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)


What’s an RCT anyway?

  • Question: What is a randomized controlled trial (RCT)? And why should I care?
  • Answer: An RCT is one of the strongest types of studies in showing that a drug or a treatment actually improves a symptom or disease. If I have strep throat, I want to know what antibiotic works best in killing the bacteria, & RCTs are one of the best ways to find that answer.

In the simplest kind of RCT, subjects are randomly assigned to 2 groups.  One group gets the treatment in which we are interested, & it is called the experimental group.   The other group gets either no treatment or standard treatment, & it is called the control group.  

Here’s an example from a study to determine whether chewing gum prevents postoperative ileus after laparotomy for benign gynecologic surgery:  A total of 109 patients were randomly assigned to receive chewing gum (n=51) or routine postoperative care (n=58).  Fewer participants assigned to receive chewing gum … experienced postoperative nausea (16 [31.4%] versus 29 [50.0%]; P=0.049) and postoperative ileus (0 vs. 5 [8.6%]; P=0.032).* There were no differences in the need for postoperative antiemetics, episodes of postoperative vomiting, readmissions, repeat surgeries, time to first hunger, time to toleration of clear liquids, time to regular diet, time to first flatus, or time to discharge. Conclusion?  Postop gum chewing is safe & lowers the incidence of nausea and ileus! (Jernigan, Chen, & Sewell, 2014. Retrieve from PubMed abstract)

Do you see the elements of an RCT in above?

Let’s break it down.

  • Randomized means that 109 subjects were randomly divided into 2 or more groups. In above case, 51 subjects ended up in a gum chewing group & 58 were assigned to a routine care, no gum group.  Randomization increases the chance that the groups will be similar in characteristics such as age, gender, etc.   This allows us to assume that different outcomes between groups are caused by gum-chewing, not by differences in group characteristics.
  • Controlled means that 1 of the groups is used as a control group. It is a comparison group, like the no-gum , standard care group above
  • Trial means that it was a study. The researchers were testing (trying) an intervention and measuring the outcomes to see if it worked.  In this case the intervention was gum chewing and the measure outcomes were nausea and ileus.

Why should you care about RCTs?  Because RCTs are strong evidence that an intervention works (or doesn’t) for your patients

Critical Thinking Exercise:   Go to http://www.ncbi.nlm.nih.gov/pubmed   In the blank box at the very top enter a few key words about the problem in which you are interested + RCT.  For example:  music pain + RCT.   Then read 1 or more of the abstracts looking for random assignment (randomized), control group, and whether it was a study (trial).   You’re on your way!    -Dr.H

*Note: You may remember from other blogs that p<.05 means the difference between groups is probably cause by the intervention—in this case gum chewing.

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!!

“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)


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