DNP Campus Intensive #2 092719 Resource Reference

NUR 7304
Research &
Evidence-Based Practice
Campus Intensive #2
Kris Roberson, DNP, MPA, APRN, NP-C
Fall 2019

Welcome!
Please be seated quietly and begin Quiz 3 in Canvas.
It is open book. You have 1 hour to answer 30 multiple choice questions.
You may take a break when finished and return to start class in keeping
with the agenda.

0. Cultivate a spirit of inquiry
1. Burning question / PICO(T)
2. Search for best evidence
3. Critical appraisal of evidence
4. Integrate the evidence
5. Evaluate the outcomes
6. Disseminate the outcomes
Where am I?

Assignment Review
Wk3
Bkgrnd & Sig Paper
Wk5
RCA
Wk7
Eval Tables

Assignment Review: BSP
LITERATURE
REVIEW
Bkgrnd & Sig
Paper
EBP Paper
Synthesis
Table
Eval Tables
RCA
ID issue &
search current
knowledge

• Clinical problem in the population
• Current knowledge
• Disparity/inequity
• Supporting data/evidence
• Local/practice site problem
• Relevant quality indicator
• Literature review purpose
• Clinical question (PICOT)
• Gaps in literature
• Search strategy & results

new
knowledge
new
evidence

new
evidence

The GAP
• GAP
• Something that remains to be done or learned in an area of study
• knowledge/evidence of scientific literature
• missing pieces
• not yet explored or underexplored
• Project must address a gap in order to make a contribution to nursing science
http://sites.middlebury.edu/middsciwriting/overview/organization/gap-statements/

Identify the GAP
• Succinctly identify the gap(s) project will attempt to address
• What has/has not been learned from the review of the literature?
• What did the authors find/discuss and what did they suggest as future areas of study?
• Ask critical questions as compare/contrast studies re population, setting, conditions, variables,
methods, analysis, measurement or outcomes.
• Problem
• what variances and similarities do see between clinical scenario and literature?
• epidemiology , processes, structures/resources, etc.
• Intervention
• is there a paucity of evidence in a particular setting or with the population of interest?

Identify the GAP
• What is unique or innovative about your project?
• Signal phrases
• has/have not been studied/reported/elucidated…
• is required/needed…
• the key question is/remains…
• it is important to address…

Fill the GAP
• Create summary statement about how project will attempt to fill the gap
• State the project purpose
• The purpose of this project is to…
• Indicate the gaps the project will fill
• This project will address gaps in…

GAP Analysis
Improving Access to Healthcare Among Children in Head Start Through Site Based Preventive Health Visits
Problem Intervention GAP Statement
• Head Start practice site does
not meet 90% goal of
enrolled children (live in
poverty) being up-to-date
with well-child care.
• Barriers in accessing
preventive healthcare: lack
of health insurance; inability
to pay out of pocket; and
lack of transportation.
• Federal recommendations to
utilize community
partnerships with local HCPs
for preventive health
services not fully
implemented.
• Evidence supports the use of
school based health clinics
among vulnerable and
medical underserved
children in elementary and
middle school, yet there is
little published literature
demonstrating the use of
site based healthcare in
Head Start settings among
children 3-5 years old.
• The purpose of this project is to promote access to healthcare
among children in Head Start by providing site based well child
visits to those experiencing barriers in access to preventive
healthcare. The goal is to increase the percentage of enrolled
children who are up to date with age specific preventive visit
guidelines so that the 90% compliance goal is met or exceeded.
• This project will address the gap in evidence specific to the use of
site based well child visits in Head Start programs among children
3-5 years old. It aims to evaluate the paucity of this intervention’s
evidence in diminishing barriers in access to care that are unique
to this population and setting. This project will also contribute as a
demonstration of a fully implemented partnership between a
Head Start site and a local healthcare provider. Pointedly, it will
address the key question if access to care will be promoted
resulting in achievement of the goal percentage of children being
up to date with well child visits.

GAP Analysis
Improving Access to Healthcare Among Children in Head Start Through Site Based Preventive Health Visits
• Head Start practice site does
not meet 90% goal of
enrolled children (live in
poverty) being up-to-date
with well-child care.
• Barriers in accessing
preventive healthcare: lack
of health insurance; inability
to pay out of pocket; and
lack of transportation.
• Federal recommendations to
utilize community
partnerships with local HCPs
for preventive health
services not fully
implemented.
• Evidence supports the use of
school based health clinics
among vulnerable and
medical underserved
children in elementary and
middle school, yet there is
little published literature
demonstrating the use of
site based healthcare in
Head Start settings among
children 3-5 years old.
• The purpose of this project is to promote access to healthcare
among children in Head Start by providing site based well child
visits to those experiencing barriers in access to preventive
healthcare. The goal is to increase the percentage of enrolled
children who are up to date with age specific preventive visit
guidelines so that the 90% compliance goal is met or exceeded.
• This project will address the gap in evidence specific to the use of
site based well child visits in Head Start programs among children
3-5 years old. It aims to evaluate the paucity of this intervention’s
evidence in diminishing barriers in access to care that are unique
to this population and setting. This project will also contribute as a
demonstration of a fully implemented partnership between a
Head Start site and a local healthcare provider. Pointedly, it will
address the key question if access to care will be promoted
resulting in achievement of the goal percentage of children being
up to date with well child visits.
There is a gap with the
site not meeting the
quality indicator goal
There is a gap with the
site not fully implementing
the recommended
partnership model
There is a gap in
published literature
using site based
healthcare in head start
in children ages 3-5

GAP Analysis

Evidence Source Table
Database/Site Search Terms Results (APA Citation for each reference)
Cochrane
Joanna Briggs
Institute
PubMed
CINAHL

Assignment Review: RCA
LITERATURE
REVIEW
Bkgrnd & Sig
Paper
EBP Paper
Synthesis
Table
Eval Tables
RCA
Search evidence
for intervention
studies; Appraise

Assignment Review: Evaluation Tables
LITERATURE
REVIEW
Bkgrnd & Sig
Paper
EBP Paper
Synthesis
Table
Eval Tables
RCA
ID keeper
intervention studies
& further analyze

Assignment Review
LITERATURE
REVIEW
Bkgrnd & Sig
Paper
EBP Paper
Synthesis
Table
Eval Tables
RCA
I. Background and Significance
II. Purpose Statement
III. Intervention Lit Review
IV. Theoretical Framework

Assignment Review: DNP Project Proposal
I.  Background and Significance
II.  Purpose Statement
III.  Intervention Literature Review
IV.  Theoretical Framework
V. Methodology
VI. Implementation
VII. Anticipated Limitations
VIII. Results
IX. Conclusion
X. References
XI.  Literature Matrix (Synthesis Table)
XII. Appendices
Research & EBP
(Scholarly Project)
Research Translation
ATP/DNP Project

DNP Essentials &
Competency Assessment

DNP Essentials & Competency Assessment
 DNP degree prepares APNs to meet needs of complex healthcare system by
improving systems of care through research translation that promotes
positive population health outcomes
 DNP Essentials are foundational competencies
 Essential I: Scientific Underpinnings for Practice
 Essential II: Organizational Leadership & Systems Leadership for QI & Systems
Thinking
 Essential III: Clinical Scholarship and Analytical Methods for Evidence-Based Practice
 Essential IV: Information Systems/Technology and Patient Care Technology for the
Improvement and Transformation of Health Care
 Essential V: Health Care Policy for Advocacy in Health Care
 Essential VI: Inter-professional Collaboration for Improving Patient and Population
Health Outcomes
 Essential VII: Clinical Prevention and Population Health for Improving the Nation’s
Health
 Essential VIII: Advanced Nursing Practice

I. Scientific underpinnings for practice
• strong scientific foundation for practice
• theories to guide nursing practice
III. Clinical scholarship & analytical methods for evidence-based practice
• discovering and integrating new knowledge
• applying knowledge to solve a problem
• translate research into practice, evaluate practice, improve practice and outcomes
VII. Clinical Prevention and Population Health for Improving the Nation’s
Health
• integrate and institutionalize evidence-based clinical prevention and population
health services for populations
• analyze epidemiological, biostatistical, occupational, and environmental data in
the development, implementation, and evaluation of clinical prevention and
population health
DNP Essentials & Competency Assessment

Evaluation Tables
Level of Evidence Where is article on the hierarchy of evidence
pyramid?
Quality of
Evidence (study
strengths &
weaknesses)
High? moderate? low? very low?
Strength of the
Evidence (level of
evidence +
quality)
Confidence to act; strong or weak?

GRADE
• Grading of Recommendations, Assessment, Development, and Evaluation
• A systematic method of assessing the quality of studies
• Working Group formed in 2000
• Aim: to develop a common, transparent and sensible system for grading
the quality of evidence and the strength of recommendations
• from evidence to decision
Hockenbury, M (2012). NUR650: Evaluating the quality of evidence, module 3 notes {PowerPoint slides}. Duke University, Durham,

GRADE
Falck-Ytter, Y. & Schunemann (2009). Rating the evidence: Using Grade to develop clinical practice guidelines. {PowerPoint slides}.
Retrieved fromhttps://www.slideshare.net/yashika54/development-of-clinical-practice-guidelines-and-the-grade-approach?qid=858a641c-aede-47ac-8f0d-71099125bc14&v=&b=&from_search=

GRADE
• Better research provides increased confidence in evidence to support a
particular recommendation
• As level of evidence increases, quality of evidence increases
• RCTs without important limitations provide high quality evidence
• Observational studies without special strengths provide low quality
evidence
• Limitations or special strengths can modify the quality of the evidence

GRADE
1. Identify the level of evidence
2. Rate the quality of evidence (for each outcome)
a. Do any factors lower quality?
b. Do any factors increase quality?
3. Grade strength of the recommendation
a. Do any domains contribute to strength?

1 ID level 2 Rate quality
1
3 Grade strength

1. Identify the Level of Evidence

2. Grade the Quality of Evidence

Quality of Evidence – 4 Categories
Grade Definition
High (4)
We are very confident that the true effect lies close to that of the estimate of the effect (further research is very unlikely to change our
confidence in the estimate of effect)
Moderate (3)
We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a
possibility that it is substantially different (further research is likely to have an important impact on our confidence in the estimate of
effect
and may change the estimate)
Low (2)
Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect (further
research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate)
Very Low (1) We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect (any
estimate of effect is very uncertain)
Although the quality of evidence represents a continuum, the GRADE approach results in an assessment of the quality of a
body of evidence in one of four grades: Quality of evidence is a continuum; any discrete categorization involves some degree
of arbitrariness. Nevertheless, advantages of simplicity, transparency, and vividness outweigh these limitations.

Quality of Evidence – 4 Categories
• Do any factors lower or increase quality?

Quality of Evidence – Lower Rating If…

Quality of Evidence – Increase Rating If…

3. Grade Strength of Recommendation
Schunemann, H., Brozek, K., Guyatt, G. & Oxman, A. (2013). GRADE handbook for grading quality of evidence and strength of recommendations {updated 2013}. The GRADE
Working Group, 2013. Retrieved from https://gdt.gradepro.org/app/handbook/handbook.html.
• Strong
• confident that the desirable effects of an intervention outweigh its undesirable
effects (strong recommendation for an intervention)
• confident that the undesirable effects of an intervention outweigh its desirable
effects (strong recommendation against an intervention)
• Weak
• the desirable effects probably outweigh the undesirable effects (weak
recommendation for an intervention)
• the undesirable effects probably outweigh the desirable effects (weak
recommendation against an intervention) but appreciable uncertainty exists

• Strong
• confident that the desirable effects > undesirable effects
• (strong recommendation for an intervention)
• confident that the undesirable effects > desirable effects
• (strong recommendation against an intervention)
• Weak
• the desirable effects probably outweigh the undesirable effects
• (weak recommendation for an intervention)
• the undesirable effects probably outweigh the desirable effects
• (weak recommendation against an intervention) but appreciable uncertainty exists

GRADE
Schunemann, H. J., Vist, G. E., Jaeschke, R., Kunz, R., Cook, D. J., & Guyatt, G. (2002). Advanced topics in moving from evidence to action: Grading recommendations. In Guyatt, G
Rennie, D., Meade, M. O., & Cook, D. J.(Ed.), Users’ guides to the medical literature: A manual for evidence-based clinical practice (pp 679-701). New York, NY:McGraw-Hill.
• 4 categories of
quality evidence
• high
• moderate
• low
• very low
• 2 strengths for
recommendations
• strong
• weak

GRADE
Guyatt, G,, Oxmanc, A., Akl, E., Kunz, R., Vist, G, Brozek…Sch€unemann, H. (2011). GRADE guidelines: Introduction GRADE evidence profiles and summary of findings tables.
Journal of Clinical Epidemiology 64(2011), 383-394. Retrieved from https://www.jclinepi.com/article/S0895-4356(10)00330-6/fulltext

IRB & QI: Is This Human
Subjects Research?
Adapted from AHRQ Is this QI or Human Subjects Research?
Implications for Practice-Based Research

• “Quality improvement efforts are held up by uncertainties about
when and how IRB review should be done.”
Clinical Infectious Diseases 2009;49:328–35

• “QI is an integral part of good clinical practice and is designed to
bring about immediate improvements in health care in local
settings. In contrast, …human subjects research is not a necessary,
integral element of good clinical practice and that human subjects
research aims to generate new, generalizable, and enduring
knowledge about human health.”
• However - can be overlap between the two
Ann Intern Med. 2007;146:680-681

Intersection of QI and Research
Adapted from: Hastings Center Report, July - Aug 2006

Quality Improvement, EBP and Research

Quality Improvement, EBP and Research
Clinical Question Research Question QI Question
Purpose To guide the systematic
search for evidence to
determine the best
intervention to affect the
outcome.
To generate new
knowledge/external
evidence
To identify and fix the
processes leading to a
problem that is internal
to the clinical setting.
Evidence Type Best available evidence External evidence Internal evidence
Example In postoperative kidney
transplant patients (P),
how does a health coach
(I), compared to no
health coaching (i.e.
current practice) (C),
affect hospital
readmission rates (O1)
and patient satisfaction
(O2) within 90 days of
discharge (T)?
PICOT format required
What is the effect of a
health coach on kidney
transplant patients’
satisfaction with
hospitalization?
What is the effect of
health coaching on
kidney transplant
patients’ readmission
rates?
Why is hospital
readmission rate in our
post-kidney transplant
patient population so
high?
On our Press Gainey
reports, why are our
patient satisfaction
scores not meeting
benchmarks for our
kidney transplant
patients?

Aim is to develop QI/EBP project in a manner that determines it to be exempt or expedited
• Exempt category 3
• Expedited category 7

Research: Regulatory Definition
• Research means a systematic investigation, including research
development, testing and evaluation, designed to develop or
contribute to generalizable knowledge.
• Research is a set of behaviors or processes not an outcome
• Many systematic activities are not research (QI)
• Generalizable knowledge is an outcome that can result from many non-
research activities
45 CFR 46.102(d)

Research versus Practice
• “Research is usually described in a formal protocol that sets forth an
objective and a set of procedures designed to reach that objective.”
• Employ research methodology (e.g. randomization)
• Obligation is to adhere to protocol rather than individualization of care
• Benefit to future patients, knowledge
Belmont Report, 1979

Quality Improvement: PDSA Cycle

Hastings Center Report July-Aug 2006

Are there types of QI activities that are also
research?
• …if a project involves introducing an untested clinical
intervention for purposes which include not only
improving the quality of care but also collecting
information about patient outcomes for the purpose of
establishing scientific evidence to determine how well
the intervention achieves its intended results, that
quality improvement project may also constitute
nonexempt human subjects research under the HHS
regulations.
OHRP - Quality Improvement Activities FAQs

When might QI activities be research?:
Warning Flags
• Intent is to develop new knowledge or validate new
treatments/interventions – does not implement existing knowledge
• Follows a research methodology/design
• Fixed protocol with a rigid goal, methodology, population, time
period, etc.;
• Risks from the intervention to participants are greater than minimal
• Funding source requirement (e.g. NIH)

What types of submission go to the IRB?

Is it human subjects research?
• Human subject: means a living individual about whom an
investigator conducting research obtains:
1. data through intervention; or
2. interaction with the individual; or
3. identifiable private information*
• * Must be individually identifiable (readily identifiable)
• Different standard than HIPAA

IRB & QI Discussion
Panel:
Is This Human Subjects
Research?
Panelists:
Vernon Shanks, Associate Director, Office of Sponsored
Programs
Islam Khan, PhD, Compliance Officer, Office of Sponsored
Programs

Example 1
Measuring Absorbed Radiation Dose
• A radiology clinic uses a
database to help monitor and
forecast radiation dosimetry
(absorbed radiation dose). This
practice has been demonstrated
to reduce over-exposure
incidents in patients having
multiple procedures. Patient
data are collected from medical
records and entered into the
database. The database is later
analyzed to determine if over-
exposures have decreased as
expected.

• Conduct focus groups with
clinicians working in outpatient
settings to optimize the
electronic health record (EHR)
• Plan to develop and implement
problem lists and other tools to
improve experience of working
with EHR
• Conduct second round of focus
groups to determine the impact
of tools on satisfaction with EHR
Example 2
Impact of Streamlined Documentation Tools

Example 3
Procedure to Reduce Prescribing Error Rates
• A group of affiliated hospitals
implements a procedure known
to reduce pharmacy
prescription error rates, and
collects prescription
information from medical charts
to assess adherence to the
procedure and determine
whether medication error rates
have decreased as expected.

Example 4
Trial to Improve Outpatient Asthma Care
• Practices will be cluster
randomized to a multipart
intervention including education,
EHR decision support, and
receipt of spirometers
• The objectives are to determine if
the intervention improves
patients’ asthma outcomes
• Data from all physicians’ patients
with asthma meeting age criteria
will be included

Example 5
Implementing Capacity Assessments
• A clinic … implements a widely
accepted capacity assessment as
part of routine standard of care in
order to identify patients requiring
special services and staff expertise.
The clinic expects to audit patient
charts in order to see if the
assessments are performed with
appropriate patients, and will
implement additional in-service
training of clinic staff … if it finds
that the assessments are not being
administered routinely.

• Objectives are to decrease the rate
of clotted or insufficient samples
for outpatient blood tests. The
intent is to improve family
satisfaction by decreasing the
need to repeat lab tests
• Plan to look at existing and
prospective records to examine
the timing of procedures and
method of blood draw (i.e., finger
stick or needle stick)
Example 6
Improving the Process of Drug Monitoring

Example 7
Parent Satisfaction Survey with Fast Track Clinic
• The purpose of the survey is to
determine the parent's
satisfaction with the staff,
healthcare provider, and care
• Providers will note the child’s
diagnosis, time spent for the
visit, and comment on whether
or not the child met the "Fast
Track Clinic" criteria
• The intent is to improve triage of
patients and to improve parent
satisfaction with care

Example 8
Transition of Medical Care to Adult Provider
• Objective is to identify best
practices, constraints and gaps
in service related to the
transition of children to adult
primary care
• Procedures involve surveys of
providers
• Understanding current gaps in
care and also best practices will
be used to design future
initiatives to improve transition
from pediatric to adult care

Example 9
Participation in a National Registry
• Patient data from multiple sites
sent to a DCC and used to
produce both site and patient
specific QI reports
• De-identified or limited data
sets can be requested from the
DCC for research purposes
• The DCC acknowledges that the
data might be used for
research in the future

• An iterative process will be
implemented with an objective of
preventing missed opportunities for
vaccination (training, feedback)
• Plan is to implement the
intervention and measure change
with each PDSA cycle
• Conduct surveys to learn providers
impressions of the program
• Plan to publish to help inform other
MOC projects
Example 10
Maintenance of Certification Program to Improve
Vaccination Rates

DNP Campus Intensive #2 092719 Resource Reference

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