Translating Evidence into Practice: Is Nursing the Missing...
Transcript of Translating Evidence into Practice: Is Nursing the Missing...
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Translating Evidence into Practice:Translating Evidence into Practice:Is Nursing the Missing Link?
T J PhD RNC OBTammy Jones, PhD, RNC-OBDirector, Center for Nursing Excellence
UAMS Medical Center
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ObjectivesObjectives
• Recognize the steps and processes that • Recognize the steps and processes that support the movement of evidence into nursing practiceg p
• Identify the role of nursing in the utilization, translation and creation of ,evidence
• Understand how the nursing research process parallels the tenets of translational research
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Nursing Practice: Then and NowNursing Practice: Then and Now
• Practice was based solely • Requires that nurses use on tradition, experience or “gut” feelings rather than science
current literature to stay informed, especially studies related to their science studies related to their specialty area
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The Power of the NurseThe Power of the Nurse
• Unique roleClinical expert
Guide
HealerAd o ate– Clinical expert
– Coordinator of care
T hi li
Healer
T h
Advocate
– Touching lives
– Relieving burdens Collaborator
TeacherLeader
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“With great power comes great ibilit ”responsibility”
• Nursing voted most trusted profession for 7 consecutive years (American Gallup)
84% f A i b li ’ • 84% of Americans believe nurses’ honesty and ethical standards are high or very highvery high
• Nursing “power” should be used to empower patients and bring about empower patients and bring about optimal outcomes
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Staying Up-to-Date…not optionalStaying Up to Date…not optional
• What drives your clinical decision-ymaking?– Research & evidence
– Policy/procedure
– Habits, routines…
“ h ’ l d i ”“the way we’ve always done it”
• Hard to be a critical thinker if you don’t have current informationhave current information– Evidence is at your fingertips
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Nursing EvidenceNursing Evidence
• Types – Empirical: based on scientific research
• “The Science of Nursing”
Ethi l b d ’ k l d f & t – Ethical: based on nurse’s knowledge of & respect for patient’s values/preferences
• “The Ethics of Nursing”
– Personal: based on the nurse’s experience in caring for the particular patient
• “Interpersonal relationships of nursing”• “Interpersonal relationships of nursing”
– Aesthetic: based on the nurse’s intuition, interpretation, understanding and values
• “The art and act of nursing”
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A Balancing Act
External Internal
ClinicalR h Clinical Expertise (aesthetic)
Research(empirical)
Nurse-Patient Relationship
Patient Preference
(personal)(ethical)
Evidence for Clinical Decision-makingg
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Evidence-based Practice (EBP)Evidence based Practice (EBP)
• The conscientious use • The conscientious use of current best evidence in making decisions in making decisions about patient careT l ti i th i • Translation is the primary reason to conduct an EBP reviewreview
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*R h*Clinical Expertise
*Availability of Health Resources
*Patient history &
*Research*Clinical Practice
Guidelines
P ti t/F il
*Patient history & physical
Patient/Family Preferences &
Values
Clinical Decision-makingClinical Decision making
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To translateTo translate
• To bear remove or change from one • To bear, remove, or change from one place, state, form, or appearance to another transfer, transform <translate ideas into ,action> www.merriam-webster.com/dictionary
• Translation involves synthesis, application, evaluation, and dissemination of evidence
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EBP Process A F k f T l tiA Framework for Translation
Assess & Gather the best
Appraise the
Integrate with
expertise and patient Evaluate
the
Share the results of
the Question best
evidencethe
evidencep
factors to implement
into practice
the outcomes evidence-
based change
Utilization PhaseUtilization Phase
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First Steps Toward Translation• The importance of the
“right” questionSeeking
Informationright question– Searchable &
answerableAnalyzingDrawing
Conclusions– PICO (templates)
• Identifying the best f id
y gConclusions
sources of evidence– Cochrane Database of
Systematic ReviewsSystematic Reviews
• Appraising the evidence
SynthesizingInterpreting
evidence– Grading tools
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Translation FrameworkTranslation Framework
Integrate
Assess & Question
Gather the best
evidence
Appraise the
evidence
Integrate with
expertise and patient factors to
Evaluate the
outcomesShare the
results factors to implement
“K l d i th t l ti f h t
Translation Phase
“Knowledge is the translation of what one knows into what one does.”
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Should the evidence be translated?Should the evidence be translated?
• Should we implement this practice • Should we implement this practice recommendation?
• Would this change improve clinical Would this change improve clinical outcomes?
• Would this change improve patient or Would this change improve patient or nurse satisfaction?
• Would this change reduce the cost of care gfor patients?
• Would this change improve unit g poperations?
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Steps of TranslationSteps of Translation
• Assess the appropriateness and feasibility of the recommendation
• Create an action plan
• Pilot and evaluate the change
• Report
• Foster support
• Develop a plan for wider implementationp p p
• Communicate findings
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Creators of EvidenceCreators of Evidence
Assess & Gather the best
Appraise the
Integrate with
expertise Evaluate the Share the
Question best evidence
the evidence
pand patient factors to implement
the outcomes results
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Contribution of NursesContribution of Nurses
• Impetus for research brought about by EBP • Impetus for research brought about by EBP process– Problems/issues identified by nursesProblems/issues identified by nurses
– Gaps of evidence uncovered
– Replication studies
– Original research
• Collaborators– Research Participants
– Data collectors
C i i– Co-investigators
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Mission of Nursing ResearchMission of Nursing Research
• Johnson (1979) publication entitled • Johnson (1979) publication entitled “Translating Research into Practice”; – A time honored phrase in nursing A time honored phrase in nursing
• Nursing Language– Research Translation 1970s
– Research Utilization 1980s
– Evidence-based Practice 1990s
– Research Translation after 2000
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Goals of Nursing ResearchGoals of Nursing Research
• Contribute to the scientific knowledge base • Contribute to the scientific knowledge base of nursing and thereby improve nursing practice and optimize patient outcomesp p p
• Nursing phenomena– Descriptionp
– Exploration
– Explanation
– Prediction/Control
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Nursing Research ProcessNursing Research Process
• Identify the problem• Identify the problem
• Review the literature
• State the purpose and come up with the • State the purpose and come up with the hypothesis
• Design the study• Design the study
• Carry it out
• Analyze the data• Analyze the data
• Disseminate the results
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Translational ResearchTranslational Research
• Bringing basic biological and behavioral Bringing basic biological and behavioral sciences to the diagnosis, treatment, and prevention of human disease and health problems
• 5 stage model– Basic research
– Pilot research or methods development
ffi i l (id l i i )– Efficacy trials (ideal situation)
– Effectiveness trials (uncontrolled setting)
Dissemination trials (real world conditions that – Dissemination trials (real world conditions that support or impede uptake of new interventions)
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Translational ResearchTranslational Research
• Eric Rose M D Dean for Translational • Eric Rose, M.D., Dean for Translational Research, Columbia University Medical Center proposed a translational pathway p p p ythat does not begin with basic science discovery, but in the clinical setting
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Patient ProblemPatient Problem (Clinical Setting)
Observation back to the Deliver solution
lab/research setting
to patients
Rose Translational PathwayBridge from Discovery to Delivery
Solution Work through clinical trials
designedand regulatory approval
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Bi-directional Process
BedsideBench B i
Bi directional Process
BedsideBench Brains
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Linking Practice & Research
“Th b ff f h
Linking Practice & Research
• “The best efforts of nurse researchers are fruitless unless nurses make use of their research findings to improve patient care in research findings to improve patient care in their day-to-day practice.”
• “Ideally, every nurse should be involved in research, but practically, all nurses should, research, but practically, all nurses should, as a minimum, use research results to improve their practices.” (Black, 2007)
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So…are we the missing link?So…are we the missing link?
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Research – Practice GapResearch Practice Gap
• “Up to two decades may pass before the findings of original research becomes part of routine clinical practice.” www.ahrq.gov
• @21% of nurses report utilizing research to inform their practice during the previous six monthsmonths
• @50% of nurses reported that they do not read or subscribe to a nursing journalread or subscribe to a nursing journal
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Knowledge CreepKnowledge Creep• Slow percolation of research ideas and
fi di i h i d d ll findings into the minds, and eventually practice, of clinicians
If h “k l d ” h t • If nurses have “knowledge creep”, what does that mean for healthcare?
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What’s the problem?What s the problem?
• Lack of knowledge and awareness• Lack of knowledge and awareness
• Negative views of EBP and research
• Large amounts of information in • Large amounts of information in professional journals
• Lack of time and resources to search for • Lack of time and resources to search for and appraise the evidence
• Pressure to continue with practices steeped Pressure to continue with practices steeped in tradition
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What can organizations do?What can organizations do?
• Creation/support of a culture of inquirypp q y– Evidence readily available (databases/journals)
– Adopt or create an EBP model
– EBP/Research mentors and champions
– Comprehensive EBP education in nursing curriculums and/or new graduate residenciescurriculums and/or new graduate residencies
– EBP fellowships
– EBP portfoliosEBP portfolios
– Organizational recognition of EBP projects
– Organized EBP/Research councils or committees
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What can nurses do?What can nurses do?
• Self Assessment• Self Assessment– What do you believe about EBP?
• Does it lead to quality care?• Does it lead to quality care?
– Is it (EBP) a way of thinking?
Do you view EBP as an “add on” to your – Do you view EBP as an add-on to your current practice?
– To what extent is your care evidence-To what extent is your care evidence-based?
– How much knowledge of the EBP process How much knowledge of the EBP process do you possess and how much do you use?
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Do your scales tip?
External Internal
ClinicalR h Clinical Expertise (aesthetic)
Research(empirical)
Nurse-Patient Relationship
Patient Preference
(personal)(ethical)
Evidence for Clinical Decision-makingg
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Do your part to bridge the gapDo your part to bridge the gap
• Gain knowledge and • Gain knowledge and skills of EBP/research
• Be an EBP/Research Be an EBP/Research mentor or find one
• Make a conscious effort Make a conscious effort to be a user andgenerator of evidence
• Role model a spirit of inquiry
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The Preferred Nurse
• What are the characteristics of
• Seeks knowledge and stays up to datecharacteristics of
the nurse you want to:
stays up-to-date
• Resistant to practice changesto:
– Work with
– Care for you, your
g
• Utilizes, translates and creates evidencey y
friends or family
– Emulate• Content with “status quo”
• Critical thinker
• Task oriented
• “Naysayer”
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Be the “Preferred” NursesBe the Preferred Nurses
Don’t wait for the best evidence to come to Don t wait for the best evidence to come to you. Seek out the best evidence or generate it for yourself.f y f
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ReferencesReferences• Coopey, M. & Nix, M. (2006). Translating research into evidence-based
nursing practice and evaluating effectiveness. Journal of Nursing Care Quality, 21(3), 195-202.Q y, ( ),
• Fawcett, J., Watson, J., Neuman, B., Walker, P. & Fitzpatrick. J. (2001). On nursing theories. Journal of Nursing Scholarship, 33(2), 115-119.
• Fugate-Woods, N. & Magyary, D. (2010). Translational research: Why nursing’s interdisciplinary collaboration is essential Research and Theory forinterdisciplinary collaboration is essential. Research and Theory for Nursing Practice, 24(1), 9-26.
• Koehn, M. & Lehman, K. (2008). Nurses’ perceptions of evidence- based practice. Journal of Advanced Nursing, 62(2), 209-215.
• Melnyk, B. & Fineout-Overholt, E. (2005). Evidence-based Practice in Nursing & Healthcare. Philadelphia:Lippincott, Williams & Wilkin.
• Mitchell, P. (2004). Lost in translation? Journal of Professional Nursing, 20 (4), 214-215.
• Newhouse, R. (2007). Creating infrastructure supportive of evidence-based nursing practice: Leadership strategies. Worldviews on Evidence-based Nursing, 1st quarter, 21-29.
• www cumc columbia edu/news/in vivo/vol4 iss1 mar apr 05• www.cumc.columbia.edu/news/in-vivo/vol4_iss1_mar_apr_05
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Additional Information & Resources
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Research Utilization (RU) vs. EBPResearch Utilization (RU) vs. EBP
• RU uses only research evidence; EBP• RU uses only research evidence; EBP incorporates non-research activity; RU is dependent on research publication and p pavailability
Research Utilization
Evidence-based tipractice
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Resources - PICOResources PICO
• PICO (Clinical question formation)• PICO (Clinical question formation)– What is the practice issue/area– How was the issue identifiedHow was the issue identified– What is the scope of the problem– What are the PICO components
• Problem/Patient/Population• Intervention• Comparison with other treatmentsComparison with other treatments• Outcomes
– State the question in a searchable/answerable form
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Resources: Levels of EvidenceSystematicSystematic
Review (RCTs)
At least (1) RCT
Case control and cohort studies
Systematic Review of Descriptive Studies
At least (1) Descriptive Study
Expert Opinions
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Resources – Rapid Appraisal– Are the results of the study valid?
• Random assignment of subjects• Blinded subjects and providers• Blinded subjects and providers• Instruments valid and reliable• Control group appropriate
– What are the results?• How large is the intervention/treatment effect• How precise is the intervention/treatment• How precise is the intervention/treatment
– Will the results help me in caring for my patients?
• Risks/benefits of treatment• Feasible in clinical setting• Patient/family values and preferencesPatient/family values and preferences
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Library resourcesLibrary resources
• UAMS students/employees• Contact Susan Steelman, UAMS
Resource Librarian, to schedule a free one-on-one consultationone-on-one consultation – 501-686-6737 – [email protected]