a new approach known as realist review and synthesis, which focuses on understanding the mechanisms by which an intervention works or does not work. Hynes, Whittier, and Owens (2013) used the QUERI model to demonstrate how HIT approaches could be characterized as facilitators or barriers to implementation. Three pathways were found to contribute to translation: (1) compliance and collaboration with information technology policies and procedures; (2) operating within organizational policies and building collaborations with end users, clinicians, and administrators; and (3) obtaining and maintaining research resources and approvals. Harrison et al. (2013) emphasized the importance of planning support in the development of a framework called CAN-IMPLEMENT. In Canada, the Queen’s University Research Roadmap for Knowledge Implementation (QuRKI) is being used to highlight mutually supporting/interconnected cycles of research studies supporting implementation (Harrison & Graham, 2012). In Australia, multidisciplinary Health Networks were used as a framework to collaboratively develop evidence-based policies and drive implementation (Briggs, Bragge, Slater, Chan, & Towler, 2012).

INFORMATICS TOOLS THAT PROMOTE THE USE OF EVIDENCE AND APPLY KNOWLEDGE TO PRACTICE

Adoption of evidence is now understood far beyond passively providing access to a single clinical practice guideline or Webinar. The attention has shifted to understanding the conditions that foster ongoing and lasting change once the evidence is found and introduced, often using multiple implementation strategies. Increasingly, not only is the intervention being tested based on the best available evidence but the implementation strategies being used to apply the evidence are also grounded in science.

Clinical Practice Guidelines

Clinical practice guidelines are essential to the practice of medicine. They provide evidence-based recommendations for healthcare providers about the care of patients with specific diseases or conditions (Shekelle, 2018). For about 20 years, healthcare providers could turn to the National Guideline Clearinghouse and the National Quality Measures Clearinghouse to find evidence-based information that could be referred to during the development of policies, the establishment of treatments, and could be used to measure outcomes (Plunkett, 2018). However, recently, several significant developments related to clinical practice guidelines have occurred in the United States. ECRI has developed a new Institute Guideline Trust. (ECRI Institute Guideline Trust, 2019).

In 2011, the Institute of Medicine, now known as the National Academy of Medicine, released a report that proposed methods for guideline development, including systematic reviews of medical literature and further assessment information related to alternative care. This report stated that practice recommendations not informed by a systematic review should not be considered clinical practice guidelines. As a result, the number of guidelines in the National Guideline Clearinghouse was reduced by 50% (2619 in 2014 to 1440 in 2018) and guidelines that were older and not informed by such rigorous evidence were removed from the system while those that were determined to be trustworthy and based on evidence were retained (Shekelle, 2018). Also, the National Guideline Clearinghouse Extent of Adherence to Trustworthy Standards (NEATS) instrument was developed. This instrument contains 15 items that assess information such as disclosure of funding sources, multidisciplinary input, information regarding conflict resolution, patient perspective inclusion, systematic review information, rationale-based recommendations, outline of pros and cons, referencing of evidence, recommendations, and plans for updating the guideline (Ju et al., 2019).

In 2018, the National Guideline Clearinghouse was shut down due to a lack of government funding to maintain the Web site meaning users of the Web site would no longer have access to the information. This lack of access to such important information negated a critical recommendation from the Institute of Medicine (Shekelle, 2018). After the shutdown of the clearinghouse, the ECRI Institute Guideline Trust (ECRI Institute, 2020.) announced that it would assume responsibility for the clearinghouse. The Web site now allows users to search and retrieve summaries of clinical practice guidelines.

ESTABLISHING AN INFRASTRUCTURE TO SUPPORT EVIDENCE-BASED PRACTICE

Research findings tell us the evidence is not consistently integrated into practice. Further evaluations and reflections of these studies suggest that unconnected and fragmented approaches to accessing evidence at the pointof-care are not sufficient, stressing the need to provide EBP tools that are integrated into the nursing workflow or infrastructure (Bakken et al., 2008). This section will outline components that may be used in developing an infrastructure that supports EBP in healthcare.

Standardized Terminologies

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