Category Archives: evidence based practice

evidence based practice, reading research, research, Writing

“Here Comes Santa Claus?” What IS the Evidence?

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How strong is the evidence regarding our holiday Santa Claus (SC) practices? And what are the opportunities on this SC topic for new descriptive, correlation, or experimental research?  Although existing evidence generally supports SC, in the end we may conclude, “the most real things in the world are those that neither children nor men can see” (Church, as cited in Newseum, n.d.).santa3

If you want to know the answers, check out: Highfield, M.E.F. (2011).  Here comes Santa Claus: What’s the evidence? Advanced Emergency Nursing Journal, 33(4), 354-6. doi: http://dx.doi.org.libproxy.csun.edu/10.1097/TME.0b013e318234ead3   Using bona fide published work, the article shows you how to evaluate the strength of evidence and how to apply it to practice.   You can request a full-text for your personal use from your library or from the author via www.researchgate.net/home .  

Critical thinking: Check out this related research study with fulltext available through PubMed: Black Pete through the eyes of Dutch children
(https://www.ncbi.nlm.nih.gov/pubmed/27322583 ).   Write a follow-up research question based on the findings of this study & post in comments below.

For more info: For those unfamiliar with ResearchGate, it is a site where you can track authors who publish in your area of interest, and you can set up your own profile so that people can track your work.  Take a look.   

evidence based practice, HCAHPS, Outcome measurement, Research design

What are you asking? (or “Can HCAHPS sometimes be a DIRECT measure?”)

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In a prior blog (Direct speaking about INdirect outcomes: HCAHPS as a measurement*), I argued that HCAHPS questions were indirect measures of outcomes.  Indirect measures are weaker than direct measures because they are influenced by tons of variables that have nothing to do with the outcome of interest.  But wait!! There’s more!  HCAPS can sometimes be a DIRECT measure; it all depends on what you want to know.

(If you know this, then you are way ahead of many when it comes to measuring outcomes accurately!!)

KEYKEY POINTS:

  • If your research question is what do patients remember about hospitalization then HCAHPS is a DIRECT measure of what patients remember.  
  • However if your research question is what did hospital staff actually do  then HCHAPS is an INDIRECT* measure of what staff did. 

What is HCAHPS?  HCAHPS (pronounced “H-caps”)  questions are patient perceptions of what happened, which may or may not be what actually happened.    Patients are asked to remember their care that happened in the past, and memories may be less than accurate. (See this link for more on what HCAHPS is: http://www.hcahpsonline.org/Files/HCAHPS_Fact_Sheet_June_2015.pdf )

Example:  HCAHPS question #16 is, “Before giving you any new medicine, how often did hospital staff tell you what the medicine was for?”    Whether the patient answers yes or thinkerno, the response tells us only how the patient remembers it.

Why is this important?     

  • Because if you want to know whether or not RNs actually taught inpatients about their medications, then for the most direct & accurate measure you will have to observe RNs .
  • However, if you want to know whether patients remember RNs teaching them about discharge medications, then HCAHPS question #16 is one of the most direct & accurate measure of what they remember.

*FOR MORE INFORMATION on why you want to use DIRECT measures SanDiegoCityCollegeLearningResource_-_bookshelfsee https://discoveringyourinnerscientist.com/2016/11/04/direct-speaking-about-idirect-outcomes-hcahps-as-a-measurement/

CRITICAL THINKING:  Pick any HCAHPS question at this link and write a research question that for which it would be a DIRECT outcome measure: question(http://www.hcahpsonline.org/files/March%202016_Survey%20Instruments_English_Mail.pdf)

For your current project, how are you DIRECTLY measuring outcomes?

Evidence based nursing, evidence based practice, Outcome measurement, research methods

Bake it into your project cake!

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In the last post we compared stronger direct measures of outcomes with weaker indirect
measuremeasures of project outcomes.

So…what direct measures are you “baking into your project cake”? What do you hope will be your project outcome & what measurement will show that you achieved it? –pain scores? weight? skin integrity? patient reports of a sound night’s sleep?  Share your story.  Help others learn.

Or if you just stuck with HCAHPS (or other) as outcome measure, explain why that was the best choice for your project.  (Maybe in your case it was a direct measure!)

Happy measuring!

For More Info on direct vs. indirect measures & Critical thinking: Check out t Direct speaking about INdirect outcomes: HCAHPS as a measurementquestion

evidence based practice, Meta-analysis, pain assessment, Pain management, research, Research design, Uncategorized

Ouch! Whose Pain Feels Worse?

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levels-of-evidenceIs pain experience as diverse as our populations?  This week I came across an interesting meta-analysis.

A meta-analysis (MA) is one of the strongest types of evidence there is. Some place it at the top; others, 2nd after evidence-based clinical practice guidelines.  (For more on strength of  evidence, click here.)

MA is not merely a review of literature, but is a statistical integration of studies on the same topic.  MA that is based on integration of randomized controlled trials experiment(RCTs) or experimental studies is the strongest type of MA.  MA based on descriptive or non-experimental studies is  a little less strong, because it just describes things as they seem to be; & it cannot show that one thing causes another.

MA example: This brand, new MA included 41  peer-reviewed, English-language, experimental studies with humans:  Kim HJ, Yang GS, Greenspan JD, Downton KD, Griffith KA, Renn CL, Johantgen M, Dorsey SG. Racial and ethnic differences in experimental pain sensitivity: Systematic review and meta-analysis. Pain. 2016 Sep 24 [Epub ahead of print] doi: 10.1097/j.pain.0000000000000731. PMID: 27682208.    All 41 studies used experimental pain stimuli such as heat, cold, ischemic, electrical and others and compared differences between racial/ethnic groups.

Pain reliefMain findings?  “AAs [African Americans], Asians, and Hispanics had higher pain sensitivity compared to NHWs [non-Hispanic Whites], particularly lower pain tolerance, higher pain ratings, and greater temporal summation of pain.” (https://www.ncbi.nlm.nih.gov/pubmed/27682208)  (Temporal summation is the increase in subjective pain ratings as a pain stimulus is repeated again and again.)

Critical thinking:  Given that this is a well-done meta-analysis and that the pain was created by researchers in each study, how should this changequestion your practice?  Or should it?   How can you use the findings with your patients?  Should each patient be treated as a completely unique individual? Or what are the pros & cons of using this MA to give us a starting point with groups of patients?  [To dialogue about this, comment below.]

For more info? Request the full Kim et al. article via interlibrary loan from your med center or school Heart Bookslibrary using reference above.   It is available electronically pre-publication.   Also check out my blog on strength of different types of evidence.

Happy evidence hunting. -Dr.H

Evidence based nursing, evidence based practice, quality improvement, research

“Two roads diverged in a yellow wood, and sorry I could not travel both and be one traveler, long I stood and looked down one as far as I could…” R.Frost

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Below is my adaptation of one of the clearest representations that I have ever seen of when the roads diverge into quality improvement, evidence-based practice, & research.  Well done, Dr. E.Schenk PhD MHI, RN-BC!qi-ebp-research-flow-chart

 

Evidence based nursing, evidence based practice, Literature review, PICO, reading research, research, Research class, School papers

You Got A Problem With That? Try PICO*

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IF….

  • The Purpose of evidence-based practice (EBP) =  BEST PATIENT CARE, &
  • The Definition of EBP = Best evidence + Clinical judgment + Patient/Family preferences & values

THEN…How do I get started with EBP to improve patient care?

One of the 1st steps is to identify clearly the clinical issue that needs solving.   One way to do that is by using PICO.*

WHAT IS PICO?   PICO is an acronym to help you clarify the clinical problem & to help you prepare to search the literature for evidence

  • P = Patient population or problem
  • I = Intervention or treatment that you want to try out & is based in best evidence
  • C = Comparison intervention or treatment (This might be some standardized care on your unit; or un-standardized care given by individual nurses based on their individual expertise)
  • O = Outcome you want to achieve.

EXAMPLE:  Let’s say you work with post-op patients and want to speed up patients’ return of normal GI function.  Right now on your unit, patients are NPO post-op progressing to ice chips and so on as their bowel sounds start returning.  But you have 2 concerns: a) some patients’ GI function seems quite slow to return; & b) quicker return to a nutritious diet may speed healing.  You read an article that gum chewing can reduce the time of postoperative ileus.  With that information, here is how your PICO problem would look:

  • P = Postoperative patients with ileus
  • I = Gum chewing postop
  • C = NPO with gradual diet progression when bowel sounds start returning
  • O = Reduce time of postop ileus with sooner return to nutritious eating

CRITICAL THINKING: Now you try it.  What is problem for patients (or nurses) on your unit? Try writing it out in a sentence or two and then put it into PICO format.  You are now on your way with beginning an EBP project that will promote the very BEST PATIENT CARE.

*Note: Some use PICOT that includes “T”.  The “T” stands for the time it will take to show an outcome.  Because the timing does not seem to me relevant to all questions I typically omit it, but you may find it helpful.  If so, use it!