Introduction to Research and Evidence-based Practice

Research in Nursing

NUTH 3003

Kate Hinic, RN, MS, APN

Objectives

• Define nursing research

• Describe the purpose of research in an evidence-based practice environment

• Define evidence-based practice (EBP)

• Formulate PICO questions

• Identify resources for locating evidence

• Apply principles of EBP in a case study activity

Understanding Research

• Nursing research develops knowledge to:

– Build the scientific foundation for clinical practice

– Prevent disease and disability

– Manage and eliminate symptoms caused by illness

– Enhance end-of-life and palliative care.

• Purpose of most research studies is linked to evidence-based practice.

– Identify ways of helping nurses make evidence-based treatment decisions on how to prevent or address a problem.

Research is…

• Systematic

• Rigorous

• Inquiry to gather data

• Focused on creating new knowledge, promoting understanding, testing theories, and assessing outcomes of interventions

What makes it nursing research?

• Knowledge that is important for, and relevant to nursing and nurses

• The metaparadigm of nursing

– Metaparadigm????

– Human, environment, health, nursing

• Theories of nursing processes, actions, interventions, environments

• Theories for health-related processes & experiences of humans in their environments, as they interface with nurses in their practice

Definition of nursing research

“Nursing research is a formal, systematic, and rigorous process of inquiry used to generate and test theories about the health-related experiences of human beings within their environments and about the actions and processes that nurses use in practice.”

(Fawcett & Garity, 2009, p.5)

Fawcett & Garity, 2009, p.5

What do we need nursing research to do?

• Inform practice

• Explain

• Predict

• Improve

• Promote understanding

• Explore new phenomena

Sources of evidence in nursing practice

• Tradition/tenacity—we’ve always done it like this

• Authority—my clinical instructor told me to …

• A priori- logic—it seems like common sense; it seems reasonable

• Theory that is tested – Descriptive-explores and describes human health

situations-descriptive research methods

– Explanatory- describes influencing factors, relationships among variables-correlational research methods

– Predictive-examines effects of intervention--tested with experimental methods

Theory

A theory is the interlinking of relatively concrete and specific concepts, the propositions that narrowly describe those concepts, and the propositions that state specific associations among the concepts.

• A concept is an idea expressed in words.

• A proposition is a statement that describes:

A concept

Associations among concepts

Theory examples

• Self efficacy theory: An individual’s sense of capability to perform to an expected standard will influence his or her motivation to master new skills.

• Lewin’s change theory: Change occurs after increased driving forces and decreased restraining forces permit unfreezing, movement to a new equilibrium, and refreezing via increased restraining forces – restraining forces can be formalization of policy, rules,

and expectations.

Many ways to categorize studies

• Theory generating – What are the processes

involved when an organization begins to use an evidence-based nursing approach?

• Theory-testing – Does the use of a nursing

research mentor facilitate the change process on a unit where evidence-based nursing is being implemented?

• Descriptive – How do nurses with varying

levels of education feel about evidence-based practice?

• Correlational – What is the relationship

between educational level and participation in EBP activities?

• Experimental – Do units with research mentors

have more evidence-based activities than units without?

• Quantitative • Qualitative

History

• 1800’s - Florence Nightingale & epidemiological approach • 1900 - AJN • 1920’s – first nursing doctoral program • 1950’s - research primarily by nurse educators • 1960’s - conceptual models and nursing theories distinguish the science of

nursing from other health care fields • 1970’s - increasing numbers of doctorally prepared nurses, Nursing

Research journal • 1980’s – infusion of research content into nursing education • 1986 – establishment of the National Center for Nursing Research • 1993 –establishment of the NINR as one of the NIH institutes • 1990’s –expansion of research funding, NINR priorities, research reported

in most clinical nursing journals • 2000’s – Evidence-based nursing, rating the evidence, complex research

methodologies, teams & large data-sets

Context of Research in Nursing

• Culture of quality and safety

• IOM Reports

– To Err is Human

– Patient Safety and Quality: An evidence-based handbook for nurses

National Institute of Nursing Research

• NINR became a full institute with the NIH in 1993.

• Provides funding for nursing research

– FY 2010 funding exceeded $140 million

• Provides training and support to nurse researchers

• Focus is on promotion of health and quality of life

Future of Nursing Research

• Continued focus on EBP

– Translational research

• Replication studies in different settings to strengthen evidence base

• Emphasis on systematic reviews

• More interdisciplinary research

• Expanded dissemination of findings

• Increased focus on cultural issues and health disparities

Importance of Research in Nursing

• Safe, current, clinical practice

• Defining and refining nursing’s unique body of knowledge

• Credentialing – Magnet Status

Evidence-based Practice (EBP)

• The conscientious and judicious use of current best evidence in conjunction with clinical expertise and patient values to guide health care decisions.

Sackett et al., 2000

Evidence Triad

Sackett et al., 1996; Penn State University, 2013

Foundation for evidence based practice: findings must be

• Unbiased

• Trustworthy

• Reproducible

• Relevant to practice

• Clinically as well as statistically significant

EBP – 4 Basic Steps

• Turn your need for information into an answerable question

• Find the best evidence

• Appraise the evidence for validity and usefulness

• Apply the findings to practice and evaluate performance

Sackett et al. 2000

AHRQ Model of Knowledge Transfer, 2008 Retrieved from http://www.ahrq.gov/qual/advances/

Important clinical questions

P – patient condition, problem, population

I – intervention/treatment

C – comparative intervention

O – outcome

Let’s try it

You wonder if the use of alcohol based hand sanitizers is as effective as handwashing in prevention of infection in the hospital.

P = Population in hospitalized patients

I = Intervention is the use of hand sanitizers

C = Comparison as effective as traditional handwashing

O = Outcome in controlling infection?

Penn State University, 2013

Sample Clinical Questions

• For the older adult with diabetes, does participation in a regular exercise program improve glycemic control?

• Does amount and quality of sleep affect academic performance, weight, and feelings of well-being in college students?

• In new mothers, what is the effect of a peer support group on self-efficacy and duration of breastfeeding?

EBP – Let’s try it!

A staff nurse in a busy primary care clinic notices that quite a few of his older adult patients have had recent falls in the community. Each of their lives have changed since the fall either due to injury, disability, or fear. He wonders if there is anything he or the clinic can do to help prevent these falls and their negative consequences in his patients.

Moving towards answers

• Nursing actions should be

– Clinically appropriate

– Cost effective

– Result in positive patient outcomes

• So, where does this evidence come from?

Sources of Evidence

Answering our question

• Institutional practice guidelines or policies

• Find the evidence

– Guidelines

• http://guidelines.gov/content.aspx?id=37219&search=fall+prevention

– Systematic Review

– Professional organizations

• American Geriatrics Society Guidelines http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2010/

Resources for EBP

• Pre-appraised evidence

• Systematic reviews

• Clinical practice guidelines

– http://guidelines.gov/

• Guideline synthesis http://guidelines.gov/syntheses/synthesis.aspx?id=35256&search=pap+smears

– http://www.cdc.gov/std/treatment/2010/

• Clinical decision support tools

Finding the Evidence

• Remember the evidence hierarchy

• First, look for systematic reviews and meta-analyses

• Individual studies

– Require appraisal

• Online textbooks

– UpToDate

• Other

Finding the evidence @ SHU

Walsh Library

http://www.shu.edu/academics/libraries/

Suggested Databases:

CINAHL

PubMed

HaPI

DARE (Database of Abstracts and Reviews of Effects)

Cochrane Database of Systematic Reviews

Evidence Appraisal

• Is the study question clear and does it address my clinical question?

• Were the methods used appropriate?

• Do the results make sense?

• Are there other studies with similar results?

• Are the population and sample adequately described and similar to my patients?

Applying the Evidence

• Apply findings

– Should the practice change be accepted, rejected, modified for clinical practice?

– Who does the change affect? (Get buy-in!)

– What is the process for change?

– Is the change cost-effective?

• Education

– Solicit input initially and throughout process

• Monitor outcomes

Monitoring practice

• Implementation is an ongoing process

• Continued monitoring for at least 6 months

• Assessment of staff learning needs

• Comparison of pre- and post- outcomes

• Comparison with other areas that have not made the change

• Comparison with national benchmarks

EBP in Action • SBAR tool for interprofessional

communication (IHI, 2010)

– Poor communication identified as a major source of errors

– SBAR encourages appropriate and respectful communication

• Back to sleep for infants

– Traditional sleep in prone position to prevent aspiration

– Supine position linked with reduced risk of SIDS

Clinical Expertise

• Experience + continuing education

• Professional organization membership

• Attendance at hospital grand rounds

• Can be “borrowed” from a more senior nurse

The Patient

• Accurate assessment and understanding of current patient condition critical

• Cultural, spiritual, and health values information

• Family dynamics

Example use of EBP

• Group Activity – Formulating PICO questions

– Scenarios

– Worksheet

• Beginning to search

– Databases - findings

• Applying the evidence

– Practice change?

– Education and approval?

– Monitoring change?

Participation in research

Every nurse can be involved!

– Journal club

– Using evidence-based clinical practice guidelines or policies

– Joining a research group

– Collaborating with others to generate ideas for research

– Recruiting study participants

– Discussing relevant research findings with clients

Your responsibility

• All nurses are accountable for safe and competent patient care.

• All nurses have a responsibility to understand and be able to apply nursing research.

Thank you

. . . only by putting into practice what is learned from research will care be made safer.

Marita G. Titler, PhD, RN, FAAN