Tag Archives: evidence based practice

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“I like my coffee (and my evidence) strong!”

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Let’s say you are still working to solve the issue of whether gum chewing reduces post-operative ileus. You identified titles of all relevant articles using PubMed database (http://www.ncbi.nlm.nih.gov/pubmed), and had the librarian pull the full articles for you.

Now you find yourself looking at a formidable stack of articles on the topic. You are sure that some are probably better quality than coffee2others, but how can you tell?

Professionals have agreed on which types of evidence are strongest. Here’s one well-accepted hierarchy form strongest #1 to weakest #6 (Melnyk & Fineout-Overholt, 2005).

  1. Systematic reviews, Meta-analyses, or Evidence-based clinical practice guidelines based on systematic review of RCTs
  2. Randomized controlled trial
  3. Controlled trials without randomization
  4. Case controlled or cohort studies
  5. Systematic review of descriptive studies
  6. Single descriptive or qualitative study
  7. Expert opinion of individuals or committees

Number 1= Strongest.   Number 6=Weakest

When you are trying to solve a problem, FIRST look for the three (3) types of evidence that are the very strongest (#1). These are:

  1. Systematic reviews that are summaries of research findings from many studies;
  2. Meta-analyses that are summaries of research findings in which the data from those other studies are combined into one big study;
  3. Evidence-based clinical practice guidelines that are clinical recommendations based on a summary of research and other evidence. An expert panel has often agreed on the summary and recommendations.

Your next strongest option, #2, is at least one randomized controlled trial (RCT). In an RCT a group of subjects is randomly separated into at least two groups. One group gets the experimental treatment—whether it is a drug or teaching plan or something else—and the other group usually gets standard treatment or a placebo. Then the group outcomes are compared statistically to see which did better.

Usually the title or first few lines of the article will tell you that the article is a systematic review, a meta-analysis, an evidence-based clinical practice guideline, or an RCT. Rarely is this left a mystery! (Never assume that a research study article is strong just because you LIKE the findings, or that it is weak because you DON’T like the findings.)

I’ll comment on other levels of evidence soon, but let’s focus on the strongest types first. Try the critical thinking for practicing the ideas above.

Critical Thinking:  Using the article titles below, rank these three (3) research studies in order from Strongest evidence to Weakest evidence:

Want to read more?  A good summary of one hierarchy is and why it’s important is at this 5 minute youtube video: https://www.youtube.com/watch?v=5H8w68sr0u8 . While that hierarchy does not precisely match the one above, the video still has lots of good information.

 

 

Evidence based nursing, Literature review

How to Re-Invent the Wheel (NOT!!)

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You can avoid re-inventing the wheel by checking in with top notch wheelexperts who have already examined the practice problem that you face.

In other words, it’s time to head to the library. After all that’s what the library is: the experiences and research written down by experts, who have spent a lot of time thinking about the same problem that you are facing. Really it’s pretty amazing that we have access to health professionals all over the world who are eager to help you avoid re-inventing the wheel.imagesCAGYW6WB

The best experts in the field are talking directly to you through their publications!

Of course it’s important to ask your colleagues in your own and other institutions about their ideas on the problem, but that’s not enough. You will be limited by what they happen to know; or worse you will be limited by what they don’t happen to know! Nurses on your floor can provide practical, site-specific insights, but it’s easy to see why you would want to add newest information from the top experts. That is BEST evidence.

Remember: EBP = Best evidence + Clinical judgment + Patient/family preferences/values

HOW do you find the experts in the library?

  1. The first step is to identify KEY WORDS from your PICO.
  2. Use single words or put phrases in parenthesis in your list of words (e.g., “postoperative ileus”). A librarian can help with key words, too.
  3. Google the site PubMed (PubMed is a complete database of healthcare publications)
  4. In the search box at the top of the PubMed page, type in your key words
  5. You will get a list of articles on your topic (and some related articles on the right side)
  6. Click on the box beside the ones that you want & email that list tocomputers shaking hands your facility librarian with a request to pull the complete articles for you! (Of course if you are a student with some direct access to full-text articles in a school library, then it may be quicker to get them on your own. It’s up to you, but part of your “village that it takes” might be the librarian.) [See “Take five!” if you want more on to why PubMed beats Google Scholar.]

EXAMPLE: Let’s get specific….

  • Take this problem that we have discussed before:
    • P = Postoperative patients with ileus (Population or Problem)
    • I = Gum chewing postop (Intervention to try out)
    • C = NPO with gradual diet progression when bowel sounds start returning (Comparison intervention)
    • O = Reduce time of postop ileus with sooner return to nutritious eating (Outcome that you want)
  • What are some key words from the above PICO stated problem? “Postoperative ileus” adults “gum chewing”
  • Go ahead. Pull up PubMed. Paste in the key words You should get 11 articles about gum chewing & postoperative ileus. Check the boxes of the ones you want, then…
  • Click on the “SEND TO” link near the upper right corner of the screen and email the list to the librarian with a request for full-text of the articles. (You can send to yourself, too)
  • Congratulate yourself on an EBP literature search well-started!

CRITICAL THINKING: Why wouldn’t you simply use google.com to find expert opinions?  [If you want more “data”  related to this question.  Check out“Take five!”]

FOR MORE INFO: Check out this tutorial on how PubMed works & what’s in it http://www.nlm.nih.gov/bsd/disted/pubmedtutorial/020_010.html You pay for PubMed through your taxes—get your $$ worth!

 

 

Evidence based nursing, Professional Nursing

It Takes a “Village”

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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

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!

 

Evidence based nursing, Professional Nursing

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

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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)

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

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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)

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“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!

Evidence based nursing, Professional Nursing

In Conclusion: “Back to the future”

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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

Evidence based nursing

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

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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.

Evidence based nursing, Professional Nursing

NEW site to Discovering Your Inner Scientist

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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.