Tag Archives: evidence based practice

Significant or not?

What’s the difference between statistical and clinical significance? Here’s a quick, non-exhaustive intro.

Significant

In short, statistical significance is when the difference in outcomes between an experimental and a control group is greater than would happen by chance alone. For example, in a trial of whether gum chewing promoted return of bowel activity among post-op patients, one post-op group would chew gum and the other group would not.  Then researchers would statistically compare timing of return of bowel activity between the two groups to see if the difference was greater than would occur by chance (p<.05 or p<.01). If the probability (p) level of the statistical test is less than .05 then we have very strong evidence that gum chewing made the difference. [See example of gum chewing trial in free full text Ledari, Barat, & Delavar (2012).]

All well and good.

More 70 Significant Antonyms. Full list of opposite words of significant.

However, the effect of an intervention may be statistically significant, but not clinically meaningful to practitioners. Or the intervention’s effects may not be statistically significant, and yet still be clinically important enough to be worth the time, cost, and effort it takes to implement.

 What is clinical significance, and how can we tell if something is clinically significant? Two overlapping views:

  • “Clinical relevance (also known as clinical significance) indicates whether the results of a study are meaningful or not for several stakeholders.7 A clinically relevant intervention is the one whose effects are large enough to make the associated costs, inconveniences, and harms worthwhile.8” (Armiji-Oliva, 2018). 
  • Clinical significance is “the practical importance of research results in terms of whether they have genuine, palpable effects on the daily lives of patients or on the health care decisions made on their behalf” (p. 449, Polit & Beck 2012).

Let me illustrate. Researchers recently examined the effects of a 1300-1500 quiet time on a post-partum unit. Outcome measures showed that women’s exclusive breastfeeding rates increased 14%. However, this change was not statistically significant (p = .39)—a probability value well above p < .05. Nonetheless, researchers concluded that the findings were clinically significant because a higher percent of women exclusively breastfed their infants after quiet time, and arguably for those couplets the difference was “genuine” and “palpable” (p. 449, Polit & Beck). The time, cost, and effort of implementing a low risk quiet time was reasonably associated with producing valuable outcomes for some.

Always remember that the higher the risk of the intervention, the more cautious should be your translation of findings into a particular practice setting.  Don’t overestimate, but don’t overlook, clinical significance in your search to improve patient care.   

Critical thinking: How might issues of statistical versus clinical significance inform the dialogue on mask wearing during the pandemic?

For more info:

Evidence-based Practice Institute

I recommend this event. I have no conflict of interest.

New virtual EBP Institute – Advanced Practice Institute: Promoting Adoption of Evidence-Based Practice is going virtual this October.

This Institute is a unique advanced program designed to build skills in the most challenging steps of the evidence-based practice process and in creating an organizational infrastructure to support evidence-based health care. Participants will learn how to implement, evaluate, and sustain EBP changes in complex health care systems. 

Each participant also receives Evidence-Based Practice in Action: Comprehensive Strategies, Tools, and Tips From the University of Iowa Hospitals and Clinics. This book is an application-oriented EBP resource organized based on the latest Iowa Model and can be used with any practice change. The Institute will include tools and strategies directly from the book.

3-Day Virtual Institute

Wednesday, October 7

Wednesday, October 14

Wednesday, October 21

(participation is required for all 3 days)

Special pricing for this virtual institute: 5 participants from the same institution for the price of 4

Learn more and register for the October 2020 Advanced Practice Institute: Promoting Adoption of Evidence-Based Practice. 

Kristen Rempel

Administrative Services Specialist Nursing Research & Evidence-Based Practice

University of Iowa Health Care | Department of Nursing Services and Patient Care

200 Hawkins Dr, T155 GH, Iowa City, IA 52242 | 319-384-6737

uihc.org/nursing-research-and-evidence-based-practice-and quality

A practical place to start

Enrolled in an MSN….and wondering what to do for an evidence-based clinical project?

Recently a former student contacted me about that very question. Part of my response to her is below:

“One good place to start if you are flexible on your topic is to look through Cochrane Reviews, Joanna Briggs Institute, AHRQ Clinical Practice Guidelines, or similar for very strong evidence on a particular topic and then work to move that into practice in some way.  (e.g., right now I’m involved in a project on using evidence of a Cochrane review on the benefits of music listening–not therapy–in improving patient outcomes like pain, mood, & opioid use).

Once you narrow the topic it will get easier.  Also, you can apply only the best evidence you have, so if there isn’t much research or other evidence about the topic you might have to tackle the problem from a different angle” or pick an area where there IS enough evidence to apply.

Blessings! -Dr.H

Challenges to “Medical dogma” – Practice your EBP skills

Medscape just came out with Eric J. Topol article: 15 Studies that Challenged Medical Dogma in 2019. Critically check it out to practice your skills in applying evidence to practice. What are the implications for your practice? Are more or stronger studies needed before this overturning of dogma becomes simply more dogma? Are the resources and people’s readiness there for any warranted change? If not, what needs to happen? What are the risks of adopting these findings into practice?

Your thots? https://www.medscape.com/viewarticle/923150?src=soc_fb_share&fbclid=IwAR1SBNNVGW6BBWuKw7zBjhWIoQoMGtXZCy-BwpTTyavHSxmLleJuliKKG4A

“Two roads diverged in a yellow wood…” R.Frost

TIME TO REPUBLISH THIS ONE:

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

DNP vs. PhD: If the shoe fits….

For RNs wanting to pursue a doctorate, it is important to pick a degree that Glass slipperbest matches your anticipated  career path.   The shortest simplest explanation of the difference in these degrees is probably:

  1. PhD If you want to be a nurse scientist & teach in a university & conduct  nursing research. 
  2. DNP – If you want to be an advanced practice nurse, who primarily uses research in leadership, QI, patient care, etc. along with measuring project outcomes.

An excellent, free full-text, critique can be found at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4547057/  

Of course, some DNPs teach in universities, particularly in DNP programs.  PhDs may otherwise be better prepared for faculty roles.  I encourage you to look carefully at the curriculum at the school where you hope to study and expectations of a university where you hope to teach.  Speak with faculty,  & choose wisely.

It’s Up to you: Accept the Status Quo or Challenge it

Yes.  Change can be painful.question

Yes. It is easier to do things the way we’ve always done them (and been seemingly successful).

Yet, most of us want to work more efficiently or improve our own or patients’ health.Tension

 So, there you have the problem: a tension between status quo and change. Perhaps taking the easy status quo is why ‘everyday nurses’ don’t read research.

Ralph (2017) writes encountering 3 common mindsets that keep nurses stuck in the rut of refusing to examine new research:

  1. I’m not a researcher.
  2. I don’t value research.
  3. I don’t have time to read research.

But, he argues, you have a choice: you can go with the status quo or challenge it (Ralph).  And (admit it), haven’t we all found that the status quo sometimes doesn’t work well so that we end up

  • choosing a “work around,” or
  • ignoring/avoiding the problem or
  • leaving the problem for someone else or
  • ….[well….,you pick an action.]

TensionHow to begin solving the problem of not reading research? Think of a super-interesting topic to you and make a quick trip to PubMed.com. Check out a few relevant abstracts and ask your librarian to get the articles for you. Read them in the nurses’ lounge so others can, too.

Let me know how your challenge to the status quo works out.

Bibliography: Fulltext available for download through https://www.researchgate.net/ of  Ralph, N. (2017 April). Editorial: Engaging with research & evidence is a nursing priority so why are ‘everyday’ nurses not reading the literature, ACORN 30(3):3-5. doi: 10.26550/303/3.5

More? Not always better! Check out NNT.

EBPPractice based in evidence (EBP) means that you must critique/synthesize evidence and then apply it to particular setting and populations using your best judgement.  This means that you must discriminate about when (and when NOT) to apply the research.  Be sure to use best professional judgment to particularize your actions to the situation!

Add to your repertoire of EBP tools,  ratiothe Number Needed to Treat (NNT).   This is not mumbo -jumbo.   NNT explained here–short & sweet: http://www.thennt.com/thennt-explained/ 

FindingsCRITICAL THINKING:   Check out this or other analyses at the site.  How does the info on antihypertensives for mild hypertension answer the question of whether more is better?  Are there patients in whom you SHOULD treat mild HTN?  (“We report, you decide.”)   http://www.thennt.com/nnt/anti-hypertensives-for-cardiovascular-prevention-in-mild-hypertension/

MORE INFO:  Check out what the data say about other risk/benefit treatments at http://www.thennt.com/ 

Creation & Use of Evidence: Different!

The difference between research and evidence-based practice (EBP) can sometimes be confusing, but the contrast between them is sharp.  I think most of the confusion comes because those implementing both processes measure outcomes.  Here are differences:

  • RESEARCH :  The process of research (formulating an answerable question, designing project methods, collecting and analyzing the data, and interpreting themagnifyingGlassmeaning of results) is creating knowledge (AKA creating research evidence).  A research project that has been written up IS evidence that can be used in practice.  The process of research is guided by the scientific method.
  • EVIDENCE-BASED PRACTICE:   EBP is using existing knowledg(AKA using EBPresearch evidence) in practice.  While researchers create new knowledge,

The creation of evidence obviously precedes its application to practice.  Something must be made before it can be used.  Research obviously precedes the application of research findings to practice.  When those findings are applied to practice, then we say the practice is evidence-based.

A good analogy for how research & EBP differ & work together can be seen in autos.

CreateCar
Creating a car!

 

  • Designers & factory workers create new cars.

    UseCar
    Using a car!
  • Drivers use existing cars that they choose according to preferences and best judgments about safety.

 

 

CRITICAL THINKING:   1) Why is the common phrase “evidence-based research” unclear?  Should you use it?  Why or why not?  2) What is a clinical question you now face. (e.g., C.Diff spread; nurse morale on your unit; managing neuropathic pain) and think about how the Stetler EBP model at http://www.nccmt.ca/registry/resource/pdf/83.pdf  might help.  Because you will be measuring outcomes, then why is this still considered EBP.

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

It’s that time of year again! Enjoy this illustration of how to use one model in applying best, available evidence to practice. Have fun and a merry and bright season.

Discovering Your Inner Scientist

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…

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