Category Archives: evidence based practice

Missing in Action: The Pyramid foundation

Last post I commented on the potentially misleading terms of Filtered & Unfiltered Filtered Unfiltered jpgresearch.  My key point?  Much so-called “unfiltered research” has been screened (filtered) carefully through peer-review before publication; while some “filtered research”  may have been ‘filtered’ only by a single expert & be out of date. If we use the terms filtered and unfiltered we should not be naive about their meanings. (Pyramid source:  Wikimedia Commons )

This week, I address what I see as a 2nd problem with this evidence based medicine pyramid.  That is, missing in action from it are descriptive, correlation, & in-depth qualitative research are not mentioned.  Where are they?  This undercuts the EBM pyramid as a teaching tool and also (intentionally or not) denigrates the necessary basic type of research on which stronger levels of evidence are built.  That foundation of the pyramid, called loosely “background information,” includes such basic, essential research.

Ask an ExpertYou may have heard of Benner’s Novice to Expert  theory.  Benner used in-depth, qualitative interview descriptions as data to generate her theory.  Yet that type of research evidence is missing from medicine’s pyramid!  Without a clear foundation the pyramid will just topple over.  Better be clear!

I recommend substituting (or at least adding to your repertoire) an Evidence Based NURSING (EBN) pyramid.  Several versions exist & one is below that includes some of the previously missing research!  This one includes EBP & QI projects, too! Notice the explicit addition of detail to the below pyramid as described at https://www.youtube.com/watch?v=MfRbuzzKjcM.EBN

Critical thinking:  #1List some EBM & EBN pyramid differences.  #2 Figure out where on the hierarchy this project would go: Crowell, J., OʼNeil, K., & Drager, L. (2017). Project HANDS: A bundled approach to increase short peripheral catheter dwell time. Journal of Infusion Nursing, 40(5), 274-280. doi: 10.1097/NAN.0000000000000237.   1st use medicine’s EBM pyramid; & then 2nd use nursing’s EBN pyramid.  #3 Label Crowell et al.’s study as filtered or unfiltered and explain what you mean by that.

For more info:  Watch the YouTube video at the link above.

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Filtered vs. Unfiltered: What do these terms mean?

Are we talking cigarettes?  water? coffee? other?   Yes, other.   In this case about what is sometimes called “filtered” or “unfiltered” literature in the evidence-based medicine pyramid of research evidence.  (I have more than one issue with this particular pyramid as a representation of all evidence, but for right now let’s look at filtered information & unfiltered information.  Pyramid source:  Wikimedia Commons  
Filtered Unfiltered jpg

Filtered is considered stronger–meaning that we can be more confident that literature from this category better  supports cause and effect.  I agree.

Unfiltered evidence (usually single studies etc) is considered weaker–meaning that we must be more cautious about its accuracy in representing reality.  I agree.

But, “Is unfiltered information really unfiltered?”  No filtering at all? My qualified answer is, “No.”   Argue with me if you like.

My opinion: If the “unfiltered” article is a primary source, research study that has strong design and is published in a peer-review journal then it has been filtered by multiple, expert peer reviewers just to make it to publication.

Thus, when discussing filtered vs. unfiltered one should be very clear on what those terms mean and do not mean.

Critical Thinking: When filtered literature (systematic reviews & critically appraised topics & articles) has been filtered by one individual, is that superior to unfiltered literature in terms of introducing bias?  What if the “filtered” evidence is 7 years old and a primary, “unfiltered” source(s) from this year has different findings?   What is the relationship between “filtered” and “unfiltered”–after all the “unfiltered” is the pyramid base so what does that mean?

For more Info:  For peer review, the lower level filtering of single studies, consider its 1)  advantages (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4975196/)  and 2) its potential flaws (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1420798/)

Want to change the world? Make a list

For new graduate RNs (& those who help them) entering the workforce, Dr. Pat Benner PhD RN FAAN, who wrote Novice to Expert, has some great, very practical advice: Changehttps://www.youtube.com/watch?v=yxsBVPxS_zg  (1:56)  (hint: Remember the only behavior you can control is your own!)

And…it’s pretty good advice for any who assume a new job, too!

For More Information: If you want to know what it feels like sometimes to be a new growing plantgrad RN, check out the 2 main themes and the subthemes voiced by new graduates in the free full-text: Hussein et al., (2017). New graduate nurses‘ experiences in a clinical specialty: a follow up study of newcomer perceptions of transitional support. BMC Nursing, 16(42). doi: 10.1186/s12912-017-0236-0. eCollection 2017.

Critical Thinking:   Whether or not you are a new grad, did you have experiences similar to those in Hussein’s study?   Can you use Benner’s suggestions to deal with the issues?

 

33,000 foot view isn’t enough! Get down on the Ground To See What’s Really Happening!

My last blog post listed the usual sections of a research report (title, abstract, introduction, methods, results, & discussion/conclusion); and I illustrated the amazing things you can learn from only an article title!Its not enough

This week? Abstracts.   Abstracts are great; abstracts are not enough!

An abstract gives us only enough info to INaccurately apply the study findings to practice.

An abstract typically summarizes all the other sections of the article, such as  the question the researcher wanted to answer, how the researcher collected data to answer it, and what that data showed.  This is great when you are trying to get the general picture, but you should Never assume that the abstract tells you what you need to know.

Wrong WayAbstracts can mislead you IF you do not read the rest of the article.  They are only a short 100-200 words and so they leave out key information.   You may misunderstand study results if you read only the abstract.   An abstract’s 33,000 foot level description of a study, cannot reveal the same things that can be revealed in the up-close & personal description of the full article.

So…what is the takeaway?  Definitely read the abstract to get the general idea.  Then read the full article beginning to end to get the full & beautiful picture of the study.  Davies & Logan (2012) Butterflyencourage us,  Don’t give up reading the full article just because some parts of the study may be hard to understand.  Just read and get what you can, then re-read the difficult-to-understand parts.  Get some help with those PRN.

 

Critical thinking:   What info is missing from the below abstract that you might want to know?

J Nurses Prof Dev. 2016 May-Jun;32(3):130-6. doi: 10.1097/NND.0000000000000227.    Partnering to Promote Evidence-Based Practice in a Community Hospital: Implications for Nursing Professional Development Specialists. Highfield ME1, Collier A, Collins M, Crowley M.

ABSTRACT: Nursing professional development specialists working in community hospitals face significant barriers to evidence-based practice that academic medical centers do not. This article describes 7 years of a multifaceted, service academic partnership in a large, urban, community hospital. The partnership has strengthened the nursing professional development role in promoting evidence-based practice across the scope of practice and serves as a model for others.

More info on abstracts & other components of research articles?  Check out Davies & Logan (2012) Reading Research published by Elsevier.

Nightingale: Avante garde in meaningful data

In honor of Nurse Week, I offer this tribute to the avante garde research work of Florence Nightingale in the Crimea that saved lives and set a precedent worth following.

Nightingale was a “passionate statistician” knowing that outcome data are convincing when one wants to change the world.  She did not merely collect the data, but also documented it in a way that revealed its critical meaning for care.

As noted by John H. Lienhard (1998-2002): Nightingale coxcombchart“Once you see Nightingale’s graph, the terrible picture is clear. The Russians were a minor enemy. The real enemies were cholera, typhus, and dysentery. Once the military looked at that eloquent graph, the modern army hospital system was inevitable.  You and I are shown graphs every day. Some are honest; many are misleading….So you and I could use a Florence Nightingale today, as we drown in more undifferentiated data than anyone could’ve imagined during the Crimean War.” (Source: Leinhard, 1998-2002)

As McDonald (2001) writes in the BMJ free, full-text,  Nightingale was “a systemic thinker and a “passionate statistician.”  She insisted on improving care by making policy & care decisions based on “the best available government statistics and expertise, and the collection of new material where the existing stock was inadequate.”(p.68)

Moreover, her display of the data brought its message home through visual clarity!

Thus while Nightingale adhered to some well-accepted, but mistaken, scientific theories of the time (e.g., miasma) her work was superb and scientific in the best sense of the word.   We could all learn from Florence.

CRITICAL THINKING:   What issue in your own practice could be solved by more data?  How could you collect that data?   If you have data already, how can you display it so that it it meaningful to others and “brings the point home”?

FOR MORE INFO:

HAPPY NURSE WEEK TO ALL MY COLLEAGUES.  

MAY YOU GO WHERE THE DATA TAKES YOU!

 

 

Quasi- wha??

Two basic kinds of research design exist:  

  1. Experimental design in which
    • the researcher manipulates some variable,randomized
    • the participants are randomly assigned to groups, &
    • one group is a control group that gets a placebo or some inert treatment so that outcomes in that group can be compared to the group(s) that did get the treatment.
  2. Non-experimental design in which the researcher doesn’t manipulate anything, but just observes & records what is going on.   Some of these are descriptive, correlational, case, or cohort study designs for example.

One particularly interesting “experimental” design is one in which 1 or 2 of the experimental design ideal requirements as listed above are missing.  These are called quasi-experimental designs.

thinking3In a quasi experimental design

  • The researcher manipulates some variable, but….
  • Either the participants are NOT randomly assigned to groups
  • &/OR there is no control group.

A quasi-experimental design is not as strong as a true experiment in showing that the manipulated variable X causes changes in the outcome variable Y.  For example, a true experimental study with manipulation, randomization, and a control group would create much stronger evidence that hospital therapy dogs really reduced patient pain and anxiety.  We would not be as confident in the results of a quasi-experimental design examining the exact same thing.  In the next blog, we’ll examine why.

For more info:  Check out earlier blog:    “What is an RCT anyway?” at https://discoveringyourinnerscientist.com/2015/01/23/whats-a-randomized-controlled-trial/Idea2

Critical thinking:  Go to PubMed & use search terms “experiment AND nurse” (without the quotation marks).  Open an interesting abstract and look for the 3 elements of a classic experimental design. Now look for “quasi experiment AND nurse” (without the quotation marks.)  See what element is missing!

Not Just The Thought That Counts! (or is it?) Evidence-based gift giving.

Is it just the thought that counts?  or not?   (Probably depends on the relationship between giver & recipeient as per Paul Tournier’s The Meaning of Gifts that I highly recommend.)

In the meantime enjoy this article in the Washington Post on the holiday evidence for picking the best kinds of gifts.   OR as it is actually titled: “The trick to not giving a terrible gift this year”

Critical Thinking: Note the outcome measures cited for each study:

  1. Were they direct or indirect; & what is the advantage of eachgifts
  2. Were they self-report or observation; & what are the pros & cons of each?
  3. Were the studies descriptive? or experimental?   What does that tell you about cause & effect?
  4. Read Tournier’s tiny book, The Meaning of Gifts & draw your own conclusions.

For more info:  Ask yourself what you would most like for Christmas & check out your friends wishlists!   Check some of the studies cited in the Washington Post article, including Gino & Flynn (2011) evidence on preferences for $, solicited gifts, & unsolicited gifts.  The findings might surprise you:  http://www.sciencedirect.com/science/article/pii/S0022103111000801