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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
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
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
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
“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
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
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”
A Balancing Act
External Internal
ClinicalR h Clinical Expertise (aesthetic)
Research(empirical)
Nurse-Patient Relationship
Patient Preference
(personal)(ethical)
Evidence for Clinical Decision-makingg
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
*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
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
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
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
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.”
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?
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
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
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
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
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
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
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)
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
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
Bi-directional Process
BedsideBench B i
Bi directional Process
BedsideBench Brains
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)
So…are we the missing link?So…are we the missing link?
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
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?
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
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
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?
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
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
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”
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
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
Additional Information & Resources
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
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
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
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
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]
