Nur3052 ch4

Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 4: Critically Appraising Knowledge for Clinical Decision

Making


The Need for Critical Appraisal

It is vital to discern biased evidence from unbiased, reliable from unreliable

Practice that is based on flawed evidence cannot be considered EBP


Knowledge Sources

In the past, practice was based largely on tradition, logic, and expertise

Research Utilization (RU) movement began to change this

RU emphasized the use of single studies, however

The process for generating practice-based evidence (e.g., quality improvement data) has improved


Weighing the Evidence

Practitioners take into account the validity and reliability of the specific evidence

Reliance on inexplicit or inferior knowledge sources (tradition; trial and error) is rapidly becoming unacceptable


Knowledge Sources for EBP1. Valid research evidence

The primary basis of clinical decisions

2. Clinical expertise

To best use research by filling in gaps and combining it with practice-based evidence to tailor clinical actions for individual patients’ contexts

3. Patient choices and concerns

For determining the acceptability of evidence-based care to the individual patient

• The main criterion is certainty


Question

Which of the following sources of knowledge would a nurse prioritize when determining the turning schedule for an immobilized patient?

a. The traditional practice on the unit

b. The nurse’s knowledge of skin breakdown

c. The preferences of the patient and the patient’s family

d. A clinical practice guideline for preventing skin breakdown


Answer

d. A clinical practice guideline for preventing skin breakdown

Rationale: EBP encompasses patient preferences and the clinical expertise of individual practitioners, but the primary source of knowledge is research evidence. Clinical practice guidelines synthesize this evidence in order to guide practice.


Rating the Strength of Evidence

Not necessarily synonymous with “hierarchy of evidence”

High-level study design does not necessarily mean high quality

Grading the strength of a body of evidence addresses three domains – quality, quantity, and consistency


Rating the Strength of a Body of Evidence Quality: the extent to which a study’s design, conduct,

and analysis has minimized selection, measurement, and confounding biases (internal validity)

Quantity: the number of studies that have evaluated the question, overall sample size across all studies, magnitude of the treatment effect, strength from causality assessment, such as relative risk or odds ratio

Consistency: whether investigations with both similar and different study designs report similar findings (requires numerous studies)


What is Meant by “Evidence”

Research evidence

Clinical knowledge gained via the individual practitioner’s experience

Patients’ and practitioners’ preferences

Basic principles from logic and theory


Question

Tell whether the following statement is true or false.

A post-operative patient’s statement that Dilaudid (hydromorphone) has been ineffective in treating her pain can be considered a form of evidence.


Answer

True

Rationale: Patient preferences and experiences are an important consideration and are a form of evidence. While the patient’s preference does not likely constitute the “final word” on treatment choices, it must be weighed carefully and integrated into the nurse’ choice of intervention.


Internal Evidence

Evidence that is generated by outcomes management, quality improvement, or EBP implementation projects

Aimed at improving outcomes at the site where improvement efforts are conducted

Quality Indicator Systems:

AHRQ National Healthcare Quality Report

National Quality Forum (NQF)

National Database of Nursing Quality Indicators® (NDNQI®)


Question

Tell whether the following statement is true or false.

Internal evidence is characterized by findings that are applicable and generalizable to multiple practice settings.


Answer

False

Rationale: Unlike external evidence, the generation of internal evidence is intended to improve clinical practice and patient outcomes within the local setting that it is conducted.


Combining Internal and External Evidence The PDSA Cycle

1. Plan: Plan the change and observation

2. Do: Try out the change on a small scale

3. Study: Analyze the data and determine what was learned

4. Act: Refine the change based on what was learned and repeat the testing

Health & Medicine

Nur3052 ch4