If The (EBP Practice Guideline) Shoe Fits, Wear It! Definitely!

If you want to solve a priority clinical problem using the best research evidence out there, you & your team have at least a couple of options:

1) You can DIY (do it yourself), which means finding, critiquing, synthesizing, and translating the research into clinical practice recommendations: OR

2) You can take advantage of experts’ work by finding evidence-based clinical practice guidelines that you can simply adopt or adapt to your setting.

Either option is good, but in this post I want to focus on option #2: Evidence-based practice guidelines.

What are practice guidelines?  Clinical practice guidelines are “systematically developed statements” that help RNs, other providers, and patients to decide on the best course of care. When the guideline authors use research to write them, then we call them evidence-based practice guidelines (http://www.agreetrust.org/resource-centre/practice-guidelines/).

What’s the advantage?  In evidence-based practice guidelines, experts have already done the hard work of finding, critiquing, synthesizing, and translating the research into practice recommendations for you.   You need only to adopt or adapt them to fit your setting, and establish a regular review time to make sure they are supporting excellent care and still in date.

Where can you find EBP practice guidelines to adopt or adapt?  A few places are:

Consider “bookmarking” these sites or adding them to your “favorites” in your internet browser.

You may even find multiple guidelines on your subject.  Then you and your team get to choose the one that BEST fits your setting & solves the clinical problem!  How cool is that?  (Note: The gold standard for critiquing guideline quality is the AGREE II tool, but ….more on that another day.)

Critical thinking exercise

  1. Go to National Guidelines Clearinghouse.
  2. Search for “family presence during resuscitation”
  3. Look at the ENA clinical practice recommendations on that page and see how strong the evidence is to support each one. (You can also take a look at the process of guideline development & the research used to support it.)
  4. Then decide how might you adopt or adapt one of those recommendations in your own setting?
  5. Have an informal conversation with a colleague about your thoughts on this.

If you can use one or more of the recommendations, you have now brought more research evidence into your practice.  Congratulations!!

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“Take 5!” (minutes to learn about 4 search strategies)

“TAKE 5” minutes to learn about 4 best strategies to find nursing research articles. Watch the video at this link: https://www.youtube.com/watch?v=Em7b9jr-ZK8&list=PLQKD1cO-QY3Rt2PaLd3dykeL4HZo7mCZv&index=7

(Well it’s technically 5:23 minutes, but as with calories, who’s counting?)

A great place to use these 4 strategies is the highly comprehensive and reliable PubMed database. You already pay for that publicly available healthcare research database with your tax dollars, so go to http://www.ncbi.nlm.nih.gov/pubmed/ and get your money’s worth!   PubMed even has a link to show you how to use those 4 strategies specifically on PubMed. (Check that out at http://www.nlm.nih.gov/bsd/disted/pubmedtutorial/020_340.html)

One of your search terms can be nurs* if you want a better chance of finding only nursing articles. You’ll know what that little asterisk means after you “TAKE 5!” with the first video link.

Some PubMed articles are free for you to print or save. Many are not. That means you will need to take the list of articles that you found in your search to your hospital librarian for help. OR if you have access to library databases through a school you can find full text of most articles there or order them through interlibrary loan.

If you don’t have access to library databases yourself, here’s a good way to work with a hospital librarian.

  1. Use the 4 search strategies to find relevant articles on PubMed.
  2. Give that list of articles to your librarian who is likely to have a budget and time to pull the full articles for you.
  3. If you find only one article that fits the problem you are trying to solve, you can take that article to the librarian and ask the person to find you more like that one.

Another public database is Google Scholar, but it is not as accurate or thorough. For its strengths and weaknesses and how to use it well, you might find this handout useful (https://www.dit.ie/media/library/documents/kevinst/Guide%20How%20to%20use%20Google%20Scholar.pdf).

Happy evidence hunting!

“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.

“It Takes 2 to Tango” (Or to Answer Research Questions)

It takes 2 people to dance the tango, and 2 types of data to answer research questions.

Researchers answer hypotheses and research questions by collecting and analyzing data.   The collected data often are numbers (AKA quantitative data) that are analyzed with statistical tests.  

In contrast, some researchers may collect word data to answer the research question. The word data are usually subjects’ descriptive answers to open-ended interview questions.   Researchers analyze the word data (AKA qualitative data) by looking for patterns in subjects’ descriptions.

A researcher may also choose to collect and analyze both numbers (quantitative) data AND word (qualitative) data to answer a research question more completely. This is similar to what an RN might do when the RN asks the patient to rate pain from 0 to 10 (number data) and also to describe the character, location, & severity of the pain (word data). You can see that having both types of data can give a more complete picture clinically. The same is true in research.  (Using both quantitative & qualitative data is called mixed methods.)

Many nurses associate research only with numbers data and statistical analysis. Here is an excerpt of how analysis of numbers/quantitative data may look. “The majority of patients were female (58.5%), the mean age was 59.5 years, 53.1% of the patients had cancer, and 55.5% had undergone surgery….The majority of patients (56.6%) reported pain in the abdominal region. The mean duration of pain in patients with chronic pain was 4.8 years (SD =10.8), and for patients with acute pain 5.9 days (SD =5.9).” (de Rond et al, 2000, p.429) Notice the statistical calculation of percents, means (averages), and standard deviations (SD).*

In contrast, sometimes word data and analysis is the only way to answer a research question!   Here is an example of how such qualitative data analysis was used to answer the question of what social processes were blocking the comforting of hospice patients: “Open coding initially generated five [barriers to appropriate opioid use to manage pain among hospice patients]…: within the patient, within the physician, within the family, within the nurse, and within the healthcare system….Two basic psychosocial processes became apparent as the foundation of these barriers: fear and avoidance behaviors.” (Zerwekh et al, 2002, p.85)  Notice that the researchers identified 5 barriers and 2 processes by analyzing nurses’ descriptions.

At other times researchers may collect and analyze BOTH numbers (quantitative) data and word (qualitative) data, as in this excerpt: “[In response to the question of] ‘Who asked me about my pain and how did they do this?’ Seven of the eight children interviewed indicated they had been asked about their pain. …Some children did provide evidence of areas where they felt improvements could be made. One child indicated she would like nurses: to check on me more often (Case 1). However, another child (Case 3) indicated that nurses asked her about her pain too often and that this was particularly annoying if it meant they woke her up.” (Twycross & Finley, 2013, p.3100)   Notice in this mixed methods case that 70% (7 of 10) said they had been asked about pain, and that several gave descriptions suggesting improvements.

 

CRITICAL THINKING: Read this excerpt and identify whether the researcher collected and analyzed quantitative or quantitative data or used mixed methods:“Approximately 82% of all patients received pain medications in the hospital, doctor’s office, outpatient clinic, or surgery center. The most commonly administered medications were morphine (33%) and meperidine (27%) for inpatients and acetaminophen with codeine (23%) and ibuprofen (15%) for outpatients.   Overall, one third of patients requested their first one to two doses of pain medication while in the surgical setting. Of these, 37% were inpatients and 25% were outpatients. After discharge, 76% of all patients received pain medications.” (Source: Apfelbaum, Chen, Mehta, & Gan, 2003, DOI: 10.1213/01.ANE.0000068822.10113.9E)

 

*Standard deviations (SD) are how the data spread out while means (averages) are how the data clump together.

Ebola or Other Outbreak: When We Can’t or Shouldn’t Experiment

 What do we do to study the cause of disease when we cannot or should not expose people to disease risk (i.e., manipulate the independent variable). For example, while we want to understand Ebola transmission and outcomes, legally and ethically we cannot & should not expose people to Ebola risk factors.   We cannot do Ebola experiments on people.

Thus, we have to observe what happens when nature takes its course. One common research design in which we let disease/nature take its course is a case-control study. What is a case-control study?

Here’s a quick explanation.   The researcher looks for people who have (or had) the disease and then looks back in time at their history of exposure to risk factors for the disease. Those who have been exposed and who did not (or not yet) get the disease are the control subjects. If risk factors for the disease are not well-known then it may be difficult to find control subjects because we would have a hard time telling who was exposed.

Case-control and other studies in which we look back at what happened in the past are called retrospective studies. (In contrast, most nursing studies are prospective studies—in other words they start at the present and move forward. For example, if we were doing research on Ebola symptom management, we would try out symptom management strategies on persons with Ebola and measure into the future how well those strategies work.)

A great flow diagram and clear explanation of case control studies is at http://www.ciphi.ca/hamilton/Content/content/resources/explore/fb_case_v_cohort.html . Check it out!

Critical thinking practice: If you were to design a case-control study related to information in the excerpt below, answer these questions:

  • Who would be the case subjects?  
  • Who would be the control subjects?
  • What are the risk factors?
  • Why would the study be retrospective?

“Ebola virus, a member of the Filoviridae group, is transmitted by direct contact with blood, secretions, or contaminated objects and is associated with high case-fatality rates (28). Investigations of outbreaks in Africa suggest that Ebola infection may be more severe during pregnancy and that mortality rates are higher. Pregnant women infected with Ebola more often have serious complications, such as hemorrhagic and neurologic sequelae, than do nonpregnant patients (31). Unlike risk for death from Lassa fever, which is highest during the third trimester of pregnancy, risk for death from Ebola is similar during all trimesters (33).” (Jamieson et al, 2006, http://wwwnc.cdc.gov/eid/article/12/11/06-0152_article)

 

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

“What are you implying?”—the question to ask about Findings*

As you read closer and closer to the end of a research report, you should start asking, “What are the implications of what this researcher found?”   In other words now that the findings show X what is the Y that we do in response?

Sometimes the researcher labels a section IMPLICATIONS. Other times implications are included in the DISCUSSION section.

What implications you look for may depend on your role. Are you a direct, inpatient care RN? Then you want to know what the research implies about the need to maintain or change practice.   Are you in staff development or teaching clinical students? Then you want to know whether this means you should be teaching something or some “how-to” differently.   Management/administrator? Then what does this mean for leadership or organizations. And,…if you’re a researcher, then you want to know what is the next question raised by this study, OR perhaps does this study need to be repeated before we can feel confident in the findings.   (Of course, if you’re a student looking at a study may mean that you are one step closer to completing one of those evidence-based assignment papers.)

If you look carefully, you will see that the researcher tells you what they think the implications are for patient care, education, management, research, students, patients, or others.

Research does not give final answers. Exhilaratingly a research article often raises more questions than it answers—especially because any research project can only narrowly be designed to examine one teeny area of reality.   (OK. Perhaps only researchers would find that thrilling.)

So, as you read think: What do these research findings mean for RN practice?

Critical Thinking Practice: Find the implications in this excerpt from the Discussion section of Brown & McCormack (2005):  The study revealed that accurate and holistic pain assessment for older people were (sic) deficient in the acute surgical setting…. As a number of older people experienced hearing difficulties, it was also possible that patients did not respond because they misunderstood or simply did not hear what they were being asked. Herr and Mobily (1991) suggest that a reliable assessment of the older persons’ pain can be best obtained if they are offered privacy rather than asked to discuss pain in a public location. Whilst this can be difficult to achieve in a ward environment, measures such as drawing the curtains or moving closer to the patient, may afford some improved degree of enhanced communication and privacy for pain assessment. (p.1295)

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*In earlier posts at http://discoveringyourinnerscientist.blogspot.com/ , I summarized what titles, abstracts, introductions, methods, results, and discussions sections of a research report are all about.

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