This model for evidence-based clinical decision making shows how using your clinical expertise and considering patients’ values and preferences ensures that you will apply the evidence in practice both safely and appropriately.[Figure is on p. 51 of text.]
•Box 5-1 (on text p. 52) reviews the parts of development of a clinical “PICOT” question. These elements direct the nurse to:Identify patients by age, gender, ethnicity, and disease or health problem Which intervention is worthwhile to use in practice (e.g., a treatment, diagnostic test, prognostic factor)? What is the usual standard of care or the intervention used now in practice? What result do you wish to achieve or observe as a result of an intervention (e.g., change in patient behavior, physical finding, patient perception)? How much time is needed for an intervention to achieve an outcome (e.g., the amount of time needed to change quality of life or patient behavior)?
After critiquing all articles for a PICOT question, synthesize or combine the findings to consider the scientific rigor of the evidence and whether it has application in practice.
The hierarchy of available evidence offers a guide to the types of literature or information that offer the best scientific evidence.This diagram of the hierarchy of evidence shows that stronger evidence is farther up the triangle. For instance, a well-designed randomized controlled trial (RCT) carries more weight than the opinion of even experts.A randomized controlled trial is the highest level of experimental research.[Discuss each level.][Figure is on p. 54 of text.]
When you read an article, do not put it down and walk away because of the statistics and technical language. Know the elements of an article and use a careful approach when reviewing each one.•An abstract is a brief summary of the article that quickly tells you if it is research or clinically based. An abstract summarizes the purpose of the article. •The introduction contains more information about the purpose of the article. •A good author offers a detailed background of the level of science or clinical information that is available on the topic. •The “middle section” or narrative of an article differs according to the type of evidence-based article it is: clinical or research. •Aclinical articledescribes a clinical topic, often including a description of a patient population, the nature of a certain disease or health alteration, how patients are affected, and appropriate nursing therapies. •A research article contains several subsections within the narrative, including the following: A purpose statement explains the focus or intent of a study and includes hypotheses—predictions made about the relationship or difference between studies—and questions or variables—concepts, characteristics, or traits that vary within or among subjects. • The methods or design explains how a research study was organized and conducted to answer the research question or test the hypothesis. • Clinical and research articles have a summary section. In a clinical article, the author explains the clinical implications for the topic presented. In a research article, the author details the results of the study and explains whether a hypothesis is supported or how a research question is answered. • Clinical implications: A research article includes a section that explains whether findings from the study have clinical implications. [Ask the class to write the parts of a clinical study, then to write the parts of a research study. Review the components of each.]
Critiquing evidence involves evaluating it, which includes determining the value, feasibility, and usefulness of evidence for making a practice change (ONS, no date). When critiquing evidence, first evaluate the scientific merit and clinical applicability of the findings of each study. Then using a group of studies and expert opinion, determine what findings have a strong enough basis for use in practice. After critiquing the evidence, you will be able to answer the following questions: Do the articles together offer evidence to explain or answer my PICOT question? Do the articles show support for the reliability and validity of the evidence? Can I use the evidence in practice?
Evidence is integrated in a variety of ways through teaching tools, clinical practice guidelines, policies and procedures, and new assessment or documentation tools. Depending on the amount of change needed to apply evidence in practice, it becomes necessary to involve a number of staff members from a given nursing unit.After the change is implemented, ask yourself, “How does the intervention work? How effective was the clinical decision for my patient or practice setting?”When evaluating an EBP change, determine whether the change was effective, if modifications in the change are needed, or if the change needs to be discontinued.When a practice change occurs on a nursing unit level, the first group to discuss the outcomes of the change is often the clinical staff on that unit. Clinicians enjoy and appreciate seeing the results of a practice change.In addition, the practice change will more likely be sustainable and remain in place when staff are able to see the benefits of an EBP change.
What are some of the advantages and disadvantages of belonging to such a committee? [Discuss.]
How would the incidence of such infections come to a nurse’s attention? How would awareness of a trend of increased incidence come to a nurse’s attention?What are some other possible causes of SR-BSIs from central venous catheters? [Discuss.]
Before conducting any study with human subjects, the researcher obtains approvals from the agency’s human subjects committee or institutional review board. An IRB includes scientists and laypersons who review all studies conducted at the institution to ensure that ethical principles, including the rights of human subjects, are followed.Confidentiality guarantees that any information a subject provides will not be reported in any manner that identifies the subject and will not be accessible to people outside the research team.
[Ask the class: What clinical question would you develop to address such a problem?Discuss.] [Ask the class: What outcomes would you use to measure implementation of changes suggested by the study? Discuss.]
The relationship among research, evidence-based practice, and quality improvement is overlapping and reinforcing. [Figure is on text p. 60.]See Table 5-3 [on text p. 61] to review the similarities and differences of these three methods.When implementing a research project, EBP and QI can inform opportunities for research. Rapid-cycle improvements measured through QI often identify gaps in evidence. Similarly, EBP literature reviews often identify gaps in scientific evidence. Thus the two processes help to identify topics for research.
A thorough analysis of QI data leads clinicians to understand work processes and the need to change practice. One type of QI Program, the PDSA cycle or approach, is described here.