Evidence-Based Practice for the Advanced Practice Nurse

¶ … Applying Evidence-Based Research in Nursing Practice

What is the difference between research and evidence-based practice projects? Provide an example of EACH ONE and the reasons for the difference. Why should nurses be interested in learning about EBP? (evidence-based practice).

Research and evidence-based practice are not synonymous, and the distinctions are not necessarily intuitive. Research is a generic term that holds many different meanings depending on the context in which the term is used. The purpose of research is to generate new knowledge for theory building. That is to say that a body of existing knowledge or an observed phenomenon can be validated when new data emerges from a study. By tradition, research is conducted in such a way that sources of bias are liminated or avoided as much as possible.

Evidence-based research is a particular type of inquiry that is designed to identify proof or evidence of the theories in which the research is grounded. Evidence-based practice incorporates information from many different sources in order to identify, establish, and evaluate nursing best practices ("Health Leaders," 2014). Conclusions from peer-reviewed research, data from quality improvement studies and other approaches to practice evaluation, as well as expert opinions, are synthesized to form the most robust models of nursing practice, and to address emerging and enduring problems of practice ("Health Leaders," 2014).

Nurses strongly desire to provide the best nursing care for their patients, and it follows that this professional desire will translate into active search for best evidence-based practices that can be encompassed in their own nursing care practice. If the evidence-based practices are made available to nurses through professional development activities, the dynamic is referred to as transfer-of-training, in that, the recently acquired learnings are transferred to the existing nursing practice. For example, consider that the historical best practice in a hospital is to take vital signs every four hours for patients in a non-critical care unit, but the research supports taking vital signs twice in 24-hours as adequate. The previous best practice for taking vitals may be changed to reflect the evidence-based practice that has determined taking vitals two times -- twelve hours apart -- each day is sufficient for patient safety and comfort.

2 How would a nurse practitioner and a nurse manager differ with regard to how they use and incorporate EBP in their areas of practice?

The role that a professional plays in a medical or healthcare institution will influence the way they use and incorporate evidence-based practice into their quotidian responsibilities and their interactions with other professionals at their place of work. The nurse manager must understand the language of research and the culture of the institution. The expert knowledge and skills possessed by a nurse manager must be balanced against her capacity to act as an organizational change agent. Being able to read, understand, and interpret research articles from juried journals requires that the nursing manager be able to identify variables, comprehend phenomena, and understand statistical analyses ("Health Leaders," 2014). A nurse practitioner can be less research savvy than a nurse manager, but she will still need to be able to evaluate a research study and grasp a nursing practice holistically, such that, appropriate research findings can be gauged by resident experts and stakeholders, with the end result being incorporation of evidence-based practices that are a good fit for the institution and for which robust indicators of practice improvement are indicated.

3 What strategies will you use in your new practice as an advance nurse to review and critique literature pertinent to your practice?

4 What levels of evidence are present in relation to research and practice, and why it is important regardless of the method you use?

A hierarchy of levels of evidence for practice has been developed for use with qualitative research studies (Daly, et al., 2007). And an extensive hierarchy of levels of evidence is offered by Johns Hopkins that includes the following (Dearholt, et al., 2012): Level I -- experimental study and randomized controlled trial (RCT) with systematic review of RCTs with or without meta-analysis; Level II -- Quasi-experimental study with systematic review of combination of RCTs and quasi-experimental, or quasi-experimental studies only, with or without meta-analysis; Level III -- Non-experimental study with systematic review of combination of RCTs and quasi-experimental, or quasi-experimental studies only, with or without meta-analysis, and qualitative study or systematic review, with or without meta-analysis; Level IV -- Opinion of respected authorities and/or nationally recognized expert committees / consensus panels based on scientific evidence, including clinical practice guidelines and consensus panels; Level V -- Based on experimental and non-research evidence, including literature reviews, quality improvement program or financial evaluation, case reports, and opinion of nationally recognized experts based on experimental evidence.

An important responsibility of a nurse manager or an advanced practice nurse is to interpret the rigor of articles about nursing practice by using levels of evidence as a guide. The levels of evidence provide a standard by which the field of nursing can evaluate the rigor of research in order to be confident that the findings are worthy of regard and consideration for being embedded in nursing practice. Without a robust standard, practitioners could arrive at independent decisions about research quality that would be like comparing apples to oranges, and ostensibly put patients at risk. As an advance practice nurse, I will be able to maintain a routine of comparing the research I read and review to the hierarchies of levels of evidence, and also to critique the literature pertinent to my practice by looking for indicators of strong empirical approaches to research.

5 What factors must be assessed when critically appraising quantitative studies (e.g., validity, reliability, and applicability)?

Threaded throughout the hierarchy of the levels of evidence for quantitative research are indicators that are related directly or indirectly to the constructs of validity, reliability, and applicability. Indicators include sample size, sampling plan and procedures, elimination or reduction of sources of bias, and results of statistical tests. The use of randomly assigned trials is also important when assessing the quality and trustworthiness of a research study. An understanding of these indicators is critical to an effective review of the literature.

6 What are some of the obstacles or barriers to implementing EBP (evidence-based practice) in nursing? Provide a RATIONALE for your answer.

In a hospital setting, it is desirable to have everyone become an innovator and an early adopter of an evidence-based practice that will replace or supplant an outdated practice. Moreover, where an evidence-based practice change is moving through the hospital in a top-down fashion, it is entirely appropriate and generally effective for the evidence-based practice to be introduced in formal professional development or in staff meetings and debriefs. It is not practical or desirable for every change of practice to be the focus of action research or a PICOT process (Stillwell, et al., 2010). For expediency and often for patient safety and hospital liability issues, a substantial body of evidence-based practice must be implemented through top-down processes. Information can expeditiously be communicated to the staff nurse level and to the advance practice nurse level through regular staff meetings or through special sessions in which there is ample time for Q&A. If there is time and money available, videos and webinars can be created that provide instruction, which can be reviewed at the leisure of the staff receiving the training.

7 Conducting research projects while ensuring the protection of human subjects is necessary. What are some methods to protect personal rights of someone in one of the groups that is labeled as vulnerable? Justify your rationale.

Ethical issues are a concern for professionals who are interested in using research findings. This means that the research articles must explain what the researchers have done to protect the human subjects in their studies. Research that is conducted under the aegis of a university will necessarily follow the required human subjects review procedures. However, these procedures might not be adequate for someone who is in one of the groups that is labeled as vulnerable since the objective is to procure informed consent for participation in the study. This can be difficulty under a number of circumstances, which means that alternative procedure must be put in place, such as ensuring that a guardian is involved in the decision to participate in the study, or that consent materials are adapted to the an appropriate level for the study participants to understand -- and to decline to participate if they so desire.

8 Why is it important to incorporate a theory or model related to change when implementing practice changes? Does the benefit of incorporating a change model outweigh the time and effort it took to include it?

Developing a critical mindset, in which nurses begin to ask if a particular process or procedure is being optimized, can set them on the path to reading the literature and seeking evidence to validate the practice or to identify improvements. Establishing this type of process as a normative approach to change is likely to pave the way to support of future change initiatives. Indeed, incorporating a theory or model related to change when implementing practice changes provides a framework for reference when things do not go according to plan, such as when implementation is not successful or stakeholders only give lip service to an evidence-based practice that is being introduced. The benefit of incorporating a change model outweighs the time and effort it took to include it primarily because it lends credibility.

9 Identify barriers to the implementation of evidence-based practice. What are two ways to address this problem?

As with any change in an organization, issues of by in surface and must be addressed. An important aspect of the nurse manager's job responsibilities is facilitating needed change processes. Barriers to the implementation of evidence-based practice include a lack of appreciation for the benefits that can be gained from the change, and feeling like the change is being railroaded from "on high" by leaders who do not have true understanding of the problem. Professionals may be resistant to changes in their practice unless they can be show how the alterations will benefit the patient, and benefit them in terms of new capacity to save time and to save money. High-level edicts for change are rarely well accepted by professionals who prefer to participate in change efforts at all stages.

Two ways to address resistance to implementation of evidence-based practice include increased participating in the change stages, and changing the culture of the organization to embrace critical thinking. One of the most effective approaches to institutional change has been shown to be that of ownership. When nurses are engaged in articulating the practice problem and then determining how best to address the practice problem, they give evidence of greater buy-in, and the change effort is much more likely to successful -- and to be accomplished on a faster track than other less participatory approaches can achieve (Herman, 2011). While it is critical that leadership signals that the change initiative is valued, it is also important to enable shared leadership, inquisitive implementation (such as occurs through action research or the PICOT process), and shared evaluation of the implementation (Stillwell, et al., 2010).

10. When reviewing the literature and different types of evidence, there are often gaps in the findings. Are such gaps a help or a hindrance when wanting to create a change?

Research is critical to the development and improvement of medical practice. Indeed, for medical and healthcare research to be appropriately and adequately applied to nursing practice. A space or gap exists between research findings and the actual practice of medicine that must be brought together in order for evidence-based practice to be established ("Health Leaders," 2014). Moreover, when there are gaps in the findings in the literature, or even more commonly, different types of evidence are presented across studies, the hierarchy of levels of evidence can inform decision making about whether to make implement changes in practice based on the evidence provided and the relative strength of the research approaches as they are outlined in the hierarchy of levels of evidence. The gaps can be seen as opportunities to explore the practice in more particular detail through action research or a PICOT study (Stillwell, et al., 2010).

A critical function of evidence-based practice is the provision of information that explains why particular approaches, methods, and processes exist, how they came to exist, whether they need to be improved, and what the schedule for improvement should be given the evidence that has emerged from the reliable sources: research, quality improvement, and expert opinion ("Health Leaders," 2014). From this brief explanation, it should be apparent that driver of evidence-based practice is validation of traditions or opinions about practice, or -- absent validation -- replacement of practices that are not based on evidence, and for which new evidence has emerged ("Health Leaders," 2014). That is to say that, evidence-based research is an ongoing and iterative dynamic that enables application of new research findings to established practice, and thereby results in improved practice which is based on evidence and thereby becomes the current best practice.

11. What is the difference between statistically significant evidence and clinically significant evidence? How would each of these findings be used to advance an evidence-based project?

Statistically significant evidence assess the probability that the effects of a treatment or the risk factors of certain outcomes are due to chance, a determination that is accomplished through the testing of hypotheses (Skelly, 2011). As such, statistical significance is dependent on three primary and interrelated factors: 1) The size of the sample, the variability of the outcomes, and the effect size, which is demonstrated by the size of the difference of the effect that is observed between or across groups in the study. The key indicator of statistical significance is the probability as signaled by the P. value, which is the observed difference if there is no association among the variables. Statistical significance indicates how likely the differences that are observed, say, between two treatment groups is due to chance alone. Clinical significance, on the other hand, measures the treatment effects in clinical practice in terms of relative risk (Leung, 2001). A measure that is independent from the prevalence of the disease, relative risk in clinical practice is the ratio of the risks to the group receiving the treatment compared to the event rate in the control group (Leung, 2001). An evidence-based project can often be advanced by using a measure that of clinical statistical significance as it includes a clinical measure with, say, a 95% CI (confidence interval) (Leung, 2001).