Category Archives: Professional Nursing

“Is it?” “It is!” Expert opinion as valuable evidence for practice.

Remember back when you asked your mom why you should make your bed, set the table, or do some other then-distasteful task? Maybe you said, “Do I have to?”

Because I Said SoRemember her answer? Sometimes it was just: “Because I said so!” Was that enough evidence to support your practice of setting the table or making your bed?  You bet! After all she was THE expert on such things.

Likewise…is expert opinion good evidence for your practice? Yes, it is. EXPERT OPINION of individuals or committees is the 7th level of evidence for nursing practice (Melnyk & Fineout-Overholt, 2005), and should be considered.

Of course the first question that you must ask is: “Is the person/committee (who is telling you how to prevent falls, promote safety, teach patients, and so on and on) an actual EXPERT on that topic?” The answer is a matter of judgment. If the person/committee has special education, credentials, or experience or is a recognized authority on the topic about which they are giving advice, then you could reasonably conclude yes, they are experts. In that case the advice should be considered evidence for practice.    (Caution: Your judgment of their expertise matters!–don’t just follow along.  Don’t forget that person who is expert in one area may not be an expert in another.)

The 2nd question that you must ask is; “Does any research or stronger level of evidence exist on the topic?”

  • If it does NOT exist, then you should use that expert opinion in combination with scientific principles, anecdotal case reports, and theory. Or you might create some new research yourself. (Source=Iowa EBP Model)
  • If it DOES EXIST, then you should pay most attention to the stronger evidence and interpret the weaker evidence of expert opinion in that light.

QUESTIONCritical thinking:  Try your new knowledge in this example. Many educators and professionals who run journal clubs consider journal clubs effective based on feedback from participants. At least in 2008, 80% of experimental studies suggested that journal clubs helped with learning and being able to critically review a research article. However, no research is available on whether the learning from journal clubs actually translates into practice (Deenadayalan et al., 2008). You are considering a journal club. What would you decide to do and why?

For more, see:

It Takes a “Village”

BEST patient care results from using the best evidence in practice using your clinical judgment and the preferences and values of patients & families. In shorthand this is called evidence-based practice (EBP).

Most of the time it takes more than one person to bring evidence into practice.   Maybe not really a whole village,….but definitely anyone  who will be affected by the change OR whose cooperation you need to make the change!

team

In the last blog, we considered how to identify a problem clearly by using the acronym PICO.   Here was our example:

  • P = Postoperative patients with ileus (Patient population & Problem)
  • I = Gum chewing postop (Intervention to try out)
  • C = NPO with gradual diet progression when bowel sounds start returning (Comparison intervention—maybe the current protocol or highly varied individual RN expertise)
  • O = Reduce time of postop ileus with sooner return to nutritious eating (Outcome—what you want to happen!)  (For more on PICO check out last week’s post: “You Got a Problem with That? Try PICO)

The next BIG question: “Is the problem you have identified a PRIORITY?”

priority

  • Some priorities are triggered by problems—for example, your observation that something is not working, or poor PI outcome data, or below benchmark HCAHPS scores.
  • Others are triggered by new knowledge—for example, you read an   article, new research has come out, or your professional organization has new standards.

Now what? You need to gather your “village,” even if it’s only 2 people!!   Let’s say postoperative ileus is a BIG, PRIORITY problem on your unit, and you saw a research article on how gum chewing reduces time of postop ileus. Your next question is, “Who do I need to help reduce ileus by trying out gum chewing?” Well…your manager would certainly want to know, and the surgeon. Other patient-care RNs on the unit are critical to its success, too. And maybe you could use some help in finding and critiquing articles/evidence.

team

NO need to go it alone in solving the issue! Find others who care about the problem. Invite them & anyone (stakeholders) who would need to know about the postop gum chewing. The team can be 2 people if you like; or a lot more.

  • If you have a unit-based council, then you already have a pre-made team!
  • If you need to find some teammates, consider some of these people: a respected clinician with lots of respect; a new graduate with lots of energy; someone who loves to read research; & others.

Critical Thinking: Think of a clinical problem on your unit. Write it out in PICO format and list the names of those who would be on your problem-solving “village” team.  Whose cooperation do you need?

Want to read more? Melnyk, B.M., Fineout-Overholt, E., Stillwell, S.B., Williamson, & K. (2009). Evidence-Based Practice: Step by Step: Igniting a Spirit of Inquiry, American Journal of Nursing, 109(11), 49-52, doi: 10.1097/01.NAJ.0000363354.53883.58

EBP: What’s the point? & What is it anyway?*

The next few blogs will focus on how to improve your nursing practice by finding & using the best evidence.

  • 1st– What is the point or goal of evidence-based practice (EBP)? Best patient care.
  • 2nd– What is the definition of Evidence based Practice (EBP)?

Evidence-based Practice (EBP) =

Best evidence(research &/or nonresearch) +

Clinical Expertise +

Patient/family preferences & values

(See http://guides.mclibrary.duke.edu/c.php?g=158201&p=1036021 for more.)

  • 3rd– What should I do step-by-step to use the best evidence in order to give BEST patient care? At Dignity NHMC we use the Iowa model as a step-by-step guide (Titler et al, 2001). (Other readers should check to see if their hospital has adopted a model that they should follow.)   NHMC employees can find a copy of the Iowa model reprinted with permission and other information at S:\Everyone\everyone\EVIDENCE BASED PRACTICE-RN Scientist Role.  Additionally NHMC employees can contact the nursing EBP/research facilitator at martha.highfield@dignityhealth.org or extension 3339 for questions or one-to-one help.
  • What is the general process of EBP?Most models include the following elements:
  1. Identify clearly the clinical issue that needs solving.Maybe this is a problem that you’ve encountered in your practice, or maybe it is something you heard about from a colleague or journal. For example, what is the best way to manage injection pain in children?
  2. Find the best evidence. Research is typically regarded as best evidence.  When no research has been done on the topic we can still use expert opinions, case studies, and scientific principles.
  3. Critique the strength of the evidence. This is figuring out how much confidence you have that the research studies are coming to the right conclusions.  If you’re not sure, an NP or CNS could help or point you to another mentor.
  4. Combine (synthesize) all evidence.When research study outcomes contradict each other, then we have to look at which studies are most carefully done.  Again an APN can help.
  5. Write clinical recommendations for your settingbased on best evidence+clinical expertise+patient/family values & preferences.
  6. Try out (or pilot) the clinical recommendationsin your setting using clinical judgment and patient/family preferences and values.
  7. Evaluate the outcomes.
  8. PRN “tweak” your recommendations to improve outcomes& roll out the project to other units if appropriate.
  9. Reinforce the “new & improved” evidence-based practiceso that it is sustained.
  10. Monitor outcomes.

CRITICAL THINKING:  What is one patient-care issue that you think can be improved on your unit?  For example: Reducing post-op ileus? Cutting down on nighttime noise on the unit? Dealing with nurses’ potential alarm fatigue?  Other?   Write the problem out.  Writing it out makes you think it through more clearly so don’t just think it—write it.  Then, STAY TUNED next blog for more on clarifying the problem.

Reference: Titler, M.G., Kleiber, C., Steelman, V.J., Rakel, B.A., Budreau, G., Everett, L.Q., Buckwalter, K.C., Tripp-Reimer, T., Goode, C.J. (2001) The Iowa Model of Evidence-Based Practice to Promote Quality Care. Critical Care Nursing Clinics of North America, 13(4), 497-509.

*The next few blogs will focus more on how to use research in practice (commonly known as Evidence-based Practice)

“Which Came 1st–The chicken or the egg?” (or, Why Correlation is Not Causation)

Correlation is not causation. RNs who want to use research in practice must take this seriously.

What does it mean?   Answer: Just because two things happen together, we cannot say that one causes the other.

Consider the example of drinking coffee and staying awake. The more coffee you drink, the more hours you will stay awake.   But isn’t it also true that the more hours you try to stay awake, the more coffee you will likely drink?

Thus, in a study about coffee drinking and sleep, you may read that coffee and hours of being awake are correlated. In other words, they occur together. When one goes up, the other goes up.   What is not clear is whether the coffee is causing the person to be awake longer, OR whether being awake longer is causing the effect of more coffee consumption.   The unsolved mystery is: “Which is the cause and which is the effect?”[1]

Likewise consider the consistent relationship between chickens and eggs. Every egg was produced by a hen. Every one. In statistical terms this means that on a scale of 0 to 1 (with 0 being no relationship whatsoever and 1 being a relationship that occurs 100% of the time) eggs and chickens have a perfect 100% relationship of 1. (A statistician would write this as r=1.0).   What is unclear is whether (when the world was young), the chicken appeared first and caused the first egg, or the egg came first and caused the first chicken. Again the unsolved mystery is: “Which is a cause and which is the effect?”

Okay, so let’s do some critical thinking about actual research.  You read these results:

“More calls for assistance related to less fall-related patient harm. Surprisingly, longer response time to call lights also related to fewer total falls and less fall-related patient harm. Generally speaking, more call light use related to longer response times.”[2]

When you read this article, what should you be assuming about the researchers’ findings in terms of relationships instead of cause-and-effect? (Hint: Think about chickens & eggs, or coffee & insomnia.)

[1] Bonus info: We call causes “independent variables” and we call effects, “dependent variables”

[2] Tzeng, H.M,. & Yin, C.Y. (2009). Relationship between call light use and response time and inpatient falls in acute care settings. Journal of Clinical Nursing, 18(23), 3333-3341. doi: 10.1111/j.1365-2702.2009.02916.x. Epub 2009 Sep 4.

In Conclusion: “Back to the future”

A great conclusion to a study can take several forms.   One of these is like the abstract. The researcher summarizes the entire study in 100-200 words or so.   Researchers can also end with the suggestions for future research or an intriguing quote.   A great conclusion will give you the “bottom line” of why the study is important to you!

Thus it is sometimes valuable when FIRST encountering a new research article, to scan the abstract, intro, discussion/implications, and conclusion FIRST.   This will give you the big picture—the 30,000 foot level picture. Then you can get down at “ground level” and read the whole research article more carefully.

Research reports are Not mystery novels, and the plot will Not be spoiled if you read the conclusion first!  You may find that doing this makes it easier to understand the article.

If you are writing a research report yourself, then make sure that you keep the conclusion lively and interesting!   You know your project—what is THE main take away that you want readers to have?

CRITICAL THINKING….

Assume that you read the following Conclusion from Brown & McCormack (2006) BEFORE reading the rest of the article.   What ideas would you look for in the article that show up here in this “end-of-the-article-abstract-and-implications”? Which of their conclusions would you check out within the main article?

     This ethnographic study highlighted a number of issues that affected the older persons’ pain experience in the acute surgical setting. Additionally, it provided insight into how nurses approached the assessment and management of pain in this patient group. The study demonstrated the value of applying multiple sources and methods of data collection in order to obtain a more complete view of the competing forces that operate within the ward environment.

     Data analysis revealed three action cycles for further developmental work – pain assessment practices, knowledge/ insight and strategies to cope with episodes of uncontrolled pain and organization of care, along with ward culture, have been identified as having an inhibitory effect on pain management in older people. In addition, recognition that patient barriers may contribute to ineffective pain management is a point worthy of consideration.

     Improving pain management practices, therefore, requires healthcare professionals to reflect on reactions, values and beliefs surrounding pain and examine how these have the potential to influence the care provided. Consequently, there is a need for a focused, collaborative, interdisciplinary approach to challenge current pain management practices and implement change. There is a growing acknowledgement that successful interventions must deploy multiple strategies, targeting aspects of the individual, the organization, its culture and characteristics of the message, simultaneously (Kitson 2001). (p.1296)

Reference: Brown, D., & McCormack, B. (2006). Determining factors that have an impact upon effective evidence-based pain management with older people, following colorectal surgery: An ethnographic study. The Authors. Journal compilation, 1987-1298. doi: 10.1111/j.1365-2702.2006.01553.x

NEW site to Discovering Your Inner Scientist

Welcome to my new Discovering Your Inner Scientist blog location–a site focused on nursing evidence-based practice and scientist interests!  This site should be more user-friendly.

The blog remains focused on the interests primarily of staff RNs and is inspired by my colleagues at Dignity Health Northridge Hospital Medical Center.

For earlier posts on how to read research, go to http://discoveringyourinnerscientist.blogspot.com/  .   I plan to pick up the discussion here where that site left off, and I will continue to welcome your comments.